Every finding on record at Somerwoods Rehabilitation and Healthcare Center

Based on observation, interview, and review of the facility's policies, the facility failed to consistently provide snacks for all residents in the facility, which had the potential to affect any resident who received snacks from the dietary department.The findings include: Review of the facility's policy titled, Offering/Serving Bedtime Snacks, undated, revealed it was the practice of the facility to offer and serve residents with a nourishing snack. Further review the snacks were to be in accordance with the residents' needs, preferences and requests at bedtime on a daily basis. Observation on 04/28/2026 at 12:09 PM, of the second-floor nourishment refrigerator, revealed snack items available included two sugar-free Jello containers; one can of diet soda; one quarter-full pitcher of tea that was undated and lacked a lid. Further observation revealed the refrigerator also included one nutritional shake, and seven half-pint cartons of milk. Observation of the first-floor nourishment refrigerator, on 04/29/2026 at 7:57 PM, revealed one undated fruit salad; one undated pudding; and six pre-made sandwiches dated 04/28/2026. Observation of the bread on the sandwiches revealed it was hard to the touch. Observation of the third-floor nourishment refrigerator, on 04/29/2026 at 8:25 PM, revealed six pre-made sandwiches dated 04/28/2026. Per observation of the bread on the sandwiches revealed it was hard to the touch. Observation of the [NAME] unit nourishment refrigerator, on 04/29/2026 at 8:40 PM, revealed five pre-made sandwiches dated 04/28/2026, with bread that was hard to the touch. Additionally, observation revealed two pitchers containing a flavored beverage that were undated and uncovered. During a Resident Council meeting conducted on 04/28/2026 at 10:30 AM, attended by Residents (R)1, R15, R25, R44, R51, R69, and R116, the residents expressed concerns regarding the inconsistency and availability of bedtime snacks, with all residents agreeing that there was never enough snacks available for everyone. The residents reported the facility did not routinely provide snacks as expected and stated they frequently relied on family members or personal funds to obtain desired snack items. The residents further said staff used their own money to purchase snacks to meet the residents' requests. In addition, the residents stated their preferred snack items, including snack cakes and chips, were no longer offered by the facility. In interview with Licensed Practical Nurse (LPN) 2 on 04/28/2026 at 12:12 PM, she stated the nursing floors did not have enough snacks to go around. She said they did not have snacks that suited the residents' preferences either. LPN 2 further stated because of the lack of snacks and suitable snacks, the nurses used their own money to buy snacks and bring in so residents would have snacks available. In interview with Registered Nurse (RN) 1 on 04/28/2026 at 12:25 PM, she stated residents should be able to have snacks when they wanted them, and it was important they have snacks they liked. RN 1 further stated after a recent purchase of the facility by new owners, they had quit all of the snacks. In interview with State Registered Nurse Aide (SRNA) 9 on 04/29/2026 at 12:26 PM, she stated staff were told the facility's new budget dictated what foods and snacks were available. She further stated the facility regularly did not provide enough snacks for all residents to have one. In interview with RN 4 on 04/29/2026 at 8:30 PM, she stated her nursing floor did not receive sufficient snacks from the dietary department to provide each resident with a bedtime snack. She said her census was 43 residents, and the dietary department typically provided approximately eight sandwiches to distribute for nighttime snack. RN 4 reported when snacks were depleted and residents continued to request a snack, she contacted other floors to obtain additional snacks. She further stated if no snacks were available, she would purchase snacks with her own money to meet the residents' requests. In interview with the Dietary Manager (DM) on 04/29/2026 at 8:01 PM, he stated the dietary department delivered sandwiches for snacks three times daily, which were before noon, after lunch, and after dinner. He said the department currently prepared approximately 20-30 sandwiches total per day for facility-wide snack distribution. The DM reported less than one year ago, the department prepared approximately 40 sandwiches daily for snacks; saying, that was ridiculous. He further stated the dietary department did not supply enough sandwiches for every resident to have one if they wanted one. In interview with SRNA 17 on 04/29/2026 at 8:27 PM, after touching the premade sandwiches dated 04/28/2026 in the nourishment refrigerator, she stated she would not give those sandwiches to residents to eat because the bread was hard and could pose a choking hazard. In interview with the Administrator on 04/30/2026 at 3:19 PM, he stated the facility had changed the types of snacks given and reduced the amount given to residents, saying, it's not what we used to have. The Administrator further stated it was his expectation that every resident have a snack if they wanted one.

Based on observation, interview, and facility policy review, the facility failed to prepare, store, and serve food in a sanitary manner to help prevent potential contamination and foodborne illness, which had the potential to affect all residents consuming food from the dietary department. The findings include: Review of the facility's policy titled, Dietary Employee Personal Hygiene, date reviewed/revised 09/01/2024, revealed the facility was to utilize guidelines for employee personal hygiene to prevent contamination of food by foodservice employees. Continued review revealed hands were to be washed after engaging in activities that contaminated the hands, and employees were not to use their bare hands to contact with ready-to-eat foods. The policy additionally stated gloves were to be worn and changed appropriately to reduce the spread of infection. Review further revealed all dietary staff were required to wear hair restraints, including hairnets, hats, and/or beard restraints, to prevent hair from contacting food. 1). Review of the 2013 U.S. Public Health Service Food Code, revealed food employees should wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covered body hair. Continued review of the Code revealed the hair restraints were to be designed and worn to effectively keep food employees' hair from contacting exposed food, clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Observation during the initial kitchen tour on 04/27/2026 at 1:10 PM, revealed three male dietary aides (DA's) working in the kitchen area without beard guards in place. Per observation, a cook was actively preparing food without a beard guard and the Dietary Manager (DM) was present in the kitchen area without wearing a beard guard. Further observation of the kitchen area at 1:33 PM, on that same date, revealed a fifth male dietary employee working in the kitchen area without a beard guard in place, and the DM, who had been present for the entire tour of the kitchen, was not wearing a beard guard for any of the tour. Observation, conducted from the kitchen entrance, on 04/27/2026 at 2:55 PM, revealed [NAME] 7 working on the tray line with a beard guard pulled down beneath his chin, leaving his facial hair exposed. Observation further revealed DA 5 wearing a beard guard with his facial hair not fully covered while working in the kitchen area. Observation, conducted during supper tray line service, on 04/27/2026 beginning at 4:30 PM, revealed [NAME] 4 working on the tray line without a beard guard in place. Observation revealed the DM present in the tray line area without a hairnet or beard guard in place. DA 5 was observed wearing a beard guard; however, it did not fully cover his mustache, while he working on the tray line. Observation at 4:45 PM, revealed DA 5 was rolling silverware while his facial hair remained exposed outside of his beard guard. Observation on 04/27/2026 at 5:00 PM, revealed the DM was again observed in the kitchen area without wearing a beard guard and then exited the kitchen area. The DM was observed to reenter the kitchen area at 5:07 PM, and remained in the kitchen without wearing a beard guard while tray line service continued. Observation, conducted during lunch tray line service, on 04/28/2026 beginning at 11:35 AM, revealed DA 9 entered the kitchen area wearing a hairnet without a beard guard leaving his facial hair exposed. Per observation, DA 9 was also wearing a scrub top without an undershirt, which left his chest hair exposed. Observation on 04/28/2026 at 3:48 PM, revealed [NAME] 7 working on the tray line with his mustache not fully covered by his beard guard. Observation further revealed DA 21 working in the kitchen area without a hairnet in place. Observation on 04/29/2026 at 3:28 PM, revealed DA 5 working in the kitchen area with a beard guard worn improperly, leaving his facial hair exposed. Continued observation revealed [NAME] 7 working on the tray line with the beard guard pulled beneath his chin, leaving his mustache exposed. Observation on 04/29/2026 at 7:53 PM, revealed the DM working in the kitchen area without a beard guard in place. Per observation, [NAME] 7 was wearing a beard guard pulled beneath his chin, leaving his mustache exposed; DA 5 was working without a beard guard; and DA 22 was working without a hairnet or beard guard in place. Continued observation revealed when staff became aware the State Survey Agency (SSA) Surveyor had entered the kitchen area, they dispersed throughout the kitchen and began adjusting and applying hair and beard coverings. During interview on 04/27/2026 at 1:34 PM, [NAME] 7 stated he knew he was supposed to wear a beard guard but did not realize that staff with only a mustache were required to wear facial hair protection over their mustache. [NAME] 7 additionally stated facility management had never corrected the manner in which he wore the beard guard or instructed him to wear it differently. During interview on 04/27/2026 at 1:38 PM, Dietary Aide 5 stated he had never been trained on the importance of wearing a hairnet and reported that he just does it. Dietary Aide 5 further stated he forgot to put on a beard guard and no staff member or manager had previously instructed him to wear one. During interview on 04/29/2026 at 8:01 PM, the Dietary Manager (DM) stated he had, at times, forgotten to wear his beard guard throughout the SSA Survey dates. 2). Observation during the initial kitchen tour on 04/27/2026 at 1:10 PM, revealed clean cups and bowls loosely piled and improperly stored in milk crates on metal shelving in the dry storage area and additional clean cups and bowls loosely stacked in milk crates on the floor of the dish room, and serving bowls stacked face-up along the tray line. Observation on 04/27/2026 at 4:49 PM, revealed bowls were stacked face-up on the tray line with the food contact surfaces exposed. Observation on 04/30/2026 at 2:28 PM, revealed clean cups loosely stored in milk crates placed directly on the floor of the wash room. During interview on 04/29/2026 at 8:01 PM, the Dietary Manager stated the cups and bowls stored in milk crates should have been covered to prevent contaminates from falling on them. During interview on 04/30/2026 at 2:28 PM, DA 23 stated clean dishes should not have been stacked in milk crates placed on the floor. The DA further stated clean dishes should not be stored that way because the floor was dirty and could contaminate the dishes with germs, potentially causing illness to residents. 3). Review of the Smucker's (name brand) website's (https://www.smuckers.com/frequently-asked-questions) frequently asked questions (FAQs) section revealed, We recommend refrigerating our fruit spreads, jams, jellies and preserves after opening, per the instructions on the back label of our products. For maximum freshness and flavor, we do not recommend using opened products if they have been without refrigeration for more than 48 hours. Observation during the initial kitchen tour on 04/27/2026 at 1:10 PM, of the refrigerator, revealed pimento cheese stored without a date label; pre-cracked eggs stored in a bucket without an open date; 10 Jello containers labeled Dinner 04/20; and seven vanilla pudding bowls labeled 04/24. Observation of the freezer revealed undated, opened garlic bread; premade pot pies dated 03/18/2026; and fish stored in the freezer without date labeling. Observation, conducted during supper tray line service, on 04/27/2026 beginning at 4:30 PM, revealed a container of Smucker's grape jelly labeled 04/16 stored on a shelf in the food preparation area, and not refrigerated as according to the manufacturer's instructions on the container. Observation of the bread room revealed a red plastic cup lying on the floor in the corner of the room. Observation on 04/28/2026 at 11:47 AM, revealed the previously observed opened container of grape jelly remained unrefrigerated on a shelf in the food preparation area. Observation at 11:48 AM, revealed the red plastic cup remained lying in the same corner of the bread storage room. Observation of the second-floor nourishment refrigerator, on 04/28/2026 at 12:09 PM, revealed a quarter-full pitcher of tea that was undated and lacked a lid. Observation on 04/29/2026 at 3:28 PM, revealed the previously observed opened grape jelly container remained unrefrigerated stored on a shelf in the food preparation area. Observation of the first-floor nourishment refrigerator, on 04/29/2026 at 7:57 PM, revealed one undated fruit salad; one undated pudding; and six pre-made sandwiches dated 04/28/2026. Observation of the sandwiches revealed the bread on the sandwiches was hard to the touch. Observation of the third-floor nourishment refrigerator, on 04/29/2026 at 8:25 PM, revealed six pre-made sandwiches dated 04/28/2026, and the bread on the sandwiches was hard to the touch. Observation of the [NAME] unit nourishment refrigerator, on 04/29/2026 at 8:40 PM, revealed five pre-made sandwiches dated 04/28/2026, with bread that was hard to the touch. Additionally, observation revealed two pitchers containing a flavored beverage observed to be undated and uncovered. During interview on 04/29/2026 at 8:01 PM, the DM stated staff were expected to follow refrigeration instructions for food items, but reported food might have been left unrefrigerated for the convenience of staff. He explained the kitchen area was to be swept thoroughly on a daily basis and said he did not have an explanation for why a red plastic cup had remained on the floor for multiple days in the bread room. 4). Observation on 04/27/2026 beginning at 4:30 PM, revealed a red plastic cup lying on the floor in the corner of the bread storage room. Observation on 04/27/2026 at 4:49 PM, during dinner meal service, revealed [NAME] 6 was observed rolling silverware, then walking to the tray line and food preparation area without removing gloves or performing hand hygiene. Observation revealed [NAME] 6 opened a drawer, retrieved a ladle, placed the ladle on the tray line, exited the tray line area, and returned to rolling silverware, all while continuing to wear the same gloves. Continued observation, during tray line service, revealed [NAME] 7 removed multiple plates from the plate warmer and stacked the plates face-up on the tray line while repeatedly touching the inside food-contact surface of the plates where resident food was to be placed. Observation further revealed [NAME] 6 touched the inside food-contact surfaces of the salad bowls during tray line preparation. In addition, [NAME] 7 was also observed touching his face while working on the tray line and not removing gloves or performing hand hygiene prior to resuming food service activities. Observation, conducted during lunch tray line service, on 04/28/2026 beginning at 11:35 AM, revealed [NAME] 10 touched rolls with gloved hands after touching serving utensils, and was also observed touching the inside food-contact surfaces of bowls where resident food would be placed. Continued observation revealed [NAME] 10 left the tray line, walked to the oven area, retrieved a tray of rolls, and touching the bottom surface of the baking tray while moving it from the top of the oven to a table located behind the tray line. Further observation revealed [NAME] 10 then returned to the tray line and resume preparing resident meal trays without changing gloves or performing hand hygiene. Observation on 04/28/2026 at 11:47 AM, revealed revealed the red plastic cup remained lying in the same corner of the bread storage room. During interview on 04/27/2026 at 4:53 PM, [NAME] 6 stated she should have changed her gloves and washed her hands between tasks to prevent cross contamination and reduce the spread of germs that could cause residents to become ill. During interview on 04/27/2026 at 5:26 PM, [NAME] 7 stated he should have removed his gloves and washed his hands after touching his face with gloved hands while working on the tray line. [NAME] 7 reported he should not touch the food contact surface of plates where resident food was to be placed. [NAME] 7 further stated proper hand hygiene was important to reduce the spread of germs to residents. During interview on 04/28/2026 at 11:41 AM, [NAME] 10 stated she should not have touched the rolls with gloved hands after touching serving utensils and leaving the tray line to retrieve additional rolls. [NAME] 10 reported she was unsure whether tongs should have been used to serve the rolls and said she would need to ask the Dietary Manager (DM). However, observation revealed [NAME] 10 did not consult the DM and continued serving residents without using tongs or changing gloves. During interview on 04/29/2026 at 11:42 AM, with the Director of Nursing (DON), she stated she expected all nurses and staff to follow the facility policies and procedures. During interview on 04/29/2026 at 8:01 PM, the DM stated he expected dietary staff to follow all facility policies and procedures to ensure resident safety. He further stated he was responsible for supervising the dietary staff and ensuring dietary staff followed the facility policies and procedures. During interview on 04/30/2026 at 3:19 PM, the Administrator stated the DM had oversight of the kitchen. The Administrator said the expectation was for all policies and procedures to be followed for the safety of residents and staff. Additionally, the Administrator stated dietary staff should have been following all manufacturer guidelines for storing food items. During interview on 04/30/2026 at 3:35 PM, the Infection Preventionist (IP) stated all new dietary staff received infection control training, as well as the facility's annual infection control training. During a follow-up interview on 05/01/2026 at 11:38 AM, the Administrator stated cups and bowls should have been covered if stored in milk crates to prevent contaminants from falling into them. The Administrator reported clean dishes should never have been stacked directly on the floor due to infection control concerns. The Administrator further stated cups and bowls were to be dried face down to prevent contaminants from falling into them.

Based on observation, interview, and facility policy review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases which had the potential to affect all residents. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 09/01/2024, revealed the facility was expected to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per nationally accepted standards and guidelines. Continued review revealed the facility's infection control practices applied to all staff. Review of the Centers for Medicare and Medicaid (CMS) regulation, F880 (the CMS tag for Infection Prevention and Control in nursing homes) revealed it mandated all facilities must review and update their Infection Prevention and Control Program (IPCP) annually and as necessary. Per continued review of F880, revealed the facilities review of their IPCP ensured their policies reflected current Centers for Disease Control and Prevention (CDC)/CMS guidelines and the facility's annual risk assessment to avoid top-tier citations. 1). Observation on 04/28/2026 at 9:05 AM, revealed State Registered Nurse Aide (SRNA) 3 entered room [ROOM NUMBER], and opened a can of soda for the resident in bed A and poured it into a tumbler for that resident. Continued observation revealed SRNA 3 proceeded to work between beds A and B (the resident residing in Bed B was not in the room), taking the cup from bed B out to obtain ice and touched the ice scoop to the cup and proceeded to scoop ice into the cup. In interview with SRNA 3 on 04/28/2026 at 9:16 AM, she stated she should not have touched the cup to the ice scoop because it was an infection control concern for resident safety. The SRNA initially stated she would go rinse the scoop off. When the State Survey Agency (SSA Surveyor) questioned her about the scoop touching the ice, SRNA 3 stated she should go dispose of the ice and sanitize the cooler to ensure resident safety from the spread of germs from resident to resident. 2). Observation on 04/27/2026 2:19 PM, in room [ROOM NUMBER], revealed a male urinal hanging from the handrail in the bathroom. In interview with the Infection Preventionist (IP) on 04/30/2026 at 3:35 PM, she stated she expected residents' urinals to be sanitized and stored properly. 3). Observation on 04/28/2026 at 4:07 PM revealed a visibly soiled brief laying on the bedside table of Resident (R) 19. During interview with SRNA 1 on 04/28/2026 at 4:10 PM, she stated the soiled brief did not belong to either resident in the room and she knew that because it was a size small and neither resident could wear that size. She further stated leaving a soiled brief on the bedside table was an infection control concern, especially because she did not know which resident the brief belonged to. During interview with SRNA 2 on 04/28/2026 at 4:10 PM, she said the soiled brief could not belong to either resident in the room it was left in. She further stated that not only was that an infection control risk for the residents in the room it was also gross. 4). Observation on 04/28/2026 at 11:15 AM, revealed Styrofoam cups stored in a tote, haphazardly, on the hydration cart. Continued observation revealed the SRNAs grabbed a cup out of the tote to provide fluids for residents; however, the cups were not individually wrapped so the aides touched other cups. In interview on 05/01/2026 at 10:15 AM, the IP stated she expected residents' cups to be stored in a way that prevented staff from touching directly where the residents drank from the cups. During interview with the Infection Preventionist (IP) on 04/30/2026 at 3:35 PM, she stated all new employees received infection control training in orientation, as well as yearly refreshers in October. In additional interview on 05/01/2016 at 10:15 AM, the IP said it was her expectation for all staff to follow the facility's infection control policy. She reported possible negative outcomes for poor infection control would be eye infections, UTIs (urinary tract infections) and other infection outbreaks. During interview with the Director of Nursing (DON) on 04/29/2026 at 11:42 AM, she stated she expected all nurses and staff to follow the facility's policies and procedures (pertaining to infection control). During interview with the Administrator on 05/01/2026 at 11:55 AM, he stated he expected all employees to adhere to the facility's infection control protocols. He reported failure to follow facility policy and infection control guidelines could result in the spread of infection. The Administrator further stated it was important to follow the infection control guidelines and policy, for the health, safety, and well-being of residents and staff.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents were able to exercise choice regarding use of bed rails, including the right to request or refuse their use, for 11 (Resident (R)4, 5, 6, 7, 10, 11, 20, 40, 65, 92, and 99) out of the 38 total sampled residents. The facility did not consistently assess, document, and honor resident preferences related to bed rail use. This had the potential to limit resident autonomy and negatively impact quality of life.The findings include: Review of the facility's Resident Rights policy, undated, revealed the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. Review of the facility's Proper Use of Bed Rails policy, undated, revealed it was the facility's policy to utilize a person-centered approach when determining the use of bed rails. Per policy review, an assessment was required and of which the components of was to be considered when determining the resident's needs. Continued policy review revealed the facility was to assess residents to determine if the bed rail met the definition of a restraint. Further review revealed, A bed rail is considered to be a restraint if the bed rail keeps a resident from voluntarily getting out of bed in a safe manner due to his/her physical or cognitive inability to lower the bed rail independently. In addition, review of the policy revealed if the bed rail was determined to be a restraint, the facility would follow their procedures related to physical restraints. 1. Review of R4's medical record revealed the facility admitted resident on 02/20/2026, with diagnoses including moderate protein-calorie malnutrition, intestinal adhesions [bands] with obstruction, and age-related physical debility. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R4 as having a Brief Interview for Mental Status (BIMS) score of 15 out of15, indicating intact cognition. Review of R4's Comprehensive Care Plan, initiated 02/01/2026, revealed the facility identified the resident as at risk for falls with a goal stating the resident would remain free from falls/injury and pain. Continued review of the care plan revealed for Activities of Daily Living (ADLs)/Personal Care R4 was to have staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. 2. Review of R5's medical record revealed the facility admitted the resident on 07/15/2022, with diagnoses including chronic obstructive pulmonary disease, morbid (severe) obesity, and rheumatoid arthritis. Review of the Quarterly MDS Assessment, dated 02/23/2026, revealed the facility assessed R5 as having a BIMS score of eight out of 15 indicating moderate cognitive impairment. Review of R5's Comprehensive Care Plan, initiated 02/02/2026, revealed the facility identified the resident would participate in ADLs/personal care. Continued review revealed several interventions including for transfers. Per review, the interventions included the resident might return to use of a sit to stand lift for her transfers and for toileting to have a bedside commode (BSC) in the room, with substantial assistance of one staff, per therapy, which was revised 03/10/2026. Further review revealed another intervention to use quarter rails, which was listed as quarter rails x 2 (quarter rails times two). initiated 03/26/2024, revised 08/26/2024, and noted as resolved 08/26/2024. Observation on 04/27/2026 at 1:40 PM, 04/28/2026 at 3:20 PM, and 04/30/2026 2:40 PM, revealed R5 was sitting up in a chair in her room. Further observation revealed no visual evidence of rails on the resident's bed. In interview with R5, on 04/27/2026 at 1:40 PM, she stated she had been frustrated when her quarter bed rails had been removed last year. She said she preferred to be able to adjust herself by using those rails, instead of having to use her call light for staffs' assistance. She further stated she felt helpless and not a grown up. 3. Review of R6's medical record revealed the facility admitted the resident on 01/16/2026, with diagnoses including type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, unspecified, and moderate protein-calorie malnutrition. Review of the Quarterly MDS Assessment, dated 04/01/2026, revealed the facility assessed R6 as having a BIMS score of nine out of 15 indicating moderate cognitive impairment. Review of R6's Comprehensive Care Plan, initiated 01/13/2026, revealed the facility developed a goal for Activities of Daily Living/Personal Care was to be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. In interview with R6 on 04/28/2026 at 10:39 AM, R6 stated his bed rails had been removed. He reported his daughter had to raise heck to get the rails placed back on his bed. R6 further stated he was unable to reposition or self-transfer without them, and it limited his mobility and independence. He said, I felt trapped. 4. Review of R7's medical record revealed the facility admitted the resident on 03/21/2025, with diagnoses including coronary artery disease (CAD), congestive heart failure (CHF), and seizure disorder. Review of the Quarterly MDS Assessment, dated 04/01/2026, revealed the facility assessed R7 as having a BIMS score of nine out of 15 indicating moderate cognitive impairment. Review of R7's Comprehensive Care Plan, initiated 03/23/2025, revealed the facility developed a goal for ADLs/Personal Care to be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. In interview on 04/28/2026 at 12:09 PM, R7 stated she had not liked having her beds removed. She stated, I almost fell once because I didn't have anything to grab hold of and catch me. She further stated, I could move around more with the bed rails. I could use them to move myself up in the bed or help getting out of bed. 5. Review of R10's medical record revealed the facility admitted the resident on 03/25/2026 with diagnoses including acute and chronic respiratory failure with hypoxia, degenerative joint disease (DJD) and stroke. Review of the Annual MDS Assessment, dated 04/03/2026, revealed the facility assessed R10 as having a BIMS score of 11 out of 15 indicating moderate cognitive impairment. Review of R10's Comprehensive Care Plan, initiated 03/27/2026, revealed the facility developed a goal for ADLs/Personal Care to be completed with staff support as appropriate to maintain or achieve highest practical level of functioning through the next review. In interview with R10, on 04/29/2026 at 11:55 AM, she stated the facility had taken her bed rail off about two months ago. She stated she would rather have the bed rails, as she felt better with them there, because she had problems with falling out of bed at home. 6. Review of R11's medical record revealed the facility admitted the resident on 01/29/2026, with diagnoses including end-stage renal disease (ESRD), stroke and dysphagia (difficulty swallowing) following a cerebral infarction (ischemic stroke). Per review of the Annual MDS Assessment, dated 02/09/2026, R11 had a BIMS score of 15 out of 15 indicating intact cognition. Review of R11's Comprehensive Care Plan, initiated 01/31/2026, revealed the facility developed a goal for ADLs/Personal Care to be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. In interview with R11, on 04/29/202611:44 AM, she stated the facility had taken her bed rails from her and she could not get them back. She reported she needed the rails to get in/out of bed and she had used them frequently. R11 further stated she would like to have the bed rails back. 7. Review of R20's medical record revealed the facility admitted the resident on 06/06/2025, with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness) affecting the right dominant side due to cerebral infarct, seizure disorder and generalized muscle weakness. Per review of the Quarterly MDS Assessment, dated 02/09/2026, the facility assessed R20 to have a BIMS score of 12 out of 15 indicating moderately impaired cognition. Review of R20's Comprehensive Care Plan, initiated 06/06/2025, revealed the developed a goal stating the resident would participate in ADLs/ Personal Care. In interview with R20, on 04/28/2026 at 2:10 PM, revealed she was unhappy about her bed rails being removed. She said she preferred having the rails on the bed and they (the rails) made her more independent and she had not had to call out for the aides' help. She reported she had seizures, and she was afraid she would fall from the bed and injure herself. 8. Review of R40's medical record revealed the facility admitted the resident on 04/12/2023, with diagnoses including type 2 diabetes mellitus, and chronic venous hypertension (idiopathic) without complications of bilateral lower extremity. Per review of the Quarterly MDS Assessment, dated 04/07/2026, the facility assessed R40 with a BIMS score of 12 out of 15 indicating moderately impaired cognition. Review of R40's Comprehensive Care Plan, initiated 01/01/2024, revealed the facility developed a goal for ADLs/Personal Care to be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. Further review revealed the Interventions included quarter side rails x 2 to assist with bed mobility. Review of R40's nursing note dated 04/23/2026 at 10:35 PM, documented by Licensed Practical Nurse (LPN) 6 revealed, Resident got her bed rail back today. Resident is pleased that she will be able to sleep in her bed for the first time in 12 days due to not being able to get in and out of bed without the bedrail. Further review of the not revealed R40 would now be able to elevate her bilateral lower extremities (BLE) to decrease edema which had gotten significantly worse since she had not been able to elevate them. In addition, review revealed R40's BLE were still weeping from increased edema. In interview with R40, on 04/30/2026 at 3:35 PM, she stated she had been delighted to have recently had her quarter bed rails returned to her bed. She said she refused to sleep in the bed until the rails were returned and she slept sitting up in her wheelchair for 12 days until her rails were put back on. R40 stated, I try to do everything I can for myself. I would never have wanted them to take the rails. She reported telling staff, you ain't putting me in that bed with no rails. R40 further stated she could not get in her bed without the rails, even with people helping her. 9. Review of R65's medical record revealed the facility admitted the resident on 07/15/2026, with diagnoses including chronic obstructive pulmonary disease, Parkinson's disease and Other specified arthritis, multiple sites. Per review of the Quarterly MDS Assessment, dated 04/07/2026, R65 had a BIMS score of 15 out of 15 indicating intact cognition. Review of R65's Comprehensive Care Plan, initiated 07/16/2024, revealed the facility developed a goal for ADLs/Personal Care would be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. In interview with R65, on 04/29/2026 at 11:45 AM, she stated the facility took her bed rails and now her pillow fell off the bed frequently. She reported she had a hard time breathing and it made it harder for her to get up/down from the bed without the rails. R65 further stated the facility told her the rail was a safety issue. 10. Review of R92's medical record revealed the facility admitted the resident on 10/16/2024, with diagnoses including paroxysmal atrial fibrillation, morbid (severe) obesity and stroke. Per review of the Quarterly MDS Assessment, dated 04/23/2026, the facility assessed R92 as having a BIMS score of 12 out of 15 indicating moderately impaired cognition. Review of R92's Comprehensive Care Plan, initiated 10/18/2024, revealed the facility determined the resident was at risk for falls and developed a goal stating the resident would remain free from falls/injury. Continued review of the care plan revealed the facility developed a goal for ADLs/Personal Care to be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. During interview with R92 on 04/29/2026 at 12:38 PM, the resident stated the facility removed her bed rails and she no longer felt safe sleeping in bed without them. R92 reported she previously suffered a stroke which resulted in left-sided weakness and she sometimes felt as though she could fall from the bed during the night. She said she had voiced concerns to facility staff regarding the removal of the bed rails; however, the rails had not been replaced. R92 explained because she no longer felt safe without side rails, she had began using two nightstands positioned on each side of her bed in an attempt to create her own protective barriers. Observation, at the time of interview, revealed two nightstands positioned tightly against both sides of the bed with exposed pointed corners near the sleeping surface. When the State Survey Agency (SSA) Surveyor asked R92 about the potential safety risk posed by the furniture, the resident stated she placed pillows between herself and the nightstands. R92 further stated however, she did not intend to stop using the nightstands because the arrangement made her feel safe. 11. Review of R99's medical record revealed the facility admitted the resident on 01/06/2026, with diagnoses including colostomy malfunction, respiratory failure and pressure ulcer stage 2. Per review of the Quarterly MDS Assessment, dated 03/10/2026, revealed the facility assessed R99 as having a BIMS score of 14 out of 15 indicating intact cognition. Review of R99's Comprehensive Care Plan, initiated 01/07/2026, revealed the facility developed a goal for ADLs/Personal Care to be completed with staff support as appropriate to maintain or achieve the highest practical level of functioning through the next review. Further review revealed an intervention for bed rails was originally listed as an intervention for the goal, but the care plan had been noted as resolved with a date of 03/23/2026. In interview with R99 on 04/28/2026 at 3:55 PM, the resident stated the facility removed his bed rails and the removal had made mobility and positioning in bed significantly more difficult for him. R99 reported he was no longer able to independently reposition or pull himself up in bed and now relied on staffs' assistance for repositioning. The resident stated he weighed over 400 pounds and expressed concern for both his own safety and the safety of staff assisting him. He explained he was fearful he could fall from the bed during care and potentially injure staff attempting to assist him. R99 further stated, look at me, what do you think my body would do to a [AGE] year-old aide? R99 additionally said the bed rails he previously had, assisted him with repositioning and provided him with a sense of safety and stability while in bed. During interview with the Ombudsman on 04/30/2026 at 9:38 AM, she stated she was aware of the recent bed rail issues with the facility and most of the residents who had rails removed wanted them returned as soon as possible. She said as she understood, it came from corporate and to remove all bed rails was the directive, specifying that the facility previously used the quarter rails versus the full bed rails. She further stated she had received many calls and [NAME] (Facility's new owners) has been a nightmare and she planned to visit the facility soon to reevaluate who wanted the bed rails and who already had them. In interview with Licensed Practical Nurse (LPN) 5 on 04/28/2026 at 9:40 AM, she stated she would like the bed rails returned to the residents who used them properly. She stated, the facility just took them, carte blanche. LPN 5 reported she understood it was a state or federal law that said the rails were restraints and corporate wanted them removed for that reason. She further stated some people could not do much for themselves and without their rails, they needed more help from staff. In interview with Registered Nurse (RN) 3 on 04/28/2026 at 11:00 AM, she stated she understood the bed rail removal was due to the government saying the rails were a restraint. She reported the facility had an assessment process, and they installed the quarter rails for people who met the requirements. She further stated, I would give them to everyone who wanted them and could use them safely and we all hate the policy. In interview with the Director of Nursing (DON) on 04/29/2026 at 11:42 AM, she stated she understood the bed rail removal to be Per CMS guidelines. She further stated the corporate office believed the rails were a potential for harm. The DON said, It was a blanket corporate policy. In interview with the Administrator on 05/01/2026 at 11:55 AM, he stated he believed the confusion on the bed rail policy was poor roll-out and the change in direction from the corporate office. He further stated there was confusion among the staff about the new process.

Based on observation, interview, record review and facility policy, the facility failed to contact the physician timely regarding a change in resident condition for 1 of 38 sampled residents (Resident (R)127). The findings include: Review of the facility's policy titled, Oxygen Administration dated 04/09/2025, revealed oxygen was to be administered to residents who needed it, consistent with professional standards of practice, their comprehensive person-centered care plans, and the resident's goals and preferences. Continued review of the policy revealed oxygen was tp be administered under orders of a physician, except in case of an emergency. Further review revealed In emergency cases, oxygen was to be administered and orders for oxygen were to be obtained as soon as practicable when the situation was under control. Review of R127's Face sheet revealed the resident was admitted to the facility on [DATE], with diagnoses of acute chronic diastolic heart failure and idiopathic pulmonary fibrosis. Review of R127's Admission/Tracking Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2026, it had not been completed. However, further MDS review revealed the Brief Interview for Mental Status (BIMS) assessment had been completed and the facility assessed R127 to have a score of 13 out of 15, which indicated no cognitive impairment. Review of R127's Nurse Progress Note dated 04/26/2026 at 7:30 PM, documented by Licensed Practical Nurse (LPN) 6 revealed R127 complained of shortness of air upon exertion. Continued review of the Note revealed LPN 6 contacted R127's Power of Attorney (POA) and confirmed the resident had utilized oxygen at home. Per review of the Note, LPN 6 applied oxygen (O2) at 2 liters per minute (LPM) to R127 per nursing judgement. Further review revealed LPN 6 documented R127's O2 saturation (sat) was 96% prior to administering the O2 and was 100% after applying the O2. Review of R127's Physician orders revealed no documented evidence of an order for O2 having been obtained until 04/30/2026. Review of the O2 order dated 04/30/2026, for O2 to be administered at 2 LPM via nasal cannula prn (as needed) to keep the resident's O2 sat's above 90% every day and night for idiopathic pulmonary fibrosis/respiratory failure. During interview on 04/30/2026 at 3:42 PM, with LPN 6, she stated she was not aware of the facility's O2 policy. She reported she had used her nursing judgement to apply the O2 to R127 on 04/26/2026. LPN 6 said she checked with another nurse and was told she could use her nursing judgement to apply the O2 to R127. She further stated she had not contacted the physician after applying the O2 and said the order had been approved by the physician at a later date (04/30/2026). During interview on 05/01/2026, with the Administrator, he stated his expectation was for the physician to always be contacted with a change in condition of a resident. He said a nurse could use their nursing judgement to apply O2. The Administrator further stated however, the physician should have been contacted as soon as possible after applying O2 to make the physician aware of changes in a resident, and for any further orders.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure confidentiality of resident's personal and medical records, which had the potential to affect 38 out of 38 sampled residents.The Findings Include: Review of the facility's policy titled, Resident Rights, undated, revealed the resident had a right to confidentiality of his or her personal and medical records. The policy further stated the resident had a right to having secure and confidential medical records. Review of the facility's policy titled, HIPAA Security Measures, undated, revealed the facility was to take appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's (personal health) information and/or records that were in electronic format. 1). Observation on 04/27/2026 at 5:16 PM, revealed a computer opened with resident information visible on the screen on medication cart. Continued observation revealed no staff were present in the immediate area on the facility's short hall, 3rd floor. During interview on 04/27/2026 at 5:31 PM, Licensed Practical Nurse (LPN) 4, stated she should not leave computers opened with residents health information in view. She further stated she would close the computer for privacy. 2). Observation on 04/29/26 at 11:05 AM, revealed an opened computer lying on a medication cart with resident information visible on the screen. Per observation, the opened computer on the medication cart was located on the long hall of the 3rd floor. Further observation revealed no staff were present in the area of the medication cart at the time of observation. 3). Observation on 04/29/2026 at 12:01 PM, revealed the computer Licensed Practical Nurse (LPN) 5 had been using was left lying opened and unattended at the nurses' station on the third floor. Further observation revealed resident information was visible on the screen of the computer. During an interview on 04/29/2026 at 12:01 PM, LPN 5 stated she had been attending to a resident and left the computer lying opened. She further stated she assumed the unit manager (UM) would lock the screen if someone came around. During interview on 04/29/2026 at 12:03 PM, UM 1, stated the computer screen should not have been left open. The UM further stated LPN 5 knew better. During interview on 04/29/2026 at 11:42 AM, Director of Nursing (DON) 1 stated she expected all nurses and staff to follow the facility's policies and procedures (regarding security of residents' information). During interview on 05/01/2026 at 11:42 AM, the Administrator stated computer screens should always be closed so they were not showing the residents' information. He further stated his expectation was for staff to close their computer screens so they could not be seen by others.

Based on interview, and review of facility documentation, the facility failed to immediately report all allegations and incidents of potential abuse, to the appropriate external authorities, including law enforcement and/or the State Survey Agency (SSA), in accordance with facility policy and federal regulations for 1 of 38 sampled residents, (Resident (R)95). The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident Property, Suspicious Injuries of Unknown Source, Exploitation, undated, revealed the facility's policy prohibited abuse of residents by any other person, including any member of the facility's staff. Continued review of the policy revealed the facility was to educate all staff so that every employee understood the policy. Additionally, review of the facility's policy was to report all instances of alleged or suspected abuse. Review of the facility's policy titled, Resident Rights in Kentucky Nursing Homes, undated, revealed residents had the right to be free of abuse. Review of R95's electronic Health Record (EHR) Face Sheet revealed the facility admitted the resident on 06/22/2018. Continued review of R95's EHR revealed the resident was noted to have a diagnosis of Dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance since 10/02/2022. Review of R95's Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 12/23/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R95's most recent Comprehensive MDS Assessment, with an ARD of 03/15/2026, revealed the facility assessed the resident as having a BIMS score of 12 out of 15, which indicated the resident was moderately cognitively impaired. Review of the facility documentation titled, Administrator Review, Family Concern, dated 09/12/2024, revealed the facility had prior knowledge of allegations involving an inappropriate relationship between Registered Nurse (RN) 1 and R95, including exchanged messages, kissing, and discussions regarding life insurance policies. Continued review of the documentation revealed the facility implemented interventions which included instructing RN 1 not to provide care for R95. Further review of the documentation revealed however, there was no documented evidence the allegation had been reported to the State Survey Agency (SSA) upon discovery of the incident. Review of a facility memorandum dated 04/30/2026, revealed the memorandum noted the facility had prior knowledge, dating back to approximately 02/2024, related to inappropriate interactions between RN 1 and R95, which include social media communication, and conversations regarding R95's life insurance policy. Per continued review of the memorandum, the facility instructed RN 1 to cease social media contact with R95. Further review revealed no evidence the allegation had been reported to the SSA or local law enforcement upon discovery of the inappropriate interactions between RN 1 and R95. Record review of a Staff Questionnaire on Abuse Reporting and Awareness, dated 02/03/2026, completed by RN 1 revealed the RN acknowledged having received training related to identifying and reporting abuse, neglect, and exploitation. Per continued review, RN 1 identified herself as a mandated reporter, and indicated suspected abuse was to be reported immediately to the Director of Nursing (DON) as an individual to whom suspected abuse should be reported. Further review revealed RN 1 also noted the facility's responsiveness to abuse concerns was fair. Review of R95's social media messages, provided by Family Member (FM) 1 (the resident's wife) on 04/29/2026 at 9:23 PM, revealed the FM thought were inappropriate communication between Registered Nurse (RN) 1 and R95. Per review of the social media messages, they included inappropriate language directed toward R95 from RN 1; discussion of R95's life insurance policy by RN 1; and communication that indicated a personal relationship between RN1 and R95. During interview with (R95's) FM 1 on 04/29/2026 at 6:21 PM, the FM stated she became aware of an inappropriate relationship between R95 and RN 1 that began approximately two years ago. FM1 reported she believed the relationship was sexual in nature and stated R95 had told her (FM 1) they had kissed. She said RN 1 attempted to have R95 remove her (FM 1) as his Power of Attorney (POA), and the RN had asked questions about the resident's life insurance policies. FM 1 explained RN 1 had inappropriate conversations with R95, and she reported her concerns about that to the facility's Administrator. She stated the Administrator told her he would attempt to no longer assign RN 1 to R95's floor; however, due to staffing needs, the RN might still have to work on the resident's floor. FM 1 further stated she observed RN 1 on the unit after her concerns were reported to the Administrator. She reported she also had shown the social media messages, containing inappropriate messages between RN 1 and R95, to the Administrator and DON from her phone. During interview with R95 on 04/30/2026 at 2:15 PM, he stated he had exchanged social media messages with RN 1 and verbally confirmed the messages were inappropriate and not something I would do with other staff. R95 reported he previously had kissed RN 1 on the lips and said he had communicated with the RN as recently as six months prior to the current interview. R95 further stated RN 1 had never been removed from his floor; however, he had been told the RN was not supposed to enter his room. He additionally stated however, RN 1 had been in his room. During interview on 04/30/2026 at 2:21 PM, RN 1 denied having a personal relationship with any resident and stated, No, I would never do that. During the interview, the SSA Surveyor informed RN 1 the State Survey Agency (SSA) had reviewed messages between herself and R 95, and the RN requested to continue the interview in the medication room for privacy. In the medication room, RN 1 stated she and R95 had a few conversations. RN 1 said, I know how it looks. RN 1 reported R95's wife (FM 1) had contacted the Administrator alleging inappropriate conduct between her and R95. RN 1 said she denied the allegations when the Administrator asked; however, the Administrator instructed her she was no longer to work on R95's floor or enter his room. She further stated although staff had been notified she was not permitted to work on that (R95's) floor, she had continued to be floated there at times. During interview with the Administrator on 04/30/2026 at 3:19 PM, he stated FM 1 met with him approximately two years prior to the current date. He said the FM alleged RN 1 and R95 had kissed. The Administrator explained he informed FM 1 that RN 1 would not be assigned to work on R95's floor, unless there was an emergency staffing situation requiring her presence. He said the facility had not performed a sexual consent assessment on R95 because the resident had never expressed a desire to have a sexual relationship. The Administrator reported the facility's leadership, including administrative and legal staff, discussed FM 1's allegations and collectively determined the allegations did not rise to the level of reporting to State Agencies or local law enforcement. The Administrator further stated he had not believed a kiss on the cheek constituted a reportable offense.

The facility failed to ensure the resident environment remained as free of accident hazards as possible related to unsecured access to a shower room containing possibly harmful items, which had the potential to affect all ambulatory residents in the facility.The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed all residents would be treated in a manner and in an environment that promoted a safe environment. Review of the facility's policy titled, Accidents and Supervision, revised 04/29/2026, revealed the facility intended to provide an environment as free from hazards as was possible. Observation on 04/27/2026 at 3:12 PM, of the second-floor shower room, revealed the door locking mechanism had been disabled and the door was unsecured. Continued observation of the shower room revealed an unsecured cabinet containing one unopened package of razors and one opened package of razors, as well as an unsecured closet containing five razors. During interview with Licensed Practical Nurse (LPN) 2 on 04/27/2026 at 3:18 PM, she stated she had worked on the second floor for over three months and the shower room door locking mechanism had not been functional during that whole time. LPN 2 reported the razors in the shower room were not safety razors and should not have been left in the shower room. She further stated the unsecured door could allow residents to enter the area unsupervised and access the razors. During interview with LPN 7 on 04/29/2026 at 3:08 PM, she stated she had been an employee for more than three years and the door to the shower room had never locked. She said she had reported that door verbally to the Maintenance Department on multiple occasions; however, could not identify to whom in that Department she reported the door failure to. LPN 7 stated she had never submitted repairs using the facility's electronic TELS (a building management platform) maintenance reporting system. She stated repairs had been completed on the same door before, with no repairs made to the locking mechanism. She further stated, Disposable razors should not be out where residents could access them. During interview with State Registered Nurse Aide (SRNA) 9 on 04/29/2026 at 3:08 PM, she stated she reported issues to the Maintenance Department verbally. She also said she did not use the faciity's TELS system. SRNA 9 reported without being able to lock the shower room door, residents were at risk of a potential fall, self-care, and loss of dignity related to unintentional male/female encounters. She also stated residents were at risk of self-harm or harm to other residents, due to the unsecured razors. During interview with the Maintenance Director on 04/27/2026 at 3:50 PM, he stated facility staff entered all work orders into the facility's TELS system regardless of severity. He reported there were currently 12 open work orders; however, none included the second-floor shower room door locking mechanism, and said, no work order had been submitted for repair of that locking mechanism. The Maintenance Director explained he and his team conducted monthly facility walkthroughs to identify maintenance concerns; however, the unsecured shower room door had never been identified as an issue. He verbally acknowledged the unsecured door posed a safety risk, as residents could enter the shower room, fall, and staff might not be aware of the resident's location. During interview with the Administrator on 05/01/2026 at 11:38 AM, he stated facility staff were able to submit work orders in through the facility's TELS system. He further stated razors should never have been left in an unsecured area. The Administrator verbally acknowledged the razors had the potential to result in resident injury and infection control concerns.

Based on observation, interview, and review of facility documents and policy, the facility failed to establish a system to ensure thorough accounting of the disposition of all controlled drugs to enable accurate reconciliation of those drugs, which had the potential to affect residents receiving narcotic medications from 3 out of 5 medication carts. The findings include: Review of the facility policy titled, Medication Administration, undated, revealed if medication was a controlled substance, the narcotic book was to be signed. Review of the facility policy titled, Controlled Substance Administration and Accountability, undated, revealed controlled drugs were to be accounted for by two licensed nurses who had access keys at the end of each shift. Further review of the Controlled Substance Administration and Accountability policy revealed the two nurses must sign for the documentation verification. Review of the facility's, Shift-Change Controlled Substance Count sheet for April 2026, revealed six staff signatures were not documented for three out of five medication carts. During interview on 04/27/2026 at 1:28 PM, Registered Nurse (RN) 1 stated, the Shift-Change Controlled Substance form was to be filled out daily or you don't have proof of anything and can lose account of medication. The RN further stated there also would be no way of knowing who had been responsible for the medications that day. During interview on 04/27/2026 at 1:41 PM, Licensed Practical Nurse (LPN) 1, stated the Shift-Change Controlled Substance form showed that both nurses were looking at and accounting for the narcotic medications. The LPN further said the Shift-Change Controlled Substance form was completed so there was no discrepancy and to make sure there was nothing wrong. During interview on 05/01/2026 at 9:16 AM, Unit Manager (UM) 1, stated the narcotic logs should be, signed by the whoever was on shift as there could be discrepancies in the count and of where the medication went if it were missing. She further stated the shift-change controlled substance form was audited weekly by the weekend supervisor or the Assistant Director of Nursing (ADON). During interview on 04/29/2026 at 11:42 AM, the Director of Nursing (DON) 1, stated she expected all nurses and staff to follow the facility's policies and procedures (for managing narcotic medication). During interview on 05/01/2026 at 11:42 AM, the Administrator stated the expectation was for narcotics to be counted every shift. He said a full count should be done and reported to the DON if it was not correct. The Administrator further stated the purpose of the Shift-Change Substance form was to make sure the counts were correct.

Based on observation, interview, and review of the facility's policies, the facility failed to post menus and failed to ensure the posted menus were updated when the planned meals were modified after the posting, which affected residents consuming their meals from the facility's dietary department.The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed the resident had the right to and the facility must promote and facilitate resident self-determination through support of resident choices. Further review revealed the choices included the right to make choices about aspects of their life in the facility that were significant to the resident. Review of the facility's policy titled, Menus and Adequate Nutrition, undated, revealed menus were to be posted in areas accessible by residents at least one week in advance. Continued review of the Menus and Adequate Nutrition, policy revealed alternatives should be immediately available if the primary menu or selections for a particular meal were not to the resident's liking. Observation, on 04/27/2026 at 2:25 PM and on 04/28/2026 at 12:17 PM, revealed the menus were not posted on any of the four resident floors (floor one, floor two, floor three and the [NAME] unit). Further observation revealed the photo frames dedicated to menus were empty. During a Resident Council meeting conducted on 04/28/2026 at 10:30 AM, attended by Residents (R)1, R15, R25, R44, R51, R69, and R116, the residents all stated approximately two months ago, in a previous council meeting, the Dietary Manager (DM) attended the meeting. The residents all stated the DM told the council he was not sure why his staff were not posting the menus; however, they were supposed to be doing that. The stated the DM told them he would address the concerns with the dietary staff and ensure they were posting the correct menus. The Resident Council members all verbally agreed it was frustrating to not know what meals would be served and they wanted the issue corrected. During interview with Registered Nurse (RN) 1 on 04/28/2026 at 12:15 PM, she stated menus should be posted so residents were aware of the meals being served and could decide whether to accept the meal or request a substitution. She further stated menus had previously not been consistently posted, and then were briefly resumed. In addition, she said the menus were discontinued again approximately one week ago. During interview with R104 on 04/28/2026 at 12:20 PM, he stated he had previously obtained copies of the menus from the ground floor reception area and posted them on the resident floors himself. R104 reported he discontinued doing that though because the menus were never correct, and that resulted in residents becoming upset when the meals served did not match the posted menu. He said residents expected to receive the meals listed on the posted menu when it was posted; however, when different meals were served, residents were not provided sufficient notice or opportunity to request a substitution meal. R104 explained, on 04/27/2026, after staff contacted the dietary department to determine what meal was being served for dinner, he was able to request a substitution meal hours in advance. He stated however, the substitution meal was not provided at the time of the scheduled dinner service. He further stated instead of the substitution meal, he received two bowls of chicken noodle soup hours after the dinner meal service had ended. During interview with R62 on 04/29/2026 at 12:21 PM, he stated the lack of posted menus did not bother him because when the menus previously had been posted they were never accurate. R62 further stated the only way to know what meal was being served was when the tray was delivered. During interview with State Registered Nurse Aide (SRNA) 9 on 04/29/2026 at 12:26 PM, she stated posted menus were rarely accurate. She reported when the menus were not accurate, staff might have to contact the dietary department multiple times to request a substitution meal. CNA 9 further said at times, those substitution meals were never delivered. During interview with the Dietary Manager (DM) on 04/29/2026 at 8:01 PM, he stated the dietary department was responsible for ensuring menus were posted and accurate. The DM stated the facility had implemented a process in which residents assisted with posting menus in resident areas; however, he had not been checking to ensure the menus were being posted. Additionally, he stated it was important for menus to be posted so residents were aware of meals being served and able to make substitution requests in a timely manner. During interview with the Administrator on 04/30/2026 at 3:19 PM, he stated the DM was responsible for ensuring menus were posted for resident access and ensuring the menus were accurate and updated when changes occurred. The Administrator said the facility had recently started allowing residents to post the dietary menus, in an attempt to get residents more involved with the facility. He reported there was no official process in place for the facility to ensure menus were posted and accurate, and he depended on the DM and dietary department to ensure that occurred. The Administrator further stated it was his expectation for menus to be posted daily and be accurate.

Based on observation, interview and review of the facility's assessment, the facility failed to implement the facility assessment dated [DATE], for the [NAME] Wing of the facility, which had the potential to affect all residents residing on the [NAME] Wing. The findings include: Review of the facility's Facility Assessment revealed the required staff at night for the [NAME] Wing of the facility, was supposed to have been two State Registered Nurse Aide (SRNA)'s. Review of the staffing schedule for the the week of 04/27/2026, revealed there had been only one SRNA scheduled for nights on the [NAME] Wing. In interview on 04/29/2026 at 10:00 AM, Resident (R)129 stated he had not slept well. He reported there had been only one SRNA on duty at nights and when he called for assistance to be scooted up in bed the SRNA came in alone and pulled him up in the bed. R129 further stated sliding down in the bed was a major problem for him because he could not pull himself back up. In interview with R25 on 04/29/2026 at 10:55 AM, he stated he had bad bowel movements while in bed, and had to lay in it for over two hours because there was not enough staff to assist him. He reported the SRNA working, had entered his room panting from all of the nonstop work they had to do to take care of residents. R25 further stated some SRNAs had entered his room and started crying because their workload was so overwhelming. In interview with Family Member (FM) 1 on 04/29/2026 at 6:21 PM, she stated staff rarely checked on residents on night shift. She reported she had discovered her loved one in the mornings with soaked briefs which she believed had led to an increase in urinary tract infections (UTI) for the resident. FM 1 said the resident would go two to three days without having showers or clothing changes. She further stated staff members had told her the facility was short staffed and that was why it took so long to assist her loved one with ambulating from the bed to a chair. In interview with R95 on 04/30/2026 at 2:15 PM, the resident stated he had experienced long wait times, especially on nights and weekends, that exceeded one hour. R95 further stated he overheard an SRNA say she did not have time to answer call lights, she only made her rounds. In interview on 04/30/2026 at 1:14 PM, the Staffing Scheduler stated she used the facility's assessment grid to know how many staff to schedule for each area of the facility. She reported she was aware that for the [NAME] Wing of the facility the facility assessment indicated there was to be two SRNA's for that wing; however, the facility did not have enough staff to fulfill the facility assessment requirements for staffing for that area. The Staffing Scheduler explained the facility had positions posted for hiring but were not getting many applicants to fulfill the posted jobs. She stated with the facility's short staffing, residents had to wait longer for their call lights to be answered. The Staffing Scheduler further stated, Residents always deserve to have the best of care, and someone should always be available to help them. In interview on 04/30/2026 at 10:50 AM, the Administrator stated the facility currently had new staff coming out of orientation very soon. He said the facility had an SRNA's program and four SRNA's would be starting full time next week. The Administrator reported the facility followed the facility assessment for staffing; however, the assessment was older and they adjusted it dependent on changes in resident acuity. He further stated he expected all residents to receive care timely and not have to wait an extended amount of time for the care they required.

Based on observation, interview, and facility document and policy review, the facility failed to store food in accordance with accepted professional standards for food service safety. Leftover food items were not labeled with a product name and open or use-by date. Raw meat was stored above cooked food items in a reach-in refrigerator. These failures had the potential to affect all residents receiving meals from the dietary department. Findings included: 1. The facility's Dietary Policy Manual, revised 01/23/2018, revealed a policy titled, Food Storage that specified, All incoming foods will have a delivery date and an 'open date' or 'use by' date. When the foods are stored in a container other than the original container, the container will be labeled with the name of the product. A concurrent observation of the reach-in refrigerator and an interview with the Dietary Supervisor on 02/17/2025 at 9:40 AM revealed leftover green beans and leftover green chili were stored without labels that included a product name or dates. In addition, a bag of petit fours (bite-sized desserts) was inside a bag labeled as bologna. The Dietary Supervisor confirmed the items observed were green beans, petit fours, and green chili. The Dietary Supervisor stated the food items should have been labeled, and the petit fours were in a bag incorrectly labeled as bologna. During an interview on 02/20/2025 at 10:37 AM, Dietary Aide (DA) 18 stated the process for putting away left over food items included labeling them with the name of the contents, the use-by date, and the date the item was made. During an interview on 02/20/2025 at 10:40 AM, [NAME] 19 stated leftover food items were to be labeled with the name of the food, the date it was made, and the discard date. During an interview on 02/21/2025 at 12:17 PM, the Administrator stated he expected food items to be labeled and dated according to facility policy. 2. An observation on 02/17/2025 at 9:48 AM of the reach-in refrigerator revealed an undated document titled, Proper Food Storage in Refrigerators and Freezers was posted on the refrigerator door. The document specified that raw meats should be stored below produce, cooked food items, and ready-to-eat food items. The inside of the refrigerator contained a bag of raw meat, confirmed by the Dietary Supervisor to be ground beef patties. The raw ground beef patties were stored on the top shelf of the refrigerator above a container of prepared white chicken chili. During an interview on 02/20/2025 at 10:37 AM, DA18 stated raw meats were to be stored below cooked foods. During an interview on 02/21/2025 at 12:17 PM, the Administrator stated he expected food items to be stored according to facility policy.

Based on interview, record review, and facility policy review, the facility failed to report a possible incident of resident-to-resident abuse to the state survey agency (SSA) within two hours for two (Resident (R) 78 and R13) of four residents reviewed for abuse. The findings included: Review of the facility Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 03/10/2017, revealed 'Abuse' is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm or pain or mental anguish. Further review of the policy revealed that it failed to define/address the meaning of willful, a term defined in the Code of Federal Regulations at S483.5 in the definition of abuse which means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. A facility policy titled, Abuse, Neglect, or Misappropriation of Resident Property Policy, revised 03/10/2017, revealed the section titled Reporting/Response specified, The Administrator will ensure that the Division of Licensure and Regulation [SSA] and the Department of Social Services, Adult Protective Services will be notified immediately but no later than 2 hours after the allegation is received and determination of alleged abuse is made, of all complaints of abuse, neglect, including injuries of unknown origin, or misappropriation of resident property. An Admission Record revealed the facility admitted R78 on 01/19/2022. According to the Admission Record, the resident had a medical history that included diagnoses of depression, generalized anxiety disorder, and cognitive communication deficit. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/21/2025, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident had intact cognition. R78's Care Plan Report included a focus area, initiated 06/03/2024, that indicated the resident exhibited problematic behaviors, including manipulative behavior, and seeking things to complain about. An Admission Record revealed the facility admitted R13 on 03/20/2024. According to the Admission Record, the resident had a medical history that included diagnoses of major depressive disorder, anxiety disorder, and cognitive communication deficit. A quarterly MDS, with an ARD of 11/12/2024, revealed R13 had a BIMS score of 14/15, which indicated the resident had intact cognition. R13's Care Plan Report revealed a focus area, initiated 05/29/2024, that indicated the resident had problematic behaviors characterized by ineffective coping and anxiety related to loss of control. During an interview on 02/19/2025 at 2:37 PM, State Registered Nurse Aide (SRNA) 26 stated she recalled an incident several months prior in which R13 was propelling their wheelchair to the nursing station to get ice, and R78, who was by the elevator, mumbled under their breath, If that [explicit] rolls this way, I'm gonna [going to] kill [them]. SRNA 26 stated she redirected R78, who yelled at R13. SRNA26 stated R13 replied, You're not going to talk to me that way. SRNA26 stated R78 then pushed R13's wheelchair down the hallway, after R13 had turned their back. SRNA26 stated she was able to intervene before R13 traveled farther than a foot. SRNA26 described R13 as angry but not frightened following the incident. SRNA26 stated she reported the incident to Registered Nurse (RN) 27. During an interview on 02/20/2025 at 8:36 AM, the Administrator confirmed the incident in which R78 pushed R13's wheelchair and let go of it, stating R13 rolled a few feet down the hallway. Interview with the Administrator revealed that the facility was aware of the incident but chose to not report it to the state survey agency as a possible allegation of abuse because RN27 stated it was not a reportable incident. Interview with the Administrator revealed they reached the conclusion that the incident was not reportable because there was no harm or intent to harm, and the residents were not angry for more than 30 seconds after the incident. However, review of the federal definitions related to abuse revealed the regulation does not require the individual to intend to inflict injury or harm, During an interview on 02/21/2025 at 10:27 AM, the Director of Nursing (DON) stated that it was up to the Administrator to determine what did and did not get reported to the state survey agency.During an interview on 02/19/2025 at 2:37 PM, State Registered Nurse Aide (SRNA) #26 stated she recalled an incident several months prior in which Resident #13 was propelling their wheelchair to the nursing station to get ice, and Resident #78, who was by the elevator, mumbled under their breath, If that [explicit] rolls this way, I'm gonna [going to] kill [them]. SRNA #26 stated she redirected Resident #78, who yelled at Resident #13. SRNA #26 stated Resident #13 replied, You're [you are] not going to talk to me that way. SRNA #26 stated Resident #78 then pushed Resident #13's wheelchair down the hallway, after Resident #13 had turned their back. SRNA #26 stated she was able to intervene before Resident #13 traveled farther than a foot. SRNA described Resident #13 as angry but not frightened following the incident. SRNA #26 stated she reported the incident to Registered Nurse (RN) #27. During an interview on 02/20/2025 at 8:36 AM, the Administrator confirmed there was an incident in which Resident #78 pushed Resident #13's wheelchair and let go of it. The Administrator stated Resident #13 rolled a few feet down the hallway. The Administrator stated they did not report the incident to the state survey agency because RN #27 stated it was not a reportable incident. The Administrator stated they reached the conclusion that the incident was not reportable, because there was no harm or intent to harm, and the residents were not angry for more than 30 seconds after the incident. During an interview on 02/21/2025 at 10:27 AM, the Director of Nursing (DON) stated that it was up to the Administrator to determine what did and did not get reported to the state survey agency.

Based on observation, interview, and facility policy review, the facility failed to store medications securely in one of five medication carts. Specifically, nursing staff left a medication cart unlocked in the hallway while administering medications in resident rooms. The findings include: Review of a facility policy titled, Medication Storage, dated 09/2020, revealed, The medication cart shall be locked at all times, when not under the direct physical supervision of a licensed nurse or medication aide. Observation on 02/18/2025 at 8:53 AM revealed a medication cart located on the 200 Hall was unlocked. Registered Nurse (RN) 11 was observed in room [ROOM NUMBER], administering medications. RN11 was approximately 16 feet from the medication cart and was not within eyesight of the medication cart. Observation and interview on 02/18/2025 at 9:03 AM revealed RN11 was in room [ROOM NUMBER] administering medications. The medication cart remained unlocked in the hallway, out of R11's line of sight. RN11 exited room [ROOM NUMBER] and returned to the medication cart. When interviewed, RN 11 stated it was important to lock the medication cart when she went into resident rooms. RN11 stated she had not paid attention to whether she had locked the medication cart when she went into the resident rooms. During an interview on 02/20/2025 at 3:52 PM, RN13, the Unit Manager, stated the medication cart should be locked when the nurse went into resident rooms to administer medications. During an interview on 02/21/2025 at 8:45 AM, the Director of Nursing (DON) stated the medication cart should be locked when the nurse was administering medications in resident rooms. During an interview on 02/21/2025 at 8:56 AM, the Administrator stated the medication cart should be within sight of the nurse or it should be locked.

Based on observation, interview, record review, and facility document and policy review, the facility failed to ensure staff donned personal protective equipment (PPE) when providing care to two (Resident (R) 42 and R29) of two residents reviewed for contact precautions. The findings include: A facility policy titled, Standard and Transmission - Based Precautions, revised 06/13/2024, revealed the section titled Contact Precautions, indicated, Necessary when transmission of microorganism is by direct contact [sic] Precautions include gloves, gown, and containment of microorganism. Facility signage titled, Contact Precautions, revised 04/2023, indicated, All Healthcare Personnel must .Wear gloves when entering room and remove before leaving room .Wear a gown when entering room and remove before leaving. 1. An Admission Record revealed the facility admitted R42 on 10/16/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of recurrent enterocolitis due to clostridium difficile. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/14/2025, revealed R42 had a Brief Interview for Mental Status (BIMS) score of 15/15, which indicated the resident was cognitively intact. R42's physician orders revealed an order dated 02/17/2025 for vancomycin (an antibiotic) 125 milligrams (mg) four times a day for 10 days for clostridium difficile. R42's Progress Notes, dated 02/18/2025 at 4:18 PM, revealed that on 02/17/2025 the resident met the criteria for contact precautions. The notes revealed that the medical doctor, resident, and resident representative were aware. During an observation and interview on 02/17/2025 at 8:31 AM, State Registered Nurse Aide (SRNA) 2 was observed in R42's room, providing care without wearing a gown and gloves. SRNA2 stated she missed the signage, but she knew she should be wearing a gown and gloves while inside rooms that had residents on contact precautions. She stated she was unsure if the resident was on contact precautions because she had not worked with the resident for a while. During an interview on 02/17/2025 at 8:51 AM, R42 confirmed their diagnosis of clostridium difficile and that the previous staff had not worn PPE to provide care. 2. An Admission Record revealed the facility admitted R29's medical history included a diagnosis of zoster (shingles) without complications. R29's Progress Notes, dated 02/18/2025 at 9:27 AM, revealed that on 02/14/2025 the resident had a rash on their forehead that was confirmed as shingles per the medical doctor. An additional Progress Notes, dated 02/18/2025 at 4:19 PM, revealed that on 02/14/2025 the resident met the criteria for contact precautions. The notes revealed that the medical doctor and the resident were aware. Review of R29's Care Plan Report revealed a focus area initiated 02/17/2025, that indicated the resident had an actual infection/skin integrity impairment related to shingles. An intervention initiated 02/18/2025, directed staff to use Contact Precautions. During an observation on 02/18/2025 at 12:02 PM, SRNA7 and SRNA8 went into R29's room to serve the resident a meal tray. Although R29 was on contact precautions for shingles, neither SRNA gowned or gloved before entering the room. SRNA7 and SRNA8 were interviewed on 02/18/2025 at 12:03 PM. SRNA7 stated their understanding that contact precautions only applied if staff were providing care, not offering meal trays. SRNA8 added that contact precautions were only necessary if you touched the resident or provided personal care. During an interview on 02/19/2025 at 3:32 PM, Administrative Licensed Practical Nurse (LPN) 30, who was also the Infection Preventionist, stated that for rooms where residents were on contact precautions, staff were required to wash their hands before entering and wear a gown and gloves. During an interview on 02/21/2025 at 10:27 AM, the Director of Nursing (DON) stated she expected staff to wear a gown and gloves and fully wear PPE before entering a room where contact precautions were in place. The DON stated if the resident had been on enhanced-barrier precautions, staff would not need to wear a gown and gloves if they were not touching the resident, but this did not apply to contact precautions. During an interview on 02/21/2025 at 10:42 AM, the Administrator stated if a resident was on contact precautions and not enhanced-barrier precautions, staff should don and doff PPE as directed by the signage.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents' Comprehensive Care Plans (CP) were revised in order to provide adequate supervision and monitoring to prevent elopement for one (1) of fourteen (14) sampled residents (Resident #1). Record review revealed, on the morning of 06/23/2022, Resident #1, was placed on fifteen (15) minute checks, at approximately 10:00 AM, after a fell ow resident reported Resident #1 had a plan to exit the facility (elope) the following morning. However, his/her care plan was not revised to incorporate this increased monitoring. In addition, the facility assessed Resident #1 to be safe to smoke unsupervised in an unsecured area. The facility failed to update the resident's care plan to address the resident's need for increased supervision, after his/her plan for elopement was known by staff. The facility allowed Resident #1 to continue to smoke unsupervised in an unsecured area. On 06/23/2022, at approximately 6:30 PM, Resident #1, whom the facility had previously assessed to be at risk for wandering and elopement, left the building, unsupervised by staff, via the exit to the smoking area. Resident #1 was found approximately one-hundred thirty (130) miles away on 06/25/2022. Resident #1 was able to exit the facility as he/she had the door code issued to residents deemed safe to smoke unsupervised in an unsecured outside area. The facility's failure to have an effective system in place to ensure each resident's care plan was updated with interventions to reduce or prevent the likelihood of an elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/01/2022 and was determined to exist on 06/23/2022, in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F 657, Care Plan Timing and Revision at a Scope and Severity (S/S) of a J and, at 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F 689 at a S/S of a J along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on 07/01/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 07/12/2022, alleging removal of the IJ on 07/05/2022. The State Survey Agency determined the IJ had been removed on 07/05/2022, as alleged, prior to exit on 07/13/2022 with remaining noncompliance in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a S/S of a D and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F-689 at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Wandering/Elopement Purpose, undated, revealed its purpose was to ensure resident safety from an actual/potential elopement and validate that appropriate interventions were in place to prevent, as much as possible, the resident from exiting the facility. Further review revealed measures to be taken to assess for elopement risk when a resident was identified as a wandering risk included completing the Wandering Risk Evaluation (WRE). Continued review revealed if residents were identified as at risk for wandering, the facility must place a photo of the resident on the Elopement Board located at the nurses' stations and update the care plan. Review of the facility's policy titled, Resident Care Plan, taken from the Nursing Policy Manual, Version 8/2012, Page Revision 11/13/2017, revealed the facility must provide a written resident-centered care plan based upon Physician's Orders, assessment of residents' needs and preferences and pre-admission screening as well as resident review. Further review revealed the comprehensive care plan must occur within seven (7) days after the completion of a comprehensive assessment, and review of the modification of the plan must occur after each assessment, including the comprehensive and quarterly review assessments. Continued review revealed that resident care planning would be an ongoing process and include current problems and/or needs identified from complete assessments including the Minimum Data Set (MDS) and Care Area Assessments (CAA's) relevant to the resident's response to aging, illness, and his/her general health status. Per the policy, any new problem or need of the resident identified between scheduled care plan reviews would be addressed by the appropriate disciplines and brought to the next scheduled care plan meeting to inform the Interdisciplinary Care Plan (ICP) team or Interdisciplinary Team (IDT) of its addition. Review of the facility's policy titled, Smoking Policy, taken from Administrative Policies, dated 01/2009, page revision 03/27/2019, revealed smoking was allowed only in designated outdoor areas, and assessment of the resident's ability to smoke in a safe manner would occur prior to the resident smoking in those areas. Review of the Determination of Smoking Residents' Supervision Needs section of the policy revealed a licensed nurse would assess each resident who desired to smoke, utilizing the Smoking Evaluation, at admission, re-admission, or with a significant change. Further review revealed the interdisciplinary care plan team (ICP/IDT) would review and determine the smoking status (supervised/unsupervised) after completion of each assessment. Per the policy, when the Smoking Evaluation identified a resident with any potential hazard risk, including but not limited to a cognitive deficit, the resident would be allowed to smoke only during the facility's designated smoking times with direct staff supervision. Continued review revealed when the Smoking Evaluation identified a resident without any potential hazard risk and who was safe to smoke independently, the resident would be allowed to smoke unsupervised, at any time of his/her choice. Additional review revealed the ICP/IDT would ensure the details of a resident's smoking status was addressed in the baseline and subsequent comprehensive care plans and that resident education provided on the smoking status would occur in the Resident Education progress notes. Review of Resident #1's Electronic Medical Record (EMR) revealed the facility readmitted the resident, on 12/20/2021, with diagnoses that included Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting Left Non-Dominant Side, Cognitive Social or Emotional Deficit following Other Cerebrovascular and Nontraumatic Subarachnoid Hemorrhage, Concentration and Short-Term Memory Loss/Deficit, Frontal Lobe and Executive Function Deficit following Other Cerebrovascular Disease, and Epilepsy. Further review revealed the facility had previously admitted the resident on 10/01/2020 and discharged on [DATE]. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 04/08/2022, revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #1's Admission WRE, completed on 12/30/2021, revealed the facility assessed the resident to be at risk for wandering/elopement. Review of the quarterly WRE, dated 04/08/2022, revealed the resident's score dropped by one (1) point, reducing the category of risk to Wandering Not at Risk. However, the WRE included a note stating that Resident #1 was on the Wander List, but staff was unable to place a WanderGuard device on the resident or on his/her wheelchair, as he/she removed it within minutes of placement. Also, the note stated Resident #1 had not attempted but, had expressed the desire to leave the facility. Review of Resident #1's Smoking Evaluation revealed the facility assessed Resident #1's smoking safety on a monthly basis. Review of the most recent Smoking Evaluation, dated 06/13/2022, revealed the facility assessed Resident #1 to be a safe smoker which indicated the resident could smoke without supervision. Further review of the evaluation revealed it did not include an assessment for elopement risk in an unsecured outdoor smoking area. In addition, the facility did not complete a new Smoking Evaluation after the facility became aware of Resident #1's plan to elope, nor did they update the resident's care plan. Review of the facility's Investigational Summary, dated 06/24/2022, revealed Resident #1 had continually verbalized the desire to discharge with general statements of wanting to live somewhere with more people like him/her or go home to a grandparent's house. According to the investigation, Resident #1 had also commented to residents and staff about people coming to get him/her. Continued review revealed, on the morning of 06/23/2022, Resident #7 reported to Licensed Practical Nurse (LPN) #4 that Resident #1 was planning to leave the facility on the following morning. Per the report, LPN #4 immediately looked for and found Resident #1 in his/her room, and then reported the information to the Director of Nursing (DON). The Investigation Summary noted the DON found Resident #1 in the hallway and instructed LPN #2 to keep a close watch on the resident. Per the report, around 10:00 AM, the DON took the incident to the Interdisciplinary Team (IDT) meeting where it was decided to place Resident #1 on fifteen (15) minute checks. Continued review of the Summary revealed LPN #2 located Resident #1, at 6:30 PM on 06/23/2022, in his/her room before she discovered the resident was missing at 6:45 PM and had left the facility. The Summary stated Resident #1 was found one-hundred thirty (130) miles away on 06/25/2022 unharmed. Review of Resident #1's Comprehensive Care Plan, initiated on 01/03/2022, most recently revised on 04/12/2022, revealed a focus (problem area) in which the resident's acts were characterized by ineffective coping: wandering and/or at risk for unsupervised exits from the facility; removed WanderGuard at will, threw it away, or hid it; that he/she had a BIMS' score of fourteen (14), but had been noted to have some short term memory loss and manipulative behavior, and had been placed on nondocumented frequent observation. This focus included interventions of replacing the WanderGuard with each self removal; ensure the resident's picture and name were on the Wandering Resident/Elopement Board and book; and, ensure a WanderGuard arm bracelet was on his/her wheelchair. Further review of Resident #1's care plan, revision date 04/12/2022, revealed a focus that he/she was a daily smoker. Interventions included: assist resident in obtaining smoking materials from secured storage area upon request, assist resident in returning smoking materials to secured storage area upon conclusion of smoking, assist resident to designated smoking area during established facility smoking times if needed, and Resident #1 was a safe smoker. Continued review of Resident #1's care plan revealed a focus for Chronic/Progressive decline in intellectual functioning characterized by deficit in memory, judgment, decision making, and thought process related to a history of Subarachnoid Hemorrhage. Interventions included: encourage resident to make choices; allow resident sufficient time to verbalize needs; establish daily routine with resident; and, observe and report changes in cognitive status. Review of Resident #1's Care Plan, revision date 04/12/2022, revealed it was not revised or updated to incorporate the increased monitoring of every fifteen (15) minute supervision, directed by the IDT on 06/23/2022 at 10:00 AM. In addition, his/her care plan was not updated to reflect the need for increased supervision, after the facility was made aware of the resident's plan for elopement. The facility allowed Resident #1 to continue to smoke unsupervised in an unsecured area. Review of Resident #1's Progress Notes revealed a Care Plan - General Note, on 04/13/2022 at 4:29 PM, revealed a change for Resident #1 in which he/she would no longer have a WanderGuard, would move from the second floor to the first floor. Also, the note stated the resident's smoking status was reassessed, and he/she became an unsupervised smoker, meaning he/she could smoke outside without staff present. Continued review of the note revealed Resident #1's guardian had told staff that she understood Resident #1 could not be restrained; and, if he/she left the facility, the staff would have to contact the guardian and Adult Protective Services (APS). The note also contained the guardian's statement if Resident #1 is given an inch, (he/she) will take a mile. Additional review of the Progress Notes revealed multiple entries that reflected Resident #1's desire to leave the facility. However, review of the care plan revealed the resident continued to be an unsupervised smoker. Interview with Resident #1's Guardian, on 06/26/2022 at 9:17 PM, revealed Resident #1 was not capable of making rational decisions for himself/herself and that he/she, Talks a good story and for a while sounds plausible, but (he/she) really has issues. Continued interview revealed Resident #1's Guardian stated the facility had put a WanderGuard in place at admission but, the resident kept cutting it off. The Guardian stated that she had recommended to the SSD (Social Services Director) that they keep a current photo, after Resident #1 moved to the first floor, because he/she was likely to run, and the facility might need it. Additional interview with Resident #1's Guardian, on 06/30/2022 at 11:20 AM, revealed she did not ask for Resident #1 to stop wearing a WanderGuard bracelet, but the facility came to her about it. She stated she felt unsure about whether it was the best thing, but told the staff, in the care plan meeting on 04/13/2022, that You all see [him/her] every day, so if you think it is best, then okay. She also stated she told staff that if you give [him/her] an inch, [he/she] will take a mile. She stated the staff members did explain they would move Resident #1 to the first floor, remove the WanderGuard, and he/she would have the privilege to smoke without an aide going with him/her. She stated she knew that an aide had gone with him/her before this because she had been at the facility and found Resident #1 outside for smoking with an aide providing supervision. She stated she was worried that if the facility let the resident have an unsupervised outside privilege, Resident #1 would leave. Interview with Resident #1, on 06/28/2022 at 10:37 AM, revealed he/she had planned elopement for a couple of days and had only shared the plan with the friend who came to pick him/her up. The resident stated he/she did not want to wait for discharge, but wanted to live by his/her children. Resident #1 further stated removing the WanderGuards was just a matter of having to pull and twist it. Interview with Speech Therapist (ST) #1, on 06/24/2022 at 5:30 PM, revealed Resident #1 gave the impression upon an initial meeting that he/she was cognitively intact, and the resident did have a BIMS score of fourteen (14). However, with further contact, it became clear that he/she had short term memory loss, and his/her functional reasoning had deficits. ST #1 stated the resident did not believe those deficits existed, and his/her attention was poor. Interview with Physical Therapy Assistant (PTA) #1, on 06/24/2022 at 6:09 PM, revealed Resident #1 had stated before his/her desire not to live in the facility, and he/she missed his/her children and grandbaby. Interview with the Minimum Data Set (MDS) Coordinator, on 06/28/2022 at 5:16 PM, revealed when something changed or an order was entered for a resident, the nurse would record it in the chart. She stated the care plan would be updated the next morning when orders were reviewed in IDT meetings. The MDS Coordinator stated she was present for the meetings, and updated care plans, as needed. She stated the IDT told her what to enter in the care plan, and it was updated in real time. She also stated after that happened, direct care staff members were able to see the updated care plan the next time they logged into that particular chart. Interview with the Activities Director, on 06/28/2022 at 5:29 PM, revealed she was in the IDT meeting on 06/23/2022 when fifteen (15) minute checks were decided for Resident #1 because somebody had reported he/she was planning to leave. She stated her office was on the first floor by the door that led to the smoking area. Continued interview revealed she could see people coming and going to and through the door, but she could not see the outside smoking area. The Director reported she only had one (1) staff member with her that day, and she had communicated the fifteen (15) minute checks for Resident #1 to the assistant. However, the Activities Director stated her department was not responsible for performing the fifteen (15) minute checks on the resident. Interview with the Director of Nursing (DON), on 06/24/2022 at 3:28 PM, revealed on the morning of 06/23/2022 during her morning rounds, Licensed Practical Nurse (LPN) #4, a night nurse, pulled her aside and stated another resident had informed him that Resident #1 was planning to leave the facility on Friday (06/24/2022)morning around 3:00 AM to 4:00 AM, with a cousin who would pick him/her up. Further interview revealed during the Interdisciplinary Team meeting (IDT), on 06/23/2022 at 10:00 AM, she informed other management about the situation. She stated the IDT decided to place Resident #1 on frequent checks of every fifteen (15) minutes. Further interview revealed she notified Resident #1's Guardian and continued rounds during the day. The DON stated Resident #1 was always in the smoking area or in the hallway, with no indications that anything was going on or anything was wrong. Additional interview with the DON, on 06/28/2022 at 4:50 PM, revealed, after she was informed of Resident #1's elopement plan, she instructed LPN #2 to keep an eye on Resident #1 but did not share this information with other direct care staff. The DON also stated since Resident #1 was on fifteen (15) minute checks, she felt he/she was safe for unsupervised smoking, but was not. She stated the care plan was not updated, but should have been, with increased supervision and a change in smoking status to keep Resident #1 from being in an unsecured area. Per the interview, the DON reported she checked on Resident #1, who was on the first floor, several times before she left the facility around 5:00 PM. She stated she never asked Resident #1 about any plans to leave, and she expected a direct care nurse to communicate the required increased supervision to aides because this was important for assistance in monitoring. Interview with the Administrator, on 06/28/2022 at 5:46 PM, revealed smoking had nothing to do with the situation with Resident #1 leaving the facility. He stated the IDT felt it was better to place the resident on fifteen (15) minute checks than restrict his/her smoking privilege. He stated he expected staff members to follow policies and any continued education they received to guide resident care. Additional interview with the Administrator, on 06/29/2022 at 10:38 AM, revealed leadership was not open with staff about fifteen (15) minute checks on 06/23/2022 in order to prevent Resident #1 from knowing they knew he/she had an exit plan. He stated they felt Resident #1 was intelligent and would work around the plan to revise it if he/she believed staff knew about the elopement plan. The Administrator stated that residents assessed as safe smokers had a distinct code just for the door to the smoking area and must use that door to exit and re-enter the building for smoking. He stated he expected all staff members to follow policy and accepted standards of practice in providing care and safety for residents, including updating the care plan. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 07/11/2022 that alleged removal of the IJ on 07/05/2022. Review of the IJ Removal Plan revealed the facility implemented the following: 1. On 07/03/2022 and 07/04/2022, the Administrator and the Minimum Data Set (MDS) Coordinator reviewed all residents' care plans to ensure the care plan was revised to reflect changes to include interventions for increased supervision, including fifteen (15) minute checks and smoking supervision. 2. On 06/24/2022, the DON, Administrator and the Staff Development Coordinator (SDC) interviewed one-hundred percent (100%) of staff to identify residents verbalizing a desire to leave the facility and ensured increased supervision was included on the resident's care plan if an elopement risk was identified. The wandering program would be updated for all identified areas of concern. The interviews were completed by 07/04/2022 with any remaining interviews with staff members who had not worked to be completed upon their next shift. 3. On 07/01/2022, the DON initiated re-education with all staff which was completed by 07/04/2022. The education included that in the event a resident expressed a desire to leave the facility, staff was to notify the nurse, the DON, and the Administrator, so the resident could be reassessed for wandering. 4. On 07/01/2022, the Maintenance Director changed the door code to the smoking area to ensure that only staff had access to the door code. 5. On 07/01/2022, the Administrator completed education, with all alert and oriented residents who smoked, on the change in the process of only staff being able to access the door codes because of the safety risk of elopement. 6. On 06/30/2022, the DON completed an audit of all at risk wandering evaluations to identify residents at risk for wandering. Each assessment was reviewed and compared to the actual care needs of the resident. This audit included residents with guardianship that were verbalizing the desire to leave the facility. Smoking evaluations were reviewed for all residents identified as at risk for an elopement to ensure that the residents were not independent smokers. The smoking evaluation was updated for any identified areas of concern. 7. On 07/01/2022, the DON and LPN #1/Treatment Nurse initiated an in-service with all nurses that included: review of the residents' smoking evaluations when completing a wandering risk evaluation; that a resident who was at risk for wandering could not be an independent smoker; that the smoking evaluation would need to be updated if the resident was identified as an smoker; and, that the care plan must be reviewed to ensure it reflected the most current wandering risk assessment and required smoking supervision. The inservice also included implementation of the wandering program when residents were identified with an elopement risk, including residents with guardianship, who verbalize the desire to leave. The inservice also included the wandering risk program, which consisted of completing a wandering risk evaluation, placing a photo on the Wander Board, and updating the care plan and the care guide. The inservice also included that only staff could have access to the door code, emphasizing to never give residents the code. The inservices were completed by 07/04/2022 with any remaining inservices for staff who had not worked or who received the inservice, by certified mail, with instructions to review, sign the inservice, and return to the SDC or DON before the next scheduled work shift. No staff will be allowed to work without receiving the inservice. 8. On 07/01/2022, the Clinical Director initiated an inservice with the MDS Coordinator, the Dietary Manager (DM), the SSD, Staff Facilitator, Quality Improvement Nurse, and Activities Director on the requirements for completing a comprehensive care plan for each resident and to review and revise the care plan for each resident change to include interventions for increased supervision. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of audits documentation revealed the DON and MDS Coordinator had conducted care plan audits on 07/03/2022 and 07/04/2022 regarding the need for increased supervision, including fifteen (15) minute checks and smoking supervision. The MDS Coordinator updated care plans as of 07/04/2022. Interview with the Clinical Director, on 07/13/2022 at 8:22 PM, confirmed audits were completed. 2. Interviews with the Administrator, on 07/13/2022 at 7:34 PM, and the Staff Development Coordinator (SDC), on 07/13/2022 at 4:05 PM, confirmed one-hundred percent (100%) of staff were interviewed regarding identification of residents expressing the desire to leave the facility. Results of the interviews revealed other than those already assessed as wandering/elopement risks, none were identified as having expressed the desire to leave the facility. 3. Review of inservice documents revealed re-education for all staff was completed, by 07/04/2022. The inservice included how to report if residents stated they wanted to leave the facility. The actions were to stay with the resident while notifying the assigned nurse; and, if the nurse could not be found right away, the DON or Administrator would be notified. Interviews with staff revealed confirmation that this education was completed. These interviews included SRNA #9, on 07/12/2022 at 4:30 PM; SRNA #3 on 07/13/2022 at 4:50 PM; Housekeeping #1, on 07/13/2022 at 5:01 PM; Cook #1, on 07/13/2022 at 5:34 PM; SRNA #8, on 07/13/2022 at 6:47 PM; SRNA #9, on 07/13/2022 at 6:51 PM; Registered Nurse (RN) #1, on 07/12/2022 at 3:01 PM; LPN #5, on 07/13/2022 at 4:53 PM; LPN #1 on 07/13/2022 at 4:35 PM; LPN #6, on 07/13/2022 at 5:44 PM; Quality Improvement (QI) Nurse #1 and QI Nurse #2, on 07/13/2022 at 9:28 AM; Activities Director, on 07/13/2022 at 5:39 PM; the MDS Coordinator, on 07/13/2022 at 6:10 PM; and the SSD, on 07/13/2022 at 6:21 PM. 4. Review of TELS Reports (a system generated report documenting staff have tested door alarms) documents revealed exterior door alarm checks were completed daily and that the door code for the exit door to access the smoking area had been changed on 07/01/2022. Interview with the Maintenance Director, on 07/13/2022 at 4:29 PM, revealed he changed door codes every two (2) weeks with daily alarm testing, as well as having changed the smoking exit door code on 07/01/2022. 5. Review of facility's documents on resident education revealed the Administrator had conducted education with alert and oriented residents who smoked on the change in process, which was only staff could facilitate exit and entry to the smoking area. Interview with the Administrator, on 07/13/2022 at 7:34 PM, revealed he had conducted the education. Interviews with Resident #2, on 07/12/2022 at 2:15 PM; Resident #7, on 07/12/2022 at 2:35 PM; Resident #5, on 07/12/2022 at 2:00 PM; and Resident #11, on 07/12/2022 at 2:30 PM, revealed they had received education that a staff member must open the door to the smoking area to exit or enter the building. 6. Review of the wandering evaluation audits and smoking evaluation audits, dated 06/30/2022, revealed the DON had completed the audits on that date. Residents at risk for elopement were specifically reviewed with their smoking evaluation to ensure these residents were identified as supervised smokers. Review of Resident #13's care plan and Resident #14's care plan revealed both care plans had been updated to reflect their status as a supervised smoker. 7. Review of inservice documents revealed that all nurses on staff had received education by 07/04/2022 that included the necessity of completing a smoking evaluation when also completing a wandering risk evaluation. Further review revealed nurses had received education that residents who were identified as at risk for wandering could not be an independent smoker, and the care plan must be reviewed to ensure it reflected the most current wandering risk and smoking supervision status. The education included details of the wandering program implementation and only staff could have door codes and could not reveal those to residents. Review of copies of certified mail revealed all nurses received the inservice in a written format. Interviews with RN #1 on 07/13/2022 at 5:50 PM; LPN #5 on 07/13/2022 at 4:53 PM; LPN # 6 on 07/13/2022 at 5:44 PM; the MDS Coordinator on 07/13/2022 at 6:10 PM; and the SDC on 07/13/2022 at 4:05 PM confirmed they had received the education. 8. Review of inservice documents, dated 07/01/2022, revealed the Clinical Director conducted an inservice covering requirements for completing a comprehensive care plan for each resident and the expectation to review and revise the care plan for each change to include interventions for increased supervision. Interviews with the MDS Coordinator, on 07/13/2022 at 6:10 PM; the SSD, on 07/13/2022 at 6:21 PM; Quality Improvement Nurse #1, on 07/13/2022 at 9:28 AM; and the Activities Director, on 07/13/2022 at 5:39 PM, confirmed they had received this education.

Based on observation, interview, record review, review of a weather archives website, https://www.timeanddate.com/weather, review of the Kentucky Incident Based Reporting System (KYIBRS) Report, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of fourteen (14) sampled residents (Resident #1). Review of Resident #1's Electronic Medical Record (EMR) revealed the facility readmitted the resident on 12/20/2021 with diagnoses that included Hemiplegia and Hemiparesis Left Side, Short-Term Memory Loss, and Epilepsy. Resident #1 had a guardian. The facility assessed Resident #1 as high risk for wandering/elopement at admission. It was also noted Resident #1 had a history of wandering. Review of Resident #1's Investigational Summary revealed, on the morning of 06/23/2022, the facility was informed that Resident #1 had a plan for elopement the next day. The facility placed Resident #1 on fifteen (15) minute checks around 10:00 AM that morning. In addition, the facility was aware the resident had the door code to access the smoking area, unsupervised. However, the facility did not rescind Resident #1's privilege to smoke in an outside smoking area, unsupervised by staff. At approximately 6:45 PM on 06/23/2022, Resident #1's eloped/exited the facility without staff knowledge. Resident #1 was found approximately one-hundred thirty (130) miles away on 06/25/2022. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 07/01/2022 and was determined to exist on 06/23/2022, in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657, Care Plan Timing and Revision at a Scope and Severity (S/S) of a J and, 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F-689 at a S/S of a J along with Substandard Quality of Care. The facility was notified of the Immediate Jeopardy (IJ) on 07/01/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 07/12/2022, alleging removal of the IJ on 07/05/2022. The State Survey Agency determined the IJ had been removed on 07/05/2022, as alleged, prior to exit on 07/13/2022 with remaining noncompliance in the areas of 42 CFR 483.21 Comprehensive Person-Centered Care Planning, F-657 Care Plan Timing and Revision at a S/S of a D and 42 CFR 483.25 Free of Accidents/Hazards/Supervision, F-689 at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Wandering/Elopement Purpose, undated, revealed its purpose was to ensure the resident's safety from actual/potential elopement and validate that appropriate interventions were in place, as much as possible, to prevent the resident from exiting the facility. Further review revealed measures to be taken to assess for elopement risk, when a resident was identified as a wandering risk, included completing the Wandering Risk Evaluation (WRE). Continued review revealed that if residents were identified as at risk for wandering, the facility must place a photo of the resident on the Wander Board which was located at each nurses' station and update the care plan. Review of the facility's policy titled, Smoking Policy, taken from the Administrative Policies, dated 01/2009, page revision 03/27/2019, revealed the facility recognized the rights of its residents with respect to their lifestyle choices and preferences, while also acknowledging the potential health and safety hazards associated with smoking to residents, visitors, and staff. Further review of the policy revealed smoking was allowed only in designated outdoor areas, and an assessment of the resident's ability to smoke in a safe manner would occur prior to the resident smoking in designated outside areas. Review of the Determination of Smoking Residents' Supervision Needs section of the policy revealed a licensed nurse would assess each resident who desired to smoke, utilizing the Smoking Evaluation, at admission, re-admission or with a significant change. Further review of the facility's policy titled, Smoking Policy, taken from Administrative Policies, dated 01/2009, page revised 03/27/2019, revealed the Interdisciplinary Care Plan Team would review and determine the smoking status (supervised/unsupervised) after completion of each assessment. Further review revealed when the Smoking Evaluation identified a resident with any potential hazard risk, including but not limited to a cognitive deficit, the resident would be allowed to smoke only during the facility's designated smoking times with direct staff supervision. Continued review revealed when the Smoking Evaluation identified a resident without any potential risk hazard, and who was safe to smoke independently, the resident would be allowed to smoke unsupervised, at any time of his/her choice. Also, nothing in the policy outlined how unsupervised smokers could access the smoking area. Review of Resident #1's Electronic Medical Record (EMR) revealed the facility readmitted the resident, on 12/20/2021, with diagnoses that included Hemiplegia and Hemiparesis following Unspecified Cerebrovascular Disease affecting Left Non-Dominant Side, Cognitive Social or Emotional Deficit, and Concentration Deficit following Other Cerebrovascular and Nontraumatic Subarachnoid Hemorrhage, Short-Term Memory Loss, Frontal Lobe and Executive Function Deficit and Epilepsy. Further review revealed the facility admitted Resident #1 on 10/01/2020 and discharged [DATE]. Review of Resident #1's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 04/08/2022, revealed a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), which indicated the resident was cognitively intact. Review of Resident #1's functional status revealed the resident could walk fifty (50) feet with two (2) turns and was independent with walking in the room and unit corridor. In addition, the facility assessed the resident as independent with locomotion on the unit, but required oversight or cueing for locomotion off the unit. The MDS Assessment revealed Resident #1 used both a walker and a wheelchair. Review of Resident #1's Care Plan, initiated on 01/03/2022, and revised on 04/12/2022, revealed a focus of wandering and/or at risk for unsupervised exits from the facility. The facility placed Resident #1 on nondocumented frequent observations. This focus included interventions of replacing the WanderGuard (a tracking device designed to prevent persons at risk for wandering from leaving the facility unaccompanied by sounding an alarm when the resident went through a doorway with a Wander Guard receiver in place) with each self removal, ensure the resident's picture and name were on the wandering resident board and book, and place a WanderGuard arm bracelet on the wheelchair. Further review of Resident #1's care plan revealed a focus that he/she was a daily smoker. Interventions noted to assist the resident to the designated smoking area during established facility smoking times. The facility assessed the resident to be a safe smoker. Review of Resident #1's Admission WRE, completed on 12/30/2021, revealed the facility assessed the resident to be at high risk for wandering/elopement with a score of six (6) of twenty-one (21). His/her previous WRE, prior to discharge from the previous admission, dated 08/25/2021, revealed a score of twelve (12) of twenty-one (21), indicating a high risk for wandering/elopement. This previous WRE also documented a history of one (1) or more attempts to leave the facility in the previous three (3) months. Any score greater than five (5) was considered high risk for wandering/elopement. Review of the latest WRE, dated 04/08/2022, revealed a score of five (5), which indicated the facility assessed the resident as Not at Risk for Wandering. However, the note stated Resident #1 was on the WanderGuard program and had expressed the desire to leave the facility. A new WRE was not done, on 06/23/2022, after staff learned of Resident #1's plan for elopement. Review of Resident #1's EMR revealed the facility assessed Resident #1's smoking safety on a monthly basis. Review of the most recent Smoking Evaluation, dated 06/13/2022, revealed the facility assessed Resident #1 to be a safe smoker indicating he/she could smoke without supervision. Further review of the evaluation revealed it did not include assessment for elopement risk in an unsecured outdoor smoking area. Continued review revealed the facility did not conduct a new evaluation on 06/23/2022, after the facility learned of Resident #1's elopement plan. Review of Resident #1's Progress Notes revealed a Health Status Note, dated 12/30/2021 at 4:43 PM, which documented application of a WanderGuard (a device designed to alarm when a resident is near an exit) to his/her right ankle. Review of a Health Status Note, dated 01/20/2022 at 12:18 PM, revealed Resident #1 was still on the WanderGuard program due to a history of attempts and threats to leave the facility in the past. Review of a Behavior Note, dated 03/29/2022 at 8:44 AM, revealed Resident #1 had removed the WanderGuard, and it had been replaced, along with education regarding its importance. Review of a Behavior Note, dated 03/31/2022 at 9:39 AM, revealed Resident #1 refused to wear the WanderGuard and cut it off almost immediately after having it placed. Further review revealed Resident #1 removed and hid three (3) WanderGuard devices in two (2) days. Review of a Health Status Note, dated 04/02/2022 at 10:31 AM, revealed the resident's continued refusal to wear a WanderGuard and that the resident was a supervised smoker. Review of Resident #1's Progress Notes revealed a Care Plan - General Note, on 04/13/2022 at 4:29 PM, that Resident #1 would no longer have a WanderGuard device; the facility would move the resident from the second floor to the first floor; and the facility would change the resident's smoke to an unsupervised smoker, meaning he/she could smoke outside without staff present. Continued review revealed the note stated Resident #1's Guardian understood Resident #1 could not be restrained, and if he/she left the facility, the staff would have to contact her and Adult Protective Services (APS). The Note also stated the Guardian stated, if Resident #1 is given an inch, (he/she) will take a mile. Further review revealed a Health Status Note, dated 05/13/2022 at 11:15 AM, revealed that staff requested permission from the guardian for the resident to walk outside, supervised by therapy staff. Review of Resident #1's Frequent Monitoring document, dated 06/23/2022, revealed increased monitoring began at 10:00 AM with continuing checks every fifteen (15) minutes until 6:30 PM. Further review revealed no documentation of who had observed the resident at any of the times. Continued review revealed Resident #1 was last observed in room [ROOM NUMBER] at 6:30 PM. Review of Resident #1's Investigational Summary, dated 06/24/2022, revealed the resident had a history of substance abuse and oppositional/defiant behavior. Further review revealed he/she was readmitted three (3) months after discharge subsequent to difficulties living with his/her guardian/parent. Further review revealed Resident #1 had continually verbalized the desire to discharge with general statements of wanting to live somewhere with more people like him/her or go home to a grandparent's house. According to the investigation, Resident #1 had also commented to residents and staff about people coming to pick him/her up. Continued review of the Investigational Summary, dated 06/24/2022, revealed, on the morning of 06/23/2022, Resident #7 reported to Licensed Practical Nurse (LPN) #4 that Resident #1 was planning to leave the facility on the following morning. The report stated LPN #4 immediately looked for and found Resident #1 in his/her room, and then reported the information to the Director of Nursing (DON). The Investigational Summary further noted the DON found Resident #1 in the hallway, and instructed LPN #2 to keep a close watch on the resident. The DON later took the incident to the Interdisciplinary Team (IDT) meeting where it was decided to place Resident #1 on fifteen (15) minute checks. Continued review of the Investigational Summary revealed LPN #2 located Resident #1, at 6:30 PM on 06/23/2022, in his/her room. LPN #2 discovered Resident #1 missing at 6:45 PM. The report stated LPN #2 immediately searched the activity space and deck where Resident #1 would routinely have been. Further review revealed residents reported to LPN #1 that Resident #1 had left in a private vehicle with an unknown individual. Review of the weather archives website, https://www.timeanddate.com/weather, revealed the outside temperature, on 06/23/2022 at 6:45 PM, was approximately eighty-six (86) degrees Fahrenheit; the humidity was thirty-six percent (36%); there were sunny skies; and winds out of the northeast at nine (9) miles per hour in the area of the facility. Review of the local police department's Kentucky Incident Based Reporting System (KYIBRS) Report, dated 06/25/2022, revealed officers could not locate any cameras in the area. Further review revealed interviews with staff demonstrated Resident #1 had been talking about trying to leave the facility since he/she was readmitted . Review of the Police Report revealed Resident #1 was found by the sheriff's department of the county where Resident #1 was located (approximately one-hundred thirty (130) miles away). The report stated the sheriff's department held Resident #1 until his/her guardian could come to their office. Continued review revealed Resident #1's Guardian was notified of the resident's location by the sheriff's office, on 06/25/2022 at 2:12 PM. Observation of the porch area on the northeast side of the building, on 06/24/2022 at 2:58 PM, revealed several individuals sitting on the porch, smoking, with no one identifying themselves as a member of staff. Continued observation revealed the smoking area was not secured with complete fencing or a gate. Further observation revealed the sidewalk leading from the smoking area lead directly to a parking lot with direct access from the street. The SSA Surveyor later learned this area was the residents' smoking area, and the door was coded so that safe smokers could let themselves in and out. Observation of the smoking area, on 06/28/2022 at 2:00 PM, revealed facility staff allowed the SSA Surveyor to exit to the area and provided the door code for re-entry. Further observation revealed two (2) residents in wheelchairs, one (1) smoking and one (1) not smoking, (no oxygen was in use) with no staff in the area. Continued observation revealed an open space with enclosures on two (2) sides consisting of a facility wall and fencing on two (2) sides. However, one side of the fencing was not adjacent, or connected, to a facility wall, leaving an ungated access. The sidewalk from the adjacent parking area lead directly to the smoking area through the ungated access. The sidewalk was accessible without enclosure or gate leading to the parking lot/lawn area outside the facility. Upon re-entry to the facility, the SSA Surveyor used the provided door code successfully and re-entered the facility. No observation could be made of Resident #1 as he/she never returned to the facility. Interview with Resident #1, on 06/28/2022 at 10:37 AM, revealed he/she had planned elopement only for a couple of days and had only shared the plan with the friend who came to pick him/her up. Resident #1 stated his/her return to the facility in December 2021 was only to get therapy, and the insurance cut therapy services from five (5) days per week, an hour each session, to three (3) days per week for twenty-five (25) minutes. Further interview revealed he/she had been informed of this from rehab staff about two (2) weeks ago, and she eventually would be discharged but had no specific date. Resident #1 stated he/she did not want to wait for discharge, but wanted to go live by his/her children. Resident #1 further stated removing the WanderGuards was just a matter of having to pull and twist and stated I'm pretty [NAME] that way. Additional interview revealed the resident felt he/she met the goals and therapy had been reduced. Resident #1 stated he/she had told his/her Physician and the Nurse Practitioner (NP) he/she was ready to leave the facility and live in an assisted living facility about ten (10) minutes from his/her daughters. However, Resident #1 stated, after an extended period waiting for this, nothing was happening to transfer him/her to the assisted living facility. Interview with Resident #1's Guardian, on 06/26/2022 at 9:17 PM, revealed Resident #1 returned home, on 06/25/2022. The Guardian stated the facility had declined to re-admit Resident #1 due to him/her leaving Against Medical Advice (AMA) and having been gone longer than twelve (12) hours. Further interview revealed she was Resident #1's court appointed guardian and conservator, but could not care for Resident #1 fulltime because he/she was a handful even on good days. She stated she had to find placement independently when Resident #1 was being discharged from the rehabilitation hospital, and she brought him/her to the facility initially because it was closer to her, which she thought was important. The Guardian stated Resident #1 told the staff he/she wanted to get stronger and live near his/her daughters. However, she stated the daughters had not heard from him/her despite Resident #1 having left with a high school friend who took him/her to the county where the daughters resided. Continued interview revealed this information had been relayed to law enforcement officials. She further stated Resident #1 was not capable of making rational decisions for himself/herself, and he/she talks a good story and for a while sounds plausible, but (he/she) really has issues. Resident #1's Guardian stated the facility had put a WanderGuard in place at admission, but the resident kept cutting it off. The Guardian stated that she had recommended to the SSD that they keep a current photo after Resident #1 was moved to the first floor because he/she was likely to run, and they might need it. Additional interview with Resident #1's Guardian, on 06/30/2022 at 11:20 AM, revealed she did not ask for Resident #1 to stop using the Wanderguard device, the facility came to her about it. She stated she felt unsure about whether it was the best thing, but stated she told them, in the care plan meeting on 04/13/2022, that you all see him/her everyday, so if you think it is best, then okay, but that if you give him/her an inch, he/she will take a mile. She stated the staff did explain they would move Resident #1 to the first floor, remove the WanderGuard, and he/she would have the privilege to smoke without an aide going with him/her. She stated she knew that an aide had gone with him/her before this because she had been at the facility and found Resident #1 outside smoking with an aide providing supervision. She stated she was worried that if staff let the resident have an outside privilege, Resident #1 would leave. Interview with LPN # 4, on 06/29/2022 at 8:10 AM, revealed, on 06/23/2022 around 6:20 AM, Resident #7 reported to him that he/she overheard Resident #1 voicing a plan to leave the facility after midnight that day. Resident #7 stated Resident #1 was giving his/her personal belongings away. Further interview revealed he immediately checked Resident #1's room and found him/her asleep in bed. He then informed the DON of what Resident #7 had told him. Interview with SRNA/KMA #1, on 06/27/2022 at 4:58 PM, revealed she was working on Resident #1's floor, on 06/22/2022 and 06/23/2022. Further interview revealed Resident #1 was mostly independent for care, requiring minimal assistance and ambulating independently with a walker. She stated Resident #1 seemed happy the day of the incident, and she had seen him/her visiting with Resident #8 before dinner. She stated she was not certain of the time other than it had to have been after 6:00 PM when Resident #8's daughter told her that she thought she had seen Resident #1 leaving with somebody but could not give a description. She stated she then went to LPN #2, and they looked for Resident #1 outside then started a search in the building. She stated the residents, who must be supervised, were those who could not manage safely while others, such as Resident #1, had the privilege to go out to smoke unsupervised, so he/she would not be accompanied by a staff member. She further stated she was not aware of Resident #1 being on fifteen (15) minute checks on 06/23/2022. Interview with LPN #2, on 06/24/2022 at 6:46 PM, revealed she was working on 06/23/2022 at the time of Resident #1's elopement. She stated it was probably around 6:20 PM when she became aware that Resident #1 was gone. She further stated she and State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) #1 had seen Resident #1 several times while passing supper trays. She stated, at one point, they observed Resident #1 visiting Resident #8; and, LPN #2 asked Resident #1 if he/she was going to eat and pointed out that his/her plate was already on the table. Further interview revealed Resident #1 stated he/she was going to eat, and the last time she saw him/her was in the hallway near the dining room. LPN #2 stated she immediately went to look for Resident #1 after SRNA/KMA #1 told her that Family Member (FM) #2 had observed Resident #1 going down the sidewalk. LPN #2 stated FM #2 was acquainted with Resident #1. Additional interview revealed LPN #2 initiated a search outside, particularly of the porch and sidewalk, and also asked the residents on the porch if they knew anything. However, LPN #2 stated the residents were tightlipped. Interview with Physical Therapist (PT) #1, on 06/24/2022 at 4:59 PM, revealed she had worked with Resident #1 significantly, but the Physical Therapy Assistants (PTA) and Certified Occupational Therapy Assistants (COTA) had worked more with the resident. PT #1 stated Resident #1 had been known to use other residents' mobile phones in the past, and his/her guardian would not allow Resident #1 to have a mobile phone. PT #1 stated Resident #1 tended to reveal a significant number of details about himself/herself, particularly in settings where socialization occurred, such as therapy. Additional interview revealed PT #1 asked Resident #2 about the incident, specifically what he/she knew because the resident had reported Resident #1's plan to leave ahead of the elopement. In addition, PT #1 stated Resident #2 was aware of who Resident #1 left with but, refused to give that information because he/she had promised Resident #1 not to reveal it. Interview with Speech Therapist (ST) #1, on 06/24/2022 at 5:30 PM, revealed Resident #1 gave the first impression that he/she was cognitively intact and did have a BIMS score of fourteen (14) or fifteen (15). However, with additional contact, it became clear that Resident #1 had short term memory loss, and his/her functional reasoning had deficits. ST #1 stated, Resident #1 did not believe those deficits existed, and his/her attention was poor. Interview with PTA #1, on 06/24/2022 at 6:09 PM, revealed Resident #1 had stated before the desire to not live in the facility, and he/she missed his/her children and grandbaby. PTA #1 stated Resident #1 had reported his/her re-admission to the facility in December 2021 was to gain strength so that he/she could live independently, somewhere close to his/her children, in a less restrictive setting. She further stated Resident #1 had frequently said his/her children would be coming to get him/her at some point. PTA #1 stated it had been difficult to watch Resident #1 struggle to continue living at the facility because staff could see him/her fall apart daily. Interview with COTA #1, on 06/28/2022 at 4:12 PM, revealed Resident #1, on a consistent basis, told her the resident's goal was to live in the least restrictive environment, such as assisted living or living independently, and be closer to his/her children. COTA #1 stated Resident #1 had not given her any specifics about leaving and stated, on the day of departure, she had helped Resident #1 rearrange his/her room. Per the interview, the COTA stated Resident #1 was excited about that as well as that his/her daughter was coming Saturday, 06/25/2022, for his/her birthday. Continued interview with COTA #1, on 06/28/2022 at 4:12 PM, revealed she did not know until later on the day of the elopement that Resident #1 had been on fifteen (15) minute checks. She also stated Resident #1 had worked very hard and made progress from having no use of the left side to walking independently with a rolling walker or rollater, and he/she was safe in ambulation. Additionally, COTA #1 stated she would have concerns with Resident #1's short term memory if he/she was living independently. Interview with the Social Services Director (SSD), on 06/24/2022 at 4:22 PM, revealed she had been in contact with Resident #1's Guardian and had obtained further information, including from Resident #2 (who had a BIMS score of fifteen (15), indicating intact cognition). She stated Resident #2 had reported to therapy staff that Resident #1 was with an old friend from high school. She stated she was informed by the on-call nurse that Resident #3 had reported seeing Resident #1 get into a car. She stated Resident #1 exited the building from the old front door by the smoking area. Further interview revealed she reported to the local police department (PD) officer that Resident #1 had a guardian; and, although his/her cognition was intact, he/she was impulsive and often made poor decisions. Continued interview with the SSD, on 06/24/2022 at 4:22 PM, revealed the SSD talked to the residents who were smokers and had spent time with Resident #1. She stated Resident #4, Resident #7, and Resident #10 had told her they were aware Resident #1 was gone, but they did not know where he/she had gone and had not seen his/her departure. The SSD stated Resident #5 told her he/she was unaware of Resident #1's location, but Resident #5 had lent Resident #1 a mobile phone for him/her to call relatives. Per the interview, the SSD stated she was very worried for Resident #1 and that he/she could be very manipulative and was susceptible to manipulation from others. Additional interview with the SSD, on 06/28/2022 at 10:59 AM, revealed, during the care plan (CP) meeting on 04/13/2022, based on the Psychiatric Nurse Practitioner (NP) recommendation, a proposal was discussed to move Resident #1 to the first floor to provide more independence and reduce frustration. However, she stated the Guardian felt Resident #1 was not ready for that. She also stated the NP had suggested moving the resident to another Personal Care Home (PCH), but Resident #1 wanted to move in the other direction to somewhere nearer his/her children. The SSD stated the reason for the meeting was because Resident #1 had been removing the WanderGuard devices. In addition, the SSD stated staff had encouraged Resident #1 to be patient about rescinding the guardianship and being able to leave. Additional interview revealed Resident #1 was prone to impulsive behaviors. She further stated that recently the Psychiatric NP had ordered fifteen (15) minute checks for Resident #1 after scratches were found on his/her wrist, and there was broken glass in his/her room. The SSD stated this order was subsequently discontinued. Interview with the Activities Director (AD), on 06/28/2022 at 5:29 PM, revealed she was in the IDT meeting, on 06/23/2022, when fifteen (15) minute checks were determined to be needed for Resident #1. This was done because someone had reported the resident had a plan to elope from the facility. She stated her office was on the first floor by the door that exited to the smoking area. The AD stated she could see people entering and exiting from the door, but she could not see the outside area. Per the interview, the AD stated she only had one (1) staff with her that day, and she had communicated the fifteen (15) minute checks to the assistant. She stated her interactions with Resident #1, prior to the incident, did not show any differences in the resident's behavior. Interview with the Attending Physician (AP), on 06/29/2022 at 8:53 AM, revealed he was aware Resident #1 had filed to rescind guardianship and that he/she received documents from the court; but, he was not aware of the content of those documents. The AP stated Resident #1's behavior had been stable and appropriate as far as he knew, and he was not aware he/she had been moved from the second to the first floor. He stated he had seen Resident #1, on 06/14/2022, and was not aware of room location at the time; had no concerns for his/her safety; and no inclination that he/she was an elopement risk. He stated that Resident #1 had been total care when initially admitted , then advanced to self propel in a wheelchair, but by this time, he/she was using a wheelchair at times, but was also ambulating independently with a walker. The AP stated Resident #1 was emotionally labile and impulsive. He stated staff would take this into consideration in determining whether he should have been notified of Resident #1's verbalization that he/she was leaving. The AP stated he did not think Resident #1 would leave the facility AMA; and, he actually thought Resident #1 would be a long term resident and likely would not ever be completely independent. He stated he tried to discharge the resident to the mother's care, but she could not manage and brought the resident back for readmission. He stated, prior to the incident, Resident #1 had no imminent plans for discharge. He also stated he did not recall being informed of cuts on Resident #1's wrist in early June 2022. Interview with the Director of Nursing (DON), on 06/24/2022 at 3:28 PM, revealed on the morning of 06/23/2022, LPN #4, a night nurse, pulled her aside during morning rounds and told her another resident, who LPN #4 would not name, had informed her that Resident #1 was planning to leave the facility on Friday morning (06/24/2022, the next day) around 3:00 AM to 4:00 AM, with a cousin who would pick him/her up. From there, the DON stated she went to the first floor, visualized Resident #1, but did not speak to him/her at that time as he/she was on the phone. Further interview revealed during the Interdisciplinary Team (IDT) meeting, she informed other management staff about the situation, and the IDT decided to place Resident #1 on frequent checks of every fifteen (15) minutes. She further stated she notified Resident #1's Guardian and continued rounds during the day, where she reported Resident #1 was always in the smoking area or in the hallway with no indications that anything was going on or anything was wrong. The DON stated she went home about 5:00 PM. Continued interview with the DON, on 06/24/2022 at 3:28 PM, revealed about 6:45 PM on 06/23/2022, she had multiple calls and learned that Resident #1 had left the facility. Further interview revealed she talked to LPN #2, the nurse assigned to Resident #1's floor, who had telephoned the on-call nurse leader, LPN #1, as well as the Social Worker, who were both on site. The DON stated the police and Resident #1's Guardian had been called, and were on their way to the facility. She also stated the Administrator was out of town, but was notified. Continued interview revealed she kept checking in with staff and did not return to the facility. She stated the on-call nurse was at the facility and handling the situation; and police were on-site and issued a Go [TRUNCATED]

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was served under sanitary conditions. During observation of the lunch tray line on 07/21/19, a dietary staff member left the tray line and removed food from the oven and another warmer using pot holders. The dietary worker then returned to the tray line and continued to plate the food without changing gloves or performing hand hygiene. The findings include: Review of the facility policy, Resident Meal Service, dated (MONTH) 2013, revealed gloves were to be worn when making sandwiches, salads, handling any ready-to-eat foods, food contact surfaces, and raw meats. The policy further stated if the gloves were damaged or soiled when an interruption occurred in the process, the gloves must be discarded and hand hygiene performed between glove changes. Observation of the tray line on 07/21/19 at 11:46 AM, revealed the dietary worker, who was plating the meal, left the tray line and used pot holders to remove a dish from a warmer and a dish from the oven. The worker then returned to the tray line and proceeded to plate the meal and pick up rolls with the gloved hand that had been in the pot holder. Interview with the dietary worker on 07/24/19 at 8:57 AM, revealed she should have changed gloves and washed hands prior to returning to the tray line to plate the food, after placing her hands in the pot holders with the gloves on. Interview with the Assistant Dietary Manager on 07/24/19 at 9:03 AM, revealed she was not sure if there was a policy that specifically stated when to change gloves on the tray line. However, she stated the dietary worker should have changed her gloves and washed hands after using the pot holders with the gloves on to remove the food from the oven and warmer.

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure an accurate significant change Minimum Data Set (MDS) assessment was conducted for one (1) of thirty (30) sampled residents (Resident #51). Resident #51 had a significant change MDS completed on 05/16/19 related to enrollment in the hospice program; however, the assessment did not reveal the resident was receiving hospice care. The findings include: Review of the facility policy, Resident Assessment Manual, dated (MONTH) (YEAR), revealed residents in a hospice program would be coded on the Minimum Data Set assessment as receiving hospice services. Review of Resident #51's medical record revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Observation of Resident #51 on 07/23/19 at 10:42 AM, revealed the resident was lying in bed and voiced no complaints. Review of Resident #51's medical record and hospice documentation for Resident #51 revealed the resident was admitted to Hospice on 05/07/19 and was currently receiving hospice care. Review of resident #51's Minimum Data Set (MDS) significant change assessment, dated 05/16/19, revealed the resident was not coded to be receiving hospice care. Interview with the MDS Coordinator on 07/23/19 at 10:24 AM, revealed she initiated the significant change in condition for Resident #51 related to the resident's enrollment in Hospice. She stated she had not checked that the resident was receiving hospice care as she did not have the signed statement from the hospice physician at the time of the assessment. However, the completion date of the assessment date was 05/16/19, which was nine (9) days after the resident was enrolled in Hospice. Interview with the DON on 07/24/19 at 12:18 PM, revealed the MDS Coordinator was responsible for ensuring the MDS's were coded correctly. She also stated that occasionally an MDS may be randomly pulled for accuracy but this was not a consistent practice.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure one (1) of five (5) sampled residents (Resident #24) with pressure ulcers received care consistent with professional standards of practice to promote wound healing and prevent infection of the ulcers. Observation of wound care on Resident #24 revealed proper hand hygiene was not performed between glove changes during wound care. The findings include: Review of the facility's Handwashing Policy, dated (MONTH) 2014, revealed personnel were required to wash their hands before and after touching wounds and after removing gloves. Review of Resident #24's medical record revealed the facility admitted the resident on 09/30/16 with [DIAGNOSES REDACTED]. Review of Resident #24's Minimum Data Set assessment, dated 05/05/19, revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident had one (1) unhealed Stage 2 pressure ulcer. Observation of Resident #24's sacral pressure ulcer wound care on 07/23/19 at 12:35 PM, revealed Licensed Practical Nurse (LPN) #1 removed the old dressing from the wound, and then removed the glove from her right hand and immediately donned a new glove to the right hand without performing any hand hygiene. LPN #1 was then observed to clean the wound with normal saline and proceed to provide the wound care as ordered. Interview with LPN #1 on 07/23/19 at 12:55 PM, revealed she should have washed her hands after she removed her gloves. She stated she knew she should have but was nervous and forgot. Interview with the Infection Control Nurse on 07/24/19 at 9:47 AM, revealed LPN #1 should have removed her gloves after removing the old dressing and should have washed her hands prior to putting on clean gloves. The Infection Control Nurse stated she conducted frequent audits of infection control procedures by observing the staff when wound care was performed. She further stated she had not observed any issues related to infection control measures recently. Interview with the Director of Nursing (DON) on 07/24/19 at 12:15 PM, revealed random monitoring of infection control practices had occurred by the Infection Control Nurse. She stated it was her expectation that staff would perform hand hygiene between glove changes.

Based on interview, record review, and review of facility policies and procedures, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). Although the facility developed a plan of care for Resident #1 that addressed the resident's wandering behaviors and risk for unsupervised exits from the facility, the plan failed to address the resident leaving the unit without staff supervision each week with a community member to attend church on an adjacent floor. In addition, the plan did not address the resident's ability to move independently about the facility without requiring staff assistance, enabling the resident to go to the facility's basement/ground floor level and exit the facility through doors which were not equipped with wanderguard sensors. On 02/17/19, at approximately 9:25 AM staff allowed Resident #1 to leave the unit unsupervised with other residents and a minister from the community. However, when the minister and other residents exited the elevator on the first floor, Resident #1 remained in the elevator, went to the basement/ground floor, and exited the facility through a door, which was not equipped with a wanderguard sensor. Staff was unaware that Resident #1 had exited the facility until alerted by a visitor that the resident was across the street at a convenience store. Facility staff assisted the resident back to the facility and assessed the resident to have sustained an abrasion to the hand. The facility's failure to ensure a comprehensive person-centered care plan was developed for each resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/18/19, was determined to exist on 02/17/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689), and continued until 02/20/19. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. An acceptable Allegation of Compliance was received on 04/23/19, which alleged removal of the Immediate Jeopardy on 02/20/19. The facility implemented corrective actions which were completed prior to the State Survey Agency's investigation. The State Survey Agency verified that the corrective actions were implemented as alleged and it was determined Immediate Jeopardy was removed and deficient practice corrected on 02/20/19, as alleged by the facility. The findings include: Review of the facility's policy, Resident Care Plan, revised 11/13/17, revealed, It is the policy of the facility to provide a written resident-centered care plan based upon physician's orders [REDACTED]. Development and implementation of the resident's care plan will occur by participating disciplines available in the facility at a team conference under direction of the RN (Registered Nurse) Coordinator. Review of Resident #1's medical record revealed the facility admitted the resident on 01/20/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) indicating the resident was severely cognitively impaired. Further review of the assessment revealed Resident #1 utilized a wheelchair for locomotion, but was able to move on and off the unit independently requiring no physical assistance from staff. Review of a Wandering Risk Evaluation completed for Resident #1 on 01/15/19 revealed the facility assessed the resident to be at risk for wandering/elopement and was to wear a wander guard bracelet. Review of a facility investigation revealed on 02/17/19 at approximately 9:25 AM, staff allowed Resident #1 to leave the third floor unit (where the resident resided) unaccompanied by staff, with other residents and a visiting minister, to attend church services on the first floor of the facility. Resident #1 left the unit in a wheelchair via the elevator. However, when the minister and other residents exited the elevator after arriving on the first floor, Resident #1 remained on the elevator and went down to the basement/ground floor unaccompanied. Resident #1 then left the wheelchair in the facility, exited the building through a door which was not equipped with wanderguard sensors, and walked across the street to a convenience store. Further review of the investigation revealed staff was unaware that the resident had exited the facility until alerted by a visitor that the resident was at the store. Upon arrival to the store, Resident #1 informed the staff that he/she had fallen while outside stating it was quite a jolt. Staff assessed the resident to have an abrasion to the hand, and assisted the resident back to the facility. Review of Resident #1's Comprehensive Care Plan initiated on 01/23/17 revealed the facility assessed the resident to be at risk for wandering/unsupervised exits from the facility due to the resident's impaired cognition, memory loss, and dementia. The Care Plan stated Resident #1's whereabouts would be known to staff to prevent the resident from leaving the facility unsupervised. Interventions initiated included utilizing a wanderguard bracelet, checking it daily to ensure it was in place/functioning, and allowing the resident to wander on the unit. However, there was no evidence the facility considered the fact that staff routinely permitted Resident #1 to leave the unit unsupervised by staff with his/her whereabouts unknown during activities on other floors. In addition, there was also no evidence found to indicate the facility considered the resident's ability to move between floors and locations in the facility readily, without requiring staff supervision. In addition, further review of the care plan revealed the facility had failed to develop interventions related to ensuring the resident did not go to the basement/ground floor of the facility where the entrance and exit doors were not equipped with a wanderguard sensor. Interview with the MDS Coordinator on 04/16/19, at 1:54 PM revealed when completing a resident care plan, she relied on the Nurse Aide Behavior Sheets and Progress Notes to determine if the resident had any episodes of wandering or exiting the facility during the look back period. The MDS Coordinator stated that based on the documentation she had reviewed when last updating the resident's care plan, Resident #1 had no significant changes, and therefore no new interventions were developed or implemented related to the resident's wandering/unsupervised exits. Interview with Licensed Practical Nurse (LPN) #1 on 04/15/19 at 4:15 PM, and 04/17/19 at 12:12 PM revealed she was Resident #1's Nurse on Sunday, 02/17/19. LPN #1 stated she was aware that the resident wandered and was at risk for leaving the facility. However, the LPN stated Resident #1 left the floor each week with other residents unsupervised by staff with the minister. The LPN stated other residents with wanderguard bracelets would also leave the unit with the minister to attend the activity. LPN #1 stated there was no special procedure or requirement in place prior to this incident for staff to accompany the residents. The LPN stated staff would deactivate the alarms on the elevators to allow the residents wearing wanderguard bracelets to utilize the elevators and go to the activity. LPN #1 stated that on 02/17/19, she observed Resident #1 leave the unit with a couple of other residents for church. The LPN stated, The next thing I knew someone called and said (he/she) was across the street at the store. Interview with the Director of Nursing on 04/16/19 at 11:10 AM revealed on 02/17/19 staff deactivated the elevator alarm to allow Resident #1 and other residents with wanderguard bracelets to leave the unit unsupervised with the minister to attend church. The DON stated this practice was routine on Sundays. Interview with the Administrator on 04/16/19 at 2:39 PM, revealed at the time of the incident neither the basement/ground floor elevators nor exit/entrance doors were equipped with a wanderguard sensor. The Administrator stated the basement/ground floor level of the facility had no resident rooms and the area was routinely unoccupied on weekends. **The facility implemented the following corrective actions to remove the Immediate Jeopardy and deficient practice on 02/20/19: 1. On 02/17/19, the facility placed Resident #1 on acute monitoring for any changes in behavior. No changes were noted. 2. On 02/18/19 and 02/19/19, the Interdisciplinary Team (IDT) reviewed and revised Resident #1's care plan to include frequent monitoring for change in behavior and to provide the resident with supervision during recreation programs. 3. On 02/17/19, the House Supervisor assessed all residents who utilize a wanderguard bracelet to ensure their bracelet was in place and functioning. In addition, the House Supervisor checked all door and elevator sensors to ensure they were functioning appropriately. No concerns were identified. 4. On 02/18/19 and 02/19/19, the Director of Nursing (DON) and Quality Assurance Performance Improvement (QAPI) Nurses reviewed the wander risk evaluations of all residents to ensure that all residents who needed a wanderguard bracelet had the intervention in place. 5. On 02/18/19, 02/19/19, and 03/14/19, the DON and QAPI Nurses audited the comprehensive care plans for all residents who were at risk for wandering/elopement to ensure the care plan contained wandering/elopement interventions; that the care plan indicated the resident required a wanderguard bracelet; that the resident's photograph was on the wander board (system utilized by the facility to identify residents at risk for wandering/elopement); and that the resident's profile sheet was in the wander book. 6. On 02/18/19, the DON and QAPI Nurses conducted an audit to ensure the wandering books and picture boards correctly identified all residents who were at risk for wandering/elopement, and that staff had been checking the system daily. No concerns were identified. 7. On 02/17/19, the House Supervisor initiated education with all staff and the Staff Facilitator completed the education on 02/18/19. The education included not allowing residents who were at risk for wandering/elopement to ride the elevator without a staff member present, checking all residents who utilized a wanderguard bracelet daily to ensure the bracelet was in place and functioning, and if an exit alarm sounded and the cause could not be determined a head count is to be completed. Beginning 02/19/19, no staff were permitted to work without receiving the education or being reeducated regarding this topic, if needed. The education will also be included in the facility's orientation program. 8. On 2/18/19, the Director of Maintenance changed the Wander Guard access codes as a precautionary measure. 9. On 2/18/19, the Administrator relocated signage inside the elevator and posted signage outside each elevator advising visitors to allow staff to reset the alarm and check the elevator if the sensor alarmed. 10. A staff member was stationed at the basement/ground floor reception desk at all times until 03/18/19, when the basement/ground floor entrance/exit doors and elevators were equipped with wanderguard sensors. 11. On 02/18/19, the facility contacted the wanderguard vendor to evaluate/install wanderguard sensors to the basement/ground floor entrance/exit doors and elevators. The sensors were installed on 03/14/19. The ground floor sensors alarm at the location of the alarm as well as annunciating at the first floor nurses' station. 12. Beginning on 02/18/19, the QAPI Nurses conducted daily audits to ensure staff was completing wanderguard bracelet checks daily to ensure they were in place and functioning. The QAPI Nurses will continue the monitoring daily Monday through Friday until 03/02/19 and then weekly thereafter. No issues have been identified. 13. The Administrator, Maintenance Director, or DON have audited the Wander Guard elevator and exit sensors to ensure function and staff response. These audits were conducted five (5) times per week through 03/31/19 and will continue to be conducted three (3) times per week through 04/30/19 and then weekly in (MONTH) 2019. The Administrator/DON/Maintenance Director will address all identified concerns immediately. 14. Beginning on 02/18/19, the Administrator and DON have conducted observations to ensure staff were accompanying residents who utilized a wanderguard bracelet while in the elevators and attending activities and events. The Administrator and DON discussed the observations weekly during the Interdisciplinary Team (IDT) meetings. 15. Beginning 02/18/19, IDT members will randomly monitor residents who utilize wanderguard bracelets in the elevators and off their units to ensure staff are accompanying the residents. 16. The QAPI Nurses reviewed the basement/ground floor monitoring logs daily Monday through Friday from 02/19/19 through 03/19/19, and no resident with a wanderguard bracelet was observed on the ground floor unescorted. The basement/ground floor monitoring remained in place three (3) days beyond the installation of the new equipment. No issues were identified. 17. Staff conduct wander/elopement risk evaluations on all residents at the time of admission/readmission. Administrative Nurses validated that the evaluation had been completed during the twenty-four (24) hour chart check. QAPI Nurses validated that interventions were in place for any resident identified to be at risk for wandering/elopement. 18. The Administrative Nurses submitted the results of the wander/elopement risk evaluation audits to the Executive Quality Assurance (QA) Committee for further guidance and/or recommendations. The meeting was scheduled for the second quarter of 2019. The Executive QA Committee includes the Administrator, DON, Activities Director, Social Services Director, Staff Facilitator, MDS Coordinator, QI Nurses, Treatment Nurse, Unit Manager, Dietary Manager, and the Medical Director. **The State Survey Agency verified the facility had implemented the following corrective actions to remove the Immediate Jeopardy and deficient practice on 02/20/19 as alleged: 1. Record review and interview on 04/24/19 at 1:24 PM with the Director of Nursing (DON) revealed the facility had placed Resident #1 on acute monitoring for three (3) days to observe for any changes in behaviors. Staff documented no behavioral changes for the resident. 2. Review of Resident #1's care plan and interview on 04/24/19 with the DON at 1:24 PM, with the Quality Improvement (QI) Coordinator at 10:02 AM and with the QI Assistant at 10:02 AM revealed Resident #1's plan of care was reviewed and revised on 02/18/19 and 02/19/19 to include frequent monitoring for changes in the resident's behavior and providing the resident with supervision during recreational programs. 3. Record review and interview on 04/24/19 at 11:44 AM with the House Supervisor revealed that on 02/17/19, she ensured all residents with wanderguard bracelets had the bracelet in place and that the bracelet was functioning appropriately. The House Supervisor also stated all doors and elevators equipped with wanderguard sensors were checked to ensure the sensors were present and functioning. 4. Record review and interview on 04/24/19 with the DON at 1:24 PM, with the QI Coordinator at 10:02 AM, and the QI Assistant at 10:02 AM revealed the nurses reviewed the Wander Risk Evaluations for all residents on 02/18/19 and 02/19/19 to ensure residents requiring a wanderguard bracelet had the intervention in place. 5. Record review and interview on 04/24/19 with the DON at 1:24 PM, with the QI Coordinator at 10:02 AM and the QI Assistant at 10:02 AM revealed on 02/18/19, 02/19/19 and 03/14/19, the DON, QI Coordinator, and QI Assistant reviewed the care plans for all residents who utilized a wanderguard bracelet to ensure the resident's care plan included the use of a wanderguard bracelet, that their photograph was on the wander board (system utilized by the facility to identify residents at risk for wandering/elopement), and that the resident's profile sheet was in the wander book. 6. Record review and interview on 04/24/19 with the DON at 1:24 PM, with the QI Coordinator at 10:02 AM, and the QI Assistant at 10:02 AM revealed on 02/18/19, the DON, QI Coordinator, and QI Assistant had reviewed the identification picture books located on each resident floor to ensure the books included photographs of residents identified to wander or be at risk for elopement. In addition, the staff stated they also reviewed logs to ensure staff were checking the wanderguard system daily. 7. Review of training records, test records, and interview on 04/24/19 with the House Supervisor at 11:44 AM and the Staff Development Nurse at 10:56 AM revealed the House Supervisor began educating staff on 02/17/19 after the incident with Resident #1 and the Staff Facilitator started training staff on 02/18/19. The training included ensuring residents with wanderguard bracelets did not leave the unit floor without a staff member with them and staff remaining with the resident while off the unit, what actions to take if a wanderguard sensor alarmed, and checking each resident's wanderguard bracelet daily for placement and functioning. The Staff Facilitator stated all staff were educated and those on leave were educated upon return and prior to starting work with residents. Interviews on 04/24/19 with Central Supply Staff at 9:45 AM, Registered Nurse (RN) #3 at 10:25 AM, the Maintenance Director at 10:32 AM, LPN #6 at 10:40 AM, Dietary Staff Member #1 at 10:47 AM, Housekeeping Staff Member #1 at 10:51 AM, Activities Staff at 11:05 AM, State Registered Nurse Aide (SRNA) #13 at 11:12 AM, SRNA #4 at 11:17 AM, the Administrative Assistant at 11:21 AM, LPN #4 at 11:29 AM, SRNA #12 at 11:34 AM, SRNA #11 at 11:39 AM, SRNA #10 at 12:56 PM, and SRNA #9 at 1:01 PM revealed all the staff had received the above training and taken a posttest to ensure understanding. 8. Record review and interview with the Maintenance Director on 04/24/19 at 10:32 AM revealed he had changed the wanderguard access codes on 02/18/19 as a precaution to ensure no one but staff had the code. 9. Observation of the elevators on 04/24/19 at 9:52 AM and interview with the Administrator on 04/24/19 at 1:44 PM revealed signage had been posted inside both sets of elevators and outside each elevator on every floor. The signage advised visitors to ask staff for assistance if the elevator alarmed. 10. Review of a door monitoring checklist and interview on 04/24/19 with the Administrative Assistant at 11:21 AM and the Central Supply staff at 9:45 AM revealed both had monitored the basement/ground floor exit door and the elevators on the ground floor after the incident on 02/17/19. Additional interviews on 04/24/19 with the Maintenance Director at 10:32 AM, LPN #6 at 10:40 AM, SRNA #13 at 11:12 AM, SRNA #4 at 11:17 AM, LPN #4 at 11:29 AM, SRNA #12 at 11:34 AM, SRNA #11 at 11:39 AM, SRNA #10 at 12:56 PM, and SRNA #9 at 1:01 PM revealed they clocked in to work on the ground floor and observed staff monitoring the elevator and entrance/exit doors after the incident on 02/17/19, and until the sensors were installed on the basement/ground floor elevators and doors. 11. Review of invoices and interview on 04/24/19 at 1:44 PM with the Administrator revealed the facility contacted a wanderguard vendor to install wanderguard sensor alarms on the basement/ground floor elevators and entrance/exit doors. The alarm sensors were installed on 03/14/19 and the Administrator stated staff continued to monitor the ground floor until 03/18/19 to ensure the new system was working correctly. Observation on 04/24/19 at 9:52 AM and interview with SRNA #10 at 12:56 PM revealed that when a wanderguard sensor alarmed on the basement/ground floor level, it sounded at the alarm and on the first floor. SRNA #10 stated staff on the first floor responded to alarms from the basement/ground floor. Observation of the wanderguard alarm box on the first floor revealed labels and lights were present for basement/ground floor alarms. 12. Review of the Transmitter Testing Logs and interviews on 04/24/19 with the QI Coordinator and QI Assistant at 10:02 AM revealed they had conducted daily audits to ensure staff was checking each resident's wanderguard bracelet for placement and functioning daily. The audits were completed from 02/17/19 through 03/02/19 and then weekly. 13. Review of audit logs and interview on 04/24/19 with the Administrator at 1:44 PM revealed he checked off the wanderguard sensor alarms on the elevators five times per week from 02/17/19 through 03/31/19, and three (3) times per week in (MONTH) 2019, with no concerns identified. 14. Review of audit documentation and interviews on 04/24/19 with the Administrator at 1:44 PM and the DON at 1:24 PM revealed both had conducted monitoring at different times of the day to observe staff assisting residents who utilized wanderguard bracelets to activities, beauty shop, etc., and to ensure staff were remaining with residents while they were off the unit. 15. Interviews with the QI Coordinator and the QI Assistant at 10:02 AM on 04/24/19, revealed they had not observed any resident wearing a wanderguard bracelet in the elevators unaccompanied by staff or off the unit without staff present. In addition, interview with the Administrator on 04/24/19 at 1:44 PM, revealed the Activity Director had reported no observations of a resident wearing a wanderguard bracelet coming to an activity on a floor where they did not reside without a staff escort to and from the activity. 16. Review of audits and interviews on 04/24/19 with the QI Coordinator and the QI Assistant at 10:02 AM revealed they reviewed the door monitoring logs daily from 02/19/19 thru 03/19/19. Staff monitored the basement/ground floor level continuously from 02/17/19 until the new alarm sensors were installed. 17. Record review and interview on 04/24/19 with the QI Coordinator and the QI Assistant at 10:02 AM revealed the QI Nurses checked each newly admitted resident's record to ensure a wandering risk assessment had been completed for the resident and a care plan had been developed, if warranted. 18. Review of the QA Meeting Minutes and interview on 04/24/19 with the DON at 1:24 PM, QI Coordinator at 10:02 AM, Maintenance Director at 10:32 AM, Administrative Assistant at 11:21 AM, and the Administrator at 1:44 PM revealed the facility conducted a QA meeting on 02/18/19. During the meeting, the incident with Resident #1 was discussed and an action plan was developed. The QA Team has met at least weekly since the incident to discuss the ongoing audits and progress of the action plan. Further interview revealed an Executive QA meeting was scheduled for the second quarter of 2019.

Based on observation, interview, record review, review of the facility's investigation, and review of facility policies and procedures, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of three (3) sampled residents (Resident #1). On 02/17/19 at approximately 9:25 AM, staff allowed Resident #1, whom the facility assessed to be at risk for wandering/unsupervised exits from the facility, to leave the third floor in a wheelchair via the elevator with a visiting minister and other residents to attend an activity on the first floor. However, Resident #1 did not exit the elevator when it reached the first floor and continued down to the basement/ground floor of the facility, which was not equipped with wanderguard sensors. The resident left the wheelchair in the facility, exited the door, which was not equipped with a wanderguard sensor, and walked to a convenience store across the street from the facility (approximately 450 - 475 feet from the basement exit). In addition, Resident #1 sustained a fall in the parking lot of the store resulting in an abrasion to the resident's hand. Staff was unaware the resident had left the building until they were alerted by a visitor at approximately 9:40 AM, that Resident #1 was across the street at the convenience store. Staff assisted the resident back to the facility at approximately 9:45 AM. The facility's failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 04/18/19, was determined to exist on 02/17/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689), and continued until 02/20/19. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care. An acceptable Allegation of Compliance was received on 04/23/19, which alleged removal of the Immediate Jeopardy on 02/20/19. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. The State Survey Agency verified the corrective actions were implemented as alleged and it was determined Immediate Jeopardy was removed and deficient practice corrected on 02/20/19, as alleged by the facility. The findings include: Review of the facility's policy, Wandering/Elopement, revised 02/26/19, revealed the purpose of the policy was to ensure each resident's safety from actual/potential elopement and to validate that appropriate intervention were in place to prevent the resident from exiting the center as much as possible. Measures to assess wandering residents for elopement risk included complete a wandering risk evaluation. If resident scores above five (5) on the evaluation place a transmitter on resident . Review of Resident #1's medical record revealed the facility admitted the resident on 01/20/17 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) which indicated the resident had severe cognitive impairment. Review of a Wandering Risk Evaluation for Resident #1 completed on 01/15/19, revealed the facility assessed the resident to be at risk for wandering/elopement and he/she was to wear a wanderguard bracelet. Review of Resident #1's plan of care initiated on 01/23/17, revealed the facility assessed the resident to be at risk for wandering and/or unsupervised exits from the facility due to the resident's impaired cognition, memory loss, and [DIAGNOSES REDACTED].#1 included utilizing a wanderguard bracelet (a bracelet that alarms when it is near a wanderguard sensor). Review of a facility investigation initiated on 02/17/19, revealed on Sunday, 02/17/19, at approximately 9:25 AM, facility staff caring for Resident #1 allowed the resident to get on the elevator without staff supervision, with multiple other residents and a visiting minister, to attend church services on another floor of the facility. However, when the minister and the other residents exited the elevator on the first floor, Resident #1 remained on the elevator and continued down to the ground/basement level. Further review of the investigation revealed the resident exited the elevator on the ground/basement floor, left the wheelchair at the facility, and walked across the street to a convenience store (approximately 450 - 475 feet from the ground/basement exit), without staff supervision or knowledge. Continued review of the investigation revealed a visitor alerted a staff member that Resident #1 was at the convenience store. Nursing staff proceeded to the convenience store and assisted Resident #1 back to the facility at 9:45 AM. Upon assessment, Resident #1 reported falling outside of the facility, stating it was quite a jolt. Further assessment revealed the resident sustained [REDACTED]. The investigation also revealed that while Resident #1 was out of the facility, the resident's family member had received notification from the resident's Cardiologist's office that the resident's internal defibrillator had activated at approximately 9:35 AM. Review of weather archives revealed the outside temperature on 02/17/19 at 9:30 AM, was approximately 45 degrees Fahrenheit in the area of the facility. Observations of Resident #1 on 04/15/19 at 2:22 PM, revealed the resident was on the bed and stated he/she had resided at the facility for about a month. Further interview with the resident revealed he/she wore the ankle bracelet (wanderguard) because it helps me when I work on my truck. The resident also stated he/she goes outside about once a week to mow the grass. Resident #1 stated he/she remembered walking to the store to get something to eat and fell while outside. Observation on 04/16/19 at 4:45 PM, of the facility's ground/basement entrance/exit revealed a concrete service ramp with a sidewalk running down the side of the ramp. The ramp was adjacent to a small parking lot that had sidewalk access. The distance from the ground/basement exit to the convenience store was approximately 450-475 feet. In addition, the ground floor housed staff offices and non-resident areas and was routinely unoccupied on weekends. Interview with Licensed Practical Nurse (LPN) #1 on 04/15/19 at 4:15 PM and 04/17/19 at 12:12 PM revealed she was Resident #1's Nurse on 02/17/19. LPN #1 stated Resident #1 left the floor with a visiting minister to attend church services on the first floor. The LPN stated Resident #1 and residents on other units, some of which also utilized wanderguard bracelets, left the unit weekly to attend church with a visiting minister. LPN #1 stated there was no special procedure in place prior to this incident for residents wearing wanderguards to leave the unit with visitors. During further interview, LPN #1 stated the elevator on each residential floor was equipped with a wanderguard alarm and would alarm/shut down if a resident with a wanderguard attempted to board the elevator. However, LPN #1 stated staff could deactivate the alarm by entering a code, allowing residents wearing wanderguards to leave the unit. LPN #1 stated that on 02/17/19, she observed Resident #1 leave the unit along with other residents and the minister to attend church services. She stated the next thing I knew someone called and said (the resident) was across the street at the store. The LPN stated she and LPN #2 went to the store to assist the resident back to the facility. According to LPN #1, the resident told her that he/she was at the store to buy cigarettes. However, LPN #1 stated Resident #1 had not smoked for several years. LPN #1 stated she assessed the resident, who had fallen while outside the facility and sustained an abrasion to the hand. She stated the resident was wearing a flannel shirt, sweatpants, socks, and shoes. LPN #1 stated the resident sustained [REDACTED]. Interview with LPN #2 on 04/15/19 at 5:20 PM revealed she was working on 02/17/19 on Resident #1's unit. LPN #2 stated Resident #1 was confused at times, but was able to communicate his/her needs consistently. The LPN stated Resident #1 had not displayed any unusual behaviors prior to leaving the facility on 02/17/19. LPN #2 stated a visitor called the facility to report that Resident #1 was across the street at the convenience store. She stated when she and LPN #1 arrived at the convenience store, Resident #1 was sitting inside the store, and store personnel told them that the resident had sustained a fall. Interview with the current Unit Manager on 04/16/19 at 12:13 PM, revealed Resident #1 had intermittent confusion and at times would wander, but stated the resident had not previously attempted to leave the facility unsupervised to her knowledge. Interview with the Director of Nursing (DON) on 04/16/19 at 11:10 AM revealed the facility completed Wandering Risk Assessments on all residents upon admission and then quarterly. The DON stated if the facility assessed a resident to be at risk for wandering/elopement a wanderguard bracelet was initiated. The DON stated it was routine for residents to leave the unit on Sunday with the minister to attend church services on the first floor. However, the DON stated it was never intended for residents to remain on the elevator and go down to the ground/basement floor. The DON stated that neither the basement elevator nor entrance/exit door was equipped with an alarm at the time of the incident. Interview with the Administrator on 04/15/19 at 2:05 PM and 04/16/19 at 2:39 PM revealed staff notified him of the incident after Resident #1 returned to the facility. The Administrator stated he did not consider the resident leaving the facility unsupervised and without staff knowledge as an incident of elopement. The Administrator stated because it was not the resident's intention to permanently leave the facility, he did not consider it an elopement. The Administrator stated the resident's intention was to buy cigarettes and return to the facility, despite the fact that the resident did not smoke. The Administrator stated that despite the resident's assessment by facility staff to be severely cognitively impaired, he believed at times Resident #1 was clear and could safely go across the street to the store and return to the facility. Interview with Resident #1's Physician on 04/16/19 at 2:12 PM revealed Resident #1 was not physically or cognitively able to walk across the street without assistance from facility staff to the store. **The facility implemented the following corrective actions to remove the Immediate Jeopardy and deficient practice on 02/20/19: 1. On 02/17/19, the facility placed Resident #1 on acute monitoring for any changes in behavior. No changes were noted. 2. On 02/18/19 and 02/19/19, the Interdisciplinary Team (IDT) reviewed and revised Resident #1's care plan to include frequent monitoring for change in behavior and to provide the resident with supervision during recreation programs. 3. On 02/17/19, the House Supervisor assessed all residents who utilize a wanderguard bracelet to ensure their bracelet was in place and functioning. In addition, the House Supervisor checked all door and elevator sensors to ensure they were functioning appropriately. No concerns were identified. 4. On 02/18/19 and 02/19/19, the Director of Nursing (DON) and Quality Assurance Performance Improvement (QAPI) Nurses reviewed the wander risk evaluations of all residents to ensure that all residents who needed a wanderguard bracelet had the intervention in place. 5. On 02/18/19, 02/19/19, and 03/14/19, the DON and QAPI Nurses audited the comprehensive care plans for all residents who were at risk for wandering/elopement to ensure the care plan contained wandering/elopement interventions; that the care plan indicated the resident required a wanderguard bracelet; that the resident's photograph was on the wander board (system utilized by the facility to identify residents at risk for wandering/elopement); and that the resident's profile sheet was in the wander book. 6. On 02/18/19, the DON and QAPI Nurses conducted an audit to ensure the wandering books and picture boards correctly identified all residents who were at risk for wandering/elopement, and that staff had been checking the system daily. No concerns were identified. 7. On 02/17/19, the House Supervisor initiated education with all staff and the Staff Facilitator completed the education on 02/18/19. The education included not allowing residents who were at risk for wandering/elopement to ride the elevator without a staff member present, checking all residents who utilized a wanderguard bracelet daily to ensure the bracelet was in place and functioning, and if an exit alarm sounded and the cause could not be determined a head count is to be completed. Beginning 02/19/19, no staff were permitted to work without receiving the education or being reeducated regarding this topic, if needed. The education will also be included in the facility's orientation program. 8. On 2/18/19, the Director of Maintenance changed the Wander Guard access codes as a precautionary measure. 9. On 2/18/19, the Administrator relocated signage inside the elevator and posted signage outside each elevator advising visitors to allow staff to reset the alarm and check the elevator if the sensor alarmed. 10. A staff member was stationed at the basement/ground floor reception desk at all times until 03/18/19, when the basement/ground floor entrance/exit doors and elevators were equipped with wanderguard sensors. 11. On 02/18/19, the facility contacted the wanderguard vendor to evaluate/install wanderguard sensors to the basement/ground floor entrance/exit doors and elevators. The sensors were installed on 03/14/19. The ground floor sensors alarm at the location of the alarm as well as annunciating at the first floor nurses' station. 12. Beginning on 02/18/19, the QAPI Nurses conducted daily audits to ensure staff was completing wanderguard bracelet checks daily to ensure they were in place and functioning. The QAPI Nurses will continue the monitoring daily Monday through Friday until 03/02/19 and then weekly thereafter. No issues have been identified. 13. The Administrator, Maintenance Director, or DON have audited the Wander Guard elevator and exit sensors to ensure function and staff response. These audits were conducted five (5) times per week through 03/31/19 and will continue to be conducted three (3) times per week through 04/30/19 and then weekly in (MONTH) 2019. The Administrator/DON/Maintenance Director will address all identified concerns immediately. 14. Beginning on 02/18/19, the Administrator and DON have conducted observations to ensure staff were accompanying residents who utilized a wanderguard bracelet while in the elevators and attending activities and events. The Administrator and DON discussed the observations weekly during the Interdisciplinary Team (IDT) meetings. 15. Beginning 02/18/19, IDT members will randomly monitor residents who utilize wanderguard bracelets in the elevators and off their units to ensure staff are accompanying the residents. 16. The QAPI Nurses reviewed the basement/ground floor monitoring logs daily Monday through Friday from 02/19/19 through 03/19/19, and no resident with a wanderguard bracelet was observed on the ground floor unescorted. The basement/ground floor monitoring remained in place three (3) days beyond the installation of the new equipment. No issues were identified. 17. Staff conduct wander/elopement risk evaluations on all residents at the time of admission/readmission. Administrative Nurses validated that the evaluation had been completed during the twenty-four (24) hour chart check. QAPI Nurses validated that interventions were in place for any resident identified to be at risk for wandering/elopement. 18. The Administrative Nurses submitted the results of the wander/elopement risk evaluation audits to the Executive Quality Assurance (QA) Committee for further guidance and/or recommendations. The meeting was scheduled for the second quarter of 2019. The Executive QA Committee includes the Administrator, DON, Activities Director, Social Services Director, Staff Facilitator, MDS Coordinator, QI Nurses, Treatment Nurse, Unit Manager, Dietary Manager, and the Medical Director. **The State Survey Agency verified the facility had implemented the following corrective actions to remove the Immediate Jeopardy and deficient practice on 02/20/19 as alleged: 1. Record review and interview on 04/24/19 at 1:24 PM with the Director of Nursing (DON) revealed the facility had placed Resident #1 on acute monitoring for three (3) days to observe for any changes in behaviors. Staff documented no behavioral changes for the resident. 2. Review of Resident #1's care plan and interview on 04/24/19 with the DON at 1:24 PM, with the Quality Improvement (QI) Coordinator at 10:02 AM and with the QI Assistant at 10:02 AM revealed Resident #1's plan of care was reviewed and revised on 02/18/19 and 02/19/19 to include frequent monitoring for changes in the resident's behavior and providing the resident with supervision during recreational programs. 3. Record review and interview on 04/24/19 at 11:44 AM with the House Supervisor revealed that on 02/17/19, she ensured all residents with wanderguard bracelets had the bracelet in place and that the bracelet was functioning appropriately. The House Supervisor also stated all doors and elevators equipped with wanderguard sensors were checked to ensure the sensors were present and functioning. 4. Record review and interview on 04/24/19 with the DON at 1:24 PM, with the QI Coordinator at 10:02 AM, and the QI Assistant at 10:02 AM revealed the nurses reviewed the Wander Risk Evaluations for all residents on 02/18/19 and 02/19/19 to ensure residents requiring a wanderguard bracelet had the intervention in place. 5. Record review and interview on 04/24/19 with the DON at 1:24 PM, with the QI Coordinator at 10:02 AM and the QI Assistant at 10:02 AM revealed on 02/18/19, 02/19/19 and 03/14/19, the DON, QI Coordinator, and QI Assistant reviewed the care plans for all residents who utilized a wanderguard bracelet to ensure the resident's care plan included the use of a wanderguard bracelet, that their photograph was on the wander board (system utilized by the facility to identify residents at risk for wandering/elopement), and that the resident's profile sheet was in the wander book. 6. Record review and interview on 04/24/19 with the DON at 1:24 PM, with the QI Coordinator at 10:02 AM, and the QI Assistant at 10:02 AM revealed on 02/18/19, the DON, QI Coordinator, and QI Assistant had reviewed the identification picture books located on each resident floor to ensure the books included photographs of residents identified to wander or be at risk for elopement. In addition, the staff stated they also reviewed logs to ensure staff were checking the wanderguard system daily. 7. Review of training records, test records, and interview on 04/24/19 with the House Supervisor at 11:44 AM and the Staff Development Nurse at 10:56 AM revealed the House Supervisor began educating staff on 02/17/19 after the incident with Resident #1 and the Staff Facilitator started training staff on 02/18/19. The training included ensuring residents with wanderguard bracelets did not leave the unit floor without a staff member with them and staff remaining with the resident while off the unit, what actions to take if a wanderguard sensor alarmed, and checking each resident's wanderguard bracelet daily for placement and functioning. The Staff Facilitator stated all staff were educated and those on leave were educated upon return and prior to starting work with residents. Interviews on 04/24/19 with Central Supply Staff at 9:45 AM, Registered Nurse (RN) #3 at 10:25 AM, the Maintenance Director at 10:32 AM, LPN #6 at 10:40 AM, Dietary Staff Member #1 at 10:47 AM, Housekeeping Staff Member #1 at 10:51 AM, Activities Staff at 11:05 AM, State Registered Nurse Aide (SRNA) #13 at 11:12 AM, SRNA #4 at 11:17 AM, the Administrative Assistant at 11:21 AM, LPN #4 at 11:29 AM, SRNA #12 at 11:34 AM, SRNA #11 at 11:39 AM, SRNA #10 at 12:56 PM, and SRNA #9 at 1:01 PM revealed all the staff had received the above training and taken a posttest to ensure understanding. 8. Record review and interview with the Maintenance Director on 04/24/19 at 10:32 AM revealed he had changed the wanderguard access codes on 02/18/19 as a precaution to ensure no one but staff had the code. 9. Observation of the elevators on 04/24/19 at 9:52 AM and interview with the Administrator on 04/24/19 at 1:44 PM revealed signage had been posted inside both sets of elevators and outside each elevator on every floor. The signage advised visitors to ask staff for assistance if the elevator alarmed. 10. Review of a door monitoring checklist and interview on 04/24/19 with the Administrative Assistant at 11:21 AM and the Central Supply staff at 9:45 AM revealed both had monitored the basement/ground floor exit door and the elevators on the ground floor after the incident on 02/17/19. Additional interviews on 04/24/19 with the Maintenance Director at 10:32 AM, LPN #6 at 10:40 AM, SRNA #13 at 11:12 AM, SRNA #4 at 11:17 AM, LPN #4 at 11:29 AM, SRNA #12 at 11:34 AM, SRNA #11 at 11:39 AM, SRNA #10 at 12:56 PM, and SRNA #9 at 1:01 PM revealed they clocked in to work on the ground floor and observed staff monitoring the elevator and entrance/exit doors after the incident on 02/17/19, and until the sensors were installed on the basement/ground floor elevators and doors. 11. Review of invoices and interview on 04/24/19 at 1:44 PM with the Administrator revealed the facility contacted a wanderguard vendor to install wanderguard sensor alarms on the basement/ground floor elevators and entrance/exit doors. The alarm sensors were installed on 03/14/19 and the Administrator stated staff continued to monitor the ground floor until 03/18/19 to ensure the new system was working correctly. Observation on 04/24/19 at 9:52 AM and interview with SRNA #10 at 12:56 PM revealed that when a wanderguard sensor alarmed on the basement/ground floor level, it sounded at the alarm and on the first floor. SRNA #10 stated staff on the first floor responded to alarms from the basement/ground floor. Observation of the wanderguard alarm box on the first floor revealed labels and lights were present for basement/ground floor alarms. 12. Review of the Transmitter Testing Logs and interviews on 04/24/19 with the QI Coordinator and QI Assistant at 10:02 AM revealed they had conducted daily audits to ensure staff was checking each resident's wanderguard bracelet for placement and functioning daily. The audits were completed from 02/17/19 through 03/02/19 and then weekly. 13. Review of audit logs and interview on 04/24/19 with the Administrator at 1:44 PM revealed he checked off the wanderguard sensor alarms on the elevators five times per week from 02/17/19 through 03/31/19, and three (3) times per week in (MONTH) 2019, with no concerns identified. 14. Review of audit documentation and interviews on 04/24/19 with the Administrator at 1:44 PM and the DON at 1:24 PM revealed both had conducted monitoring at different times of the day to observe staff assisting residents who utilized wanderguard bracelets to activities, beauty shop, etc., and to ensure staff were remaining with residents while they were off the unit. 15. Interviews with the QI Coordinator and the QI Assistant at 10:02 AM on 04/24/19, revealed they had not observed any resident wearing a wanderguard bracelet in the elevators unaccompanied by staff or off the unit without staff present. In addition, interview with the Administrator on 04/24/19 at 1:44 PM, revealed the Activity Director had reported no observations of a resident wearing a wanderguard bracelet coming to an activity on a floor where they did not reside without a staff escort to and from the activity. 16. Review of audits and interviews on 04/24/19 with the QI Coordinator and the QI Assistant at 10:02 AM revealed they reviewed the door monitoring logs daily from 02/19/19 thru 03/19/19. Staff monitored the basement/ground floor level continuously from 02/17/19 until the new alarm sensors were installed. 17. Record review and interview on 04/24/19 with the QI Coordinator and the QI Assistant at 10:02 AM revealed the QI Nurses checked each newly admitted resident's record to ensure a wandering risk assessment had been completed for the resident and a care plan had been developed, if warranted. 18. Review of the QA Meeting Minutes and interview on 04/24/19 with the DON at 1:24 PM, QI Coordinator at 10:02 AM, Maintenance Director at 10:32 AM, Administrative Assistant at 11:21 AM, and the Administrator at 1:44 PM revealed the facility conducted a QA meeting on 02/18/19. During the meeting, the incident with Resident #1 was discussed and an action plan was developed. The QA Team has met at least weekly since the incident to discuss the ongoing audits and progress of the action plan. Further interview revealed an Executive QA meeting was scheduled for the second quarter of 2019.

Based on observation, interview, record review, policy review, and review of appliance safety precautions, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as was possible. Observation on 11/28/17 of twelve (12) resident rooms and the common area on the third floor revealed the facility failed to maintain the heat/air unit with control knobs to operate the heat/air. Interviews with residents and staff revealed it was commonplace for the third floor not to have control knobs. Staff controlled the units by plugging them in/unplugging them to adjust the temperature and to turn the unit on and off, which at times resulted in sparks/fire emissions from the outlet. Interview with a representative from the manufacturer of the heat/air units and a review of the manufacturer's safety precautions revealed utilizing the unit's electrical cord to control the unit was a fire hazard. Observation of six (6) resident rooms and the lounge area on the third floor revealed the heat/air unit electrical plugs and/or the electrical wall outlets were burnt/melted. The facility's failure to ensure the resident environment remained free of accident hazards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/14/17, and determined to exist on 09/24/17, at 42 CFR 483.25 Quality of Care (F689 - K). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 12/14/17. An acceptable Allegation of Compliance was received on 12/27/17, which alleged removal of the Immediate Jeopardy on 12/01/17. The State Survey Agency determined the Immediate Jeopardy was removed on 12/01/17, prior to exit, which lowered the scope and severity to E level at 42 CFR 483.25 Quality of Care (F689) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of an untitled facility policy dated (MONTH) 1998 revealed the facility would provide a safe and properly maintained environment and equipment. The policy stated the facility would make every effort to prevent equipment breakdown, and repairs would be made on a timely basis. In addition, the policy also stated that to some degree, the quality of resident care was dependent on the performance of the facility's equipment. A review of the safety precautions for the General Electric heat/air units utilized at the facility revealed that due to the risk of electric shock, which could result in injury or death, the unit should never be unplugged by pulling on the power cord. All electric service cords that become frayed or otherwise damaged are to be replaced immediately with a new power supply cord. The policy also stated that cords with visible cracks, abrasions, or damage at the plug or connector end should not be used. An interview with the General Electric (GE) representative on 12/14/17 at 3:25 PM revealed plugging in/unplugging the heat/air units should never be the method used to turn the units on and off because it damaged the wires/cord and created a fire hazard. Observations conducted on 11/28/17 at 9:50 AM revealed the electrical outlet for the heat/air unit in room [ROOM NUMBER] was observed to be charred and black in color. Additional observations on 11/28/17 at 3:50 PM revealed the knobs to control the functioning of the heat/air units, including turning the units on and off, had been removed in rooms 303, 305, 306, 307, 308, 309, 310, 311, 312, 314, 316, and 318. Continued observation revealed the electrical plugs on the heat/air units were burnt/melted in rooms [ROOM NUMBERS], and in the common area on the third floor. Further observations of the heat/air units and the electrical outlets in rooms [ROOM NUMBER] revealed the electrical cords and the outlets were burnt/melted. Interviews with Residents A, B, and C on 11/28/17 at 1:50 PM revealed they had to plug in or unplug the heat/air units to turn the unit on and off because there were no knobs to control the units. Review of the facility's Maintenance Request Log revealed staff documented on 10/29/17 that the heat/air electrical plugs were burnt in room [ROOM NUMBER], and on 11/11/17 in rooms [ROOM NUMBER]. Continued review of the Maintenance Request Log revealed staff documented that on 09/24/17 in the medication room, and on 11/25/17 in room [ROOM NUMBER], sparks/fire were emitted from the electrical receptacle when the heat/air units were plugged in/unplugged. Although the repairs to the electrical plugs in rooms [ROOM NUMBERS] were repaired the day they were reported, the repairs to room [ROOM NUMBER] and the medication room were not completed until one day after the issues were reported. rooms [ROOM NUMBERS] were not repaired until 11/14/17, three days after the concerns were reported. The electrical cord plug in room [ROOM NUMBER] was observed on 11/28/17 to be burnt again; however, interview with the Maintenance Director on 11/28/17 at 4:15 PM revealed he was not aware the plug was burnt again until notified by the state surveyor. Interview with Kentucky Medication Aide (KMA) #1 on 12/14/17 at 1:31 PM, who documented on 11/25/17 that sparks were emitted from the heat/air unit in room [ROOM NUMBER], revealed the resident's family reported that there were no knobs on the unit and when the unit was unplugged to turn it off, sparks were emitted from the receptacle. Interview with KMA #2 on 12/14/17 at 11:45 AM revealed she was the staff member who reported that fire was coming from the heat/air unit receptacle in the medication room on the third floor. The KMA stated she notified Maintenance staff immediately; however, it was not repaired until the following day. KMA #2 stated she was aware there were no control knobs for the heat/air units and it was normal staff practice to plug in/unplug the units to turn them on and off. The KMA stated she had observed burnt/charred electrical cord plugs and outlets in resident rooms. Interview with State Registered Nurse Aide (SRNA) #4 on 12/14/17 at 10:12 AM and SRNA #9 on 12/14/17 at 10:20 AM revealed residents and staff controlled the heat/air units by plugging in and unplugging the units because the units did not have control knobs. SNRA #4 stated the units had not had control knobs since she began working at the facility in (MONTH) (YEAR). SRNA #9 stated there had been no knobs since she started working at the facility in approximately (MONTH) (YEAR). Interviews with SRNAs #1, #3, and #5 on 11/28/17 from 1:55 to 2:15 PM revealed they plugged in/unplugged the heat/air units if residents became too hot or cold to adjust the temperatures. Interview with the Maintenance Director on 11/29/17 at 12:30 PM and on 12/14/17 at 9:06 AM revealed he was aware the heat/air units did not have control knobs and staff/residents were plugging in/unplugging the units to turn them on and off, but had not considered the actions of the staff/residents a safety hazard, even though he was aware that it was causing the plugs/units to burn/melt. According to the Maintenance Director, he had replaced electrical cords and outlets in the past because they were burnt/melted. The Maintenance Director stated if a resident was too hot or cold, staff were supposed to notify him to adjust the setting on the unit to control the temperature. An interview with the Administrator on 11/29/17 at 1:15 PM and on 12/14/17 at 9:22 AM revealed he was aware the heat/air units did not have control knobs. He stated the knobs were removed to prevent residents from controlling the heat/air units because of frequent disagreements about the temperature. The Administrator stated he was not aware residents were controlling the units by plugging them in/unplugging them or that the units had sustained damage from this practice. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1) On 11/11/17, it was recorded on the Maintenance Request Log for room [ROOM NUMBER] (Resident #1's room), heater plug burnt. Can't plug in. The unit was serviced by the Maintenance Supervisor on 11/11/17, who replaced the outlet after he noticed a scorched outlet plug. The facility was unaware of the practice by nursing staff to plug in and unplug the p-tac units (in-wall air conditioning and heating units) to control room temperature, due to the p-tac units missing control knobs. Failure to recognize this practice by staff allowed staff to continue the practice of plugging the p-tac units in and out, which created the possibility of a spark being generated during this process. The potential for the spark to cause a fire created the Immediate Jeopardy situation for Resident #1 and all other facility residents. On 11/28/17, the Administrator, Maintenance Supervisor, and Staff Facilitator met to determine the root cause of the issue. It was determined the missing control knobs caused staff to plug in and unplug the p-tac units to control room temperature. This practice caused the outlet to be scorched. 2) On 11/28/17, a review of all facility p-tac heater units was completed by the Maintenance Supervisor. All damaged outlets were replaced by the Maintenance Supervisor. The review also included verifying placement of on/off control knobs on each p-tac unit. Any unit missing an on/off knob had it replaced. All damaged outlets were replaced and on/off knobs verified in place by 3:30 AM on 11/29/17. 3) On 11/28/17, the Staff Facilitator began education with all staff regarding using the on/off knob to control room temperatures, not unplugging the unit. The education included placing a Red Tag on any unit not working properly and notifying Maintenance immediately; and notification of Maintenance if a unit is missing the on/off knob. All staff in the facility on the evening of 11/28/17 and 11/29/17 completed this education. 4) On 11/29/17, the Maintenance Supervisor ordered additional p-tac heating unit knobs so each unit would have both an on/off knob and a temperature control knob. Those knobs arrived in the facility on 11/30/17. On 11/30/17, all p-tac units were inspected by the Maintenance Supervisor and those without both an on/off knob and a temperature control knob had the additional knob applied. 5) On 11/29/17, an audit of 100% of the p-tac units was performed by administrative staff to confirm all damaged outlets were replaced and an on/off knob was present on all units. No concerns were identified. These audits were presented to the Quality Improvement (QI) Committee on 11/29/17. The committee recommended daily audits for 11/30/17 and 12/01/17, with further direction to be provided after the 12/01/17 QI Committee Meeting. On 12/01/17, the QI Committee met to review the audits from 11/30/17 and 12/01/17. The decision was made for daily audits to continue. Beginning 12/02/17, the Maintenance Supervisor, Maintenance Assistant, or the individual assigned by the Administrator will complete daily audits of 100% of the p-tac units to ensure they are plugged in and have both knobs in place. Any concerns identified during the audits will be reported to the Administrator with corrective action taken immediately. Completed audits will be given to the Administrator, for review, on a weekly basis. 6) On 12/14/17, members of the QI Committee (Administrator, DON, QI Nurses, Maintenance Director, Maintenance Assistant, and Staff Facilitator) reviewed the issue. No units had been found to be unplugged, and a missing knob was noted on only one occasion (12/14/17). The knob was immediately replaced on 12/14/17. The Staff Facilitator reported that all staff including those on leave, vacation, etc. had been educated regarding the issue. The committee determined daily audits of the PTAC units would continue until jeopardy is abated, and then per the schedule established by the QI Committee; but a minimum of three times per week until substantial compliance is achieved. The QI Committee will meet as needed but at least monthly to review the audit results, and provide ongoing direction or recommendations. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1) Interviews on 12/27/17 with the Administrator at 3:55 PM, Maintenance Supervisor at 3:40 PM, and Staff facilitator at 2:45 PM revealed they met on 11/28/17, and determined the missing control knobs caused staff to plug in and unplug the p-tac (heating/air) units to control room temperatures and caused outlets to be scorched. Observation on 12/27/17 revealed the outlet in room [ROOM NUMBER] had been replaced. 2) An interview with the Maintenance Supervisor on 12/27/17 at 3:40 PM revealed maintenance staff had inspected all facility p-tac units and all damaged outlets were replaced and power knobs were placed on all units by 11/29/17. Observation on 12/27/17 revealed no outlets or heat/air unit electrical plugs were observed burnt/black. 3) An interview with the Staff Facilitator on 12/27/17 at 2:45 PM revealed she initiated staff education on 11/28/17, and completed staff education on 11/29/17, regarding using the on/off knob to control room temperatures, and not unplugging the unit. The education included placing a red tag on any unit not working properly and notifying Maintenance immediately; and notifying Maintenance if a unit was missing the on/off knob. Interviews with State Registered Nurse Aide (SRNA) #2, SRNA #9, SRNA #11, and SRNA #12 on 12/27/17 from 11:05 AM to 2:00 PM and Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #9, and LPN #10 from 12:43 PM to 12:56 PM revealed they attended in-services provided by the facility and were aware they should utilize the on/off knobs to control the heat/air units and should not plug in/unplug the units. The staff further stated they would place a red tag on the unit and notify Maintenance if there were any problems with the units. 4) An interview with the Maintenance Supervisor revealed he ordered temperature control knobs for the p-tac units and placed the knobs on the units on 11/30/17. A review of an invoice revealed the knobs were purchased and obtained on 11/30/17. Observations of all facility p-tac units on 12/27/17 revealed the on/off and temperature control knobs were in place. 5) A review of facility audits revealed on 11/29/17 an audit was conducted of all heat/air units to confirm all damaged outlets were replaced and all units had control knobs. Further review of audits revealed the facility continued to conduct daily audits from 11/30/17 to 12/27/17 to verify that all heat/air units had control knobs and were plugged in. A review of QI meeting minutes revealed the QI Committee met on 11/29/17, 11/30/17, and 12/01/17 to review the findings of the audits. An interview with the Administrator on 12/27/17 at 3:55 PM revealed he was reviewing all audits daily and had been conducting audits himself of all units three times per week. An interview with the Administrator, Director of Nursing, and the Maintenance Supervisor from 2:50 PM to 3:55 PM revealed that all heat/air units were audited daily to confirm on/off knobs were in place and no damaged outlets/plugs were being utilized. The staff stated the information was presented to the QI Committee on 11/29/17, 11/30/17, and 12/01/17, and the facility determined that daily audits would continue. 6) A review of QI Committee notes on 12/14/17 revealed no concerns were identified and audits would continue daily. An interview with the Administrator on 12/27/17 at 3:55 PM revealed a concern with a missing knob was identified on 12/14/17, after the QI Committee meeting, the knob was replaced, and daily audits continued. Observations of all heat/air units conducted on 12/27/17 revealed no missing knobs or burnt/scorched plugs/receptacles.

Based on interview, record review, and review of the facility's policy and fall investigations, it was determined the facility failed to ensure resident care plans were reviewed/revised as required for one (1) of three (3) sampled residents (Resident #25). Review of the resident's care plan and Minimum Data Set (MDS) Assessment revealed staff failed to utilize assessment information in the MDS when the resident's care plan was reviewed/revised. Review of Resident #25's most recent MDS assessment dated [DATE] revealed staff assessed that the resident required extensive assistance of two (2) staff members with transfers and limited assistance of one (1) staff member with ambulation. However, the resident's care plan was not revised and stated Resident #25 was independent with transfers and ambulation and that staff was to assist the resident as needed. Furthermore, interview with the Physical Therapist (PT) who had provided therapy services to Resident #25 from 01/28/16-02/29/16 revealed in February 2016 she had identified a decline in the resident's functional status. The PT stated she had assessed Resident #25 to require an increased level of assistance with transfers and ambulation in February 2016; however, she failed to notify staff of the resident's change in condition as required; therefore, the resident's plan of care was not revised to reflect the resident's change in condition. On 03/07/16, the resident had a fall in the facility, which resulted in a hematoma (an area of collected blood) and laceration (a wound produced when body tissue is torn) to his/her lower back that required three (3) sutures, at a local hospital. Resident #25 had experienced a fall in the facility on 03/09/16, two (2) days later, that resulted in a laceration to the right side of the resident's head, and he/she was transferred to a local hospital for evaluation. Resident #25 remained in the local hospital until 03/11/16, and was transferred back to the facility with a [DIAGNOSES REDACTED]. Interviews with staff revealed if PT staff had notified nursing staff of the resident's change in condition in February 2016 the falls, which resulted in injury to the resident, could have been prevented. The findings include: Review of the facility's policy titled Resident Care Plan, dated August 2012, revealed care plans were an ongoing process for facility residents and would include current problems or needs identified through resident assessments that included the MDS. Any new problems identified for facility residents were to be reflected on the resident's plan of care. Review of Resident #25's medical record revealed the facility admitted the resident on 01/02/15 with [DIAGNOSES REDACTED]. Resident #25's Annual MDS dated [DATE] revealed the resident required extensive assistance of two (2) staff members with transfers and limited assistance of one (1) staff member with ambulation. Resident #25's comprehensive care plan, last revised on 03/08/16, revealed the resident was at risk for falls. Resident #25's risk factors for falls included the following: history of falls, fall with injury, impaired cognition, decreased safety awareness, use of [MEDICAL CONDITION] medications, unsteady gait, orthostatic [MEDICAL CONDITION], and knees will buckle underneath him/her. However, Resident #25's care plan stated that the resident was independent with transfers and ambulation and staff was to assist the resident as needed, which differed from the resident MDS assessment information. Interventions implemented in January 2015 to prevent falls for Resident #25 included: nonskid footwear when out of bed, keep personal items within reach, keep bed at posted level, and encourage rest periods routinely and when the resident appears unsteady. In February 2015, staff implemented routine checks to ensure the resident's personal and safety needs were met and the resident's ADL (Activities of Daily Living) function plan of care included Hipsters (padded clothing worn to protect hips from injury if a fall occurred) which were to be provided for the resident daily. Staff had also implemented a soft mat floor tile to Resident #1's floor in his/her room (implemented 04/06/15). Review of Resident #25's fall investigations revealed the resident had experienced nine (9) falls in the past six (6) months. Review of the resident's care plan revealed staff failed to review/revise Resident #25's care plan after each fall occurred, including the implementation of preventive measures to prevent further falls for the resident. Review of a fall investigation that occurred on 09/21/15 revealed at 6:35 AM staff responded to a noise in the facility dining room and observed Resident #25 on the floor of the dining room, sitting on another resident's toes. Staff investigated the resident's fall and identified that Resident #25 had decreased safety awareness, an unsteady gait, and ambulated with no assistance in the facility; however, the resident's care plan had not been reviewed/revised to reflect new interventions to prevent further falls from occurring. Resident #25 experienced a fall on 11/07/15 at 12:00 PM, when staff observed the resident in his/her room, sitting on padded floor in front of the resident's recliner. Staff documented on the fall investigation that Resident #25 had decreased safety awareness and was fatigued related to disease process; however, no new interventions were implemented to prevent further falls for Resident #25. Review of Resident #25's fall investigations revealed on 11/10/15 at 7:00 PM staff observed the resident walking in the dining room and tripped over his/her own feet and fell on to the floor. Staff identified on the fall investigation that Resident #25 had a somewhat unsteady gait, fatigue secondary to disease process, and no safety awareness. A root cause was not identified on the resident's fall investigation and no new interventions were implemented to prevent the resident from further falls. Resident #25's fall investigation dated 12/27/15 at 2:35 PM revealed staff observed the resident lying on the padded floor in his/her room and was assessed to have no injuries. Staff identified on the fall investigation that Resident #25 had decreased safety awareness and Alzheimer's; however, no evidence was provided that the resident's care plan had been reviewed/revised or that any new interventions had been implemented to prevent falls for Resident #25. Resident #25's fall investigation dated 12/31/15 at 8:45 PM revealed staff heard a loud noise and observed the resident on the floor of another resident's room, sitting on the bottom of an overbed table that had been overturned on the floor. Staff documented on the fall investigation that Resident #25 had decreased safety awareness, an unsteady gait, and a decline in mental status. No evidence was provided that indicated staff had implemented any new interventions to prevent further falls. Resident #25's fall investigation dated 01/19/16 at 8:45 PM revealed the resident was observed ambulating out of the facility dining room, toward his/her room, and was observed to stumble and fall. Staff had documented that Resident #25 had decreased safety awareness, fatigue, and an unsteady gait, and a therapy referral was initiated after the fall. Review of the resident's care plan revealed staff failed to revise the resident's plan of care to indicate the therapy evaluation that had been implemented for Resident #25. Resident #25's fall investigations revealed on 02/10/16 at 9:15 PM staff responded to a sound and observed Resident #25 on the floor, lying on his/her right side, in his/her room. Staff documented the resident had decreased safety awareness, an unsteady gait, and a decline in mental status; however, no new interventions were care planned to prevent further falls for the resident. The fall investigation indicated staff was to conduct neurochecks (assess for nervous system dysfunction) and to continue the use of hipsters, which had been implemented in February 2015. Interview with the Physical Therapist (PT) on 03/15/16 at 11:45 AM revealed she provided therapy services to Resident #25 from 01/28/16-02/29/16 and that she identified a decline in the resident's functional status in February 2016. She stated she had assessed the resident to require at the least, one staff member to provide supervision during transfers and ambulation to decrease the resident's risk for falls; however, she failed to notify nursing staff of the change in the resident's condition. She stated she was required to notify the MDS nurse or the Unit Manager (UM) where the resident resided of any increased level of assistance required for facility residents so their care guides could be updated to reflect the resident's functional level to decrease the risk for falls. She acknowledged she should have notified the appropriate staff of the change for Resident #25 in February 2016 so the resident's care guide would have reflected what level of assistance was required to decrease the risk of falls for the resident. Resident #25's fall investigations revealed on 03/07/16 at 4:15 PM staff responded to a loud noise that came from Resident #25's room and observed the resident lying on the floor between his/her bed and the wall in his/her room, and observed the air conditioner was unplugged and lying behind the resident. Resident #25 was observed to have a hematoma and a laceration to his/her mid back and an abrasion was observed to the resident's right upper temple. Record review revealed Resident #25 was transferred to a local hospital after the fall on 03/07/16 and the resident required three (3) sutures to repair the laceration to his/her back and was transferred back to the facility approximately four (4) hours later. Further review of the hospital record revealed the resident was assessed by a Computed Tomography (CT) scan during the hospital evaluation on 03/07/16 to have a healing [MEDICAL CONDITION] eleventh (11th) rib posteriorly. Resident #25's fall investigation dated 03/09/16 at 9:45 PM revealed staff observed Resident #25 stand from a sitting position and take three (3) or four (4) steps sideways and fall onto the floor. Resident #25 was observed to have a laceration to the right side of his/her head, which required a pressure dressing to be applied related to a small to moderate amount of bright red blood. Resident #25 was transferred to a local hospital for evaluation and treatment related to injuries sustained during the fall. Resident #25 remained in the hospital after the fall occurred on 03/09/16 and was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Interview with the MDS nurse on 03/15/16 at 1:50 PM revealed she had completed the MDS assessment dated [DATE] and reviewed/revised the needed areas of the resident's care plan at that time. She stated she had not identified that the resident's MDS information was different from the resident's care plan that had been utilized to direct the resident's assistance required by staff. She stated the resident had frequent falls in the facility, and [DIAGNOSES REDACTED]. She continued to state she had observed him/her ambulate independently in the facility a majority of the time, therefore she had not identified any concerns related to the resident's care plan directing staff to only assist the resident as needed. The MDS nurse stated PT was required to notify her when a change in the resident's functional status was identified, so the plan of care could be reviewed/revised to reflect the resident's change in condition. She also stated PT had not notified her of the changes in the resident's functional status. However, she stated if PT had notified staff when the resident was assessed to require an increased level of supervision/assistance in February 2016, then the falls which resulted in injuries in March 2016 could possibly have been prevented. Interview with the Quality Assurance (QA) nurse on 03/14/16 at 2:30 PM revealed all falls for Resident #25 had been reviewed and discussed, related to identifying root causes and ensuring appropriate interventions had been implemented and care plans reviewed/revised to prevent further falls from occurring. The QA nurse stated she had not identified any concerns with the review/revision of residents' care plans after a fall had occurred in the facility. Interview with the Director of Nursing (DON) on 03/15/16 at 2:10 PM revealed she had not identified that Resident #25's care plan had not been reviewed/revised utilizing the assessment information from the resident's MDS assessments. She stated Resident #25's care plan had been reviewed and she had no concerns related to Resident #25's care plan review/revision after falls had occurred in the facility. Per interview, if staff had been notified when the resident was assessed to require an increased level of supervision/assistance in February 2016, then it was possible that the falls which resulted in injuries in March 2016 could have been prevented. Interview with the Administrator on 03/15/16 at 2:40 PM revealed he relied on the DON to ensure resident care plans were accurate and had been developed, which included the level of assistance that residents had been assessed to require. He stated resident falls, which included preventive measures implemented and care plan updates, were discussed in the morning meetings conducted Monday-Friday, and he had not identified any concerns. He confirmed PT staff was required to communicate any changes in a resident's functional status when it was identified to ensure residents received the appropriate level of assistance to decrease the risk of falls in the facility. The Administrator stated if PT had notified nursing staff of the change in Resident #25's condition in February 2016, the falls that resulted in injury in March 2016 might have been prevented.

Based on interview, record review, review of the facility's fall investigations and review of the facility's policy, it was determined the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #25). Record review revealed Resident #25 sustained a total of nine (9) falls within a six (6) month period (09/21/15 through 03/09/16). The facility failed to provide adequate supervision and failed to conduct fall investigations for Resident #25 that identified the root cause of the resident's falls and failed to implement interventions to prevent further falls from occurring. The facility failed to ensure the assessment information was utilized to develop the care plan to ensure the resident received adequate assistance with transfers and ambulation, and failed to ensure that when the resident experienced a decline in functioning the care plan was revised to ensure the resident received adequate assistance. Review of Resident #25's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed staff assessed that the resident required extensive assistance of two (2) staff members with transfers and limited assistance of one (1) staff member with ambulation. However, the resident's care plan stated Resident #25 was independent with transfers and ambulation and staff was to assist the resident as needed. Furthermore, interview with the Physical Therapist (PT) who had provided treatment to Resident #25 from 01/28/16-02/29/16 revealed she had identified a decline in the resident's functional status in February 2016. The PT stated she had assessed that the resident required an increased level of assistance with transfers and ambulation in February 2016 but failed to notify staff of the resident's change in condition as required. On 03/07/16, the resident fell and suffered a hematoma (an area of collected blood outside a blood vessel) and laceration (a wound produced when body tissue is torn) to his/her lower back that required three (3) sutures at a local hospital on [DATE]. Review of the hospital record from 03/07/16 revealed Resident #1 also had a healing fracture of the right eleventh rib posteriorly. Interviews with facility staff revealed even though Resident #25 had resided in the facility for approximately fifteen (15) months, they had not been aware of the resident's previous injury to his/her rib and were unable to determine when Resident #25 had sustained the rib fracture. Resident #25 sustained another fall in the facility on 03/09/16, two (2) days later, which resulted in a laceration to the right side of the resident's head and the resident was transferred to a local hospital for evaluation. The record further revealed Resident #25 remained in the local hospital until 03/11/16, and was transferred back to the facility with a [DIAGNOSES REDACTED].#25 was reevaluated by his/her physician in four (4) to six (6) weeks. The findings include: Review of the facility's policy titled Fall Risk Protocol, dated November 2012, revealed that falls could be a common source of serious injury and death among the elderly. The policy further revealed staff would seek to prevent residents' falls and/or minimize any injury which could occur from a fall. The policy also stated falls that occurred in the facility would be reviewed and evaluated to determine if any patterns or trends existed for the residents. Staff was also required to ensure residents' safety through implementing or changing any interventions that were utilized to prevent falls for the residents. Review of the medical record for Resident #25 revealed the facility admitted the resident on 01/02/15 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE], revealed staff had assessed Resident #25 to require extensive assistance of two (2) staff members with transfers and limited assistance of one (1) staff member with ambulation. The MDS also indicated the resident had experienced two (2) falls, with no injury. However, Resident #25 had experienced five (5) falls at the time. Review of Resident #25's comprehensive care plan, last revised on 03/08/16, revealed staff had identified that the resident was at risk for falls. Staff identified Resident #25's risk factors for falls to include the following: history of falls, fall with injury, impaired cognition, decreased safety awareness, use of psychotropic medications, unsteady gait, orthostatic hypotension, and knees will buckle underneath him/her. The care plan included the following interventions related to falls that were implemented in January 2015: nonskid footwear when out of bed, keep personal items within reach, keep bed at posted level, and encourage rest periods routinely and when the resident appeared unsteady. Even though Resident #25 had been assessed on his/her MDS to require extensive assistance of two (2) staff members with transfers and limited assistance of one (1) staff member with ambulation, Resident #25's care plan stated that the resident was independent with transfers and ambulation and staff was to assist the resident as needed. Further review of the resident's care plan revealed in February 2015 staff implemented routine checks to ensure the resident's personal and safety needs were met and the resident's ADL (Activities of Daily Living) function plan of care included Hipsters (a padded clothing worn to decrease the risk of injury to the hips if a fall occurred). Staff had also implemented a soft mat floor tile to Resident #1's floor in his/her room (implemented 04/06/15). Review of Resident #25's fall investigations revealed the resident had experienced nine (9) falls in the past six (6) months on 09/21/15, 11/07/15, 11/10/15, 12/27/15, 12/31/15, 01/19/16, 02/10/16, 03/07/16, and 03/09/16. Review of a fall that occurred on 09/21/15 revealed at 6:35 AM staff responded to a noise in the facility's dining room and observed Resident #25 on the floor of the dining room, setting on another resident's toes. Resident #25 was assessed to have a reddened area mid way down his/her back area; however, the action taken by staff after investigating the fall was to continue with current interventions of non-skid footwear and to continue providing the resident with routine checks (every two hours). Even though when staff investigated the resident's fall and identified that Resident #25 had decreased safety awareness, an unsteady gait, and ambulated with no assistance in the facility, no new interventions were implemented to prevent further falls from occurring. Review of the resident's fall investigations revealed the resident experienced a fall on 11/07/15 at 12:00 PM, when staff observed the resident in his/her room, sitting on padded floor in front of the resident's recliner. Resident #25 was assessed to have no injury and due to his/her cognition, and per the investigation, the resident was unable to tell what he/she was doing when he/she fell . Staff identified after the fall occurred that the resident had decreased safety awareness and was fatigued related to disease process; however, according to the resident's fall investigation, no new interventions were implemented to prevent further falls for Resident #25. Review of Resident #25's fall investigations revealed on 11/10/15 at 7:00 PM staff observed the resident walking in the dining room and tripped over his/her own feet and fell on to the floor. The resident was assessed to have no injuries and staff identified on the fall investigation that Resident #25 had a somewhat unsteady gait, fatigue secondary to disease process, and no safety awareness. A root cause was not identified on the resident's fall investigation and no new interventions were implemented to prevent the resident from further falls. Review of Resident #25's fall investigations revealed on 12/27/15 at 2:35 PM staff observed the resident lying on the padded floor in his/her room. The resident was assessed to have no injuries and staff identified on the fall investigation that Resident #25 had decreased safety awareness and Alzheimer's; however, no evidence was provided that a root cause of the resident's fall was identified, and no new interventions were implemented to prevent falls for the resident. Review of Resident #25's fall investigations revealed on 12/31/15 at 8:45 PM staff heard a loud noise and observed Resident #25 on the floor of another resident's room, sitting on the bottom of an overbed table that had been overturned onto the floor. Resident #25 was assessed to have a skin tear with a blood blister to his/her left elbow as a result of the fall. Staff documented on the fall investigation that the resident had decreased safety awareness, an unsteady gait, and a decline in mental status. However, no evidence was provided that indicated staff had identified a root cause of the resident's fall, and the interventions implemented to prevent further falls were to monitor for latent injuries and redirect the resident as much as possible. Review of Resident #25's fall investigations revealed on 01/19/16 at 8:45 PM Resident #25 was observed ambulating out of the facility dining room toward his/her room. The fall investigation indicated hipsters were being utilized as care planned and non-skid footwear was in place. The fall investigation stated Resident #25 stumbled and fell on to the floor. Resident #25 was assessed to have no injuries and staff documented the resident had decreased safety awareness, fatigue, and an unsteady gait, and a therapy referral was initiated after the fall. Review of Resident #25's fall investigations revealed on 02/10/16 at 9:15 PM staff responded to a sound from the resident's room and observed Resident #25 on the floor, lying on his/her right side. Resident #25 was assessed to have no injury and staff documented that the resident had decreased safety awareness, an unsteady gait, and a decline in mental status. No evidence was provided that staff had identified a root cause of the resident's fall, and no new interventions were implemented to prevent further falls for the resident. Review of Resident #25's fall investigations revealed on 3/07/16 at 4:15 PM staff responded to a loud noise that came from Resident #25's room and observed Resident #25 lying on the floor between his/her bed and the wall in his/her room, and observed the air conditioner was unplugged and lying behind the resident. Resident #25 was assessed to have a hematoma and a laceration to his/her mid back and an abrasion was observed to the resident's right upper temple. Staff documented on the fall investigation that the resident was apparently reaching for an object and lost his/her balance. Staff also identified that the resident had decreased safety awareness, an unsteady gait, and Alzheimer's. Facility actions taken were to rearrange the furniture in the resident's room, place the resident's bed against the wall, and the resident's recliner was placed in front of the air conditioner unit. Record review revealed Resident #25 was transferred to a local hospital after the fall on 03/07/16 related to the laceration that had occurred as a result of the fall. The resident required three (3) sutures to repair the laceration to his/her back and was transferred back to the facility approximately four (4) hours later. Further review of the hospital record revealed the resident was assessed by a Computed Tomography (CT) scan during the hospital evaluation on 03/07/16 to have a healing fracture of the right eleventh rib posteriorly. Review of Resident #25's fall investigations revealed on 03/09/16 at 9:45 PM staff observed Resident #25 to stand from a seated position and take three (3) or four (4) steps sideways and fall onto the floor. The resident was observed to have a laceration to the right side of his/her head that required a pressure dressing to be applied to the lacerated area related to a small to moderate amount of bright red blood. The resident was transferred to a local hospital for evaluation and treatment related to injuries sustained during the fall. Review of Resident #25's hospital record dated 03/09/16 revealed a CT scan was performed on 03/09/16 after arrival to the hospital. The CT results indicated the resident had an area of cortical fracturing along the right lateral masses of C1 (the upper area of the cervical spine). The CT results further stated the resident's fracture was concerning for a chronic fracture; however, acute trauma could not be fully excluded. The CT impression suggested that a Magnetic Resonance Imaging (MRI) test be conducted to exclude acute injury; however, the MRI was unable to be provided to the resident related to his/her cognitive status. Resident #25 remained in the hospital after the fall occurred on 03/09/16 and was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Interview with the Physical Therapist (PT) on 03/15/16 at 11:45 AM revealed her department had provided evaluation and treatment for [REDACTED]. The PT stated the resident had been on their case load a few times and was a high fall risk related to his/her impaired balance. The PT also stated Resident #25's functioning status was unpredictable and the level of assistance required to ensure his/her safety was observed to change frequently. She continued to state Resident #25 could walk fine some days and then a few days later would require assistance to ambulate safely to decrease the risk of falls. Per interview, the resident was treated from 01/28/16-02/29/16 and she had identified a decline in the resident's functional status in February 2016. However, even though she had identified the resident was at high risk for falls, had sustained frequent falls in the facility, had impaired balance, and was assessed to require at the least, one staff member to provide supervision during transfers and ambulation to decrease the resident's risk for falls, she failed to notify nursing staff of the change in the resident as required. She stated she was required to notify the MDS nurse or the Unit Manager (UM), where the resident resided, of any increased level of assistance required for facility residents so their care guides could be updated to reflect the resident's functional level to decrease the resident risk for falls. The PT acknowledged she should have notified the appropriate staff, as required, of the change that occurred for Resident #25 in February 2016 so the resident's care guide would have reflected what level of assistance was required to decrease the risk of falls for the resident. Interview with the MDS nurse on 03/15/16 at 1:50 PM revealed she had conducted the MDS assessment dated [DATE] and reviewed/revised the needed areas of the resident's care plan at that time. The MDS nurse stated she had not identified that Resident #25's MDS information was different from the resident's care plan that had been utilized to direct the resident's assistance required by staff. The MDS nurse stated even though the resident had frequent falls in the facility, and [DIAGNOSES REDACTED]. plan. The MDS nurse further stated PT was required to notify her when a change in the resident's functional status was identified so the resident's plan of care could be reviewed/revised to reflect the resident's change in condition. She also stated PT had not notified her of any changes in the resident's functional status and if the PT had notified staff as required when the resident was assessed to require an increased level of supervision/assistance in February 2016, then the falls which resulted in injuries in March 2016, could possibly have been prevented. Interview with Licensed Practical Nurse (LPN) #1 on 03/14/16 at 12:00 PM revealed she frequently provided care to Resident #25 and was assigned to him/her when the fall occurred on 03/09/16. The LPN stated Resident #25 had an unsteady gait at times and had frequent falls in the facility; however, the resident continued to ambulate and transfer without assistance from staff until the fall occurred on 03/09/16. Interview with State Registered Nurse Aide (SRNA) #2 on 03/14/16 at 1:10 PM revealed Resident #25 had an unsteady gait and had sustained falls in the facility. She stated she had never been directed to provide any assistance to the resident for transfers or ambulation and the resident continued to ambulate independently in the facility prior to the fall that occurred on 03/09/16. Interview with SRNA # 3 on 03/14/16 at 4:05 PM revealed Resident #25 had been observed to lean to the right and have an unsteady gait for a while. The SRNA acknowledged the resident had sustained frequent falls in the facility; however, the resident continued to ambulate and transfer without assistance from staff, and the SRNA stated he had never been directed to provide assistance to the resident to decrease his/her risk for falls prior to the fall that occurred on 03/09/16. Interview with SRNA #4 at 4:25 PM on 03/14/16 revealed Resident #25 frequently fell and at times leaned to the right side when he/she was ambulating in the facility. The SRNA stated the resident's ability to ambulate had declined lately and he had not been directed to provide assistance to the resident with ambulation. However, he stated if someone was helping the resident with walking or transferring, it could have prevented a fall for the resident. The SRNA stated he was unaware why the resident's care guide had not been reviewed/revised to show the resident's recent decline in functional status. Interview with the Quality Assurance (QA) nurse on 03/14/16 at 2:30 PM revealed all falls that occurred in the facility were reviewed Monday-Friday in the morning meetings. The QA nurse stated all falls that had occurred for Resident #25 had been reviewed and discussed, related to identifying root causes and ensuring appropriate interventions had been implemented to prevent further falls from occurring. She stated she had not identified any concerns with the fall investigations conducted by the facility and felt the interventions that had been implemented were appropriate. Interview with the Director of Nursing (DON) on 03/15/16 at 2:10 PM revealed she had not identified that the level of assistance Resident #25 had been assessed to require on his/her MDS had not been care planned or provided for the resident. The DON stated all falls were reviewed Monday-Friday in the facility's morning meetings and staff ensured during that meeting, after reviewing and discussing any falls that occurred, that root causes and appropriate interventions had been identified and implemented for the residents. The DON stated Resident #25's falls had been reviewed and discussed in the morning meetings related to identifying root causes and ensuring interventions had been implemented to prevent further falls from occurring and no concerns had been identified. Per interview, she felt the interventions that had been implemented were appropriate. Continued interview with the DON revealed Resident #25's diagnoses, which included Orthostatic Hypotension, had not been discussed or factored into a possible cause of any of the resident's falls as some falls were unwitnessed and occurred when the resident had been observed to be on the floor in his/her room; when the last observation had been that the resident was sitting on the side of his/her bed. The DON stated the resident's [DIAGNOSES REDACTED]. She stated staff probably should have identified that [DIAGNOSES REDACTED]. The DON stated the Corporate Nurse Consultant had notified the facility that she had identified some concerns with the facility's fall investigations related to identifying root causes of falls that occurred in the facility, but was unable to recall when this was discussed with the Corporate Nurse Consultant as a concern. The DON stated PT had not notified her of any changes in the resident's functional status and stated if staff had been notified when the resident was assessed to require an increased level of supervision/assistance in February 2016, then it was possible that the falls which resulted in injuries in March 2016, could have been prevented. A post-survey interview with the Corporate Nurse Consultant was attempted on 03/16/16; however, she declined the request for an interview to discuss the concerns she had identified with fall investigations conducted at the facility. Interview with the Administrator on 03/15/16 at 2:40 PM revealed he relied on the DON to ensure resident care plans were accurate and had been developed, which included the level of assistance that residents had been assessed to require. The Administrator stated resident falls were discussed in the morning meetings conducted Monday-Friday. He stated falls were reviewed, which included identifying the root cause and ensuring appropriate interventions were in place after a fall had occurred. He stated he had not identified any concerns with the fall investigations that staff had conducted for Resident #25. However, he stated the Corporate Nurse Consultant had identified some concerns and had discussed identifying root cause analyses of falls with the DON but was unable to recall when the discussions had occurred. The Administrator stated even though the Consultant had identified concerns with the facility's fall investigations, no action plans had been implemented to correct the concerns that had been identified in the facility. The Administrator confirmed PT staff was required to communicate any changes in a resident's functional status, when it was identified, to ensure residents received the appropriate level of assistance to decrease the risk of falls in the facility. He stated if PT had notified nursing staff in February 2016, of the resident's increased need for assistance with ambulation/transfers, then the falls which resulted in injury in March 2016 may have been prevented.

Based on observation, interview, record review, review of the facility's investigation, and review of the facility's policies, it was determined the facility failed to review and revise the comprehensive care plan for one (1) of three (3) sampled residents (Resident #1) after a change in condition occurred. Review of Resident #1's Comprehensive Care Plan, with an effective date of 01/13/15, revealed the facility assessed Resident #1 as being at risk for wandering and at risk for unsupervised exits from the facility. The facility had initiated interventions that included ensuring the resident's wanderguard bracelet was in place. However, Resident #1 removed the wanderguard bracelet from his/her ankle on 04/01/15 and gave it to the nurse. Although staff was aware the resident removed his/her secure bracelet, they failed to review/revise Resident #1's comprehensive care plan to evaluate/consider additional interventions to protect the resident from exiting the facility unsupervised. (Refer to F323.) On 04/07/15, Resident #1 exited the facility without staff knowledge. A staff member, who was driving away from the facility after completing her shift at approximately 2:45 PM, discovered Resident #1. The staff member observed Resident #1 ambulating on the sidewalk beside a public street a short distance (approximately one-tenth of a mile) from the facility. The facility's failure to have an effective system in place to review/evaluate interventions on the care plan to prevent elopement placed residents at risk for elopement in a situation that is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was determined to exist on 04/01/15 at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490), with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 04/21/15. An acceptable Allegation of Compliance was received on 04/30/15 which alleged removal of the Immediate Jeopardy on 04/28/15. A partial extended survey was conducted on 05/04/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/28/15 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Care Planning, (dated July 2013) revealed the care plan would be reviewed if a serious problem occurred to determine if the facility was adequately addressing the resident's needs and the care plan would be revised accordingly. Review of Resident #1's medical record revealed the facility admitted the resident on 08/28/12. The facility assessed the resident to be at risk for wandering and a wanderguard bracelet (an electronic device worn by the resident which elicits an audible alarm when a resident is within a certain range of any exit door equipped with the system, and also prevents the door from immediately opening) was implemented to alert the staff if the resident attempted to exit the facility. Further review of the resident's assessments for wandering, conducted from 07/17/13 through 09/27/14, revealed Resident #1 was not assessed to be at risk for wandering and no longer required the use of the wanderguard bracelet. However, Resident #1 developed a new onset of [MEDICAL CONDITION] activity on 12/06/14 and was hospitalized for [REDACTED].#1 was at risk for wandering, and a wanderguard bracelet was applied to the resident's left ankle. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have short-term memory loss and modified independence with decision-making. Review of Resident #1's Comprehensive Care Plan dated 01/13/15, revealed the facility addressed the resident's wandering risks and risk for unsupervised exits from the facility. Interventions to prevent the resident from leaving the facility unsupervised included ensuring the wanderguard bracelet was in place, ensuring the resident's picture and name were on the wandering resident board, and ensuring the alarmed exits were functional. Review of the Annual Comprehensive MDS assessment completed on 04/17/15, revealed the facility assessed Resident #1 to have short-term memory loss with moderately impaired decision-making skills. The resident was further assessed to have behaviors of wandering which occurred 1-3 days during the assessment reference period. The facility assessed the resident to be independent with ambulation and transfers. Observation of Resident #1 on 04/20/15, at 11:20 AM, revealed the resident was independently ambulatory in and out of his/her room and in the facility hallway. A wanderguard bracelet was observed on the resident's left arm and leg. Review of the Nurse's Progress Notes dated 04/01/15, revealed Resident #1 came to the nurse at approximately 9:45 AM and handed her a wanderguard bracelet and said No. Per the Nurse's Note, the nurse (Licensed Practical Nurse #1) explained to the resident that the bracelet had to be replaced because it was part of his/her plan of care and after coaxing, Resident #1 allowed the bracelet to be reapplied to his/her left wrist. Interview with Licensed Practical Nurse (LPN) #1 on 04/20/15, at 2:00 PM, revealed she replaced the wanderguard bracelet on Resident #1's wrist after the resident removed it on 04/01/15. The LPN stated she reported the incident to the Unit Coordinator (UC) and the UC agreed the bracelet should be replaced. Interview with the UC on 04/21/15, at 3:20 PM, revealed the incident involving Resident #1 removing his/her wanderguard bracelet was discussed in the Interdisciplinary Team (IDT) meeting on 04/02/15. The IDT decided to continue using the bracelet to prevent the resident from leaving the facility without supervision. The UC stated no investigation had been conducted to attempt to determine how the resident was able to remove the bracelet and no other interventions were implemented to prevent the resident from removing his/her wanderguard bracelet and/or leaving the building unsupervised. Interview conducted on 04/21/15, at 1:45 PM with Registered Nurse (RN) #1 revealed she was the Minimum Data Set/Care Plan (MDS/CP) Coordinator and was responsible for reviewing and updating the care plan for Resident #1. RN #1 stated she believed she was present during the IDT meeting to review incidents for possible care plan revisions on 04/02/15. However, she could not recall the discussion regarding Resident #1 removing his/her wanderguard bracelet. She stated she did not update the resident's Comprehensive Plan of Care. Interview with the Administrator and Director of Nurses on 04/21/15, at 12:35 PM, revealed after the IDT discussed Resident #1 removing his/her wanderguard bracelet, the bracelet was reapplied. However, the care plan was not reviewed/revised to consider additional interventions to prevent the resident from leaving the facility unsupervised. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/30/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 was found outside of the facility at approximately 2:45 PM on 04/07/15. Resident #1 was assisted back into the facility safely. The Unit Coordinator completed a physical assessment to rule out injury or acute distress. 2) All residents were accounted for or were determined to be present in the facility by the Unit Coordinators and facility staff. All residents were accounted for at that time. 3) The Administrator and Director of Nurses immediately initiated an investigation of Resident #1's elopement. 4) The wanderguard bracelet was reapplied to Resident #1's left wrist and was verified to be secure by the Unit Coordinator on 04/07/15. 5) The Director of Environmental Services and Safety checked the wander-guard door systems at each exit and elevator on 04/07/15. All systems were functioning properly. 6) The Unit Coordinators verified the wander-guard alarms on the 2nd and 3rd floor elevators' access points were functioning properly on 04/07/15. 7) A 100% audit of residents requiring a wanderguard bracelet was conducted on 04/07/15 to ensure the bracelets were in place. All residents assessed to require a wanderguard bracelet had one in place. 8) Review of the plans of care for all residents who require a wanderguard bracelet was conducted by the MDS Nurses on 04/07/15. No concerns were identified. 9) The Transmitter Logbooks were reviewed by the Unit Coordinators on 04/07/15 for all residents who utilized a wanderguard bracelet to ensure the Licensed Nurses were checking the residents' transmitter daily per protocol. A new Log was added for Resident #1. A new log sheet was initiated because each new bracelet has a different expiration date. 10) The IDT reviewed the unsupervised exit on 04/07/15 and placed Resident #1 on increased monitoring, to be provided in no set pattern at a minimum of every two (2) hours and to be validated by the licensed nurses. The monitoring would be documented on the Frequent Monitoring of Resident Form. The increased monitoring was verbally communicated to each on-coming nurse during the change of shift report until each nurse had received the information. 11) The resident's physician and family were notified on 04/07/15 of the event. No new orders were received. 12) An updated At Risk Wandering Assessment was completed on 04/08/15 by the Unit Coordinator for Resident #1. 13) Resident #1's care plan was updated on 04/08/15 by the MDS Nurse to reflect the resident must be supervised if outside. 14) Beginning 04/07/15, Housekeeping staff will check the door function of the wander-guard system daily and record this on the Housekeeping/Laundry Weekly Round Sheet. 15) The Kentucky [MEDICATION NAME]' Books (Binders with photos of all residents assessed to be at risk for wandering for each unit) were reviewed on 04/21/15. No problems were identified. 16) The Kentucky [MEDICATION NAME]' Bulletin Boards (bulletin boards with photos specific for residents assessed to be wandering risks) maintained at each nursing unit was reviewed on 04/21/15 by the Quality Improvement Assistant Nurse. Some missing photographs were replaced. 17) The Kentucky [MEDICATION NAME]' Boards are maintained at each nurse's station. Copies of the Kentucky [MEDICATION NAME]' Books are maintained at each nurse's station, in the ground floor mailroom and the West Wing therapy gym. 18) The RN Facility Consultant conducted education related to changes in resident behavior; including removal of wanderguard bracelets, review/revision of care plan completion of the At Risk Wander Assessments, monitoring/checking of wanderguard bracelets; documentation in the Transmitter Log book, placement of wander guard bracelets, and improved documentation of IDT meetings. Education was provided by the RN Facility Consultant for the Administrator, Director of Nurses, QI Nurses, MDS Nurses, Unit Coordinators, Staff Development Nurse, Activities Director, Therapy Director, Social Services Staff, and Treatment Nurse on 04/21/15. A posttest was given after the training. 19) The RN Director of Clinical Services provided re-education to the Weekend Supervisor and Administrator on 04/24/15; and, to the Director of Nurses, Unit Coordinators, Staff Facilitator, MDS Nurses and QI Nurses on 04/27/15. Effective 04/28/15, all staff is required to complete education and post-test on the following procedures prior to completing their next shift: A. Wandering/Elopement Residents B. Elopement systems in place to prevent elopement. C. Direct care will immediately notify the charge nurse in the event a resident removes a wander guard bracelet, if it comes off, or is ill fitting. D. The Kentucky [MEDICATION NAME]' Books and bulletin boards are to assist with identification of residents who wander. E. Redirection of wandering residents to protect them from injury or possible elopement. F. Notify the nurse immediately if a resident cannot be found; and, if a resident is sighted outside the facility, the employee should keep the resident in sight. G. Staff's response to exit seeking behavior and statements. 20) All new employees will receive this education during orientation. Employees on leave of absence or vacation will complete this re-education prior to working on the floor. The facility does not utilize agency staff. 21) The RN Director of Clinical Services provided education on 04/24/15 to the Director of Environmental Services and Safety regarding use of the wander-guard equipment, testing of the doors and elevators, completion of the associated forms, redirection of residents, notification of staff regarding exit seeking residents, and response if a resident removes a bracelet. 22) The Director of Environmental Services and Safety provided education for all environmental staff on 04/24/15 regarding use of the wander guard equipment, testing the doors and elevators, completion of the associated forms, and what to do if equipment is found to be malfunctioning. 23) The Director of Environmental Services and Safety will ensure that all housekeeping, laundry, and maintenance staff are re-educated and have completed a post-test prior to completion of their next shift by 04/27/15. 24) The Administrator convened with the IDT on 04/27/15 and directed the verification of the wanderguards would be conducted and documented each shift rather than daily. A licensed nurse will complete the Transmitter Log each shift for all residents requiring a wanderguard bracelet. This was effective 04/27/15. 25) The RN Facility Consultant educated the QI Assistant Nurse on 04/27/15 regarding upkeep of the Kentucky [MEDICATION NAME]' Wander Books and Kentucky [MEDICATION NAME]' Wander Bulletin Boards. The boards will be updated when a resident is placed on, or removed from wandering precautions; and, the books and boards will be reconciled monthly. 26) Beginning 04/07/15, the Frequent Monitoring of Resident form for Resident #1 will be reviewed daily, by the Administrator, Unit Coordinator, RN Facility Consultant, QI Nurse or Weekend House Supervisor. Any issues or concerns will be corrected immediately and reported to the DON or Administrator. 27) Beginning 04/27/15, the Transmitter Log will be completed by licensed nurses each shift to ensure the wander guard bracelets are in place and functioning properly. The Administrator, Director of Admission, Weekend Supervisor, or QI Nurse audited the individual log forms daily. Any concerns will be corrected immediately and reported to the DON or Administrator. 28) The Housekeeping Staff will complete a daily round sheet to ensure the wander guard systems are functioning on the doors and elevators. Beginning 04/27/15, the Director of Environmental Services will audit these forms daily and Safety, Administrator, Weekend Supervisor, Chairman of the Safety committee or QI Nurse, and any concerns will be corrected immediately and reported to the DON or Administrator. 29) The QI Assistant Nurse will continue to update the Kentucky [MEDICATION NAME]' Books and the Kentucky [MEDICATION NAME]' Bulletin Boards as changes occur. Beginning the week of 04/27/15, the DON/QI Nurse will audit the Kentucky [MEDICATION NAME]' Book and Bulletin Board two (2) times each week for accuracy. 30) The IDT will audit shift reports daily to monitor for any resident attempts to leave the building or removal of wander guard bracelets has been identified. Concerns will be addressed immediately. 31) All Audits will be taken to the weekly QI Committee meetings for four (4) weeks and whenever a concern is identified. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of Nursing Progress Notes dated 04/07/15, revealed Resident #1 required no treatment after the elopement and was assessed to have sustained no injury when returned to the facility. 2) Review of the facility's documentation dated 04/07/15, and interviews with Unit Coordinators (UC) #1 on 05/04/15, at 6:00 PM; UC #2 on 05/04/15, at 5:50 PM; and UC #3 on 05/04/15, at 4:50 PM revealed each resident was accounted for on each unit of the facility on 04/07/15. 3) Review of the facility's investigation and interview with the Administrator and Director of Nurses on 05/04/15 at 8:05 PM, revealed the investigation was initiated on 04/07/15. 4) Review of the documentation, dated 04/07/15, revealed the secure care bracelet was replaced on Resident #1's left wrist when the resident was returned to the facility on [DATE]. 5) Review of a Door Audit dated 04/07/15, and signed by the Director of Environmental Services and Safety revealed all wanderguard door systems for the doors and elevators were examined and were functioning properly on 04/07/15. 6) Interviews with UC #2 and UC #3 on 05/04/15 revealed the elevator access was checked with the wanderguard system on 04/07/15 and no problems were identified. 7) Review of the facility's documentation dated 04/07/15, and interviews with Unit Coordinators (UC) on 05/04/15 at 6:00 PM with UC #1; at 5:50 PM with UC #2; and, 4:50 PM with UC #3, revealed a 100% audit was conducted of residents who required a secure care bracelet. All residents assessed to require a secure care bracelet had one in place. 8) Review of the facility's documentation and interviews with MDS Nurses (LPNs #3 and # 4 and RN #10) on 05/04/15, at 4:55 PM, revealed all care plans had been reviewed for residents who required a secure care bracelet. 9) Review of the Transmitter Log books revealed each resident (including Resident #1) who required a wanderguard bracelet was being monitored each shift by a licensed nurse to ensure the bracelet was in place and functioning. Interview with UC (#1, #2, and #3) on 05/04/15 revealed the UC monitored the Transmitter Log book daily to ensure the bracelets were being checked by the licensed nurses and documented/reported any concerns to the Administrator. 10) Review of the Frequent Monitoring of Resident form from 04/07/15 through 05/04/15 revealed the monitoring checks were documented as conducted at different times with no pattern, but not greater than two (2) hour intervals. Documentation further revealed a licensed nurse daily reviewed the checks. Interviews on 05/04/15, at 5:30 PM with LPN #1, 6:50 PM with CNA # 5, and 7:00 PM with CNA #7, revealed Frequent Monitoring had been conducted for Resident #1 from 04/07/15 through 05/04/15 at different times and staff was aware of the monitoring procedures for Resident #1. Interview with LPN #1 on 04/05/15, at 5:30 PM and with UC #1 at 6:00 PM revealed they had communicated the monitoring procedures related to Resident #1 to the on-coming nurse during change of shift report to ensure each nurse had received the instruction. 11) Review of documentation revealed Resident #1's Physician and Responsible Party were notified the resident had eloped from the facility on 04/07/15. 12) Review of the facility's documentation revealed a new At Risk Wandering Assessment form was completed on 04/08/15 for Resident #1. 13) Review of Resident #1's Comprehensive Care Plan revealed it was updated on 04/08/15 to reflect the elopement incident of 04/07/15 and to ensure the wanderguard bracelet would be in place and to frequently monitor the resident's whereabouts. 14) Review of Housekeeping/Laundry Round Sheets dated 04/07/15 through 05/04/15 revealed housekeeping staff had been conducting daily checks of the door functions of the wanderguard systems. 15) The Kentucky [MEDICATION NAME] Books were observed to be located at each nurse's station on 05/04/15. The Books contained pictures for each resident identified as at risk for wandering. 16) The Kentucky [MEDICATION NAME]' Bulletin Boards was observed to be maintained at each nurse's station on 05/04/15 and contained pictures for each resident identified as a wandering risk on each unit. 17) Copies of The Kentucky [MEDICATION NAME]' Books were also observed on 05/04/15 to be maintained in the ground floor mailroom and the West Wing therapy gym, in addition to each nursing unit. 18) Review of the In-service Training related to Changes in Resident Behavior, dated 04/21/15, revealed the training had been conducted by the RN Facility Consultant. Interviews conducted on 05/04/15 at 8:05 PM with the Administrator; 7:45 PM with the DON; 5:05 PM with the QI Assistant Nurse; 7:15 PM with MDS Nurse #2; 7:25 PM with MDS Nurse #3; 7:30 PM with the QI Coordinator; 8:10 PM with the Rehabilitation Manager; 8:15 PM with the Social Services Director; 8:07 PM with Activity Director; 8:20 PM with Treatment Nurse; 5:50 PM with UC #2; 6:00 PM with UC #1; and, 4:50 PM with UC #3 revealed all the staff interviewed had attended the training and were knowledgeable related to monitoring/documentation of the wanderguard bracelets. Staff was also able to verbally state the steps to take if a resident eloped from the facility. Staff completed a posttest. 19) Review of the In-service Training related to Wandering Residents and Elopements Systems dated 04/24/15 and 04/27/15, revealed the training had been conducted by the RN Director of Clinical Services. Interviews conducted on 05/04/15 at 8:05 PM with the Administrator; 7:45 PM with the DON; 5:50 PM with UC #2; 6:00 PM with UC #1; 4:50 PM with UC #3; 8:15 PM with the Weekend Supervisor; 5:05 PM with the QI Assistant Nurse; 7:30 PM with the QI Coordinator; and, 8:20 PM with the Staff Development Coordinator revealed all the staff interviewed had attended the training and was familiar with the identification system for wandering residents and the behavior management of exit seeking behaviors. Review of the In-service Training dated 04/28/15, revealed this training was also provided for all facility staff by the DON, UC, Staff Development Nurse, and QI Nurse. Interviews conducted on 05/04/15 at 3:05 PM with RN #4, 6:35 PM with RN #5, 5:30 PM with LPN #1, 6:25 PM with LPN #2, 6:45 PM with LPN #10, 8:20 PM with LPN #6, 6:50 PM with CNA #7, 6:55 PM with CNA #8, 7:00 PM with CNA #9, 7:05 PM with CNA #10, 7:10 PM with CNA #11, 7:15 PM with CNA #12, 5:45 PM with the Maintenance Director, 5:20 PM with the Environmental Services Director, 5:40 PM with Laundry Staff #1, 7:40 PM with Housekeeper (HSK) #1, 7:45 PM with HSK #2, 7:55 PM with HSK #3, 8:05 PM with HSK #4, 8:16 PM with the Weekend Supervisor, and 8:20 PM with the Staff Development Coordinator, revealed all the staff interviewed had attended the training and was familiar with the identification system for wandering residents and behavior management of exit seeking behaviors. All staff took a posttest. 20) Review of the employee list on 05/04/15 revealed no new employees had been hired by the facility since 04/28/15. 21) Review of the In-service Training Testing of the Doors dated 04/24/15, revealed the training was provided by the RN Director of Clinical Services. Interview with the Environmental Services Director on 05/04/15 at 5:20 PM revealed he attended the training regarding use of the wanderguard equipment and testing of the doors and elevations. 22) Review of the In-service Training Testing of the Doors dated 04/27/15, revealed training was provided to the housekeeping, laundry, and maintenance staff by the Environmental Services Director. Interviews conducted on 05/04/15 at 5:45 PM with the Maintenance Director, 5:40 PM with Laundry Staff #1, 7:40 PM with Housekeeper (HSK) #1, 7:45 PM with HSK #2, 7:55 PM with HSK #3, and 8:05 PM with HSK #4 revealed these staff attended the training related to testing the doors. Staff interviewed was able to verbally state how the doors and elevators were monitored each day and how the results were to be documented on the daily round sheet. 23) Review of the employee list on 05/04/15 and In-service training record confirmed all staff had been trained and a posttest completed by 04/27/15. 24) Review of the Transmitter Log books revealed the verification of the wanderguard bracelets was being conducted and documented each shift since 04/27/15 by a licensed nurse. 25) Review of the In-service Training Kentucky [MEDICATION NAME]' Boards and Books dated 04/27/15 revealed training was provided by the RN Facility Consultant for the QA Assistant Nurse related to keeping the Kentucky [MEDICATION NAME]'s Books and Bulletin Boards up to date. Interview with the QI Assistant Nurse on 05/04/15 at 5:05 PM, confirmed the training had been provided and the employee was able to relate the process to keep the books/boards up to date. 26) Review of the Frequent Monitoring of Resident Forms for Resident #1 dated 04/07/15 through 05/04/15 confirmed the Administrator or the Week end Supervisor reviewed the forms daily to ensure the monitoring was being provided for the resident. No problems had been identified. 27) Review of the Transmitter Log books dated 04/27/15 through 05/04/15 provided evidence the licensed nurses were monitoring the wanderguard bracelets each shift to ensure the bracelets were in place and functioning for each resident who was assessed to require a bracelet. Further review revealed the Administrator or the Weekend Supervisor was reviewing the logs daily. No problems had been identified. 28) Review of the daily round sheet dated 04/27/15 through 05/04/15 revealed housekeeping staff had checked the exit doors and elevators daily to ensure the alarm systems were functioning. Further review revealed the Director of Environmental Services, Administrator, or the Weekend Supervisor had been conducting daily audits of the round sheets to ensure the doors were being checked daily. No problems had been identified. 29) Review of the audits conducted by the DON and/or QI Nurse revealed the Kentucky [MEDICATION NAME]' Boards and Books were current and up to date for the residents assessed to be at risk for wandering on 05/04/15. 30) Review of the shift report audits conducted daily by IDT team revealed there had been no resident attempts to leave the building or removal of their wanderguard bracelet. 31) Review of the Quality Improvement meeting documentation dated 04/29/15 revealed all data collected and audits conducted related to the facility's response to Resident #1's elopement from the facility on 04/07/15, were reviewed during the meeting. Interview with the Administrator on 05/04/15 at 8:05 PM revealed no significant changes in the facility's implemented plan were determined to be necessary during the meeting. Interview with the Medical Director on 05/04/15, at 3:50 PM revealed he attended the 04/29/15 QI meeting and was aware of the elopement of Resident #1 and corrective plan implemented by the facility.

Based on observation, interview, record review, facility policy review, and review of the facility's investigation it was determined the facility failed to have an effective system in place to ensure that one (1) of three (3) sampled residents (Resident #1) received adequate supervision and monitoring to prevent accidents. The facility assessed Resident #1 to be an elopement risk on 12/07/12, and placed a wanderguard bracelet (an electronic device worn which elicits an audible alarm within a certain range of an exit door equipped for this device) on the resident's left ankle to ensure the resident was safe and to monitor the resident's whereabouts. On 04/01/15, Resident #1 removed the wanderguard bracelet and took it to the nurse who replaced the bracelet on the resident's left wrist. However, the facility failed to evaluate how the resident removed the bracelet, and failed to implement any additional interventions to keep the resident safe. On 04/07/15, Resident #1 again removed the wanderguard bracelet and exited the facility without staff knowledge. At approximately 2:45 PM, Resident #1 was seen by a staff member, who was driving away from the facility after work. The resident was initially seen by the employee to be approximately one-tenth of a mile from the facility on a sidewalk beside a city street. After being notified by the staff member who was going home, staff at the facility determined the resident was missing and was not on facility grounds. The resident was assisted back to the facility and staff assisted him/her back into the building and determined the resident had not sustained any injury. The facility staff was not aware the resident had left the building. The facility's failure to have an effective system in place to ensure adequate supervision and monitoring for residents who were at risk for elopement was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 04/01/15 at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 04/21/15. An acceptable Allegation of Compliance was received on 04/30/15 which alleged removal of the Immediate Jeopardy on 04/28/15. A partial extended survey was conducted on 05/04/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/28/15 as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Wandering Protocol, (dated November 2013) revealed resident pictures would be displayed on bulletin boards located on each unit or employee lounge bulletin boards. The policy noted if a resident was suspected of elopement, staff would immediately notify the supervisor, mobilize a search in the building and premises, call 911, and notify the resident's physician and family. Interview with the Administrator on 04/20/15, at 5:30 PM, revealed the facility did not have a specific policy/procedure related to Resident Supervision. Interview with the Director of Nurses (DON) on 04/21/15, at 12:35 PM, revealed the facility did not have a specific policy related to assessment of residents who wander. However, the DON stated all residents were assessed upon admission, readmission, quarterly, and when a change in condition occurred to establish the resident's wandering/elopement risks. In addition, the DON stated the wanderguard bracelets were implemented as an intervention for residents to minimize the risks for elopement. Record review revealed the facility admitted Resident #1 on 08/28/12, with [DIAGNOSES REDACTED]. The facility initially assessed Resident #1 to be at risk for wandering and a wanderguard bracelet was implemented. Further review of the resident's assessments for wandering conducted from 07/17/13 through 09/27/14, revealed Resident #1 was no longer assessed to be at risk for wandering and did not require the use of the secure care bracelet. Observation of Resident #1 on 04/20/15, at 11:30 AM, revealed the resident was sitting in a chair in his/her room. The resident was unable to speak clearly, but made attempts through gestures. Resident #1 was observed to ambulate independently in his/her room and the facility hallway without difficulty. Review of the clinical record revealed Resident #1 developed a new onset of seizure activity on 12/06/14 and was transferred to the hospital for evaluation and treatment. The resident returned to the facility on [DATE] and a new assessment for wandering/elopement determined the resident was at risk for wandering/elopement. A wanderguard bracelet was applied to the resident's left ankle. According to the Comprehensive Care Plan, dated 01/13/15, the facility addressed the resident's wandering risks and risk for unsupervised exits from the facility. Interventions to prevent the resident from leaving the facility unsupervised included ensuring the wanderguard bracelet was in place, ensuring the resident's picture and name were on the wandering resident board, and ensuring the alarmed exits were functional. Review of the Annual Minimum Data Set (MDS) assessment completed on 04/17/15 revealed the facility assessed Resident #1 to have short-term memory loss with moderately impaired decision-making skills. The resident was further assessed to have behaviors of wandering which occurred 1-3 days during the assessment reference period. The facility assessed the resident to be independent with ambulation and transfers. Review of the facility's investigation initiated on 04/07/15 revealed at approximately 2:45 PM on 04/07/15, a staff member discovered Resident #1 walking on a sidewalk beside a public street between the facility and a church. According to the investigation, the resident had removed the wanderguard bracelet and left the facility without staff knowledge. The staff person leaving the facility saw the resident and returned to the facility to inform staff she believed the resident was walking on the sidewalk. After a search, staff determined the resident was missing. Staff assisted Resident #1 back into the facility and assessed the resident to have sustained no injury. The resident was wearing a light jacket and tennis shoes. According to the archived weather records, the temperature in the area at 2:45 PM on 04/07/15 was 71 degrees Fahrenheit. Interview conducted with Certified Nurse Aide (CNA) #1 on 04/20/15, at 2:45 PM, revealed she had cared for Resident #1 on 04/07/15. The CNA stated she assisted the resident with a shower at approximately 1:15 PM and last saw the resident at 1:30 PM. CNA #1 stated Resident #1 was not in his/her room during the 2:30 PM rounds, but she was not alarmed and thought the resident was in the bathroom. CNA #1 said she was aware the resident had removed his/her bracelet once before. She stated the resident had the bracelet on his/her left wrist on 04/07/15. The CNA further stated she was not aware the resident was out of the facility until CNA #2 reported seeing the resident ambulating toward the church. Interview with CNA #2 on 04/21/15, at 12:10 PM, revealed she ended her shift at the facility and clocked out at 2:45 PM on 04/07/15. CNA #2 stated she was driving down the street away from the facility when she observed an individual, whom she believed could be Resident #1, walking between the church and the facility. The CNA stated she immediately went back to the facility, leaving the resident unsupervised, and asked staff if the resident was at the facility. According to CNA #2, the facility staff immediately searched for the resident and determined he/she was not in the building and was not on facility grounds. Further interview with CNA #2 revealed she got in her car and went back toward the location where she previously had seen the resident and spotted the resident farther down the street in front of the fire department (approximately three-tenths of a mile from the facility). The CNA stated she coaxed the resident to get in her vehicle and then transported the resident back to the facility at approximately 2:50 PM. Interview with the Director of Nurses (DON) on 04/21/15, at 12:35 PM revealed she was aware Resident #1 had been able to remove the wanderguard bracelet on 04/01/15. The DON stated the issue had been discussed in the Interdisciplinary Team Meeting (IDT) the following day. She further stated the team had made the decision to continue using the bracelet for Resident #1 to prevent elopement risks. The DON stated she could not recall if any additional monitoring had been implemented for the resident at that time, but the staff had not anticipated that Resident #1 would leave the facility unsupervised. Interview with the Administrator on 04/21/15 at 1:20 PM, revealed he also was aware the resident had removed the wanderguard bracelet and was he was also involved in the IDT meeting on 04/02/15 to discuss the issue. The Administrator stated the wanderguard bracelet had been replaced; however, no additional supervision had been added to monitor the resident's whereabouts. The Administrator stated he had not believed Resident #1 would leave the facility without supervision. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/30/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 was found outside of the facility at approximately 2:45 PM on 04/07/15. Resident #1 was assisted back into the facility safely. The Unit Coordinator completed a physical assessment to rule out injury or acute distress. 2) All residents were accounted for or were determined to be present in the facility by the Unit Coordinators and facility staff. All residents were accounted for at that time. 3) The Administrator and Director of Nurses immediately initiated an investigation of Resident #1's elopement. 4) The wanderguard bracelet was reapplied to Resident #1's left wrist and was verified to be secure by the Unit Coordinator on 04/07/15. 5) The Director of Environmental Services and Safety checked the wander-guard door systems at each exit and elevator on 04/07/15. All systems were functioning properly. 6) The Unit Coordinators verified the wander-guard alarms on the 2nd and 3rd floor elevators' access points were functioning properly on 04/07/15. 7) A 100% audit of residents requiring a wanderguard bracelet was conducted on 04/07/15 to ensure the bracelets were in place. All residents assessed to require a wanderguard bracelet had one in place. 8) Review of the plans of care for all residents who require a wanderguard bracelet was conducted by the MDS Nurses on 04/07/15. No concerns were identified. 9) The Transmitter Logbooks were reviewed by the Unit Coordinators on 04/07/15 for all residents who utilized a wanderguard bracelet to ensure the Licensed Nurses were checking the residents' transmitter daily per protocol. A new Log was added for Resident #1. A new log sheet was initiated because each new bracelet has a different expiration date. 10) The IDT reviewed the unsupervised exit on 04/07/15 and placed Resident #1 on increased monitoring, to be provided in no set pattern at a minimum of every two (2) hours and to be validated by the licensed nurses. The monitoring would be documented on the Frequent Monitoring of Resident Form. The increased monitoring was verbally communicated to each on-coming nurse during the change of shift report until each nurse had received the information. 11) The resident's physician and family were notified on 04/07/15 of the event. No new orders were received. 12) An updated At Risk Wandering Assessment was completed on 04/08/15 by the Unit Coordinator for Resident #1. 13) Resident #1's care plan was updated on 04/08/15 by the MDS Nurse to reflect the resident must be supervised if outside. 14) Beginning 04/07/15, Housekeeping staff will check the door function of the wander-guard system daily and record this on the Housekeeping/Laundry Weekly Round Sheet. 15) The Kentucky Travelers' Books (Binders with photos of all residents assessed to be at risk for wandering for each unit) were reviewed on 04/21/15. No problems were identified. 16) The Kentucky Travelers' Bulletin Boards (bulletin boards with photos specific for residents assessed to be wandering risks) maintained at each nursing unit was reviewed on 04/21/15 by the Quality Improvement Assistant Nurse. Some missing photographs were replaced. 17) The Kentucky Travelers' Boards are maintained at each nurse's station. Copies of the Kentucky Travelers' Books are maintained at each nurse's station, in the ground floor mailroom and the West Wing therapy gym. 18) The RN Facility Consultant conducted education related to changes in resident behavior; including removal of wanderguard bracelets, review/revision of care plan completion of the At Risk Wander Assessments, monitoring/checking of wanderguard bracelets; documentation in the Transmitter Log book, placement of wander guard bracelets, and improved documentation of IDT meetings. Education was provided by the RN Facility Consultant for the Administrator, Director of Nurses, QI Nurses, MDS Nurses, Unit Coordinators, Staff Development Nurse, Activities Director, Therapy Director, Social Services Staff, and Treatment Nurse on 04/21/15. A posttest was given after the training. 19) The RN Director of Clinical Services provided re-education to the Weekend Supervisor and Administrator on 04/24/15; and, to the Director of Nurses, Unit Coordinators, Staff Facilitator, MDS Nurses and QI Nurses on 04/27/15. Effective 04/28/15, all staff is required to complete education and post-test on the following procedures prior to completing their next shift: A. Wandering/Elopement Residents B. Elopement systems in place to prevent elopement. C. Direct care will immediately notify the charge nurse in the event a resident removes a wander guard bracelet, if it comes off, or is ill fitting. D. The Kentucky Travelers' Books and bulletin boards are to assist with identification of residents who wander. E. Redirection of wandering residents to protect them from injury or possible elopement. F. Notify the nurse immediately if a resident cannot be found; and, if a resident is sighted outside the facility, the employee should keep the resident in sight. G. Staff's response to exit seeking behavior and statements. 20) All new employees will receive this education during orientation. Employees on leave of absence or vacation will complete this re-education prior to working on the floor. The facility does not utilize agency staff. 21) The RN Director of Clinical Services provided education on 04/24/15 to the Director of Environmental Services and Safety regarding use of the wander-guard equipment, testing of the doors and elevators, completion of the associated forms, redirection of residents, notification of staff regarding exit seeking residents, and response if a resident removes a bracelet. 22) The Director of Environmental Services and Safety provided education for all environmental staff on 04/24/15 regarding use of the wander guard equipment, testing the doors and elevators, completion of the associated forms, and what to do if equipment is found to be malfunctioning. 23) The Director of Environmental Services and Safety will ensure that all housekeeping, laundry, and maintenance staff are re-educated and have completed a post-test prior to completion of their next shift by 04/27/15. 24) The Administrator convened with the IDT on 04/27/15 and directed the verification of the wanderguards would be conducted and documented each shift rather than daily. A licensed nurse will complete the Transmitter Log each shift for all residents requiring a wanderguard bracelet. This was effective 04/27/15. 25) The RN Facility Consultant educated the QI Assistant Nurse on 04/27/15 regarding upkeep of the Kentucky Travelers' Wander Books and Kentucky Travelers' Wander Bulletin Boards. The boards will be updated when a resident is placed on, or removed from wandering precautions; and, the books and boards will be reconciled monthly. 26) Beginning 04/07/15, the Frequent Monitoring of Resident form for Resident #1 will be reviewed daily, by the Administrator, Unit Coordinator, RN Facility Consultant, QI Nurse or Weekend House Supervisor. Any issues or concerns will be corrected immediately and reported to the DON or Administrator. 27) Beginning 04/27/15, the Transmitter Log will be completed by licensed nurses each shift to ensure the wander guard bracelets are in place and functioning properly. The Administrator, Director of Admission, Weekend Supervisor, or QI Nurse audited the individual log forms daily. Any concerns will be corrected immediately and reported to the DON or Administrator. 28) The Housekeeping Staff will complete a daily round sheet to ensure the wander guard systems are functioning on the doors and elevators. Beginning 04/27/15, the Director of Environmental Services will audit these forms daily and Safety, Administrator, Weekend Supervisor, Chairman of the Safety committee or QI Nurse, and any concerns will be corrected immediately and reported to the DON or Administrator. 29) The QI Assistant Nurse will continue to update the Kentucky Travelers' Books and the Kentucky Travelers' Bulletin Boards as changes occur. Beginning the week of 04/27/15, the DON/QI Nurse will audit the Kentucky Travelers' Book and Bulletin Board two (2) times each week for accuracy. 30) The IDT will audit shift reports daily to monitor for any resident attempts to leave the building or removal of wander guard bracelets has been identified. Concerns will be addressed immediately. 31) All Audits will be taken to the weekly QI Committee meetings for four (4) weeks and whenever a concern is identified. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of Nursing Progress Notes dated 04/07/15, revealed Resident #1 required no treatment after the elopement and was assessed to have sustained no injury when returned to the facility. 2) Review of the facility's documentation dated 04/07/15, and interviews with Unit Coordinators (UC) #1 on 05/04/15, at 6:00 PM; UC #2 on 05/04/15, at 5:50 PM; and UC #3 on 05/04/15, at 4:50 PM revealed each resident was accounted for on each unit of the facility on 04/07/15. 3) Review of the facility's investigation and interview with the Administrator and Director of Nurses on 05/04/15 at 8:05 PM, revealed the investigation was initiated on 04/07/15. 4) Review of the documentation, dated 04/07/15, revealed the secure care bracelet was replaced on Resident #1's left wrist when the resident was returned to the facility on [DATE]. 5) Review of a Door Audit dated 04/07/15, and signed by the Director of Environmental Services and Safety revealed all wanderguard door systems for the doors and elevators were examined and were functioning properly on 04/07/15. 6) Interviews with UC #2 and UC #3 on 05/04/15 revealed the elevator access was checked with the wanderguard system on 04/07/15 and no problems were identified. 7) Review of the facility's documentation dated 04/07/15, and interviews with Unit Coordinators (UC) on 05/04/15 at 6:00 PM with UC #1; at 5:50 PM with UC #2; and, 4:50 PM with UC #3, revealed a 100% audit was conducted of residents who required a secure care bracelet. All residents assessed to require a secure care bracelet had one in place. 8) Review of the facility's documentation and interviews with MDS Nurses (LPNs #3 and # 4 and RN #10) on 05/04/15, at 4:55 PM, revealed all care plans had been reviewed for residents who required a secure care bracelet. 9) Review of the Transmitter Log books revealed each resident (including Resident #1) who required a wanderguard bracelet was being monitored each shift by a licensed nurse to ensure the bracelet was in place and functioning. Interview with UC (#1, #2, and #3) on 05/04/15 revealed the UC monitored the Transmitter Log book daily to ensure the bracelets were being checked by the licensed nurses and documented/reported any concerns to the Administrator. 10) Review of the Frequent Monitoring of Resident form from 04/07/15 through 05/04/15 revealed the monitoring checks were documented as conducted at different times with no pattern, but not greater than two (2) hour intervals. Documentation further revealed a licensed nurse daily reviewed the checks. Interviews on 05/04/15, at 5:30 PM with LPN #1, 6:50 PM with CNA # 5, and 7:00 PM with CNA #7, revealed Frequent Monitoring had been conducted for Resident #1 from 04/07/15 through 05/04/15 at different times and staff was aware of the monitoring procedures for Resident #1. Interview with LPN #1 on 04/05/15, at 5:30 PM and with UC #1 at 6:00 PM revealed they had communicated the monitoring procedures related to Resident #1 to the on-coming nurse during change of shift report to ensure each nurse had received the instruction. 11) Review of documentation revealed Resident #1's Physician and Responsible Party were notified the resident had eloped from the facility on 04/07/15. 12) Review of the facility's documentation revealed a new At Risk Wandering Assessment form was completed on 04/08/15 for Resident #1. 13) Review of Resident #1's Comprehensive Care Plan revealed it was updated on 04/08/15 to reflect the elopement incident of 04/07/15 and to ensure the wanderguard bracelet would be in place and to frequently monitor the resident's whereabouts. 14) Review of Housekeeping/Laundry Round Sheets dated 04/07/15 through 05/04/15 revealed housekeeping staff had been conducting daily checks of the door functions of the wanderguard systems. 15) The Kentucky Travelers Books were observed to be located at each nurse's station on 05/04/15. The Books contained pictures for each resident identified as at risk for wandering. 16) The Kentucky Travelers' Bulletin Boards was observed to be maintained at each nurse's station on 05/04/15 and contained pictures for each resident identified as a wandering risk on each unit. 17) Copies of The Kentucky Travelers' Books were also observed on 05/04/15 to be maintained in the ground floor mailroom and the West Wing therapy gym, in addition to each nursing unit. 18) Review of the In-service Training related to Changes in Resident Behavior, dated 04/21/15, revealed the training had been conducted by the RN Facility Consultant. Interviews conducted on 05/04/15 at 8:05 PM with the Administrator; 7:45 PM with the DON; 5:05 PM with the QI Assistant Nurse; 7:15 PM with MDS Nurse #2; 7:25 PM with MDS Nurse #3; 7:30 PM with the QI Coordinator; 8:10 PM with the Rehabilitation Manager; 8:15 PM with the Social Services Director; 8:07 PM with Activity Director; 8:20 PM with Treatment Nurse; 5:50 PM with UC #2; 6:00 PM with UC #1; and, 4:50 PM with UC #3 revealed all the staff interviewed had attended the training and were knowledgeable related to monitoring/documentation of the wanderguard bracelets. Staff was also able to verbally state the steps to take if a resident eloped from the facility. Staff completed a posttest. 19) Review of the In-service Training related to Wandering Residents and Elopements Systems dated 04/24/15 and 04/27/15, revealed the training had been conducted by the RN Director of Clinical Services. Interviews conducted on 05/04/15 at 8:05 PM with the Administrator; 7:45 PM with the DON; 5:50 PM with UC #2; 6:00 PM with UC #1; 4:50 PM with UC #3; 8:15 PM with the Weekend Supervisor; 5:05 PM with the QI Assistant Nurse; 7:30 PM with the QI Coordinator; and, 8:20 PM with the Staff Development Coordinator revealed all the staff interviewed had attended the training and was familiar with the identification system for wandering residents and the behavior management of exit seeking behaviors. Review of the In-service Training dated 04/28/15, revealed this training was also provided for all facility staff by the DON, UC, Staff Development Nurse, and QI Nurse. Interviews conducted on 05/04/15 at 3:05 PM with RN #4, 6:35 PM with RN #5, 5:30 PM with LPN #1, 6:25 PM with LPN #2, 6:45 PM with LPN #10, 8:20 PM with LPN #6, 6:50 PM with CNA #7, 6:55 PM with CNA #8, 7:00 PM with CNA #9, 7:05 PM with CNA #10, 7:10 PM with CNA #11, 7:15 PM with CNA #12, 5:45 PM with the Maintenance Director, 5:20 PM with the Environmental Services Director, 5:40 PM with Laundry Staff #1, 7:40 PM with Housekeeper (HSK) #1, 7:45 PM with HSK #2, 7:55 PM with HSK #3, 8:05 PM with HSK #4, 8:16 PM with the Weekend Supervisor, and 8:20 PM with the Staff Development Coordinator, revealed all the staff interviewed had attended the training and was familiar with the identification system for wandering residents and behavior management of exit seeking behaviors. All staff took a posttest. 20) Review of the employee list on 05/04/15 revealed no new employees had been hired by the facility since 04/28/15. 21) Review of the In-service Training Testing of the Doors dated 04/24/15, revealed the training was provided by the RN Director of Clinical Services. Interview with the Environmental Services Director on 05/04/15 at 5:20 PM revealed he attended the training regarding use of the wanderguard equipment and testing of the doors and elevations. 22) Review of the In-service Training Testing of the Doors dated 04/27/15, revealed training was provided to the housekeeping, laundry, and maintenance staff by the Environmental Services Director. Interviews conducted on 05/04/15 at 5:45 PM with the Maintenance Director, 5:40 PM with Laundry Staff #1, 7:40 PM with Housekeeper (HSK) #1, 7:45 PM with HSK #2, 7:55 PM with HSK #3, and 8:05 PM with HSK #4 revealed these staff attended the training related to testing the doors. Staff interviewed was able to verbally state how the doors and elevators were monitored each day and how the results were to be documented on the daily round sheet. 23) Review of the employee list on 05/04/15 and In-service training record confirmed all staff had been trained and a posttest completed by 04/27/15. 24) Review of the Transmitter Log books revealed the verification of the wanderguard bracelets was being conducted and documented each shift since 04/27/15 by a licensed nurse. 25) Review of the In-service Training Kentucky Travelers' Boards and Books dated 04/27/15 revealed training was provided by the RN Facility Consultant for the QA Assistant Nurse related to keeping the Kentucky Traveler's Books and Bulletin Boards up to date. Interview with the QI Assistant Nurse on 05/04/15 at 5:05 PM, confirmed the training had been provided and the employee was able to relate the process to keep the books/boards up to date. 26) Review of the Frequent Monitoring of Resident Forms for Resident #1 dated 04/07/15 through 05/04/15 confirmed the Administrator or the Week end Supervisor reviewed the forms daily to ensure the monitoring was being provided for the resident. No problems had been identified. 27) Review of the Transmitter Log books dated 04/27/15 through 05/04/15 provided evidence the licensed nurses were monitoring the wanderguard bracelets each shift to ensure the bracelets were in place and functioning for each resident who was assessed to require a bracelet. Further review revealed the Administrator or the Weekend Supervisor was reviewing the logs daily. No problems had been identified. 28) Review of the daily round sheet dated 04/27/15 through 05/04/15 revealed housekeeping staff had checked the exit doors and elevators daily to ensure the alarm systems were functioning. Further review revealed the Director of Environmental Services, Administrator, or the Weekend Supervisor had been conducting daily audits of the round sheets to ensure the doors were being checked daily. No problems had been identified. 29) Review of the audits conducted by the DON and/or QI Nurse revealed the Kentucky Travelers' Boards and Books were current and up to date for the residents assessed to be at risk for wandering on 05/04/15. 30) Review of the shift report audits conducted daily by IDT team revealed there had been no resident attempts to leave the building or removal of their wanderguard bracelet. 31) Review of the Quality Improvement meeting documentation dated 04/29/15 revealed all data collected and audits conducted related to the facility's response to Resident #1's elopement from the facility on 04/07/15, were reviewed during the meeting. Interview with the Administrator on 05/04/15 at 8:05 PM revealed no significant changes in the facility's implemented plan were determined to be necessary during the meeting. Interview with the Medical Director on 05/04/15, at 3:50 PM revealed he attended the 04/29/15 QI meeting and was aware of the elopement of Resident #1 and corrective plan implemented by the facility.

Based on interview, record review, review of the facility's investigation, review of the facility Administrator's job description, and review of the facility's policy and procedures it was determined the facility Administrator failed to ensure the facility's resources, including policies related to supervision to prevent accidents and elopement, were used effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of three (3) sampled residents (Resident #1). On 04/01/15, Resident #1 removed a wanderguard bracelet from his/her left ankle that was implemented to reduce the resident's risks for elopement. The Administrator was aware the resident removed his/her wanderguard bracelet and he also attended an Interdisciplinary Team (IDT) meeting to discuss the incident related to the resident removing his/her bracelet. However, the Administrator failed to ensure policies and procedures were implemented to ensure the resident was provided the necessary supervision to prevent elopement. On 04/07/15, Resident #1 again removed his/her wanderguard bracelet and left the facility without staff knowledge. The resident was discovered outside the facility walking on a city sidewalk. (Refer to F280 and F323.) The facility's failure to have an effective system in place to ensure the Administrator used the facility's resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being for each resident was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was determined to exist on 04/01/15 at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490) with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 04/21/15. An acceptable Allegation of Compliance was received on 04/30/15 which alleged removal of the Immediate Jeopardy on 04/28/15. A partial extended survey was conducted on 05/04/15. The State Survey Agency determined the Immediate Jeopardy was removed on 04/28/15, as alleged, which lowered the Scope and Severity to D at 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.25 Quality of Care (F323), and 42 CFR 483.75 Administration (F490) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility Administrator's job description (dated September 2012) revealed the Administrator's primary purpose was to direct the overall operation of the facility's activities in accordance with federal, state, and local standards, guidelines, and regulations. Review of the Nurse's Progress Notes dated 04/01/15, revealed Resident #1 removed his/her wanderguard bracelet from his/her left ankle and gave it to the nurse. Facility staff replaced the bracelet. Review of the facility's investigation initiated on 04/07/15 revealed Resident #1 was discovered at approximately 2:45 PM on 04/07/15, by a staff member, walking down a city sidewalk between the facility and a church. According to the investigation, the resident had removed the wanderguard bracelet and left the facility without staff knowledge. The staff person leaving the facility saw the resident and returned to the facility to determine if the person she saw walking down the sidewalk was indeed the resident. After a search, facility staff determined the resident was missing. Facility staff assisted Resident #1 back into the facility and assessed the resident to have sustained no injury. The Administrator acknowledged in interview conducted on 04/21/15 at 1:20 PM, he was aware the resident had removed the wanderguard bracelet on 04/01/15. Further interview revealed the Administrator was involved in the IDT meeting on 04/02/15 to discuss the 04/01/15 incident when Resident #1 removed his/her wanderguard bracelet. However, according to the Administrator, the resident's bracelet had been reapplied and no additional supervision had been added to monitor the resident's whereabouts. The Administrator stated he did not believe the resident would leave the facility unsupervised and the IDT felt the bracelet was adequate. **The facility provided an acceptable Allegation of Compliance (AOC) on 04/30/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 was found outside of the facility at approximately 2:45 PM on 04/07/15. Resident #1 was assisted back into the facility safely. The Unit Coordinator completed a physical assessment to rule out injury or acute distress. 2) All residents were accounted for or were determined to be present in the facility by the Unit Coordinators and facility staff. All residents were accounted for at that time. 3) The Administrator and Director of Nurses immediately initiated an investigation of Resident #1's elopement. 4) The wanderguard bracelet was reapplied to Resident #1's left wrist and was verified to be secure by the Unit Coordinator on 04/07/15. 5) The Director of Environmental Services and Safety checked the wander-guard door systems at each exit and elevator on 04/07/15. All systems were functioning properly. 6) The Unit Coordinators verified the wander-guard alarms on the 2nd and 3rd floor elevators' access points were functioning properly on 04/07/15. 7) A 100% audit of residents requiring a wanderguard bracelet was conducted on 04/07/15 to ensure the bracelets were in place. All residents assessed to require a wanderguard bracelet had one in place. 8) Review of the plans of care for all residents who require a wanderguard bracelet was conducted by the MDS Nurses on 04/07/15. No concerns were identified. 9) The Transmitter Logbooks were reviewed by the Unit Coordinators on 04/07/15 for all residents who utilized a wanderguard bracelet to ensure the Licensed Nurses were checking the residents' transmitter daily per protocol. A new Log was added for Resident #1. A new log sheet was initiated because each new bracelet has a different expiration date. 10) The IDT reviewed the unsupervised exit on 04/07/15 and placed Resident #1 on increased monitoring, to be provided in no set pattern at a minimum of every two (2) hours and to be validated by the licensed nurses. The monitoring would be documented on the Frequent Monitoring of Resident Form. The increased monitoring was verbally communicated to each on-coming nurse during the change of shift report until each nurse had received the information. 11) The resident's physician and family were notified on 04/07/15 of the event. No new orders were received. 12) An updated At Risk Wandering Assessment was completed on 04/08/15 by the Unit Coordinator for Resident #1. 13) Resident #1's care plan was updated on 04/08/15 by the MDS Nurse to reflect the resident must be supervised if outside. 14) Beginning 04/07/15, Housekeeping staff will check the door function of the wander-guard system daily and record this on the Housekeeping/Laundry Weekly Round Sheet. 15) The Kentucky [MEDICATION NAME]' Books (Binders with photos of all residents assessed to be at risk for wandering for each unit) were reviewed on 04/21/15. No problems were identified. 16) The Kentucky [MEDICATION NAME]' Bulletin Boards (bulletin boards with photos specific for residents assessed to be wandering risks) maintained at each nursing unit was reviewed on 04/21/15 by the Quality Improvement Assistant Nurse. Some missing photographs were replaced. 17) The Kentucky [MEDICATION NAME]' Boards are maintained at each nurse's station. Copies of the Kentucky [MEDICATION NAME]' Books are maintained at each nurse's station, in the ground floor mailroom and the West Wing therapy gym. 18) The RN Facility Consultant conducted education related to changes in resident behavior; including removal of wanderguard bracelets, review/revision of care plan completion of the At Risk Wander Assessments, monitoring/checking of wanderguard bracelets; documentation in the Transmitter Log book, placement of wander guard bracelets, and improved documentation of IDT meetings. Education was provided by the RN Facility Consultant for the Administrator, Director of Nurses, QI Nurses, MDS Nurses, Unit Coordinators, Staff Development Nurse, Activities Director, Therapy Director, Social Services Staff, and Treatment Nurse on 04/21/15. A posttest was given after the training. 19) The RN Director of Clinical Services provided re-education to the Weekend Supervisor and Administrator on 04/24/15; and, to the Director of Nurses, Unit Coordinators, Staff Facilitator, MDS Nurses and QI Nurses on 04/27/15. Effective 04/28/15, all staff is required to complete education and post-test on the following procedures prior to completing their next shift: A. Wandering/Elopement Residents B. Elopement systems in place to prevent elopement. C. Direct care will immediately notify the charge nurse in the event a resident removes a wander guard bracelet, if it comes off, or is ill fitting. D. The Kentucky [MEDICATION NAME]' Books and bulletin boards are to assist with identification of residents who wander. E. Redirection of wandering residents to protect them from injury or possible elopement. F. Notify the nurse immediately if a resident cannot be found; and, if a resident is sighted outside the facility, the employee should keep the resident in sight. G. Staff's response to exit seeking behavior and statements. 20) All new employees will receive this education during orientation. Employees on leave of absence or vacation will complete this re-education prior to working on the floor. The facility does not utilize agency staff. 21) The RN Director of Clinical Services provided education on 04/24/15 to the Director of Environmental Services and Safety regarding use of the wander-guard equipment, testing of the doors and elevators, completion of the associated forms, redirection of residents, notification of staff regarding exit seeking residents, and response if a resident removes a bracelet. 22) The Director of Environmental Services and Safety provided education for all environmental staff on 04/24/15 regarding use of the wander guard equipment, testing the doors and elevators, completion of the associated forms, and what to do if equipment is found to be malfunctioning. 23) The Director of Environmental Services and Safety will ensure that all housekeeping, laundry, and maintenance staff are re-educated and have completed a post-test prior to completion of their next shift by 04/27/15. 24) The Administrator convened with the IDT on 04/27/15 and directed the verification of the wanderguards would be conducted and documented each shift rather than daily. A licensed nurse will complete the Transmitter Log each shift for all residents requiring a wanderguard bracelet. This was effective 04/27/15. 25) The RN Facility Consultant educated the QI Assistant Nurse on 04/27/15 regarding upkeep of the Kentucky [MEDICATION NAME]' Wander Books and Kentucky [MEDICATION NAME]' Wander Bulletin Boards. The boards will be updated when a resident is placed on, or removed from wandering precautions; and, the books and boards will be reconciled monthly. 26) Beginning 04/07/15, the Frequent Monitoring of Resident form for Resident #1 will be reviewed daily, by the Administrator, Unit Coordinator, RN Facility Consultant, QI Nurse or Weekend House Supervisor. Any issues or concerns will be corrected immediately and reported to the DON or Administrator. 27) Beginning 04/27/15, the Transmitter Log will be completed by licensed nurses each shift to ensure the wander guard bracelets are in place and functioning properly. The Administrator, Director of Admission, Weekend Supervisor, or QI Nurse audited the individual log forms daily. Any concerns will be corrected immediately and reported to the DON or Administrator. 28) The Housekeeping Staff will complete a daily round sheet to ensure the wander guard systems are functioning on the doors and elevators. Beginning 04/27/15, the Director of Environmental Services will audit these forms daily and Safety, Administrator, Weekend Supervisor, Chairman of the Safety committee or QI Nurse, and any concerns will be corrected immediately and reported to the DON or Administrator. 29) The QI Assistant Nurse will continue to update the Kentucky [MEDICATION NAME]' Books and the Kentucky [MEDICATION NAME]' Bulletin Boards as changes occur. Beginning the week of 04/27/15, the DON/QI Nurse will audit the Kentucky [MEDICATION NAME]' Book and Bulletin Board two (2) times each week for accuracy. 30) The IDT will audit shift reports daily to monitor for any resident attempts to leave the building or removal of wander guard bracelets has been identified. Concerns will be addressed immediately. 31) All Audits will be taken to the weekly QI Committee meetings for four (4) weeks and whenever a concern is identified. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of Nursing Progress Notes dated 04/07/15, revealed Resident #1 required no treatment after the elopement and was assessed to have sustained no injury when returned to the facility. 2) Review of the facility's documentation dated 04/07/15, and interviews with Unit Coordinators (UC) #1 on 05/04/15, at 6:00 PM; UC #2 on 05/04/15, at 5:50 PM; and UC #3 on 05/04/15, at 4:50 PM revealed each resident was accounted for on each unit of the facility on 04/07/15. 3) Review of the facility's investigation and interview with the Administrator and Director of Nurses on 05/04/15 at 8:05 PM, revealed the investigation was initiated on 04/07/15. 4) Review of the documentation, dated 04/07/15, revealed the secure care bracelet was replaced on Resident #1's left wrist when the resident was returned to the facility on [DATE]. 5) Review of a Door Audit dated 04/07/15, and signed by the Director of Environmental Services and Safety revealed all wanderguard door systems for the doors and elevators were examined and were functioning properly on 04/07/15. 6) Interviews with UC #2 and UC #3 on 05/04/15 revealed the elevator access was checked with the wanderguard system on 04/07/15 and no problems were identified. 7) Review of the facility's documentation dated 04/07/15, and interviews with Unit Coordinators (UC) on 05/04/15 at 6:00 PM with UC #1; at 5:50 PM with UC #2; and, 4:50 PM with UC #3, revealed a 100% audit was conducted of residents who required a secure care bracelet. All residents assessed to require a secure care bracelet had one in place. 8) Review of the facility's documentation and interviews with MDS Nurses (LPNs #3 and # 4 and RN #10) on 05/04/15, at 4:55 PM, revealed all care plans had been reviewed for residents who required a secure care bracelet. 9) Review of the Transmitter Log books revealed each resident (including Resident #1) who required a wanderguard bracelet was being monitored each shift by a licensed nurse to ensure the bracelet was in place and functioning. Interview with UC (#1, #2, and #3) on 05/04/15 revealed the UC monitored the Transmitter Log book daily to ensure the bracelets were being checked by the licensed nurses and documented/reported any concerns to the Administrator. 10) Review of the Frequent Monitoring of Resident form from 04/07/15 through 05/04/15 revealed the monitoring checks were documented as conducted at different times with no pattern, but not greater than two (2) hour intervals. Documentation further revealed a licensed nurse daily reviewed the checks. Interviews on 05/04/15, at 5:30 PM with LPN #1, 6:50 PM with CNA # 5, and 7:00 PM with CNA #7, revealed Frequent Monitoring had been conducted for Resident #1 from 04/07/15 through 05/04/15 at different times and staff was aware of the monitoring procedures for Resident #1. Interview with LPN #1 on 04/05/15, at 5:30 PM and with UC #1 at 6:00 PM revealed they had communicated the monitoring procedures related to Resident #1 to the on-coming nurse during change of shift report to ensure each nurse had received the instruction. 11) Review of documentation revealed Resident #1's Physician and Responsible Party were notified the resident had eloped from the facility on 04/07/15. 12) Review of the facility's documentation revealed a new At Risk Wandering Assessment form was completed on 04/08/15 for Resident #1. 13) Review of Resident #1's Comprehensive Care Plan revealed it was updated on 04/08/15 to reflect the elopement incident of 04/07/15 and to ensure the wanderguard bracelet would be in place and to frequently monitor the resident's whereabouts. 14) Review of Housekeeping/Laundry Round Sheets dated 04/07/15 through 05/04/15 revealed housekeeping staff had been conducting daily checks of the door functions of the wanderguard systems. 15) The Kentucky [MEDICATION NAME] Books were observed to be located at each nurse's station on 05/04/15. The Books contained pictures for each resident identified as at risk for wandering. 16) The Kentucky [MEDICATION NAME]' Bulletin Boards was observed to be maintained at each nurse's station on 05/04/15 and contained pictures for each resident identified as a wandering risk on each unit. 17) Copies of The Kentucky [MEDICATION NAME]' Books were also observed on 05/04/15 to be maintained in the ground floor mailroom and the West Wing therapy gym, in addition to each nursing unit. 18) Review of the In-service Training related to Changes in Resident Behavior, dated 04/21/15, revealed the training had been conducted by the RN Facility Consultant. Interviews conducted on 05/04/15 at 8:05 PM with the Administrator; 7:45 PM with the DON; 5:05 PM with the QI Assistant Nurse; 7:15 PM with MDS Nurse #2; 7:25 PM with MDS Nurse #3; 7:30 PM with the QI Coordinator; 8:10 PM with the Rehabilitation Manager; 8:15 PM with the Social Services Director; 8:07 PM with Activity Director; 8:20 PM with Treatment Nurse; 5:50 PM with UC #2; 6:00 PM with UC #1; and, 4:50 PM with UC #3 revealed all the staff interviewed had attended the training and were knowledgeable related to monitoring/documentation of the wanderguard bracelets. Staff was also able to verbally state the steps to take if a resident eloped from the facility. Staff completed a posttest. 19) Review of the In-service Training related to Wandering Residents and Elopements Systems dated 04/24/15 and 04/27/15, revealed the training had been conducted by the RN Director of Clinical Services. Interviews conducted on 05/04/15 at 8:05 PM with the Administrator; 7:45 PM with the DON; 5:50 PM with UC #2; 6:00 PM with UC #1; 4:50 PM with UC #3; 8:15 PM with the Weekend Supervisor; 5:05 PM with the QI Assistant Nurse; 7:30 PM with the QI Coordinator; and, 8:20 PM with the Staff Development Coordinator revealed all the staff interviewed had attended the training and was familiar with the identification system for wandering residents and the behavior management of exit seeking behaviors. Review of the In-service Training dated 04/28/15, revealed this training was also provided for all facility staff by the DON, UC, Staff Development Nurse, and QI Nurse. Interviews conducted on 05/04/15 at 3:05 PM with RN #4, 6:35 PM with RN #5, 5:30 PM with LPN #1, 6:25 PM with LPN #2, 6:45 PM with LPN #10, 8:20 PM with LPN #6, 6:50 PM with CNA #7, 6:55 PM with CNA #8, 7:00 PM with CNA #9, 7:05 PM with CNA #10, 7:10 PM with CNA #11, 7:15 PM with CNA #12, 5:45 PM with the Maintenance Director, 5:20 PM with the Environmental Services Director, 5:40 PM with Laundry Staff #1, 7:40 PM with Housekeeper (HSK) #1, 7:45 PM with HSK #2, 7:55 PM with HSK #3, 8:05 PM with HSK #4, 8:16 PM with the Weekend Supervisor, and 8:20 PM with the Staff Development Coordinator, revealed all the staff interviewed had attended the training and was familiar with the identification system for wandering residents and behavior management of exit seeking behaviors. All staff took a posttest. 20) Review of the employee list on 05/04/15 revealed no new employees had been hired by the facility since 04/28/15. 21) Review of the In-service Training Testing of the Doors dated 04/24/15, revealed the training was provided by the RN Director of Clinical Services. Interview with the Environmental Services Director on 05/04/15 at 5:20 PM revealed he attended the training regarding use of the wanderguard equipment and testing of the doors and elevations. 22) Review of the In-service Training Testing of the Doors dated 04/27/15, revealed training was provided to the housekeeping, laundry, and maintenance staff by the Environmental Services Director. Interviews conducted on 05/04/15 at 5:45 PM with the Maintenance Director, 5:40 PM with Laundry Staff #1, 7:40 PM with Housekeeper (HSK) #1, 7:45 PM with HSK #2, 7:55 PM with HSK #3, and 8:05 PM with HSK #4 revealed these staff attended the training related to testing the doors. Staff interviewed was able to verbally state how the doors and elevators were monitored each day and how the results were to be documented on the daily round sheet. 23) Review of the employee list on 05/04/15 and In-service training record confirmed all staff had been trained and a posttest completed by 04/27/15. 24) Review of the Transmitter Log books revealed the verification of the wanderguard bracelets was being conducted and documented each shift since 04/27/15 by a licensed nurse. 25) Review of the In-service Training Kentucky [MEDICATION NAME]' Boards and Books dated 04/27/15 revealed training was provided by the RN Facility Consultant for the QA Assistant Nurse related to keeping the Kentucky [MEDICATION NAME]'s Books and Bulletin Boards up to date. Interview with the QI Assistant Nurse on 05/04/15 at 5:05 PM, confirmed the training had been provided and the employee was able to relate the process to keep the books/boards up to date. 26) Review of the Frequent Monitoring of Resident Forms for Resident #1 dated 04/07/15 through 05/04/15 confirmed the Administrator or the Week end Supervisor reviewed the forms daily to ensure the monitoring was being provided for the resident. No problems had been identified. 27) Review of the Transmitter Log books dated 04/27/15 through 05/04/15 provided evidence the licensed nurses were monitoring the wanderguard bracelets each shift to ensure the bracelets were in place and functioning for each resident who was assessed to require a bracelet. Further review revealed the Administrator or the Weekend Supervisor was reviewing the logs daily. No problems had been identified. 28) Review of the daily round sheet dated 04/27/15 through 05/04/15 revealed housekeeping staff had checked the exit doors and elevators daily to ensure the alarm systems were functioning. Further review revealed the Director of Environmental Services, Administrator, or the Weekend Supervisor had been conducting daily audits of the round sheets to ensure the doors were being checked daily. No problems had been identified. 29) Review of the audits conducted by the DON and/or QI Nurse revealed the Kentucky [MEDICATION NAME]' Boards and Books were current and up to date for the residents assessed to be at risk for wandering on 05/04/15. 30) Review of the shift report audits conducted daily by IDT team revealed there had been no resident attempts to leave the building or removal of their wanderguard bracelet. 31) Review of the Quality Improvement meeting documentation dated 04/29/15 revealed all data collected and audits conducted related to the facility's response to Resident #1's elopement from the facility on 04/07/15, were reviewed during the meeting. Interview with the Administrator on 05/04/15 at 8:05 PM revealed no significant changes in the facility's implemented plan were determined to be necessary during the meeting. Interview with the Medical Director on 05/04/15, at 3:50 PM revealed he attended the 04/29/15 QI meeting and was aware of the elopement of Resident #1 and corrective plan implemented by the facility.

Based on interview, record review, and review of the facility's policies it was determined the facility failed to maintain complete clinical records for ten (10) of fourteen (14) sampled residents (Residents #1, #2, #3, #7, #8, #9, #10, #11, #12, and #13). On 03/08/15 between 8:30 AM and 9:30 AM, Resident #1 complained of shortness of breath, pain, and chest congestion. The facility assessed the resident to be slightly pale and short of air with oxygen saturation that ranged from 87 to 92% (normal range is 95 - 100%). The resident's physician was contacted and orders were received [MEDICATION NAME](antibiotic) and [MEDICATION NAME] nebulizer treatment (breathing treatment); however, the nurse failed to document the time of the telephone order. Staff interviews revealed Resident #1 did not eat or drink as usual for lunch and was observed by staff between 2:00 PM and 3:00 PM to be pale, clammy, and staring off (not focusing). The nurse was notified of the resident's further change in condition at lunch and, another change in condition that was noted around 2:00 PM to 3:00 PM; however, there was no documented evidence regarding the assessment/monitoring of the resident's condition. On 03/08/15 at 4:15 PM, the family visited Resident #1 and found the resident with labored breathing and lethargic. The nurse was notified of the resident's condition by the family; however, the nurse did not assess Resident #1 and document the findings of the assessment or the resident's condition. After the family contacted the Advanced Practice Registered Nurse (APRN), Resident #1 was transferred to the local hospital and required intubation (a tube placed in the mouth and throat for breathing). Resident #1 later sustained a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The resident was admitted to the hospital and passed away at 5:00 AM on 03/09/15. In addition, the facility failed to maintain complete clinical records for Residents #2, #3, #7, #8, #9, #10, #11, #12, and #13 related to documentation of the receipt time of telephone physician orders. Facility nursing staff failed to consistently document the time verbal telephone Physician order [REDACTED]. The facility's failure to ensure each resident had an accurate clinical record was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/08/15 at 42 CFR 483.10 Resident Rights (F157 -J), 42 CFR 483.20 Resident Assessment (F282 - J), 42 CFR 483.25 Quality of Care (F309 -J), and 42 CFR 483.75 Administration (F514 - K). The facility was notified of the Immediate Jeopardy on 03/20/15. An acceptable Allegation of Compliance was received on 03/24/15, which alleged removal of the Immediate Jeopardy on 03/25/15. A partial extended survey was conducted on 03/25-26/15. The State Survey Agency determined the Immediate Jeopardy was removed on 03/25/15, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F282), and 42 CFR 483.25 Quality of Care (F309); and 42 CFR 483.75 Administration (F514) was lowered to an E while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Receipt of physician's orders [REDACTED]. Review of the Order Form (BN2002) revealed a section for documentation of the time and date the order was received by the nurse. Review of the facility's policy titled Interact Care Path dated 11/21/12, revealed it was the licensed nurse's responsibility to document review of the resident, reporting of the resident's condition, implementation of care per orders, outcomes of treatment, and the resident's condition. 1. Interview with Licensed Practical Nurse (LPN) #1 on 03/19/15 at 2:50 PM, revealed she was assigned to care for Resident #1 on 03/08/15. According to LPN #1, the resident reported to her during the 8:00 AM medication pass, that he/she was having trouble breathing and that he/she may be getting [MEDICAL CONDITION]. LPN #1 stated Resident #1 had problems holding a cup during breakfast, which was unusual for the resident. According to LPN #1, the resident was assessed and his/her vital signs were obtained on 03/08/15 between 7:00 AM and 9:00 AM; however, the vital signs were not documented until 10:10 AM. LPN #1 stated she contacted Resident #1's Physician sometime after breakfast and obtained orders for an antibiotic and an as needed nebulizer treatment. Further interview revealed LPN #1 assisted the resident to bed after lunch (exact time unknown) with the use of a lift. The LPN stated she administered Resident #1's 2:00 PM medications between 1:00 PM and 3:00 PM and did not notice any additional concerns or changes for the resident, but she did not document the resident's oxygen saturation. Further interview with LPN #1 revealed she rechecked Resident #1's oxygen saturation later in the day at an unknown time and the results had improved; however, LPN #1 stated she did not document the results in the resident's record. Further interview with LPN #1 revealed on 03/08/15 at approximately 4:20 PM, she was approached by a family member of Resident #1 and asked what was going on with the resident. The LPN stated she reported to the family member what she had told the physician earlier in the day and that the resident had received medications. LPN #1 stated the family member did not agree with the physician's orders [REDACTED].#1 had pneumonia. LPN #1 stated she told the family member that Resident #1 very well could have pneumonia. LPN #1 stated she later (time unknown) received a call from an APRN who worked for Resident #1's Primary Care Physician. The LPN told the APRN the resident's condition and the physician's orders [REDACTED]. LPN #1 stated the APRN called her back and gave her orders for Resident #1 to be transferred to the hospital for evaluation and treatment. LPN #1 stated that she did not assess Resident #1 after the family had notified her of their concerns with the resident's condition because she was getting paperwork ready to transfer the resident to the hospital. The LPN stated she only saw the resident when the paramedics were transporting the resident on a stretcher from the facility. According to LPN #1, residents were charted on during each shift and monitored during medication administration, meals, and during walking rounds conducted at shift change. However, according to the facility's policy, it was LPN #1's responsibility, as a licensed nurse, to document her review of the resident, document the report of the resident's condition and outcomes of the resident's treatment. Review of Nurse's Notes entered at 11:16 AM revealed the Physician was notified earlier, (the time was not documented) and orders were received [MEDICATION NAME] mg (an antibiotic) twice daily and an [MEDICATION NAME] Nebulizer (medication for breathing) treatment every four (4) hours as needed. According to the Note, the medications were given, but the time was not documented in the Note. Further review of the record revealed a Note entered on 03/08/15 at 4:52 PM, which stated Resident #1's daughter was at the facility, and disagreed with the type of treatment for [REDACTED]. The Nurse Practitioner called LPN #1 to discuss the resident's situation. The Nurse's Note further stated the daughter wanted the resident sent to the hospital and orders were received to send the resident to the hospital. Review of the clinical record revealed no documented evidence of assessment findings, follow up of treatment, or the resident's condition from 11:16 AM on 03/08/15 through the time the resident left the facility, which should have been completed, according to facility policy. Further review of the clinical record revealed Physician Telephone Orders were received for Resident #1 on 02/12/15, 03/01/15, 03/03/15, 03/04/15, and 03/08/15. However, the times the physician's orders [REDACTED]. 2. Review of the medical record for Resident #2 revealed physician telephone orders were received on 03/10/15, 3/11/15, and 03/19/15. However, further review revealed the time the order was received was not included on the Telephone Order Form. 3. Review of the medical record for Resident #3 revealed physician telephone orders were received on 03/05/15, 03/06/15, 03/11/15, 03/12/15, and 03/16/15. Further review of the record revealed the time the physician orders [REDACTED]. 4. Review of the medical record for Resident #7 revealed physician telephone orders were received on 03/03/15, 03/10/15, and 03/23/15. However, further review of the medical record revealed the time the order was received was not included on the Telephone Order Form. 5. Review of the medical record for Resident #8 revealed a physician telephone order was received on 03/24/15. Further review of the medical record revealed the time the order was received was not included on the Telephone Order Form. 6. Review of the medical record for Resident #9 revealed physician telephone orders were received on 03/04/15 and 03/10/15. Further review of the medical record revealed the time the physician orders [REDACTED]. 7. Review of the medical record for Resident #10 revealed physician telephone orders were received on 03/06/15, 03/11/15, 03/12/15, 03/17/15, and 03/24/15. However, further review of the medical record revealed the time the order was received was not included on the Telephone Order Form. 8. Review of the medical record for Resident #11 revealed physician telephone orders were received on 03/06/15, 03/07/15, 03/08/15, 03/09/15, 03/11/15, 03/23/15, and 03/24/15. Further review of the medical record revealed the time the physician orders [REDACTED]. 9. Review of the medical record for Resident #12 revealed physician telephone orders were received on 03/01/15, 03/09/15, and 03/11/15. However, further review of the medical record revealed the time the order was received was not included on the Telephone Order Form. 10. Review of the medical record for Resident #13 revealed physician telephone orders were received on 03/05/15, 03/06/15, 03/07/15, 03/19/15, and 03/24/15. Further review of the medical record revealed the time the physician orders [REDACTED]. Interview conducted with Licensed Practical Nurse (LPN) #2 on 03/26/15 at 11:00 AM, revealed all physician's telephone orders should include the time the order was received/written. However, the LPN stated she often forgot to document the time when the order was received on the physician's orders [REDACTED]. Interview with the Treatment Nurse on 03/26/15 at 11:30 AM, revealed the nurse was to document the time the physician's orders [REDACTED]. Interview conducted with Registered Nurse (RN) #1 on 03/26/15 at 12:50 PM, revealed the physician's orders [REDACTED]. RN #1 stated she would often forget to include the time on the physician's orders [REDACTED]. Interview conducted with the West Wing Unit Manager on 03/26/15 at 1:15 PM, revealed the Unit Manager had been conducting daily audits of the residents' records but had not identified a problem with physician telephone orders with the times not being documented. Interview with the Director of Nursing (DON) on 03/26/15 at 2:45 PM, revealed the facility did not have a specific policy to address timing of physician's orders [REDACTED]. The DON stated that this section should be filled in each time a nurse received and documented a telephone physician's orders [REDACTED]. [REDACTED]. **The facility provided an acceptable Allegation of Compliance (AOC) on 03/13/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On 03/08/15, Resident #1 was sent to the hospital and treated in the emergency room for pneumonia,[MEDICAL CONDITION], and ST segment elevation [MEDICAL CONDITION] infarction (STEMI) ([MEDICAL CONDITION]). The resident had a stent placed. Resident #1 passed away at the hospital on [DATE]. 2) On 03/21/15-03/22/15 the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor conducted evaluations of all current residents to determine if there were any medical needs requiring physician notification which had not been addressed. Two issues were identified. A --A [MEDICAL TREATMENT] patient (identified by the facility as Resident A) refused [MEDICAL TREATMENT] and later had weeping from the lower extremities. A nursing intervention was implemented, the resident's physician was notified of the change, physician orders [REDACTED]. The Unit Manager validated implementation of the new orders and continued monitoring of the resident. B--Resident B (identified by the facility as Resident B), who had a [DIAGNOSES REDACTED]. The Physician was made aware and ordered diagnostic testing, the resident's responsible party was notified of the resident's condition, and the procedure was ordered. The Unit Manager validated the implementation of the new orders and monitoring of the patient. On 03/21/15-03/22/15, the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor reviewed all current residents' plans of care to determine that all interventions were being followed. Minor revisions were made to the care plans as needed. One care plan was significantly changed related to a patient's condition of [MEDICAL CONDITION] (interventions were in place). No change to the plans of care required notification to a Physician. 3) The INTERACT program is an evidence based Plan, Do, Check, Act process developed through funding from the Centers for Medicare and Medicaid Services (CMS) to prevent unnecessary acute care transfers and includes a binder of care paths, which are algorithms used for directing nurses through evaluating residents, providing care, and notifying the physician for certain common symptoms. It includes the SBAR (Situation, Background, Analysis, and Request) tool for nurses to complete and effectively communicate a resident's condition or change of condition with the Physician. On 03/20/15, the RN (Registered Nurse) Nurse Consultant re-educated the Staff Facilitator regarding conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluations, as well as physician notification; and for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor and began re-education of Nurses, Medication Technicians, and Certified Nurse Aides on conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluation, as well as physician notification; and for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/21/15-03/22/15, Unit Managers, MDS Nurses, QI Nurses, Weekend House Supervisor, and Staff Facilitator continued with re-education with all Nurses, Medication Technicians, and Certified Nurse Aides related to conducting an evaluation based on resident condition to include the INTERACT program, follow-up evaluations, as well as physician notification for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15, the RN Facility Consultant re-educated the Staff Facilitator regarding the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. On 3/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor on the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Beginning 03/21/15 and ongoing, all licensed staff was re-educated by the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, or Staff Facilitator regarding the requirement to follow the plan of care and if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Approximately 90 percent of the licensed nurses and approximately 75 percent of the Medication Aides and Certified Nurse Aides have completed the in-service education and posttest. These staff indicated understanding and stated all questions were answered at the end of the education sessions. Posttests were developed on 03/23/15 for Licensed Nurses, Medication Technicians, and Certified Nurse Aides to demonstrate retained knowledge of the re-education. This re-education included adding the resident to the acute charting, passing information on to the next shift of nurses, documentation of resident evaluations, the outcome, and if a change is noted. 0n 03/21/15-03/22/15, Unit Managers, MDS Nurses, QI Nurses, Weekend House Supervisor and Staff Facilitator continued with re-education with all Nurses, Medication Technicians, Certified Nurse Aides related to conducting an evaluation based on resident condition to include the INTERACT program, follow up evaluation as well as physician notification for a significant change in condition referring to the INTERACT program but not to supersede nursing judgment. This re-education included documentation of resident evaluations, the outcome, and if a change is noted in resident condition. Post Tests were developed on 03/23/15 for Licensed Nurses, Medication Technicians, and Certified Nurse Aides. No Licensed Nurse, Medication Technician, or CNA will work after 03/23/15 without having completed this re-education. No Licensed Nurse, Medication Aide, or CNA will provide patient care after 03/24/15 without having completed both the re-education and posttest. Beginning 03/21/15 and ongoing, all CNAs were re-educated with following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No CNAs will work after 03/23/15 without having received this re-education. All newly employed direct care staff will receive this education prior to working on a unit. Direct care staff on leave of absence or vacation will complete this re-education prior to working. 4) Beginning 03/23/15, the Director of Nursing, QI Nurses, Unit Managers, Staff Facilitator, Weekend House Supervisor, or RN Facility Consultant will conduct walking rounds to review with facility licensed nurse staff residents' conditions daily. These rounds will also include an investigation to determine if licensed staff are notifying the physician of significant changes in condition and completing ongoing evaluation as needed. This process will also include observation and discussion with Licensed Nurses and Certified Nurse Aides to determine if plans of care, including revisions, are being followed. The rounds will also consist of discussion with CNAs to determine if they have noted any changes in the residents throughout their shift and review of the STOP and WATCH (the tool included in the INTERACT program for CNAs to alert changes in resident condition in the electronic medical record). This will continue daily until abatement of Immediate Jeopardy then four (4) times per week for four (4) weeks thereafter. Beginning 03/23/15, the Director of Nursing, QI Nurses, Staff Facilitator, Unit Managers, Weekend House Supervisor, or RN Facility Consultant will review all Nurse's Notes daily to determine if any significant change in condition has occurred without physician notification or any significant change in condition has occurred without evaluation. This will occur daily until abatement of the Immediate Jeopardy and then four (4) times per week for four (4) weeks. The Clinical Interdisciplinary Team (IDT) which includes the Director of Nursing, Unit Managers, QI Nurses, Staff Facilitator, MDS Nurses, Weekend House Supervisor, RN Facility Consultant, or Treatment Nurse, will continue to follow the established process of reviewing the Nurse's Notes, Shift Reports, and physician's orders [REDACTED]. The Weekend House Supervisor reviews the documents Saturday and Sunday and reports to the Director of Nursing and Administrator at least daily. The Weekend House Supervisor and MDS Nurses will revise care plans through the established process. 5) On 03/20/15, an ad hoc Quality Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Associate Medical Director who approved. In attendance was the Administrator, RN Facility Consultant, Unit Managers, QI Nurses, MDS Nurses, Social Services Director, Kitchen Manager, Staff Facilitator, Admissions Director, and Activity Director. No further recommendations were made. The Administrator, Director of Nursing, QI Nurses, or RN Facility consultant will review the audits daily until abatement of Immediate Jeopardy. Thereafter, the results of these audits will be reviewed with the Quality Improvement Committee weekly and anytime a concern is identified until substantial compliance has been achieved; then per the schedule established by the Executive QI Committee. Thereafter, Members of the QI Committee will consist of at a minimum, the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, and Staff Facilitator. The Executive QI Committee consists of the Administrator, Director of Nursing Services, Unit Managers, QI Nurses, RN MDS Coordinator, Staff Facilitator, Treatment Nurse, Social Services Director, Social Services Assistant, Director of Activities, Director of Admissions, Dietary Services Director, Maintenance Director, Director of Environment and Safety, and Medical Director ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the closed record for Resident #1 revealed the resident was transferred to the hospital on [DATE]. 2) Observations conducted of Residents #11, #12, #13, and #14 on 03/25/15-03/26/15 revealed no concerns with changes of condition or following the plan of care. Review of Resident #11's medical record (identified by the facility as Resident A) revealed the facility assessed the resident to have weeping [MEDICAL CONDITION] to the lower extremities on 03/21/15. The resident's physician was notified of the change in the resident's condition on 03/21/15 at 7:39 PM, and orders were received for Keflex (antibiotic) 500 mg for [MEDICAL CONDITION] to the lower extremities. Review of the plan of care revealed no concerns. Review of the medical record for Resident #12 (identified by the facility as Resident B) revealed the facility assessed the resident to have a change in condition on 03/22/15 at 9:06 PM. The resident had [MEDICAL CONDITION] to the lower extremities. The resident's physician was notified and orders received for a venous study. Review of the plan of care revealed no concerns. Review of medical records for Residents #13 and #14 revealed the residents were assessed for a change of condition on 03/21/15 with no changes of condition identified. Review of the plans of care for these residents revealed no concerns. 3) Interview with the Staff Facilitator on 03/26/15 at 1:55 PM revealed the Staff Facilitator had been trained by the Nurse Consultant on the Interact Program related to follow-up evaluations/assessments of residents using the SBAR tool. The Nurse Consultant had also trained the Staff Facilitator on assessing changes of condition, physician notification, and following residents' plans of care. According to the Staff Facilitator, she then began training all nursing staff. Interviews with CNAs #3, #4, #5, #6, #7, and #8 on 03/26/15 at 10:52 AM, 11:11 AM, 11:34 AM, 11:50 AM, 2:05 PM, and 2:20 PM respectfully, revealed the CNAs had been trained regarding notifying the nurse of a change of condition, using the Stop and Watch program, the resident assessment for change of condition, and following the plan of care. Interviews on 03/26/15 with LPN #2 at 11:00 AM, LPN #3 at 10:55 AM, LPN #4 at 1:00 PM, RN #1 at 12:50 PM, the Treatment Nurse at 11:30 AM, the West Wing Unit Manager at 1:15 PM, and the Second Floor Unit Manager at 1:30 PM revealed they had been trained regarding changes of condition, assessing/monitoring residents after a change of condition, notification of the physician, using the SBAR form, and following the resident's care plan. Review of the INTERACT training documentation revealed the training was given on 03/20/15, the Staff Facilitator had been educated by the Nurse Consultant and the Staff Facilitator conducted training for nursing staff with no concerns identified. The documentation revealed the facility was monitoring staff that had been trained to ensure they were following the process. Review of posttests revealed staff had been given posttests and the results were reviewed by the facility. 4) Interviews on 03/26/15 with the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, the MDS Nurse at 2:15 PM, the QI Nurse at 2:25 PM, and the West Wing Unit Manager at 1:15 PM revealed walking rounds were being conducted twice daily. These rounds included review of Nurse's Notes for SBAR assessments; monitor residents for change in condition; staff to discuss residents' condition with nurses and CNAs; and ensure care plans were being followed. They were also monitoring to ensure physicians were notified if needed and to ensure that nurses conducted follow-up evaluations if needed. Review of the facility's documentation of walking rounds conducted from 03/22/15 through 03/26/15 revealed walking rounds were being completed and were ongoing on 03/26/15 with no concerns identified. 5) Interviews on 03/26/15 at 3:30 PM with the Administrator, the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, and the QI Nurse at 2:25 PM revealed the facility's Quality Assurance Committee was meeting daily to review daily audits for concerns with assessments, physician notification of change of condition, and following the residents' plans of care. Review of the Quality Assurance Committee minutes conducted on 03/21/15 through 03/26/15 revealed the facility had identified no concerns. Interviews conducted on 04/15/15 (post survey interviews) with SRNA #2 at 11:00 AM, SRNA #7 at 12:10 PM, SRNA #1 at 12:50 PM and SRNA #9 at 1:30 PM, revealed the SRNAs had been trained to ensure accurate documentation of the Stop and Watch assessments to report changes of condition. Post survey interviews on 04/15/15 with LPN #5 at 1:20 PM and LPN #6 at 1:45 PM, Revealed the LPN had been trained and were knowledgeable of the facility's Interact policy and had been trained to accurately document assessments and physician's orders [REDACTED]. Post survey interview with the West Wing Unit Manager on 04/15/15 at 12:45 PM, revealed the Unit Manager had been making rounds to review charting on residents for accuracy and to ensure changes of condition and assessments were accurately documented in the residents' medical records. Interview on 04/15/15 (post survey interview), with the DON at 2:40 PM and the Administrator at 2:50 PM revealed the Management Team had been meeting twice daily to review audits completed to ensure changes of condition, assessments, and physician notifications were documented accurately. Further interview revealed the facility Quality Assurance committee had been meeting weekly to review/monitor the effectiveness of training and ongoing interventions. Record reviews conducted for Residents #15, #16, and #17 which included physician's orders [REDACTED]. Review of in-service education initiated on 03/20/15 revealed staff was trained on the facility's Interact Program to ensure complete and accurate documentation of physician's orders [REDACTED].

Based on interview, record review, and review of the facility's policy it was determined the facility failed to notify the physician of a significant change of condition for one (1) of fourteen (14) sampled residents (Resident #1). On 03/08/15, at approximately 8:30 AM to 9:30 AM, Resident #1 (who was normally alert and oriented) complained of shortness of breath, pain, and symptoms of chest congestion. Facility staff notified the resident's physician (exact time unknown) and received orders for an antibiotic and a breathing treatment. However, at the noon meal the resident was unable to hold a cup or utensils; and between 2:00 PM to 3:00 PM the resident was pale, clammy, and staring off into space. Facility nursing assistants stated they notified the resident's nurse regarding the change in the resident's condition. However, review of the clinical record revealed no documented evidence the resident's physician was notified of the resident's change in condition. On 03/08/15, at approximately 4:15 PM, Resident #1's family found the resident with labored breathing and he/she was not responding as he/she normally did to the family. The family member notified the nurse assigned to care for the resident; however, there was no documented evidence the resident's physician was notified. The family member contacted the resident's physician's Advanced Practice Registered Nurse (APRN) to have the resident sent to the hospital. The APRN notified the facility nurse and an order was received to transfer Resident #1 to the hospital. When Emergency Medical Services (EMS) arrived at the facility at 4:53 PM, they assessed the resident to be responsive only to painful stimuli; to have an oxygen saturation of 72% (normal range 95-100%) on three (3) liters of oxygen; to have a fever and very wet lung sounds; and [MEDICAL CONDITION] (the upper chambers of the heart (atria) quiver) with a heart rate of 90-170 beats per minute. When the resident arrived at the hospital, the resident's temperature was 103 degrees Fahrenheit rectally (normal rectal temperature range 99.1-99.6 degrees Fahrenheit). Further review revealed the resident had shallow, rapid, and difficult respiration at a rate of 26 respirations per minute (normal range 12-20 breaths per minute); and the resident's oxygen saturation was 82% (normal range is 95-100%). Resident #1 was admitted to the hospital and required intubation (a tube placed in the trachea (windpipe) for mechanical breathing on a ventilator), and sustained a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The resident passed away at 5:00 AM on 03/09/15 (refer to F282 and F309). The facility's failure to have an effective system in place to ensure each resident's physician was immediately notified of changes of condition was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/08/15 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F282); 42 CFR 483.25 Quality of Care (F309); and 42 CFR 483.75 Administration (F514). The facility was notified of the Immediate Jeopardy on 03/20/15. An acceptable Allegation of Compliance was received on 03/24/15, which alleged removal of the Immediate Jeopardy on 03/25/15. A partial extended survey was conducted on 03/25-26/15. The State Survey Agency determined the Immediate Jeopardy was removed on 03/25/15, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F282), and 42 CFR 483.25 Quality of Care (F309); and the Scope and Severity was lowered to an E at 42 CFR 483.75 Administration (F514) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Notification of Physician for Change In Resident's Condition, dated August 2012, revealed it was the policy of the facility to notify the physician when a significant change in a resident's condition occurred with documentation contained within the medical record. Review of Resident #1's closed medical record revealed the facility admitted Resident #1 on 01/27/15 with [DIAGNOSES REDACTED]. Review of the Comprehensive Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. Further review of the assessment revealed the facility assessed the resident to eat independently with setup help only. Review of the closed medical record for Resident #1 revealed computerized Nurse's Notes for the resident dated 03/08/15 at 10:14 AM (the exact time of the assessment is unknown; this is the time the assessment was documented). The facility assessed Resident #1 to be slightly pale, with shortness of air, and oxygen saturation levels that ranged from 87 to 92% (normal is 95-100%), with oxygen being administered at four (4) liters per minute. The resident was noted to have chest pain with congestion in the upper lobes and diminished lung sounds in the bases. The Nurse's Note stated the resident's physician was contacted. Review of the Situation, Background, Assessment, Request (SBAR) communication note dated 03/08/15, at 11:07 AM, revealed the resident's oxygen saturation was 92% on four (4) liters of oxygen, the resident had chest congestion, a weak cough, and was short of air. Further review of the SBAR revealed new physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. An interview conducted with Certified Nurse Aide (CNA) #2 on 03/19/15 at 4:10 PM, and on 03/20/15 at 1:25 PM, revealed on 03/08/15 at approximately 7:30 AM Resident #1 was in bed and complained of smothering. The CNA assisted the resident to a wheelchair and to the dining room for breakfast. Further interview with CNA #2 revealed Resident #1 stated he/she did not feel well, was observed to be pale, and only ate about 25% of breakfast. Additional interview with CNA #2 revealed she did not report the change in the resident's condition to the resident's nurse because Licensed Practical Nurse (LPN) #1 (the nurse assigned to the resident) was already aware Resident #1 was not feeling well. According to CNA #2, later that day between 2:00 PM and 3:00 PM, the resident was in bed and she assisted the resident with changing his/her clothing. The CNA stated she did not notice any difference or change in the resident from earlier in the day. On the next shift (which started at 3:00 PM), CNA #2 stated the resident's family came to the facility and the resident was not responding to the family member and had slurred speech. According to CNA #2, the family member went to the nurses' station and spoke to LPN #1 regarding her concerns because Resident #1 was usually not like this. Interview with CNA #1 conducted on 03/19/15 at 1:25 PM, and on 03/20/15 at 11:20 AM, revealed she was in the dining room at the noon meal on 03/08/15 at approximately 12:30 PM to 1:30 PM. CNA #1 stated Resident #1 was not his/her usual self at that time. The resident was not as alert and oriented, was not able to feed himself/herself, and was not able to hold a cup or utensils. In addition, CNA #1 stated LPN #1 attempted to administer the resident's medications and the resident spilled his/her juice twice. The CNA stated LPN #1 had to assist the resident with taking his/her medications. Further interview with CNA #1 revealed while she was assisting CNA #2 to reposition Resident #1, she noticed the resident's skin was pale and clammy and the resident was staring off into space. According to CNA #1, she reported her concerns regarding Resident #1's change of condition to LPN #1; however, CNA #1 stated LPN #1 blew her off and ignored her concerns. An interview with Licensed Practical Nurse (LPN) #1 on 03/19/15 at 2:50 PM revealed she was assigned to care for Resident #1 on 03/08/15. According to LPN #1, Resident #1 did not eat anything for breakfast on 03/08/15 and the resident reported to her during the 8:00 AM medication pass that he/she was having trouble breathing and may be getting [MEDICAL CONDITION]. Additional interview revealed Resident #1 had problems holding his/her cup at breakfast. According to LPN #1, she assessed Resident #1, obtained the resident's vital signs during this time, and documented the results in the Nurse's Notes at 10:15 AM on 03/08/15. LPN #1 stated she contacted the physician for Resident #1 and obtained orders for an antibiotic and a nebulizer treatment. Further interview revealed LPN #1 assisted the resident to bed at some point after lunch (exact time unknown) and administered his/her 2:00 PM medications between 1:00 PM and 3:00 PM. LPN #1 stated she did not notice any additional concerns or changes in the resident's condition. Review of the medical record revealed no documented evidence that LPN #1 reassessed Resident #1 or notified the physician after 11:16 AM on 03/08/15. Further interview with LPN #1 revealed she did not recall the nursing assistants reporting to her that the resident's condition had worsened. According to LPN #1, she was at the nurses' station on 03/08/15 at approximately 4:20 PM to 4:30 PM, when Resident #1's family member approached her and asked what was going on with Resident #1. LPN #1 stated she reported to the family member that she had called the resident's physician earlier in the day and that the resident had received medications already. LPN #1 stated the family member did not agree with the physician's orders [REDACTED].#1 had pneumonia. Further interview with the LPN revealed she did not assess the resident or notify the resident's physician of the family member's concerns. The LPN stated she then received a call from an Advanced Practice Registered Nurse (APRN), who worked for Resident #1's Primary Care Physician. LPN #1 stated they discussed Resident #1, and then the APRN called her back and gave her orders for Resident #1 to be transferred to the hospital for evaluation and treatment. LPN #1 stated she got Resident #1's paperwork ready to transfer to the hospital; however, she did not assess the resident. LPN #1 stated she only saw the resident when the paramedics were transporting the resident on a stretcher from the facility. An interview conducted with Family Member (FM) #1 on 03/18/15 at 3:30 PM, revealed when she arrived at the facility on 03/08/15 at approximately 4:15 PM, she found Resident #1 with labored gurgling respirations that could be heard from the door; the resident was lethargic and mumbling. According to FM #1, she went immediately to the nurses' station to see what was going on with Resident #1. The family member spoke with LPN #1 regarding her concerns. FM #1 stated she did not agree with the [DIAGNOSES REDACTED]. Further interview with FM #1 revealed she informed the APRN of the resident's condition and told her that she did not agree with the treatment. FM #1 stated that after speaking with the APRN, the APRN called the facility and gave orders for the resident to be transferred to the hospital. At the hospital, Resident #1 was diagnosed with [REDACTED]. Resident #1 passed away at the hospital at 5:00 AM on 03/09/15, the next day. Interview with the Director of Nursing (DON) on 03/20/15 at 5:15 PM, revealed staff was required to report when a resident had a change in condition to a nurse. The nurse was required to assess the resident as soon as possible, notify the physician, and document their findings using the Situation Background Assessment Request (SBAR) format. According to the DON, if staff determined an emergency existed, they could contact the physician and send the resident to the hospital. The DON stated she was informed Resident #1 was transferred to the hospital on [DATE]. However, she was not aware that CNAs had reported changes of condition to LPN #1, who had not notified the resident's physician. She further stated she was not aware the LPN did not call the physician with the family member's concerns. The DON stated she was also not aware LPN #1 did not assess Resident #1 after the family member reported her concerns with Resident #1's condition on 03/08/15. Interview on 03/20/15 at 6:00 PM, with the Administrator revealed he was not aware LPN #1 had not assessed Resident #1 after concerns were reported to her by the resident's family on 03/08/15. According to the Administrator, if a change in a resident's condition was reported to the nurse, the nurse was required to contact the resident's physician. Further interview with the Administrator revealed LPN #1 should have assessed Resident #1 when the family reported concerns, and acted on the findings of the assessment. **The facility provided an acceptable Allegation of Compliance (AOC) on 03/24/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On 03/08/15, Resident #1 was sent to the hospital and treated in the emergency room for pneumonia,[MEDICAL CONDITION], and ST segment elevation [MEDICAL CONDITION] infarction (STEMI) ([MEDICAL CONDITION]). The resident had a stent placed. Resident #1 passed away at the hospital on [DATE]. 2) On 03/21/15-03/22/15, the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor conducted evaluations of all current residents to determine if there were any medical needs requiring physician notification which had not been addressed. Two (2) issues were identified. (A)--A [MEDICAL TREATMENT] patient (identified by the facility as Resident A) refused [MEDICAL TREATMENT] and later had weeping from the lower extremities. A nursing intervention was implemented, the resident's physician was notified of the change, physician orders [REDACTED]. The Unit Manager validated implementation of the new orders and continued monitoring of the resident. (B)--Resident B (identified by the facility as Resident B), who has a [DIAGNOSES REDACTED]. The Physician was made aware and ordered diagnostic testing, the resident's responsible party was notified of the resident's condition, and the procedure was ordered. The Unit Manager validated the implementation of the new orders and monitoring of the patient. On 03/21/15-03/22/15, the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor reviewed all current residents' plans of care to determine that all interventions were being followed. Minor revisions were made to the care plans as needed. One care plan was significantly changed related to a patient's condition of [MEDICAL CONDITION] (interventions were in place). No change to the plans of care required notification to a Physician. 3) The INTERACT program is an evidence based Plan, Do, Check, Act process developed through funding from the Centers for Medicare and Medicaid Services (CMS) to prevent unnecessary acute care transfers and includes a binder of care paths, which are algorithms used for directing nurses through evaluating residents, providing care, and notifying the physician for certain common symptoms. It includes the SBAR (Situation, Background, Analysis, and Request) tool for nurses to complete and effectively communicate a resident's condition or change of condition with the Physician. On 03/20/15, the RN (Registered Nurse) Nurse Consultant re-educated the Staff Facilitator regarding conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluations, as well as physician notification; and, for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor and began re-education of Nurses, Medication Technicians, and Certified Nurse Aides on conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluation, as well as physician notification; and for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/21/15-03/22/15, Unit Managers, MDS Nurses, QI Nurses, Weekend House Supervisor, and Staff Facilitator continued with re-education with all Nurses, Medication Technicians, and Certified Nurse Aides related to conducting an evaluation based on resident condition to include the INTERACT program, follow-up evaluations, as well as physician notification for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15, the RN Facility Consultant re-educated the Staff Facilitator regarding the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. On 3/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor on the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Beginning 03/21/15 and ongoing, all licensed staff was re-educated by the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, or Staff Facilitator regarding the requirement to follow the plan of care and if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Posttests were developed on 03/23/15 for Licensed Nurses, Medication Technicians, and Certified Nurse Aides to demonstrate retained knowledge of the re-education. Approximately 90 percent of the licensed nurses and approximately 75 percent of the Medication Aides and Certified Nurse Aides have completed the in-service education and posttest. These staff indicated understanding and stated all questions were answered at the end of the education sessions. No Licensed Nurse, Medication Technician, or CNA will work after 03/23/15 without having completed this re-education. No Licensed Nurse, Medication Aide, or CNA will provide patient care after 03/24/15 without having completed both the re-education and posttest. Beginning 03/21/15 and ongoing, all CNAs were re-educated with following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No CNAs will work after 03/23/15 without having received this re-education. All newly employed direct care staff will receive this education prior to working on a unit. Direct care staff on leave of absence or vacation will complete this re-education prior to working. 4) Beginning 03/23/15, the Director of Nursing, QI Nurses, Unit Managers, Staff Facilitator, Weekend House Supervisor, or RN Facility Consultant will conduct walking rounds to review with facility licensed nurse staff residents' conditions daily. These rounds will also include an investigation to determine if licensed staff are notifying the physician of significant changes in condition and completing ongoing evaluation as needed. This process will also include observation and discussion with Licensed Nurses and Certified Nurse Aides to determine if plans of care, including revisions, are being followed. The rounds will also consist of discussion with CNAs to determine if they have noted any changes in the residents throughout their shift and review of the STOP and WATCH (the tool included in the INTERACT program for CNAs to alert changes in resident condition in the electronic medical record). This will continue daily until abatement of Immediate Jeopardy then four (4) times per week for four (4) weeks thereafter. Beginning 03/23/15, the Director of Nursing, QI Nurses, Staff Facilitator, Unit Managers, Weekend House Supervisor, or RN Facility Consultant will review all Nurse's Notes daily to determine if any significant change in condition has occurred without physician notification or any significant change in condition has occurred without evaluation. This will occur daily until abatement of the Immediate Jeopardy and then four (4) times per week for four (4) weeks. The Clinical Interdisciplinary Team (IDT) which includes the Director of Nursing, Unit Managers, QI Nurses, Staff Facilitator, MDS Nurses, Weekend House Supervisor, RN Facility Consultant, or Treatment Nurse, will continue to follow the established process of reviewing the Nurse's Notes, Shift Reports, and physician's orders [REDACTED]. The Weekend House Supervisor reviews the documents Saturday and Sunday and reports to the Director of Nursing and Administrator at least daily. The Weekend House Supervisor and MDS Nurses will revise care plans through the established process. 5) On 03/20/15, an ad hoc Quality Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Associate Medical Director who approved. In attendance was the Administrator, RN Facility Consultant, Unit Managers, QI Nurses, MDS Nurses, Social Services Director, Kitchen Manager, Staff Facilitator, Admissions Director, and Activity Director. No further recommendations were made. The Administrator, Director of Nursing, QI Nurses, or RN Facility consultant will review the audits daily until abatement of Immediate Jeopardy. Thereafter, the results of these audits will be reviewed with the Quality Improvement Committee weekly and anytime a concern is identified until substantial compliance has been achieved; then per the schedule established by the Executive QI Committee. Thereafter, Members of the QI Committee will consist of at a minimum, the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, and Staff Facilitator. The Executive QI Committee consists of the Administrator, Director of Nursing Services, Unit Managers, QI Nurses, RN MDS Coordinator, Staff Facilitator, Treatment Nurse, Social Services Director, Social Services Assistant, Director of Activities, Director of Admissions, Dietary Services Director, Maintenance Director, Director of Environment and Safety, and Medical Director. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the closed record for Resident #1 revealed the resident was transferred to the hospital on [DATE]. 2) Observations of Residents #11, #12, #13, and #14 on 03/25/15-03/26/15 revealed no concerns with changes of condition or following the plan of care. Review of Resident #11's medical record (identified by the facility as Resident A) revealed the facility assessed the resident to have weeping [MEDICAL CONDITION] to the lower extremities on 03/21/15. The resident's physician was notified of the change in the resident's condition on 03/21/15 at 7:39 PM, and orders were received for Keflex (antibiotic) 500 mg for [MEDICAL CONDITION] to the lower extremities. Review of the plan of care revealed no concerns. Review of the medical record for Resident #12 (identified by the facility as Resident B) revealed the facility assessed the resident to have a change in condition on 03/22/15 at 9:06 PM. The resident had [MEDICAL CONDITION] to the lower extremities. The resident's physician was notified and orders received for a venous study. Review of the plan of care revealed no concerns. Review of the medical records for Residents #13 and #14 revealed the residents were assessed for a change of condition on 03/21/15 with no changes of condition identified. Review of the plans of care for these residents revealed no concerns. 3) Interview with the Staff Facilitator on 03/26/15 at 1:55 PM revealed the Staff Facilitator had been trained by the Nurse Consultant on the Interact Program related to follow-up evaluations/assessments of residents using the SBAR tool. The Nurse Consultant had also trained the Staff Facilitator on assessing changes of condition, physician notification, and following residents' plans of care. According to the Staff Facilitator, she then began training all nursing staff. Interviews with CNAs #3, #4, #5, #6, #7, and #8 on 03/26/15 at 10:52 AM, 11:11 AM, 11:34 AM, 11:50 AM, 2:05 PM, and 2:20 PM respectfully, revealed the CNAs had been trained regarding notifying the nurse of a change of condition, using the Stop and Watch program, the resident assessment for change of condition, and following the plan of care. Interviews on 03/26/15 with LPN #2 at 11:00 AM, LPN #3 at 10:55 AM, LPN #4 at 1:00 PM, RN #1 at 12:50 PM, the Treatment Nurse at 11:30 AM, the West Wing Unit Manager at 1:15 PM, and the Second Floor Unit Manager at 1:30 PM revealed they had been trained regarding changes of condition, assessing/monitoring residents after a change of condition, notification of the physician, using the SBAR form, and following the resident's care plan. Review of the INTERACT training documentation revealed the training was given on 03/20/15, the Staff Facilitator had been educated by the Nurse Consultant and the Staff Facilitator conducted training for nursing staff with no concerns identified. The documentation revealed the facility was monitoring staff that had been trained to ensure they were following the process. Review of posttests revealed staff had been given posttests and the results were reviewed by the facility. 4) Interviews on 03/26/15 with the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, the MDS Nurse at 2:15 PM, the QI Nurse at 2:25 PM, and the West Wing Unit Manager at 1:15 PM revealed walking rounds were being conducted twice daily. These rounds included review of Nurse's Notes for SBAR assessments; monitor residents for change in condition; staff to discuss residents' condition with nurses and CNAs; and ensure care plans were being followed. They were also monitoring to ensure physicians were notified if needed and to ensure that nurses conducted follow-up evaluations if needed. Review of the facility's documentation of walking rounds conducted from 03/22/15 through 03/26/15 revealed walking rounds were being completed and were ongoing on 03/26/15 with no concerns identified. 5) Interviews on 03/26/15 at 3:30 PM with the Administrator, the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, and the QI Nurse at 2:25 PM revealed the facility's Quality Assurance Committee was meeting daily to review daily audits for concerns with assessments, physician notification of change of condition, and following the residents' plans of care. Review of the Quality Assurance Committee minutes conducted on 03/21/15 through 03/26/15 revealed the facility had identified no concerns.

Based on interview, record review, and a review of the facility's policy it was determined the facility failed to follow the plan of care and notify the resident's physician of an ineffective breathing pattern for one (1) of fourteen (14) sampled residents (Resident #1). Review of the Comprehensive Care Plan for Resident #1 revealed the facility identified a care need of potential for, or actual ineffective breathing pattern related to the resident's history of breathing problems. According to the plan of care, interventions included to notify the resident's physician of signs and symptoms of an ineffective breathing pattern. Resident #1 experienced a change in condition on 03/08/15 between 8:30 AM and 9:30 AM. He/she complained of shortness of breath, pain, and chest congestion. The facility assessed the resident to be slightly pale and short of air with oxygen saturation levels that ranged from 87 to 92% (normal range 95-100%), with oxygen being administered at four (4) liters per minute. The resident's physician was contacted and orders were received [MEDICATION NAME](antibiotic) and [MEDICATION NAME] nebulizer treatment (breathing treatment). Staff interviews revealed the resident's condition did not improve. On 03/08/15 at 4:15 PM, the family visited Resident #1 and found the resident with labored breathing and he/she was lethargic; the nurse was notified of the resident's condition. However, the nurse failed to monitor the resident's respiratory status after being notified by the family that the resident was in respiratory distress, as per the plan of care required. The family contacted the Nurse Practitioner and orders were received to transfer the resident to the hospital. The nurse failed to assess the resident for worsening condition and notify the resident's physician of the resident's condition, per the plan of care. The resident was transferred to the local hospital. Resident #1 required intubation shortly after arrival to the hospital and later sustained a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The resident was admitted to the hospital and passed away at 5:00 AM on 03/09/15 (reference F157 and F282). The facility's failure to ensure each resident's plan of care was implemented was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/08/15 at 42 CFR 483.10 Resident Rights (F157 - J), 42 CFR 483.20 Resident Assessment (F282 - J), and 42 CFR 483.25 Quality of Care (F309 - J), and 42 CFR 483.75 Administration (F514 - K). The facility was notified of the Immediate Jeopardy on 03/20/15. An acceptable Allegation of Compliance was received on 03/24/15, which alleged removal of the Immediate Jeopardy on 03/25/15. A partial extended survey was conducted on 03/25-26/15. The State Survey Agency determined the Immediate Jeopardy was removed on 03/25/15, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F282), and 42 CFR 483.25 Quality of Care (F309); and 42 CFR 483.75 Administration (F514) was lowered to an E, while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview conducted with the Director of Nursing on 03/20/15 at 5:15 PM revealed the facility did not have a specific policy regarding following or implementing a resident's plan of care but utilized the Interact Care Path Algorithm Program for interventions of monitoring residents who had a change of condition. Review of the Interact Care Path Algorithm for Shortness of Breath dated 2011 revealed for symptoms of difficult or labored breathing that were out of proportion to the resident's level or activity, or a new complaint of shortness of breath, vital signs were to be obtained which should include the resident's oxygen saturation. If abnormal, new or worsening chest pain required notification of the Physician and monitoring the resident's vital signs every four to eight (4-8) hours. Staff was also to monitor the resident for a worsening condition. Record review revealed the facility admitted Resident #1 on 01/27/15 from the hospital with [DIAGNOSES REDACTED]. Review of the Comprehensive Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. The resident was assessed to be independent with eating and required setup help only. According to the assessment, the resident only had shortness of breath with exertion (walking, bathing, and transferring). According to the Care Area Assessment Summary (CAAS), the resident was alert, oriented to person, place, and time, and able to make needs and wants known to staff. Review of the Comprehensive Care Plan for Resident #1 dated 02/05/15, revealed the facility identified a care need of potential for or actual ineffective breathing pattern related to [DIAGNOSES REDACTED]. Interventions included monitoring for ineffective breathing pattern, shortness of breath, wheezing, crackles, cough, elevated temperature, activity intolerance, increased confusion, and pleuritic chest pain. According to the plan of care, interventions included to notify the resident's physician of signs and symptoms of an ineffective breathing pattern. Review of Resident #1's Nurse's Notes dated 03/08/15 at 10:14 AM, revealed at an earlier time (exact time unknown) the resident was assessed to be slightly pale and have shortness of air with oxygen saturation levels that ranged from 87 to 92%, with oxygen being administered at four (4) liters per minute (normal range 95-100%). The resident was assessed to have chest pain and chest congestion in the upper lobes and diminished lung sounds in the bases. The physician was contacted. Further review revealed new physician's orders [REDACTED]. Further review of the clinical record revealed a Nurse's Note dated 03/08/15 at 4:52 PM, which stated the resident's family was in the facility and reported to the nurse that the resident had labored respirations. The family member questioned the type of treatment the resident was receiving and called the Advanced Practice Registered Nurse (APRN). The APRN called the facility and requested to have the resident transferred to the emergency room . Further review of the clinical record revealed no documented evidence the nurse conducted a follow-up assessment of the resident's condition after 11:07 AM on 03/08/15. There was no documented evidence that the nurse monitored the resident's condition for improvement or decline or notified the physician after the family informed the nurse that Resident #1 was having difficulty breathing, as required per the resident's plan of care. Review of the Hospital Record for Resident #1 revealed upon arrival to the emergency roiagnom on [DATE] at 5:10 PM, the resident had shallow, rapid, and difficult respirations at a rate of 26 respirations per minute and his/her oxygen saturation was 82% (normal 95-100%); the resident's temperature was noted to be 103 degrees Fahrenheit, rectally. Further review of the record revealed the resident required intubation and sustained a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). Resident #1 was admitted to the hospital and passed away at 5:00 AM on 03/09/15. Interview conducted on 03/19/15 at 1:25 PM and on 03/20/15 at 11:20 AM, with Certified Nurse Aide (CNA) #1 revealed she was in the dining room at the noon meal on 03/08/15 at approximately 12:30 PM to 1:30 PM. According to the CNA, Resident #1 was not his/her usual self. The CNA said Resident #1 was not as alert and was slow to respond verbally. The CNA said physically the resident was unable to hold a cup or utensils and could not feed himself/herself. The resident was not able to hold his/her juice glass and spilled the juice. CNA #1 stated the resident was provided another cup of juice by Licensed Practical Nurse (LPN) #1 which the resident also spilled. Further interview with the CNA revealed during this time, the resident was administered medications by LPN #1. However, LPN #1 had to assist the resident to take his/her medications. According to CNA #1, she reported her concerns regarding Resident #1's change of condition to LPN #1; however, CNA #1 stated LPN #1 blew her off and ignored her concerns. Interview with LPN #1 on 03/19/15 at 2:50 PM revealed she was assigned to care for Resident #1 on 03/08/15. During the 8:00 AM medication pass, LPN #1 said Resident #1 reported having trouble breathing and told the nurse he/she may be getting [MEDICAL CONDITION]. Further interview with the LPN revealed Resident #1 had problems holding a cup at breakfast and did not eat anything for breakfast. According to LPN #1, she assessed Resident #1 and obtained vital signs during this time. LPN #1 stated she contacted the On-Call Physician for Resident #1 and informed the physician of Resident #1's condition. The physician gave orders for an antibiotic and a nebulizer treatment. Further interview revealed LPN #1 assisted the resident to bed at some point in the day after lunch (exact time unknown) and administered 2:00 PM medications to the resident between 1:00 PM and 3:00 PM. The LPN stated she did not notice any additional concerns or changes in the resident's condition when she administered the 2:00 PM medication. At approximately 4:20 PM on 03/08/15, the LPN said she was approached by a family member of Resident #1 and the family member asked about the condition of Resident #1 and reported to her that they thought the resident had pneumonia. According to LPN #1, she reported to the family member what she told the physician earlier in the day and that the resident received medications earlier in the day. The LPN said the family member did not agree with the resident's assessment and treatment and thought Resident #1 had pneumonia. Further interview with the LPN revealed she did not assess the resident's condition after the family member talked with her nor did she obtain vital signs on Resident #1, which she should have been doing, per the care plan. According to LPN #1, she only saw the resident when the paramedics were transporting the resident on a stretcher from the facility. According to LPN #1, care plan interventions of monitoring the resident were done when making rounds to pass medications, and to ensure the plan of care was being followed. LPN #1 stated she was not aware of any changes with Resident #1 and the resident was not in any distress when she put the resident to bed after lunch and when she administered the 2:00 PM medications. An interview conducted with Family Member (FM) #1 on 03/18/15 at 3:30 PM, revealed the FM arrived at the facility on 03/08/15 at approximately 4:15 PM and found Resident #1 having labored gurgling respirations, and the resident was lethargic and mumbling. According to FM #1, she went immediately to the nurses' station to check on the condition of Resident #1. The family member spoke with LPN #1 and was informed by the LPN that Resident #1 had an upper respiratory infection and had [MEDICATION NAME](antibiotic medication). FM #1 stated she contacted the APRN who worked with the resident's physician and informed the APRN of the resident's condition. According to FM #1, facility nursing staff did not assess Resident #1's condition while the family member was at the facility. FM #1 stated that Resident #1 was transported to the hospital via ambulance and was diagnosed with [REDACTED]. Interview with the Director of Nursing (DON) was conducted on 03/20/15 at 5:15 PM. The DON stated when a resident's care plan intervention included monitoring of symptoms the Situation, Background, Assessment, Request (SBAR) format was utilized to note an initial change of condition. The facility's acute charting (documentation of the resident's condition once per shift) was then utilized to document the monitoring of the resident. Further interview revealed when a resident experienced a change in condition, the nurse was required to assess the resident as soon as possible, notify the physician, and document findings. According to the DON, LPN #1 did not follow the resident's plan of care and assess Resident #1 after CNA #1 and FM #1 reported changes in the resident's condition on 03/08/15. According to the DON, she had been informed Resident #1 was transferred on 03/08/15, but she was not aware Resident #1 was not assessed by the nurse after the family reported concerns with Resident #1's condition on 03/08/15. Interview conducted with the Administrator on 03/20/15 at 6:00 PM, revealed he was not aware LPN #1 had not assessed Resident #1 after concerns were reported by the resident's family on 03/08/15. According to the Administrator, if a resident had a change of condition and was care planned with interventions for monitoring of the condition, the nurse was required to assess the resident, contact the physician, and document findings/notification in the medical record. Further interview with the Administrator revealed LPN #1 should have assessed/monitored Resident #1 when the family reported their concerns with the resident on 03/08/15. **The facility provided an acceptable Allegation of Compliance (AOC) on 03/24/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On 03/08/15, Resident #1 was sent to the hospital and treated in the emergency room for pneumonia,[MEDICAL CONDITION], and ST segment elevation [MEDICAL CONDITION] infarction (STEMI) ([MEDICAL CONDITION]). The resident had a stent placed. Resident #1 passed away at the hospital on [DATE]. 2) On 03/21/15-03/22/15, the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor conducted evaluations of all current residents to determine if there were any medical needs requiring physician notification which had not been addressed. Two (2) issues were identified. (A)--A [MEDICAL TREATMENT] patient (identified by the facility as Resident A) refused [MEDICAL TREATMENT] and later had weeping from the lower extremities. A nursing intervention was implemented, the resident's physician was notified of the change, physician orders [REDACTED]. The Unit Manager validated implementation of the new orders and continued monitoring of the resident. (B)--Resident B (identified by the facility as Resident B), who has a [DIAGNOSES REDACTED]. The Physician was made aware and ordered diagnostic testing, the resident's responsible party was notified of the resident's condition, and the procedure was ordered. The Unit Manager validated the implementation of the new orders and monitoring of the patient. On 03/21/15-03/22/15, the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor reviewed all current residents' plans of care to determine that all interventions were being followed. Minor revisions were made to the care plans as needed. One care plan was significantly changed related to a patient's condition of [MEDICAL CONDITION] (interventions were in place). No change to the plans of care required notification to a Physician. 3) The INTERACT program is an evidence based Plan, Do, Check, Act process developed through funding from the Centers for Medicare and Medicaid Services (CMS) to prevent unnecessary acute care transfers and includes a binder of care paths, which are algorithms used for directing nurses through evaluating residents, providing care, and notifying the physician for certain common symptoms. It includes the SBAR (Situation, Background, Analysis, and Request) tool for nurses to complete and effectively communicate a resident's condition or change of condition with the Physician. On 03/20/15, the RN (Registered Nurse) Nurse Consultant re-educated the Staff Facilitator regarding conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluations, as well as physician notification; and, for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor and began re-education of Nurses, Medication Technicians, and Certified Nurse Aides on conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluation, as well as physician notification; and for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/21/15-03/22/15, Unit Managers, MDS Nurses, QI Nurses, Weekend House Supervisor, and Staff Facilitator continued with re-education with all Nurses, Medication Technicians, and Certified Nurse Aides related to conducting an evaluation based on resident condition to include the INTERACT program, follow-up evaluations, as well as physician notification for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15, the RN Facility Consultant re-educated the Staff Facilitator regarding the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. On 3/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor on the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Beginning 03/21/15 and ongoing, all licensed staff was re-educated by the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, or Staff Facilitator regarding the requirement to follow the plan of care and if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Posttests were developed on 03/23/15 for Licensed Nurses, Medication Technicians, and Certified Nurse Aides to demonstrate retained knowledge of the re-education. Approximately 90 percent of the licensed nurses and approximately 75 percent of the Medication Aides and Certified Nurse Aides have completed the in-service education and posttest. These staff indicated understanding and stated all questions were answered at the end of the education sessions. No Licensed Nurse, Medication Technician, or CNA will work after 03/23/15 without having completed this re-education. No Licensed Nurse, Medication Aide, or CNA will provide patient care after 03/24/15 without having completed both the re-education and posttest. Beginning 03/21/15 and ongoing, all CNAs were re-educated with following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No CNAs will work after 03/23/15 without having received this re-education. All newly employed direct care staff will receive this education prior to working on a unit. Direct care staff on leave of absence or vacation will complete this re-education prior to working. 4) Beginning 03/23/15, the Director of Nursing, QI Nurses, Unit Managers, Staff Facilitator, Weekend House Supervisor, or RN Facility Consultant will conduct walking rounds to review with facility licensed nurse staff residents' conditions daily. These rounds will also include an investigation to determine if licensed staff are notifying the physician of significant changes in condition and completing ongoing evaluation as needed. This process will also include observation and discussion with Licensed Nurses and Certified Nurse Aides to determine if plans of care, including revisions, are being followed. The rounds will also consist of discussion with CNAs to determine if they have noted any changes in the residents throughout their shift and review of the STOP and WATCH (the tool included in the INTERACT program for CNAs to alert changes in resident condition in the electronic medical record). This will continue daily until abatement of Immediate Jeopardy then four (4) times per week for four (4) weeks thereafter. Beginning 03/23/15, the Director of Nursing, QI Nurses, Staff Facilitator, Unit Managers, Weekend House Supervisor, or RN Facility Consultant will review all Nurse's Notes daily to determine if any significant change in condition has occurred without physician notification or any significant change in condition has occurred without evaluation. This will occur daily until abatement of the Immediate Jeopardy and then four (4) times per week for four (4) weeks. The Clinical Interdisciplinary Team (IDT) which includes the Director of Nursing, Unit Managers, QI Nurses, Staff Facilitator, MDS Nurses, Weekend House Supervisor, RN Facility Consultant, or Treatment Nurse, will continue to follow the established process of reviewing the Nurse's Notes, Shift Reports, and physician's orders [REDACTED]. The Weekend House Supervisor reviews the documents Saturday and Sunday and reports to the Director of Nursing and Administrator at least daily. The Weekend House Supervisor and MDS Nurses will revise care plans through the established process. 5) On 03/20/15, an ad hoc Quality Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Associate Medical Director who approved. In attendance was the Administrator, RN Facility Consultant, Unit Managers, QI Nurses, MDS Nurses, Social Services Director, Kitchen Manager, Staff Facilitator, Admissions Director, and Activity Director. No further recommendations were made. The Administrator, Director of Nursing, QI Nurses, or RN Facility consultant will review the audits daily until abatement of Immediate Jeopardy. Thereafter, the results of these audits will be reviewed with the Quality Improvement Committee weekly and anytime a concern is identified until substantial compliance has been achieved; then per the schedule established by the Executive QI Committee. Thereafter, Members of the QI Committee will consist of at a minimum, the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, and Staff Facilitator. The Executive QI Committee consists of the Administrator, Director of Nursing Services, Unit Managers, QI Nurses, RN MDS Coordinator, Staff Facilitator, Treatment Nurse, Social Services Director, Social Services Assistant, Director of Activities, Director of Admissions, Dietary Services Director, Maintenance Director, Director of Environment and Safety, and Medical Director. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the closed record for Resident #1 revealed the resident was transferred to the hospital on [DATE]. 2) Observations of Residents #11, #12, #13, and #14 on 03/25/15-03/26/15 revealed no concerns with changes of condition or following the plan of care. Review of Resident #11's medical record (identified by the facility as Resident A) revealed the facility assessed the resident to have weeping [MEDICAL CONDITION] to the lower extremities on 03/21/15. The resident's physician was notified of the change in the resident's condition on 03/21/15 at 7:39 PM, and orders were received for Keflex (antibiotic) 500 mg for [MEDICAL CONDITION] to the lower extremities. Review of the plan of care revealed no concerns. Review of the medical record for Resident #12 (identified by the facility as Resident B) revealed the facility assessed the resident to have a change in condition on 03/22/15 at 9:06 PM. The resident had [MEDICAL CONDITION] to the lower extremities. The resident's physician was notified and orders received for a venous study. Review of the plan of care revealed no concerns. Review of the medical records for Residents #13 and #14 revealed the residents were assessed for a change of condition on 03/21/15 with no changes of condition identified. Review of the plans of care for these residents revealed no concerns. 3) Interview with the Staff Facilitator on 03/26/15 at 1:55 PM revealed the Staff Facilitator had been trained by the Nurse Consultant on the Interact Program related to follow-up evaluations/assessments of residents using the SBAR tool. The Nurse Consultant had also trained the Staff Facilitator on assessing changes of condition, physician notification, and following residents' plans of care. According to the Staff Facilitator, she then began training all nursing staff. Interviews with CNAs #3, #4, #5, #6, #7, and #8 on 03/26/15 at 10:52 AM, 11:11 AM, 11:34 AM, 11:50 AM, 2:05 PM, and 2:20 PM respectfully, revealed the CNAs had been trained regarding notifying the nurse of a change of condition, using the Stop and Watch program, the resident assessment for change of condition, and following the plan of care. Interviews on 03/26/15 with LPN #2 at 11:00 AM, LPN #3 at 10:55 AM, LPN #4 at 1:00 PM, RN #1 at 12:50 PM, the Treatment Nurse at 11:30 AM, the West Wing Unit Manager at 1:15 PM, and the Second Floor Unit Manager at 1:30 PM revealed they had been trained regarding changes of condition, assessing/monitoring residents after a change of condition, notification of the physician, using the SBAR form, and following the resident's care plan. Review of the INTERACT training documentation revealed the training was given on 03/20/15, the Staff Facilitator had been educated by the Nurse Consultant and the Staff Facilitator conducted training for nursing staff with no concerns identified. The documentation revealed the facility was monitoring staff that had been trained to ensure they were following the process. Review of posttests revealed staff had been given posttests and the results were reviewed by the facility. 4) Interviews on 03/26/15 with the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, the MDS Nurse at 2:15 PM, the QI Nurse at 2:25 PM, and the West Wing Unit Manager at 1:15 PM revealed walking rounds were being conducted twice daily. These rounds included review of Nurse's Notes for SBAR assessments; monitor residents for change in condition; staff to discuss residents' condition with nurses and CNAs; and ensure care plans were being followed. They were also monitoring to ensure physicians were notified if needed and to ensure that nurses conducted follow-up evaluations if needed. Review of the facility's documentation of walking rounds conducted from 03/22/15 through 03/26/15 revealed walking rounds were being completed and were ongoing on 03/26/15 with no concerns identified. 5) Interviews on 03/26/15 at 3:30 PM with the Administrator, the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, and the QI Nurse at 2:25 PM revealed the facility's Quality Assurance Committee was meeting daily to review daily audits for concerns with assessments, physician notification of change of condition, and following the residents' plans of care. Review of the Quality Assurance Committee minutes conducted on 03/21/15 through 03/26/15 revealed the facility had identified no concerns.

Based on interview, record review, hospital records, Emergency Medical Services Run Sheet, and a review of the facility's policies it was determined the facility failed to ensure one (1) of fourteen (14) sampled residents (Resident #1) received necessary care and services and was monitored and reassessed by nursing staff after the resident experienced a change in condition. On 03/08/15 between 8:30 AM and 9:30 AM, Resident #1 complained of shortness of breath, pain, and chest congestion. The resident was assessed to be slightly pale and short of air with oxygen saturation that ranged from 87 to 92% (normal range is 95 - 100%), with oxygen being administered at four (4) liters per minute. The resident's physician was contacted and orders were received [MEDICATION NAME](antibiotic) and [MEDICATION NAME] nebulizer treatment (breathing treatment). Staff interviews revealed the resident did not eat or drink as usual for lunch and was observed by staff between 2:00 PM and 3:00 PM to be pale, clammy, and staring off (not focusing). The nurse was notified of the resident's further change in condition at lunch and the change that was noted around 2:00 PM to 3:00 PM; however, the nurse did not reassess the resident at that time. On 03/08/15 at 4:15 PM, the family visited Resident #1 and found the resident with labored breathing and he/she was lethargic. The nurse was notified of the resident's condition by the family; however, the nurse did not assess the resident at that time. The family contacted the Advanced Practice Registered Nurse (APRN) and orders were received to transfer the resident to the hospital. After the nurse was notified by the APRN of the resident's condition, she still failed to assess the resident. The resident was transferred to the local hospital and required intubation (a tube placed in the mouth and throat for breathing) shortly after arrival to the hospital and later sustained a [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). The resident was admitted to the hospital and passed away at 5:00 AM on 03/09/15 (reference F157 and F282). The facility's failure to ensure each resident was monitored/assessed and provided necessary care and services was likely to cause serious injury, harm, impairment, or death of a resident. Immediate Jeopardy was determined to exist on 03/08/15 at 42 CFR 483.10 Resident Rights (F157 - J), 42 CFR 483.20 Resident Assessment (F282 - J), 42 CFR 483.25 Quality of Care (F309 - J), and 42 CFR 483.75 Administration (F514 - K). The facility was notified of the Immediate Jeopardy on 03/20/15. An acceptable Allegation of Compliance was received on 03/24/15, which alleged removal of the Immediate Jeopardy on 03/25/15. A partial extended survey was conducted on 03/25-26/15. The State Survey Agency determined the Immediate Jeopardy was removed on 03/25/15, which lowered the Scope and Severity to D at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.20 Resident Assessment (F282), and 42 CFR 483.25 Quality of Care (F309); and 42 CFR 483.75 Administration (F514) was lowered to an E while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's assessment policy titled Acute Episode, dated August 2012, revealed it was the policy of the facility to be alert to any change in a resident's condition and to respond in an appropriate manner to ensure satisfactory intervention treatment for [REDACTED]. Review of the facility's policy titled Nursing Assessment of Condition, which includes the Situation, Background, Assessment, Request (SBAR) format for communicating changes in residents to the physician, revealed if the nurse determined an emergency existed or a resident required immediate transfer to the hospital the physician was to be called, or 911 as appropriate. Staff was not required to wait to fill out forms or enter data in the computer. The policy stated documentation could be done after the event. Review of Resident #1's medical record revealed the facility admitted the resident from the hospital with a history of Pneumonia on 01/27/15. The resident's [DIAGNOSES REDACTED]. Review of the Comprehensive Admission Minimum Data Set (MDS) assessment for Resident #1 dated 02/03/15, revealed the facility assessed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. Further review of the assessment revealed Resident #1 was assessed to be independent with eating and needed setup help only. According to the assessment, the resident only had shortness of breath with exertion (walking, bathing, and transferring). Review of the Care Area Assessment Summary (CAAS) notes dated 02/03/15, revealed Resident #1 was alert, oriented to person, place, and time, and able to make needs and wants known to staff. The CAAS stated the resident was in the facility for rehabilitation. Review of the Comprehensive Care Plan developed for Resident #1 dated 02/05/15, with a focus of potential for or actual ineffective breathing pattern related to [DIAGNOSES REDACTED]. Further review of the care plan revealed staff was to notify the physician of signs/symptoms of insufficient breathing patterns or as indicated for an elevated temperature. Review of the Nurse's Notes for Resident #1 dated 03/08/15 at 10:14 AM, revealed at an earlier time (exact time unknown) Resident #1 was assessed to be slightly pale with shortness of air and oxygen saturation levels that ranged from 87 to 92% (normal range 95 - 100%), with oxygen being administered at four (4) liters per minute. The resident was noted to have chest pain with congestion in the upper lobes and diminished lung sounds in the bases. According to the Note, the physician was contacted. Review of the Nurse's Notes revealed a Situation, Background, Assessment, Request (SBAR) communication note dated 03/08/15 at 11:07 AM, revealed the resident's oxygen saturation was 92% on 4 liters of oxygen and the resident had chest congestion, a weak cough, and was short of air. The physician was notified and new orders were received [MEDICATION NAME] mg (milligrams) two (2) times per day; and an [MEDICATION NAME] Nebulizer treatment every four (4) hours as needed for chest congestion and shortness of air. Review of a Nurse's Note dated 03/08/15, at 11:16 AM, revealed the physician had been notified and orders for medications were received earlier in the shift. Review of the Medication Administration Record [REDACTED]. However, the next Nurse's Note was at 4:52 PM on 03/08/15, which noted that the resident's family was in the facility and had disagreed with the type of treatment that was ordered for the resident. The family called the Advanced Practice Registered Nurse (APRN) about their concerns. The APRN called the facility and gave orders for Resident #1 be transferred to the emergency room . Further review of the clinical record revealed no documented evidence the facility assessed Resident #1 for further change of condition or that the resident's condition was monitored after 11:07 AM on 03/08/15. Review of the Emergency Medical Service (EMS) Run Sheet for Resident #1 dated 03/08/15, revealed EMS was dispatched to the facility at 4:46 PM and arrived at the facility at 4:53 PM. According to the Run Sheet, EMS assessed the resident to be responsive to painful stimuli only and to have an oxygen saturation of 72% on three (3) liters of oxygen. Further review of the EMS Note revealed the resident had a fever and very wet lung sounds, and was in [MEDICAL CONDITION] (an irregular rapid heart rate) with a heart rate of 90-170 beats per minute. The resident was transported to the hospital and arrived at the hospital on [DATE] at 5:07 PM. Review of the Hospital emergency room Records for Resident #1 revealed upon arrival to the emergency roiagnom on [DATE] at 5:10 PM, the resident's temperature was 103 degrees Fahrenheit, rectally. The resident was assessed to have shallow, rapid, and difficult respirations at a rate of 26 respirations per minute with an oxygen saturation of 82%. Review of the arterial blood gas measurements (true measurements of oxygen and carbon [MEDICATION NAME] in the blood) obtained for Resident #1 at 5:30 PM revealed the resident had low oxygen levels of 81% (normal range 95-98%) and a high carbon [MEDICATION NAME] level of 68.2 (normal range 35-45), which was critical on 100% oxygen being delivered via face mask. Continued review of the hospital record revealed Resident #1 required intubation and sustained a [MEDICAL CONDITION] infarction. The resident was admitted to the hospital and passed away at 5:00 AM on 03/09/15. Interview with Certified Nurse Aide (CNA) #1 on 03/19/15 at 1:25 PM; and, on 03/20/15 at 11:20 AM, revealed she was in the dining room assisting residents on 03/08/15 at approximately 12:30 PM to 1:30 PM. According to the CNA, Resident #1 was not his/her usual self. The resident was not as alert and oriented because the resident had slurred delayed speech. The CNA said the resident was not able to hold a cup or utensils and was unable to feed himself/herself. The resident was not able to hold a juice glass, and had to be assisted to take the medications by LPN #1. Additional interview with CNA #1 revealed during this time LPN #1 administered medications to the resident. CNA #1 stated she observed Resident #1 to be pale, clammy, and staring off into space on 03/08/15 between 2:00 PM and 3:00 PM. According to CNA #1, she reported her concerns with the resident's change of condition to LPN #1, stating the resident was not normally like this. However, the CNA said the Nurse blew her off and ignored her concerns. Interview conducted with CNA #2 on 03/19/15 at 4:10 PM, and on 03/20/15 at 1:25 PM, revealed on 03/08/15 between 2:00 PM and 3:00 PM, Resident #1 was in bed dressed in street clothing. The CNA said she assisted the resident to change as the resident was still not feeling well. According to CNA #2, during second shift on 03/08/15 the resident's family came to the facility. CNA #2 stated the resident did not respond to the family member and his/her speech was slurred. The CNA said the family member went to the nurse's desk and spoke to LPN #1 regarding her concerns with Resident #1's condition, stating the resident had a change in condition. An interview on 03/18/15 at 3:30 PM, conducted with Family Member (FM) #1 revealed FM #1 arrived at the facility on 03/08/15 at approximately 4:15 PM. FM #1 stated when she arrived she found Resident #1 with labored gurgling respirations that could be heard from the door. According to FM #1, the resident was lethargic, mumbling, and was not responding to her as he/she usually did. Further interview revealed FM #1 went immediately to the nurses' station to ask the nurse about Resident #1. The family member spoke with LPN #1 regarding her concerns with the resident having labored breathing and not acting as he/she usually did. According to FM #1, she was informed by LPN #1 that the resident had an Upper Respiratory Infection and had [MEDICATION NAME](antibiotic medication) and a breathing treatment. FM #1 stated she did not agree with the course of treatment and contacted the APRN who worked with the resident's physician and knew the resident's history. FM #1 informed the APRN of the resident's condition and the APRN contacted the facility to have the resident sent to the hospital. According to FM #1, neither LPN #1 nor any other nurse checked on, or assessed Resident #1 while she was at the facility. FM#1 stated Resident #1 was transported to the hospital by ambulance. The resident was diagnosed with [REDACTED]. Interview with Licensed Practical Nurse (LPN) #1 on 03/19/15 at 2:50 PM, revealed she was assigned to care for Resident #1 on 03/08/15. According to LPN #1, Resident #1 did not eat anything for breakfast on 03/08/15, which was unusual for the resident. The resident reported to her during the 8:00 AM medication pass, that she was having trouble breathing and that he/she may be getting [MEDICAL CONDITION]. LPN #1 stated Resident #1 had problems holding a cup during breakfast, which was unusual for the resident. According to LPN #1, the resident was assessed and his/her vital signs were obtained on 03/08/15 between 7:00 AM and 9:00 AM. LPN #1 stated she contacted Resident #1's physician sometime after breakfast and obtained orders for an antibiotic and an as needed nebulizer treatment. Further interview revealed LPN #1 assisted the resident to bed after lunch (exact time unknown) with the use of a lift. The LPN stated she administered Resident #1's 2:00 PM medications between 1:00 PM and 3:00 PM and did not notice any additional concerns or changes for the resident. Further interview with LPN #1 revealed she rechecked Resident #1's oxygen saturation later in the day at an unknown time and the results had improved but she did not document the results in the record. LPN #1 stated she had not been notified of any concerns with Resident #1's condition by CNA #1. According to LPN #1, she was at the nurses' station on 03/08/15 at approximately 4:20 PM when she was approached by a family member of Resident #1 and asked what was going on with the resident. The LPN stated she reported to the family member what she had told the physician earlier in the day and that the resident had received medications. LPN #1 stated the family member did not agree with the physician's orders [REDACTED].#1 had pneumonia. LPN #1 said she stated to the family member that Resident #1 very well could have pneumonia. LPN#1 stated she later (time unknown) received a call from an APRN who worked for Resident #1's Primary Care Physician. The LPN stated the resident's condition and the physician's orders [REDACTED]. LPN #1 stated the APRN called her back and gave her orders for Resident #1 to be transferred to the hospital for evaluation and treatment. LPN #1 stated that she did not assess Resident #1 after the family had notified her of concerns with the resident's condition because she was getting paperwork ready to transfer the resident to the hospital. The LPN stated she only saw the resident when the paramedics were transporting the resident on a stretcher from the facility. According to LPN #1, residents were charted on during each shift and monitored during medication administration, meals, and during walking rounds conducted at shift change. An interview conducted with the APRN on 03/20/15, revealed the APRN received a call from Resident #1's family on 03/08/15 at 4:30 PM, regarding concerns with Resident #1 being short of breath and not responding to the family member. The APRN stated she called the facility to inquire about the resident. According to the APRN, she was informed that the resident was started [MEDICATION NAME] had received a nebulizer treatment. The APRN stated she felt this treatment was not adequate for Resident #1 due to the resident's recent history of pneumonia and the resident's multiple complex medical issues. The APRN discussed this with the family member, called the facility back, and gave orders to transfer the resident to the hospital. Interview with the Director of Nursing (DON) on 03/20/15 at 5:15 PM, revealed if a resident had a change of condition or a concern was reported to the nurse, the nurse was required to assess the resident using the Situation, Background, Assessment, Request (SBAR) format (the facility's method to gather information before calling the physician if a change of condition occurs). If the assessment indicated the physician needed to be notified, then staff was required to notify the physician using the care path algorithm (a protocol used to identify abnormal findings and guide physician notification). Further interview revealed the nurse was required to document the concern and the findings in the medical record. The DON stated she had been informed Resident #1 was transferred to the hospital on [DATE]. However, she was not aware that Resident #1 was not assessed by the nurse after the family reported their concerns and she was also not aware that the nurse did not even visualize the resident after concerns were reported to her until the resident was being transported from the facility by EMS. Interview with the Administrator conducted on 03/20/15 at 6:00 PM, revealed he was not aware LPN #1 had not assessed Resident #1 after she had been informed by the resident's family of their concerns on 03/08/15. According to the Administrator, if a resident had a change of condition or concerns were reported, the nurse was required to assess the resident and notify the resident's physician and family if indicated. Further interview with the Administrator revealed LPN #1 should have assessed/monitored Resident #1 when the family reported concerns with the resident on 03/08/15. **The facility provided an acceptable Allegation of Compliance (AOC) on 03/24/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) On 03/08/15, Resident #1 was sent to the hospital and treated in the emergency room for pneumonia,[MEDICAL CONDITION], and ST segment elevation [MEDICAL CONDITION] infarction (STEMI) ([MEDICAL CONDITION]). The resident had a stent placed. Resident #1 passed away at the hospital on [DATE]. 2) On 03/21/15-03/22/15, the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor conducted evaluations of all current residents to determine if there were any medical needs requiring physician notification which had not been addressed. Two (2) issues were identified. (A)--A [MEDICAL TREATMENT] patient (identified by the facility as Resident A) refused [MEDICAL TREATMENT] and later had weeping from the lower extremities. A nursing intervention was implemented, the resident's physician was notified of the change, physician orders [REDACTED]. The Unit Manager validated implementation of the new orders and continued monitoring of the resident. (B)--Resident B (identified by the facility as Resident B), who has a [DIAGNOSES REDACTED]. The Physician was made aware and ordered diagnostic testing, the resident's responsible party was notified of the resident's condition, and the procedure was ordered. The Unit Manager validated the implementation of the new orders and monitoring of the patient. On 03/21/15-03/22/15, the Director of Nursing, Unit Managers, MDS Nurses, Quality Improvement (QI) Nurses, Staff Facilitator, and Weekend House Supervisor reviewed all current residents' plans of care to determine that all interventions were being followed. Minor revisions were made to the care plans as needed. One care plan was significantly changed related to a patient's condition of [MEDICAL CONDITION] (interventions were in place). No change to the plans of care required notification to a Physician. 3) The INTERACT program is an evidence based Plan, Do, Check, Act process developed through funding from the Centers for Medicare and Medicaid Services (CMS) to prevent unnecessary acute care transfers and includes a binder of care paths, which are algorithms used for directing nurses through evaluating residents, providing care, and notifying the physician for certain common symptoms. It includes the SBAR (Situation, Background, Analysis, and Request) tool for nurses to complete and effectively communicate a resident's condition or change of condition with the Physician. On 03/20/15, the RN (Registered Nurse) Nurse Consultant re-educated the Staff Facilitator regarding conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluations, as well as physician notification; and, for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor and began re-education of Nurses, Medication Technicians, and Certified Nurse Aides on conducting an evaluation based on the resident's condition to include the INTERACT program, follow-up evaluation, as well as physician notification; and for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/21/15-03/22/15, Unit Managers, MDS Nurses, QI Nurses, Weekend House Supervisor, and Staff Facilitator continued with re-education with all Nurses, Medication Technicians, and Certified Nurse Aides related to conducting an evaluation based on resident condition to include the INTERACT program, follow-up evaluations, as well as physician notification for a significant change in condition, referring to the INTERACT program, but not to supersede nursing judgment. On 03/20/15, the RN Facility Consultant re-educated the Staff Facilitator regarding the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. On 3/20/15-03/21/15, the Staff Facilitator re-educated the Director of Nursing, Unit Managers, MDS Nurses, QI Nurses, and Weekend House Supervisor on the requirement to follow the plan of care; education further included if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Beginning 03/21/15 and ongoing, all licensed staff was re-educated by the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, or Staff Facilitator regarding the requirement to follow the plan of care and if the plan of care could not be followed and an alternative was not within their scope of practice the physician must be notified. Posttests were developed on 03/23/15 for Licensed Nurses, Medication Technicians, and Certified Nurse Aides to demonstrate retained knowledge of the re-education. Approximately 90 percent of the licensed nurses and approximately 75 percent of the Medication Aides and Certified Nurse Aides have completed the in-service education and posttest. These staff indicated understanding and stated all questions were answered at the end of the education sessions. No Licensed Nurse, Medication Technician, or CNA will work after 03/23/15 without having completed this re-education. No Licensed Nurse, Medication Aide, or CNA will provide patient care after 03/24/15 without having completed both the re-education and posttest. Beginning 03/21/15 and ongoing, all CNAs were re-educated with following the plan of care and if they were unable to follow the plan of care they must report it to the Charge Nurse. No CNAs will work after 03/23/15 without having received this re-education. All newly employed direct care staff will receive this education prior to working on a unit. Direct care staff on leave of absence or vacation will complete this re-education prior to working. 4) Beginning 03/23/15, the Director of Nursing, QI Nurses, Unit Managers, Staff Facilitator, Weekend House Supervisor, or RN Facility Consultant will conduct walking rounds to review with facility licensed nurse staff residents' conditions daily. These rounds will also include an investigation to determine if licensed staff are notifying the physician of significant changes in condition and completing ongoing evaluation as needed. This process will also include observation and discussion with Licensed Nurses and Certified Nurse Aides to determine if plans of care, including revisions, are being followed. The rounds will also consist of discussion with CNAs to determine if they have noted any changes in the residents throughout their shift and review of the STOP and WATCH (the tool included in the INTERACT program for CNAs to alert changes in resident condition in the electronic medical record). This will continue daily until abatement of Immediate Jeopardy then four (4) times per week for four (4) weeks thereafter. Beginning 03/23/15, the Director of Nursing, QI Nurses, Staff Facilitator, Unit Managers, Weekend House Supervisor, or RN Facility Consultant will review all Nurse's Notes daily to determine if any significant change in condition has occurred without physician notification or any significant change in condition has occurred without evaluation. This will occur daily until abatement of the Immediate Jeopardy and then four (4) times per week for four (4) weeks. The Clinical Interdisciplinary Team (IDT) which includes the Director of Nursing, Unit Managers, QI Nurses, Staff Facilitator, MDS Nurses, Weekend House Supervisor, RN Facility Consultant, or Treatment Nurse, will continue to follow the established process of reviewing the Nurse's Notes, Shift Reports, and physician's orders [REDACTED]. The Weekend House Supervisor reviews the documents Saturday and Sunday and reports to the Director of Nursing and Administrator at least daily. The Weekend House Supervisor and MDS Nurses will revise care plans through the established process. 5) On 03/20/15, an ad hoc Quality Improvement Committee was convened to review the facility's investigation and concerns. An Allegation of Compliance was developed and reviewed with the Associate Medical Director who approved. In attendance was the Administrator, RN Facility Consultant, Unit Managers, QI Nurses, MDS Nurses, Social Services Director, Kitchen Manager, Staff Facilitator, Admissions Director, and Activity Director. No further recommendations were made. The Administrator, Director of Nursing, QI Nurses, or RN Facility consultant will review the audits daily until abatement of Immediate Jeopardy. Thereafter, the results of these audits will be reviewed with the Quality Improvement Committee weekly and anytime a concern is identified until substantial compliance has been achieved; then per the schedule established by the Executive QI Committee. Thereafter, Members of the QI Committee will consist of at a minimum, the Director of Nursing, Unit Managers, QI Nurses, MDS Nurses, and Staff Facilitator. The Executive QI Committee consists of the Administrator, Director of Nursing Services, Unit Managers, QI Nurses, RN MDS Coordinator, Staff Facilitator, Treatment Nurse, Social Services Director, Social Services Assistant, Director of Activities, Director of Admissions, Dietary Services Director, Maintenance Director, Director of Environment and Safety, and Medical Director. ***The State Survey Agency validated the Immediate Jeopardy was removed as follows: 1) Review of the closed record for Resident #1 revealed the resident was transferred to the hospital on [DATE]. 2) Observations of Residents #11, #12, #13, and #14 on 03/25/15-03/26/15 revealed no concerns with changes of condition or following the plan of care. Review of Resident #11's medical record (identified by the facility as Resident A) revealed the facility assessed the resident to have weeping [MEDICAL CONDITION] to the lower extremities on 03/21/15. The resident's physician was notified of the change in the resident's condition on 03/21/15 at 7:39 PM, and orders were received for Keflex (antibiotic) 500 mg for [MEDICAL CONDITION] to the lower extremities. Review of the plan of care revealed no concerns. Review of the medical record for Resident #12 (identified by the facility as Resident B) revealed the facility assessed the resident to have a change in condition on 03/22/15 at 9:06 PM. The resident had [MEDICAL CONDITION] to the lower extremities. The resident's physician was notified and orders received for a venous study. Review of the plan of care revealed no concerns. Review of the medical records for Residents #13 and #14 revealed the residents were assessed for a change of condition on 03/21/15 with no changes of condition identified. Review of the plans of care for these residents revealed no concerns. 3) Interview with the Staff Facilitator on 03/26/15 at 1:55 PM revealed the Staff Facilitator had been trained by the Nurse Consultant on the Interact Program related to follow-up evaluations/assessments of residents using the SBAR tool. The Nurse Consultant had also trained the Staff Facilitator on assessing changes of condition, physician notification, and following residents' plans of care. According to the Staff Facilitator, she then began training all nursing staff. Interviews with CNAs #3, #4, #5, #6, #7, and #8 on 03/26/15 at 10:52 AM, 11:11 AM, 11:34 AM, 11:50 AM, 2:05 PM, and 2:20 PM respectfully, revealed the CNAs had been trained regarding notifying the nurse of a change of condition, using the Stop and Watch program, the resident assessment for change of condition, and following the plan of care. Interviews on 03/26/15 with LPN #2 at 11:00 AM, LPN #3 at 10:55 AM, LPN #4 at 1:00 PM, RN #1 at 12:50 PM, the Treatment Nurse at 11:30 AM, the West Wing Unit Manager at 1:15 PM, and the Second Floor Unit Manager at 1:30 PM revealed they had been trained regarding changes of condition, assessing/monitoring residents after a change of condition, notification of the physician, using the SBAR form, and following the resident's care plan. Review of the INTERACT training documentation revealed the training was given on 03/20/15, the Staff Facilitator had been educated by the Nurse Consultant and the Staff Facilitator conducted training for nursing staff with no concerns identified. The documentation revealed the facility was monitoring staff that had been trained to ensure they were following the process. Review of posttests revealed staff had been given posttests and the results were reviewed by the facility. 4) Interviews on 03/26/15 with the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, the MDS Nurse at 2:15 PM, the QI Nurse at 2:25 PM, and the West Wing Unit Manager at 1:15 PM revealed walking rounds were being conducted twice daily. These rounds included review of Nurse's Notes for SBAR assessments; monitor residents for change in condition; staff to discuss residents' condition with nurses and CNAs; and ensure care plans were being followed. They were also monitoring to ensure physicians were notified if needed and to ensure that nurses conducted follow-up evaluations if needed. Review of the facility's documentation of walking rounds conducted from 03/22/15 through 03/26/15 revealed walking rounds were being completed and were ongoing on 03/26/15 with no concerns identified. 5) Interviews on 03/26/15 at 3:30 PM with the Administrator, the Nurse Consultant at 3:15 PM, the DON at 2:45 PM, and the QI Nurse at 2:25 PM revealed the facility's Quality Assurance Committee was meeting daily to review daily audits for concerns with assessments, physician notification of change of condition, and following the residents' plans of care. Review of the Quality Assurance Committee minutes conducted on 03/21/15 through 03/26/15 revealed the facility had identified no concerns.

Based on interview, record review, facility policy review, and review of notifications from the Kentucky Department of Public Health (DPH) and the Centers for Disease Control (CDC) Health Alert Network, it was determined the facility failed to establish and maintain an effective infection control program to help prevent the development and transmission of [DIAGNOSES REDACTED] (TB) for fourteen (14) of twenty-four (24) sampled residents (Residents #1, #6, #9, #10, #12, #13, #14, #15, #16, #18, #19, #21, #22, and #23) and seventy-three (73) of seventy-five (75) unsampled residents (Residents A through Z, AA through ZZ, and 1-A through 1-W). Resident #5 received an annual [MEDICATION NAME] skin test on 07/01/13. However, after 07/02/13, the facility failed to administer [MEDICATION NAME] skin testing or blood testing, annually or upon admission, to determine the presence of [DIAGNOSES REDACTED] infection for the other residents as recommended by the Kentucky Department of Public Health, the Centers for Disease Control (CDC), and the Office of Inspector General. In addition, the facility failed to conduct TB skin testing or lab testing for forty-nine (49) (Employees #1 and #3 through #50) of the fifty (50) new employees who were hired from 07/02/13 through 01/17/14. Two of the employees were assessed to have a history of exposure to [DIAGNOSES REDACTED]. The facility further failed to conduct a TB skin test for fifty-eight (58) employees (Employees #51 through #108) who were due to receive an annual TB skin test from 07/02/13 to 01/17/14. On 02/19/13, all long-term care facilities were notified by the Kentucky Department of Public Health and the Office of Inspector General of a shortage in the manufacturing of [MEDICATION NAME] (a protein derivative used to test for [DIAGNOSES REDACTED]). The letter recommended a Blood Assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] (BAMT) (a blood test) be used as an alternative for TB screening in long-term care facilities until the [MEDICATION NAME] shortage was resolved. However, the facility failed to follow these recommendations and adopted a policy and procedure on 03/08/13 that did not require screening residents and staff for TB by utilizing a TB skin test or blood test. The facility utilized a screening tool for signs and symptoms of [DIAGNOSES REDACTED] and risk factors. The policy was developed on 03/08/13; however, residents and staff continued to receive [MEDICATION NAME] skin testing until the policy was reviewed and revised on 07/02/13; and the facility stopped giving skin tests. The facility initiated the screening tool to evaluate residents and staff for risk factors and signs/symptoms of TB. The facility's failure to have an effective system in place to ensure residents and employees were screened for the presence of [DIAGNOSES REDACTED] per recommendations of the Kentucky Department of Health and the Centers for Disease Control was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was identified at 42 CFR 483.65 Infection Control on 01/17/14, was determined to exist on 07/02/13, and is ongoing. The facility was notified of the Immediate Jeopardy on 01/17/14. The findings include: Review of the facility's "[DIAGNOSES REDACTED] Testing and Screening - Temporary Measures" policy dated 03/08/13 and revised on 07/02/13 revealed a "Complete [DIAGNOSES REDACTED] Screening User Defined Assessment" would be conducted for all residents and staff. The policy directed upon completion of the assessment, no further testing would be required if residents or newly hired employees were assessed to have negative responses to all questions on the assessment. The policy noted if residents or employees were assessed to have a positive response to "Signs and Symptoms," further medical evaluation was to include a chest x-ray. Further, the policy noted residents and employees assessed to have a negative response to "Signs and Symptoms," but a positive response to the "[DIAGNOSES REDACTED] Risks" would receive a [MEDICATION NAME] skin test unless written documentation of a prior positive skin test and negative chest x-ray was available. Review of the letter sent to all long-term care facilities on 02/19/13 from the Kentucky Department of Public Health and the Office of Inspector General confirmed a nationwide shortage of [MEDICATION NAME] (medication used for TB skin testing). The letter identified a blood test, Blood Assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] (BAMT), as an alternative option for TB screening in long-term care facilities. Review of the CDC Health Alert Network dated 04/12/13, revealed the CDC recommended any of the following three approaches for addressing the shortage of [MEDICATION NAME] skin test [MEDICATION NAME]: 1. Substituting a blood test that detects TB bacteria infection for [MEDICATION NAME] skin tests (TST). 2. Allocating [MEDICATION NAME] skin tests for priority indications, such as TB contact investigations, as determined by public health authorities. 3. Substituting [MEDICATION NAME] (another solution used to complete a TB skin test) for [MEDICATION NAME] for skin testing. Review of the letter from the Kentucky Department of Public Health and review of CDC recommendations revealed screening for [DIAGNOSES REDACTED] signs and symptoms and risk factors were not included as an alternative for TB testing. Review of the medical records for Residents #1, #10, #14, #15, #16, #18, #19, #21, #22, and #23 revealed the facility admitted these residents between 07/10/13 and 01/13/14. However, there was no documented evidence these residents received the [MEDICATION NAME] skin test or blood test to assess for the presence of [DIAGNOSES REDACTED] bacteria. Review of the medical records for Residents #6, #9, #12, and #13 revealed these residents were due for an annual [MEDICATION NAME] skin test between September 2013 and December 2013. However, there was no documented evidence the facility conducted the annual skin testing or blood tests for these residents. Review of the immunization records for 75 additional residents (Residents A, B, C, D, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, KK, LL, MM, NN, OO, PP, QQ, RR, SS, TT, UU, VV, WW, XX, YY, ZZ, 1-A, 1-B, 1-C, 1-D, 1-E, 1-F, 1-G, 1-H, 1-I, 1-J, 1-K, 1-L, 1-M, 1-N, 1-O, 1-P, 1-Q, 1-R, 1-S, 1-T, 1-U, 1-V, and 1-W) who were identified by the facility to require an admission or annual [MEDICATION NAME] skin test since 07/02/13 revealed only two of these residents (Residents YY and 1-A) received [MEDICATION NAME] skin testing or an evaluation as required. Review of the newly hired employees from 07/02/13 through 01/17/14 revealed the facility had hired 50 new employees; one employee (Employee #2) had a history of [REDACTED]. However, no other newly hired employee had a TB skin test or blood test to determine the presence of [DIAGNOSES REDACTED]. Two of these employees (Employees #5 and #6) reported past exposure to [DIAGNOSES REDACTED], but did not receive a skin test or lab test to determine the presence of the bacteria that causes [DIAGNOSES REDACTED] as required by the Kentucky Department of Public Health, the CDC, the Office of Inspector General, and the facility's policy. The facility also identified 58 employees who were due to receive an annual TB skin test. Seven of the 58 employees documented risk factors for TB, five documented signs and symptoms of TB, and two employees documented both signs and symptoms of TB and risk factors for TB; however, none of these employees received the TB skin test or the recommended blood testing by the Kentucky Department of Public Health. Interview conducted with Unit Coordinator #1 on 01/15/14, at 2:20 PM, revealed Resident #1 did not receive a TB skin test upon admission to the facility on [DATE]. UC #1 stated a TB screening tool was being conducted to assess all residents for signs and symptoms of [DIAGNOSES REDACTED] and risk factors associated with [DIAGNOSES REDACTED] and no TB skin tests or blood tests were being conducted. The UC stated this was due to a shortage of the TB medication used to test for [DIAGNOSES REDACTED]. Interview with the Director of Nurses (DON) on 01/16/14, at 11:25 AM, confirmed TB screenings to evaluate for signs and symptoms and risks associated with [DIAGNOSES REDACTED] were being conducted for all residents and employees. The DON stated a new policy had been developed by corporate staff in March 2013 after the shortage of [MEDICATION NAME] had been identified. The DON further stated the policy had been reviewed by the corporation in July 2013 and the TB screening continued to be utilized to assess residents and employees for the possible presence of [DIAGNOSES REDACTED]. The DON stated she understood the policy was acceptable to use and had not contacted the pharmacist or local health department to verify the status of the shortage or for further directions. The DON also confirmed no blood testing had been conducted for residents or staff after the letter from the Kentucky Department of Public Health was received in February 2013. Interview conducted with the Administrator on 01/16/14, at 1:30 PM, confirmed a new policy had been developed by the corporation's staff after the letter had been received from the Kentucky Department of Public Health in February 2013. The Administrator stated the new policy implemented in March 2013 and reviewed in July 2013 directed staff to perform TB screenings to evaluate the signs/symptoms and risk factors of [DIAGNOSES REDACTED]. The Administrator also confirmed TB skin testing had not been conducted routinely and no blood testing had been conducted for residents or staff after the letter was received. The Administrator stated he believed the policy adopted by the corporation was acceptable to use.

Based on interview, record review, review of the facility's [MEDICAL CONDITION] (TB) Testing and Screening Policies, and review of recommendations from the Kentucky Department of Public Health (DPH) and the Centers for Disease Control (CDC), it was determined the facility's administration failed to ensure the facility was administered in a manner that enabled residents to attain or maintain the highest practicable well-being of each resident. The facility's administration developed a temporary TB Testing and Screening Policy for residents and staff on 03/08/13 that did not require residents and staff to receive a TB skin screen for TB in accordance with accepted standards of practice, Kentucky TB Statutes/recommendations, and the Centers for Disease Control (CDC). Residents and staff continued to receive [MEDICATION NAME] skin testing until the policy was reviewed on 07/02/13 and the facility began conducting [MEDICATION NAME] screening for residents and staff to evaluate for risk factors and signs/symptoms of TB. Resident #5 received an annual [MEDICATION NAME] skin test on 07/01/13; however, the facility failed to administer [MEDICATION NAME] skin testing (TST) or blood testing, upon admission or annually after 07/01/13, to determine the presence of [MEDICAL CONDITION] infection for the other residents as recommended by the Kentucky Department of Public Health, the Centers for Disease Control, and the Office of Inspector General. The facility failed to conduct TB skin testing for eighty-seven (87) of one-hundred fifty-nine (159) residents and one-hundred seven (107) staff members as recommended by the Kentucky DPH and the CDC since 07/02/13 (refer to F441). The facility's failure to ensure the facility was administered in a manner to ensure acceptable/recommended infection control practices were followed was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was identified at 42 CFR 483.65 Infection Control on 01/17/14, was determined to exist on 07/02/13, and is ongoing. The facility was notified of the Immediate Jeopardy on 01/17/14. The findings include: Review of the Administration policy (dated January 2009) revealed the administrator was responsible for the planning, organization, and directing of employees of the facility. Review of the facility's policy entitled, "[MEDICAL CONDITION] Testing and Screening - Temporary Measures," effective 03/08/13 and revised 07/02/13, revealed, "Due to the shortage of [MEDICATION NAME] and [MEDICATION NAME] for [MEDICATION NAME] skin testing, it is necessary to follow these temporary measures for patients and employees." The policy stated no testing was required for residents and staff who gave negative responses to all questions on a [MEDICAL CONDITION] Screening Assessment. The policy further revealed residents and staff with a positive response to signs/symptoms should receive further medical evaluation to include a chest x-ray. If residents and staff had a positive response to the risk factors, the policy directed they should receive a TST unless documentation of a prior positive TST or chest x-ray was provided. Review of a letter dated 02/19/13 from the Kentucky Department for Public Health to Long Term Care Administrators revealed the facility may be impacted by two nationwide shortages of medications used in TB Infection Control programs. One of the medications was a formulation of [MEDICATION NAME], a brand of [MEDICATION NAME] Purified Protein Derivative ([MEDICATION NAME]) that is used for [MEDICATION NAME] skin tests (TST) (a TST is the standard method of determining whether a person is infected with the bacteria that causes [MEDICAL CONDITION]). According to the letter, facilities had two options for testing residents and staff for TB. One option was using [MEDICATION NAME], another brand of [MEDICATION NAME] used for skin testing, or the facility could conduct a Blood Assay for [DIAGNOSES REDACTED] (BAMT, which is blood tests that can aid in diagnosing [DIAGNOSES REDACTED] (TB) infection). The Kentucky DPH recommended using the BAMT test. Review of the Centers for Disease Control and Prevention (CDC) recommendations related to the [MEDICATION NAME] shortage revealed a skin test or blood test was recommended to test individuals for possible infections of [MEDICAL CONDITION]. Review of resident records and personnel files from 07/02/13 through 01/16/14 revealed 87 of 159 residents and 107 staff members did not receive a TB skin test or laboratory blood testing as recommended by the Kentucky Department of Public Health and the CDC. Interview conducted with the Administrator on 01/17/14, at 3:00 PM, revealed he was familiar with the 02/19/13 letter sent to long-term care facilities. The Administrator stated he did not participate in the development of the temporary policy, but believed the practices established through the corporation were acceptable. The Administrator stated the new policy developed in March 2013 and reviewed and revised in July 2013 directed staff to perform TB screening to evaluate signs/symptoms and risk factors of [MEDICAL CONDITION]. The Administrator also confirmed TB skin testing had not been conducted routinely and no blood testing had been conducted for residents or staff after the letter was received.

Based on interview, record review, and review of the facility's policy and Allegation of Compliance (AOC), it was determined the Immediate Jeopardy (IJ) identified during the annual survey concluded on 01/17/14 had been removed related to Administration. An acceptable AOC was received on 01/24/14 alleging removal of the IJ on 01/23/14. However, it was determined the IJ was not removed on 01/23/14 as alleged. The facility failed to ensure two (2) employees (Employees #2 and #51), out of fifteen (15) employee screenings reviewed, were referred to the local Health Department or the Medical Director for further diagnostic evaluation and testing as required per the facility's [MEDICAL CONDITION] Testing and Screening Policy based on the employees' history of a past positive TB skin test and documented signs/symptoms of [MEDICAL CONDITION] (TB). In addition, the facility failed to ensure the Staff Development Coordinator (SDC) was knowledgeable on how to read a TB skin test. Based on the above findings, it was determined the IJ was removed on 02/01/14 with remaining noncompliance at a scope/severity of "F" while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's AOC dated 01/24/14 revealed the facility reverted to their August 2005 "[MEDICAL CONDITION] Screening and Testing" for employees, which stated if an employee had a documented positive Mantoux skin test (TB skin test), a screening for [MEDICAL CONDITION] symptoms would be performed and if the employee had symptoms of TB, they would be referred for further evaluation and testing. Review of employee TB screening forms dated 01/17/14, revealed Employees #2 and #51, who had a past positive TB skin test, had documented symptoms of TB. Employee #2 marked on the form that she had night sweats and Employee #51 marked that she had chest pain, weight loss, and excessive fatigue. According to the facility's policy, the employees would be referred to the local Health Department or to the Medical Director for further diagnostic evaluation and testing to include a chest x-ray. There was no evidence that the employees had been referred or had any diagnostic evaluation. Interview revealed the Staff Development Coordinator (SDC) had reviewed the screenings and had identified no concerns. In addition, interview with the SDC revealed she had read the results of the TB skin tests; however, she could not convey what measurement would be considered a positive TB skin test. Interview conducted with the DON on 01/31/14 at 1:27 PM, revealed the SDC reviewed the employee screening forms; however, the SDC reported to the DON that there were no concerns. Further interview with the DON revealed she was not aware the SDC was not knowledgeable on how to read a TB skin test. Interview conducted with the Administrator on 01/31/14 at 1:25 PM, revealed no [MEDICAL CONDITION] testing/screening issues had been reported to him. In addition, the Administrator stated the facility had not identified that the SDC, who was reading TB skin test results, was not knowledgeable. Further interview with the Administrator and DON on 01/31/14 at 1:27 PM, revealed education on reading a TB skin test had not been provided to licensed staff. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: The facility Administrator met with the Regional Vice President, Director of Nursing, Quality Improvement (QI) Nurse, Corporate Nurse Consultant, Vice President of Clinical Operations (via phone), and Director of Corporate Policy (via phone) on 01/16/14. The investigation included review of the letters and documents from the Cabinet for Health and Family Services, Centers for Disease Control (CDC), and the Food Drug Administration (FDA), and resulted in the determination that an error had been made in the interpretation of these documents and the temporary policy was repealed on 01/16/14. On 01/16/14, the decision was made to immediately repeal the facility's "[MEDICAL CONDITION] Testing and Screening Temporary Measures" and revert to the facility's permanent policies for TB Testing entitled, "[MEDICAL CONDITION] Screening and Testing (Employee)" and "Resident [MEDICAL CONDITION] Testing and Screening Policy." Both of these policies have been in effect since August 2005. These policies include two-step TB testing for new-hires and new resident admissions and annual TB testing thereafter. On 01/16/14, the facility Administrator contacted the local hospital and multiple pharmacies and was able to obtain enough [MEDICATION NAME] to conduct testing for all employees and all residents, with an additional supply for admissions and new hires for approximately 60 days. On 01/16/14, the facility Administrator met with the Director of Nursing and all Administrative Nurses and conducted re-education regarding the TB Skin Testing Policy. On 01/17/14, the facility Administrator spoke with and reviewed the facility policy with the local Health Department Medical Director who advised to treat all staff and residents as if they were Day 1 employees and residents. Staff and residents who had already received a two-step TB skin test would not need the second step administered, nor was there a need to obtain new x-rays for those who have had a negative x-ray since exposure or treatment. The Health Department Medical Director advised that her opinion was that testing of employees during their next scheduled shift was sufficient to meet the regulation. On 01/17/14, the Director of Nursing spoke with the facility's Medical Director and received orders to administer TB skin testing in accordance with policy for all residents in the facility. The Staff Development Nurse began immediately conducting TB skin tests on all employees on the premises on 01/16/14 and 01/17/14. The other Administrative Nurses began TB testing for all residents on 01/17/14 to be completed before midnight on 01/17/14. Any positive resident PPDs will be addressed according to the facility's policy including screening, notification to MD, and follow-up chest x-ray. Any resident with signs/symptoms of active TB will be transferred to an acute care facility until after appropriate therapy is completed. Any positive staff PPDs will be addressed according to the facility's policy. The employee will be immediately placed on administrative leave and notification will be made to the facility's Medical Director or physician on call and the local Health Department for further diagnostic testing such as a chest x-ray, or a statement will be obtained stating a chest x-ray is not needed. The employee will be required to have a Physician's Statement to clear them for duty prior to the employee being allowed to work. Any positive resident or staff conversions of more than 10 mm induration will be immediately reported to the local Health Department by the Administrator or Director of Nursing. The reading of the resident PPDs will be conducted by licensed nurses per policy and will be overseen by the Unit Coordinator with a report to the Director of Nursing on 01/22/14 for the initial PPDs and 02/07/14 for the residents who required a second-step PPD. The reading of the staff PPDs will be conducted by licensed nurses per policy and will be overseen by the Staff Development Nurse with a report to the Director Nursing on 01/22/14 for the initial PPDs and 02/07/14 for the staff requiring a second-step PPD. A nurse assigned by the Director of Nursing will be present at the time clock each shift change until 100 percent of the staff in all departments has been tested per policy. No employee will be allowed to work until the employee has received a TB skin test or appropriate documentation is received for those who are unable to take the test. The QI Nurse and QI Assistant Nurse made copies of the Resident TB Skin Testing Policy and reviewed with all Licensed Nurses on the premises on 01/17/14 and will continue to retrain all licensed nurses who admit patients until 100 percent of the Licensed Nurses have been re-educated regarding elimination of the Temporary Measures and return to the prior policy. All residents on census have had a TB skin test or x-ray per policy. There are no residents out of the facility who have not had a TB test since 01/16/14. The Admissions Coordinator assigns residents to the beds and assembles the patient's medical record. On 01/17/14, the Admissions Coordinator was instructed by the Administrator to notify the QI Nurse or QI Assistant Nurse of any scheduled admissions. Only Licensed Nurses who have been retrained regarding the TB Testing Policy will be permitted to admit patients. The majority of the licensed nurses were re-educated on 01/16/14 and 01/17/14. The additional licensed nurses will be retrained by the QI Nurse or QI Assistant Nurse during their next working shift. The QI Nurse or QI Assistant Nurse will ensure the TB skin test is conducted per policy, by a licensed nurse who has been re-educated to the policy. The QI Nurse or QI Assistant Nurse will be available seven days per week until all licensed nurses have been retrained on the policy. The TB Testing Policy will be covered by the Staff Development Nurse or Instructor during orientation for all licensed nurse new hires. New hires will have PPDs administered per policy by the Staff Development Nurse during Day 1 of general orientation and the second step administered by the Staff Development Nurse per policy. The QI Nurse or Administrative Nurse assigned by the Director of Nursing will review all employee health files for new employees within 24 hours of orientation and three weeks after orientation for a period of 60 days and per the established schedule thereafter to ensure TB testing is being completed correctly. A Unit Coordinator, the Weekend House Supervisor, or Director of Nursing will review the immunization record daily for all new admissions for a period of 60 days and per the established schedule thereafter. The facility developed a policy, "[MEDICAL CONDITION] Testing and Screening Temporary Measures," regarding the possibility the facility becomes unable to obtain TB Testing Agent, the employee or resident will have a Blood Assay for [DIAGNOSES REDACTED] (BAMT), QuantiFeron-TB Cold In-Tube Test (IGRA), or T-Spot TB (TST) (blood tests that test for the presence of [MEDICAL CONDITION] infection). In the event the lab tests are unavailable, the facility Administrator or Director of Nursing will contact the local Health Department for direction. At this time, the facility has a sufficient quantity of [MEDICATION NAME] to last 60 or more days without reorder. The Director of Nursing will develop written education for all licensed nurses regarding the contingency policy stating what to do if the TB testing agent becomes unavailable. This education will be distributed with payroll on 01/23/14. The Unit Coordinators, Staff Development Nurse, and/or House Supervisor will report the progress of the TB testing to the facility Administrator or Director of Nursing daily until all employees and residents have completed the initial round of testing initiated on 01/16/14. The Director of Nursing will present the 01/22/14 reports from the Unit Coordinators and the Staff Development Nurse regarding TB testing to the Administrator and QI Committee on 01/22/14, and will present the 02/07/14 reports from the Unit Coordinators and Staff Development Nurse to the Administrator and QI Committee on 02/12/14. The QI Committee will review TB testing weekly through 02/28/14, then at the meeting the week of 03/26/14, and then per the established calendar thereafter. The QI Reviews will be overseen by the facility Administrator. Any identified issues will be reported to the Regional Vice President. TB Control is listed in the Annual In-Service Plan. The next scheduled "TB Control" review is scheduled for 07/14-16/14. The policies will be reviewed with staff at that time. On 01/30/14, it was identified that two employees who were unable to receive a TB skin test had signs/symptoms of TB marked yes on their screening forms and the facility had not followed its TB Policy. Upon identification of the issue, both employees were immediately placed on administrative leave on 01/30/14 and referred to the local Health Department but were unable to be seen on 01/31/14. The facility's Medical Director was contacted on 01/31/14 and gave an order for [REDACTED]. Results were received on 01/31/14 and were negative. The Administrator, Director of Nursing, and Facility Nurse Consultant received education from the Vice President of Nursing and the Employee Health Coordinator at the local Hospital. The Hospital employees reviewed the facility's policy and determined that the Director of Nursing, Administrator, and Facility Nurse Consultant were knowledgeable regarding proper placement, administration, and reading of TB skin tests including the varying millimeters of induration, "mm" for a positive result for immunocompromised patients, routine nursing facility patients, and individuals identified as low risk. The specifics of the method for reading a TB test were also reviewed. The Hospital's Employee Health Coordinator also reviewed when to conduct a screening form, e.g., past positive, and the facility's policies regarding referral to the Physicians, Medical Director, or Health Department. The Administrator and Director of Nursing have taken complete control of the TB Screening Program effective 01/31/14 for both employees and residents, including administration and reading of TB Skin Tests, Screening Forms, and QI Audits and reports until such time as all Licensed Nurses have successfully completed skills verification related to administration and reading of TSTs and Screening Forms. The Director of Nursing will conduct the TB skin tests and readings until all staff have received re-education and have demonstrated they are knowledgeable. In the absence of the Director of Nursing, the Administrator will observe a licensed nurse who has already been re-educated and demonstrated successful skills to administer and/or read the TB test in order to ensure it is administered/read correctly in the event it is "required" during the absence of the DON. **The surveyors validated the Immediate Jeopardy was removed as follows: A review of the facility's policy entitled, "[MEDICAL CONDITION] Screening and Testing," dated August 2005, revealed all employees upon hire would receive a two-step Mantoux skin test with the first step being given on the first day of work. Employees with a negative skin test would receive a second-step Mantoux skin test within seven to fourteen days, and annually by a one-step method. The policy stated if a new positive occurred, employees would be referred to the local Health Department or to the Medical Director for further diagnostic evaluation and testing to include a chest x-ray. The policy further stated if an employee had a documented positive Mantoux skin test upon hire, a screening for [MEDICAL CONDITION] symptoms would be performed. An employee with negative symptomology would have an annual screening thereafter. If symptomology was present, the employee would be referred to the local Health Department or the Medical Director for further diagnostic evaluation and testing to include a chest x-ray. Review of the facility's policy entitled, "Resident [MEDICAL CONDITION] Testing and Screening Policy," dated August 2005, revealed all residents without a known documented positive PPD reaction would receive [MEDICAL CONDITION] testing upon admission using a two-step method. The first step would be administered on admission and if negative, a second PPD would be administered seven to fourteen days thereafter. The policy stated if the second step was negative, annual testing would occur thereafter using a single-step method. The policy revealed evaluation of residents with a new positive PPD would occur by the attending physician or the Medical Director to determine the presence of active [MEDICAL CONDITION]. The policy also revealed residents with a known documented positive reaction to a Mantoux PPD test would be screened for any history and symptoms of [MEDICAL CONDITION]. A chest x-ray would be obtained for residents with a positive screening, and the attending physician or the Medical Director would be notified to determine if further testing, appropriate treatment, and management were necessary. The policy stated any resident with suspected or probable infectious [MEDICAL CONDITION] would be transferred to an alternate facility for treatment. Review of the facility's policy entitled, "[MEDICAL CONDITION] Testing and Screening Temporary Measures," dated 01/17/14, revealed in the event the [MEDICAL CONDITION] testing agent became unavailable due to the shortage of [MEDICATION NAME] and [MEDICATION NAME], either a BAMT, IGRA, or TST test would be performed. If these tests were not available from the facility's laboratory, the facility would consult with the local Health Department for measures to be taken for [MEDICAL CONDITION] testing and/or screening. Interview with the Administrator on 01/31/14, at 11:35 AM, the DON on 01/31/14, at 11:40 AM, the Corporate Nurse on 01/31/14, at 11:42 AM, and the Vice President of Clinical Operations on 01/31/14 at 1:40 PM, verified they had attended the telephone conference on 01/16/14, and confirmed the group had decided to repeal the interim [MEDICAL CONDITION] policy and revert back to the old [MEDICAL CONDITION] policy dated 2005, for both employees and residents. Interview conducted with the Administrator on 01/31/14, at 11:35 AM and 1:20 PM, revealed he had contacted the local Hospital as well as the local pharmacies, and obtained enough [MEDICATION NAME] to last at least 60 days based on the facility's average admission and new hire rate. The Administrator stated he had met with all administrative nurses, as well as the DON, to discuss the [MEDICAL CONDITION] testing policy. The Administrator stated they decided that the Staff Development Coordinator (SDC) would begin testing all employees on 01/16/14 and 01/17/14, the administrative nurses began testing residents on 01/17/14, and testing was completed by 01/17/14. The Administrator further stated the facility would revert to using the BAMT, IGRA, or TST in the event [MEDICATION NAME] was not available. The Administrator stated if the laboratory tests were not available at the facility's laboratory, he or the DON would consult the local Health Department for guidance. Interview conducted with the DON on 01/31/14, revealed either she or the Administrator would notify the local Health Department in the event the facility did not have [MEDICATION NAME] or [MEDICATION NAME] available to perform PPDs. The DON stated she had developed training and had trained all facility nurses on what to do in the event [MEDICATION NAME] or [MEDICATION NAME] was unavailable and all facility nurses had been trained on the policy and procedure. Review of in-services entitled, "Nurse Education of TB Screening Policy," revealed the DON educated staff on the new policy that required nursing staff to notify the DON should testing be required. The in-service was initiated on 01/17/14 and completed on 01/23/14. Review of an in-service roster entitled, "Administrator Review of [MEDICAL CONDITION] Test Issues," dated 01/16/14, revealed all administrative nurses attended an in-service regarding the facility's [MEDICAL CONDITION] policy, State Regulations concerning [MEDICAL CONDITION] testing, and [MEDICAL CONDITION] testing for all residents and staff. Interview conducted with QI Nurse #2 on 01/31/14, at 11:45 AM, and QI Nurse #1 on 01/31/14, at 1:00 PM, revealed they made and distributed a copy of the Resident [MEDICAL CONDITION] Testing Policies to all licensed nurses in the facility. The policy was used to retrain all nursing staff. The training was completed on 01/23/14. Observation of the facility's [MEDICATION NAME] in the facility on 01/30/14 revealed the facility had enough [MEDICATION NAME] on hand to provide 150 PPD tests. Review of an e-mail sent to the Administrator by the Health Department Medical Director dated 01/24/14, at 8:12 AM, revealed the Administrator had consulted with the Medical Director, who advised the facility to start all staff and resident annual testing. The e-mail revealed any staff or resident who had previously been tested would not require a two-step, and those staff members or residents who have had a previous positive PPD required a [MEDICAL CONDITION] assessment. The e-mail stated residents who did not have symptoms would not need a chest x-ray. Interview conducted with the local Health Department Medical Director on 01/30/14, at 2:50 PM, revealed she had consulted with the Administrator and had advised him to begin [MEDICAL CONDITION] testing for employees and residents. The Medical Director stated she had advised the Administrator to begin using the two-step method, unless the resident or staff member had already had a two-step TB test; and in that case, just to begin the annual testing. The Medical Director stated any staff or resident who had a past positive PPD would require a screening and would only require a chest x-ray if the resident or employee had a symptom of [MEDICAL CONDITION]. The physician stated she told the Administrator that waiting until the employee's next scheduled shift would be sufficient to do the PPD or screening. A review of signed physician's orders [REDACTED]. The physician's orders [REDACTED]. Interview conducted with Unit Coordinator #1 on 01/31/14, at 12:10 PM, Unit Coordinator #2 on 01/31/14, at 12:15 PM, and Unit Coordinator #3 on 01/31/14, at 12:20 PM revealed PPD skin tests or screenings for residents with a history of a positive PPD were completed on 01/17/14. The Unit Coordinators stated they had attended the in-service given by the Administrator and had discussed the repeal of the [MEDICAL CONDITION] policy and going back to the previous policy. The Unit Coordinators stated in the future, all residents without a known past positive would receive a two-step PPD upon admission and a one-step annually. If after receiving the first PPD the resident had a reaction, the physician would be notified for further orders, including a chest x-ray. The Unit Coordinators stated all employees would be given a PPD as well, unless they had a positive past PPD, and in that case a screening would be completed. If the employee documented symptoms, the employee would be referred to the Health Department or the Medical Director for further testing including a chest x-ray. The Unit Coordinators each stated all resident PPDs were negative and they had reported that information to the DON, and would be sending a report to the DON after reading the second step PPDs on 02/07/14. Interview with the weekend House Supervisor on 01/31/14, at 1:30 PM, revealed she had been assigned to the time clock on 01/18/14 and 01/19/14, to administer PPD skin tests or complete screenings for employees. Employees were not allowed to work until after the PPDs or screenings were done. Interview with Quality Improvement (QI) Nurse #2 on 01/31/14, at 12:47 PM, revealed she had been assigned to the time clock on 01/17/14, 01/18/14, and 01/19/14, to administer PPDs or complete screenings for employees. Employees were not allowed to work until after the PPDs or screenings were done. Interview conducted with Registered Nurse (RN) #3 on 01/30/14, at 4:30 PM, Licensed Practical Nurse (LPN) #4 on 01/30/14, at 4:40 PM, LPN #2 on 01/30/14, at 4:45 PM, LPN #3 on 01/30/14, at 4:50 PM, and LPN #1 on 01/30/14, at 5:05 PM revealed they had attended an in-service regarding the [MEDICAL CONDITION] policy and were knowledgeable of the facility's TB testing policy and the policy regarding the skin testing agent not being available. The nurses stated every resident had to have a two-step PPD on admission and a one-step annually. If the resident had a past positive history of PPD or [MEDICAL CONDITION], the physician or Medical Director must be notified for any additional testing and a chest x-ray must be obtained. If a resident had a positive PPD or had symptoms of TB, the physician or Medical Director, the Administrator, and the DON must notified immediately. The nurses stated no nurse was allowed to admit residents until after they were trained on the [MEDICAL CONDITION] policy. The nurses further stated they were aware they had to notify the DON and the Unit Coordinator if [MEDICATION NAME] was not available and if the laboratory was not able to conduct BAMT, IGRA, or TST testing. Interview conducted with the Admissions Coordinator on 01/31/14, at 1:02 PM, revealed she was responsible for assigning beds to residents upon admission, and had been assigned by the Administrator to notify QI Nurse #1 or QI Nurse #2 of any scheduled admissions. Interview conducted with QI Nurse #2 on 01/31/14, at 11:45 AM, and QI Nurse #1 on 01/31/14, at 1:00 PM, revealed they had reviewed all resident TB skin tests to ensure they were conducted per policy and administered by a nurse who had been re-educated on the policy. There had been no new admissions to the facility. Review of [MEDICAL CONDITION] screenings and PPD test results for all residents dated 01/17/14, revealed all residents with a history of a positive PPD had been screened and all other residents received a PPD skin test on 01/17/14. All PPDs were negative and no resident had signs or symptoms documented on the screening form. The PPDs were read on 01/20/14. Review of PPD test results for all employees revealed all employees received a TB skin test on 01/16/14 or 01/17/14. All TB skin tests were documented as being zero (0) millimeters of induration (negative for [MEDICAL CONDITION]). The TB skin tests were read on 01/19/14 or 01/20/14. Review of Quality Improvement Documentation revealed QI Nurse #1 documented she reviewed three new employee health files. QI Nurse #1 stated the new employees were not nurses. The documentation revealed the employees began employment on 01/28/14, QI Nurse #1 reviewed the health files on 01/29/14, and found no concerns, and the policy was being followed. Interview conducted with QI Nurse #1 on 01/31/14, at 1:15 PM, revealed she was required to review all new employee health files within 24 hours to ensure any symptoms of [MEDICAL CONDITION] were followed up on per facility policy. Interview conducted with the DON on 01/31/14, at 1:15 PM, revealed she checked the computer daily, and reviewed all new admissions to ensure the policy was being followed and had not identified any concerns. Interview conducted with the weekend Nursing Supervisor on 01/31/14, at 1:30 PM, revealed she reviewed any new admissions daily on the weekend to ensure the [MEDICAL CONDITION] policy was being followed and had not identified any concerns. Review of an Absence/Vacation Report dated 01/30/14, revealed Employee #2 and Employee #51 had both been placed on Administrative Leave of Absence until further notice. Interview conducted with the facility's Medical Director on 02/01/14, at 9:30 AM, revealed he had been contacted by the facility and had given the DON an order to obtain chest x-rays for both employees and had been notified that the x-rays were negative for [MEDICAL CONDITION]. Review of chest x-ray reports for Employee #2 and Employee #51 dated 01/31/14, revealed both were negative for [MEDICAL CONDITION]. Review of an e-mail and an in-service roster sent to the Administrator from the local Hospital Employee Health Nurse on 01/31/14, revealed the Administrator, DON, and Corporate Nurse, all attended an in-service provided by hospital staff regarding Center For Disease Control (CDC) guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of PPDs. Interview conducted with the Corporate Nurse on 02/01/14, at 9:00 AM, revealed she had attended the in-service on 01/31/14, by the local Hospital employee health nurse on CDC guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of a PPD. Interview conducted with the DON on 02/01/14, at 9:05 AM, revealed she had attended an in-service on 01/31/14, by the local hospital employee health nurse regarding CDC guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of a PPD. The DON stated as of 01/31/14, she was responsible for administering all PPDs and reading all PPDs until nurses were re-educated on administration and reading of a PPD and the facility's policy on [MEDICAL CONDITION] testing for both employees and residents. The DON stated if she was not available, the Administrator was required to supervise a nurse who had been re-educated on administering and reading of a PPD. Interview conducted with the Administrator on 02/01/14, at 9:45 AM, revealed he had attended an in-service on 01/31/14, by the local hospital employee health nurse on CDC guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of a PPD. The Administrator stated as of 01/31/14, the DON was responsible for administering all PPDs and reading all PPDs until nurses were re-educated. The Administrator stated if the DON was not available; the Administrator would supervise a nurse who had been re-educated on administering and reading a PPD.

Based on interview, record review, and facility policy review, guidelines from the Centers for Disease Control, the Kentucky Department of Public Health, the Office of Inspector General, and the Association of Health System Pharmaceutical Center, it was determined the facility failed to have an effective governing body, or designated persons responsible for establishing and implementing policies regarding the management and operation of the facility related to infection control practices. On 02/19/13, the Kentucky Department of Public Health and the Office of Inspector General issued a letter to all long-term care facilities regarding the recommendations for screening for [MEDICAL CONDITION] while there was a shortage of [MEDICATION NAME] (a protein derivative used to test for [MEDICAL CONDITION]). The letter recommended a Blood Assay for [DIAGNOSES REDACTED] (BAMT) be used as an option for TB screening in long-term care facilities until the [MEDICATION NAME] shortage was resolved. On 04/12/13, the Centers for Disease Control (CDC) also issued recommendations for screening for TB. However, the facility's Governing Body failed to ensure these recommendations were implemented. The Governing Body developed and implemented a policy and procedure for all residents and employees to be screened for [MEDICAL CONDITION] through an evaluation of signs and symptoms and risk factors associated with [MEDICAL CONDITION]. Although the policy was developed on 03/08/13, residents and staff continued to receive [MEDICATION NAME] skin testing until the policy was reviewed on 07/02/13. The facility began conducting a [MEDICATION NAME] screening for residents and staff to evaluate for risk factors and signs/symptoms of TB. The policy developed in March 2013 and reviewed/revised in July 2013 was also identified as the current policy and procedure for the facility (refer to F441). The facility's failure to have an effective governing body to ensure policies/procedures were developed for testing of possible [MEDICAL CONDITION] infections in accordance with the Kentucky Department of Public Health, the Office of Inspector General, and the CDC was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was identified at 42 CFR 483.65 Infection Control on 01/17/14, was determined to exist on 07/02/13, and is ongoing. The facility was notified of the Immediate Jeopardy on 01/17/14. The findings include: Review of the Governing Body policy (dated 01/02/09) revealed in some instances the standards of practice in the local community or the informed judgment of the individual clinician may warrant a method, technique, or frequency of assessment or treatment other than what was suggested in the facility policy manual. Review of the facility's policy entitled "[MEDICAL CONDITION] Testing and Screening - Temporary Measure" dated 03/08/13, and revised on 07/02/13 revealed a [MEDICAL CONDITION] Screening would be conducted for all residents and employees. The screening consisted of answering questions about signs/symptoms and risk factors associated with [MEDICAL CONDITION]. According to the policy, TB skin tests would be completed only if residents or staff had a positive response to the "[MEDICAL CONDITION] Risks." Review of a letter sent to all long-term care facilities on 02/19/13 from the Kentucky Department of Public Health and the Office of Inspector General confirmed a nationwide shortage of [MEDICATION NAME] (medications used for TB skin testing) had been identified by the Association of Health System Pharmacists Centers. According to the letter, facilities had two options for testing residents and staff for TB. One option was using [MEDICATION NAME], another brand of [MEDICATION NAME] used for skin testing, or the facility could conduct a Blood Assay for [DIAGNOSES REDACTED] (or BAMT a blood test that can aid in diagnosing [DIAGNOSES REDACTED] (TB) infection). The DPH recommended BAMT testing as opposed to skin testing utilizing [MEDICATION NAME]. Review of the Centers for Disease Control and Prevention (CDC) recommendations dated 04/12/13, revealed a skin test or blood test was recommended to test individuals for possible infections of [MEDICAL CONDITION]. Further review of the letter from the Kentucky DPH and recommendations from the CDC revealed screening for [MEDICAL CONDITION] signs and symptoms and risk factors was not included as an alternative for TB testing. Review of resident records from 07/02/13 through 01/16/14 revealed 87 of 159 residents were affected by this failure and 107 staff members did not receive a TB skin test or laboratory blood testing from 07/02/13 through 01/16/14 as recommended by the Kentucky Department of Public Health and the CDC. Interview conducted with the Administrator, who is appointed by the governing body, on 01/17/14, at 3:00 PM, revealed he was familiar with the 02/19/13 letter sent to long-term care facilities. The Administrator stated he did not participate in the development of the temporary policy, but believed the practices established through the policy were acceptable. The Administrator stated the new policy developed in March 2013 and reviewed in July 2013 directed staff to perform a TB screening to evaluate the signs/symptoms and risk factors of [MEDICAL CONDITION]. The Administrator also confirmed TB skin testing had not been conducted routinely and no blood testing had been conducted for residents or staff after the letter was received. Interview conducted with the Regional Vice President, a member of the governing body, on 01/17/14, at 1:45 PM, revealed he was not involved in the development of the temporary policy and procedure to address the [MEDICATION NAME] shortage and testing for [MEDICAL CONDITION]. The Vice President stated the policy had been developed by the corporate clinical vice president and the corporate pharmacist. The Vice President stated he had reviewed the policy and had no concerns and believed it was acceptable to assess residents and staff for possible [MEDICAL CONDITION].

Based on interview, record review, and review of the facility's policy and Allegation of Compliance (AOC) it was determined the Immediate Jeopardy (IJ) identified during the annual survey concluded on 01/17/14, had been removed related to Governing Body. An acceptable AOC was received on 01/24/14 alleging removal of the IJ on 01/23/14. However, it was determined the IJ was not removed on 01/23/14 as alleged. The facility failed to ensure two (2) employees (Employees #2 and #51), out of fifteen (15) employee screenings reviewed, were referred to the local Health Department or the Medical Director for further diagnostic evaluation and testing as required per the facility's [MEDICAL CONDITION] Testing and Screening Policy based on the employees' history of a past positive TB skin test and documented signs/symptoms of [MEDICAL CONDITION] (TB). In addition, the facility failed to ensure the Staff Development Coordinator (SDC) was knowledgeable on how to read a TB skin test. Based on the above findings, it was determined the IJ was removed on 02/01/14, with remaining noncompliance at a scope/severity of "F" while the facility develops and implements a Plan of Correction and monitors the effectiveness of systemic changes and quality assurance activities. The findings include: A review of the facility's AOC dated 01/24/14 revealed the facility alleged removal of Immediate Jeopardy on 01/23/14. A review of the AOC revealed the facility reverted to their August 2005 "[MEDICAL CONDITION] Screening and Testing" for employees, which stated if an employee had a documented positive Mantoux skin test (TB skin test), a screening for [MEDICAL CONDITION] symptoms would be performed. If symptomology was present, the employee would be referred to the local health department or the Medical Director for further diagnostic evaluation and testing to include a chest x-ray. Review of Employees #2 and #51's annual [MEDICAL CONDITION] Screenings, dated 01/17/14, revealed Employee #2 marked on the form that she had night sweats and Employee #51 marked that she had chest pain, weight loss, and excessive fatigue. There was no evidence that the employees had been referred or had any diagnostic evaluation as stated in the facility's policy. Interview conducted with the Director of Nursing (DON) on 01/31/14 at 1:27 PM, revealed the facility's SDC was responsible for reporting positive screenings to the DON and the DON reported the information to the Administrator and to the Quality Assurance (QA) Committee. The DON stated the SDC had not reported that anyone had documented symptoms of TB on a screening. Interview conducted with the Administrator on 01/31/14, at 1:25 PM, revealed no [MEDICAL CONDITION] testing/screening issues were reported to him. The Administrator stated he was required to report any issues identified to the Regional Vice President; however, none had been identified. Interview conducted with the Corporate Nurse on 01/31/14, at 10:00 AM, revealed she had reviewed all resident and employee [MEDICAL CONDITION] testing and screenings; however, she had not identified that any employee had documented signs or symptoms on the [MEDICAL CONDITION] screening forms. An interview with the Regional Vice President on 01/31/14, at 1:40 PM, revealed the Administrator was required to report any identified concerns with [MEDICAL CONDITION] testing or screening. The Regional Vice President stated he had not been notified of any identified concerns. **The facility provided an acceptable Allegation of Compliance (AOC) on 01/24/14. The facility implemented the following actions to remove the Immediate Jeopardy: The facility Administrator met with the Regional Vice President, Director of Nursing, Quality Improvement (QI) Nurse, Corporate Nurse Consultant, Vice President of Clinical Operations (via phone), and Director of Corporate Policy (via phone) on 01/16/14. The investigation included review of the letters and documents from the Cabinet for Health and Family Services, Centers for Disease Control (CDC), and the Food Drug Administration (FDA), and resulted in the determination that an error had been made in the interpretation of these documents and the temporary policy was repealed on 01/16/14. On 01/16/14, the decision was made to immediately repeal the facility's "[MEDICAL CONDITION] Testing and Screening Temporary Measures" and revert to the facility's permanent policies for TB Testing entitled, "[MEDICAL CONDITION] Screening and Testing (Employee)" and "Resident [MEDICAL CONDITION] Testing and Screening Policy." Both of these policies have been in effect since August 2005. These policies include two-step TB testing for new-hires and new resident admissions and annual TB testing thereafter. On 01/16/14, the facility Administrator contacted the local hospital and multiple pharmacies and was able to obtain enough [MEDICATION NAME] to conduct testing for all employees and all residents, with an additional supply for admissions and new hires for approximately 60 days. On 01/16/14, the facility Administrator met with the Director of Nursing and all Administrative Nurses and conducted re-education regarding the TB Skin Testing Policy. On 01/17/14, the facility Administrator spoke with and reviewed the facility policy with the local Health Department Medical Director who advised to start all staff and residents as if they were Day 1 employees and residents. Staff and residents who had already received a two-step TB skin test would not need the second step administered, nor was there a need to obtain new x-rays for those who have had a negative x-ray since exposure or treatment. The Health Department Medical Director advised that her opinion was that testing of employees during their next scheduled shift was sufficient to meet the regulation. On 01/17/14, the Director of Nursing spoke with the facility's Medical Director and received orders to administer TB skin testing in accordance with policy for all residents in the facility. The Staff Development Nurse began immediately conducting TB skin tests on all employees on the premises on 01/16/14 and 01/17/14. The other Administrative Nurses began TB testing for all residents on 01/17/14 to be completed before midnight on 01/17/14. Any positive resident PPDs will be addressed according to the facility's policy including screening, notification to MD, and follow-up chest x-ray. Any resident with signs/symptoms of active TB will be transferred to an acute care facility until after appropriate therapy is completed. Any positive staff PPDs will be addressed according to the facility's policy. The employee will be immediately placed on administrative leave and notification made to the facility's Medical Director or physician on call and the local Health Department for further diagnostic testing such as a chest x-ray, or a statement will be obtained stating a chest x-ray is not needed. The employee will be required to have a Physician's Statement to clear them for duty prior to the employee being allowed to work. Any positive resident or staff conversions of more than 10 mm induration will be immediately reported to the local Health Department by the Administrator or Director of Nursing. The reading of the resident PPDs will be conducted by licensed nurses per policy and will be overseen by the Unit Coordinator with a report to the Director of Nursing on 01/22/14 for the initial PPDs, and 02/07/14 for the residents who required a second-step PPD. The reading of the staff PPDs will be conducted by licensed nurses per policy and will be overseen by the Staff Development Nurse with a report to the Director Nursing on 01/22/14 for the initial PPDs, and 02/07/14 for the staff requiring a second-step PPD. A nurse assigned by the Director of Nursing will be present at the time clock each shift change until 100 percent of the staff in all departments has been tested per policy. No employee will be allowed to work until the employee has received a TB skin test or appropriate documentation is received for those who are unable to take the test. The QI Nurse and QI Assistant Nurse made copies of the Resident TB Skin Testing Policy and reviewed with all Licensed Nurses on the premises on 01/17/14 and will continue to retrain all licensed nurses who admit patients until 100 percent of the Licensed Nurses have been re-educated regarding elimination of the Temporary Measures and return to the prior policy. All residents on census have had a TB skin test or x-ray per policy. There are no residents out of the facility who have not had a TB test since 01/16/14. The Admissions Coordinator assigns residents to the beds and assembles the patient's medical record. On 01/17/14, the Admissions Coordinator was instructed by the Administrator to notify the QI Nurse or QI Assistant Nurse of any scheduled admissions. Only Licensed Nurses who have been retrained regarding the TB Testing Policy will be permitted to admit patients. The majority of the licensed nurses were re-educated on 01/16/14 and 01/17/14. The additional licensed nurses will be retrained by the QI Nurse or QI Assistant Nurse during their next working shift. The QI Nurse or QI Assistant Nurse will ensure the TB skin test is conducted per policy, by a licensed nurse who has been re-educated to the policy. The QI Nurse or QI Assistant Nurse will be available seven days per week until all licensed nurses have been retrained on the policy. The TB Testing Policy will be covered by the Staff Development Nurse or Instructor during orientation for all licensed nurse new hires. New hires will have PPDs administered per policy by the Staff Development Nurse during Day 1 of general orientation and the second step administered by the Staff Development Nurse per policy. The QI Nurse or Administrative Nurse assigned by the Director of Nursing will review all employee health files for new employees within 24 hours of orientation and three weeks after orientation for a period of 60 days and per the established schedule thereafter to ensure TB testing is being completed correctly. A Unit Coordinator, the Weekend House Supervisor, or Director of Nursing will review the immunization record daily for all new admissions for a period of 60 days and per the established schedule thereafter. The facility developed a policy, "[MEDICAL CONDITION] Testing and Screening Temporary Measures," regarding the possibility the facility becomes unable to obtain TB Testing Agent, the employee or resident will have a Blood Assay for [DIAGNOSES REDACTED] (BAMT), QuantiFeron-TB Cold In-Tube Test (IGRA), or T-Spot TB (TST) (blood tests that test for the presence of [MEDICAL CONDITION] infection). In the event the lab tests are unavailable, the facility Administrator or Director of Nursing will contact the local Health Department for direction. At this time, the facility has a sufficient quantity of [MEDICATION NAME] to last 60 or more days without reorder. The Director of Nursing will develop written education for all licensed nurses regarding the contingency policy stating what to do if the TB testing agent becomes unavailable. This education will be distributed with payroll on 01/23/14. The Unit Coordinators, Staff Development Nurse, and/or House Supervisor will report the progress of the TB testing to the facility Administrator or Director of Nursing daily until all employees and residents have completed the initial round of testing initiated on 01/16/14. The Director of Nursing will present the 01/22/14 reports from the Unit Coordinators and the Staff Development Nurse regarding TB testing to the Administrator and QI Committee on 01/22/14, and will present the 02/07/14 reports from the Unit Coordinators and Staff Development Nurse to the Administrator and QI Committee on 02/12/14. The QI Committee will review TB testing weekly through 02/28/14, then at the meeting the week of 03/26/14, and then per the established calendar thereafter. The QI Reviews will be overseen by the facility Administrator. Any identified issues will be reported to the Regional Vice President. TB Control is listed in the Annual In-Service Plan. The next scheduled "TB Control" review is scheduled for 07/14-16/14. The policies will be reviewed with staff at that time. On 01/30/14, it was identified that two employees who were unable to receive a TB skin test had signs/symptoms of TB marked yes on their screening forms and the facility had not followed its TB Policy. Upon identification of the issue, both employees were immediately placed on administrative leave on 01/30/14 and referred to the local Health Department but were unable to be seen on 01/31/14. The facility's Medical Director was contacted on 01/31/14 and gave an order for [REDACTED]. Results were received on 01/31/14 and were negative. The Administrator, Director of Nursing, and Facility Nurse Consultant received education from the Vice President of Nursing and the Employee Health Coordinator at the local Hospital. The Hospital employees reviewed the facility's policy and determined that the Director of Nursing, Administrator, and Facility Nurse Consultant were knowledgeable regarding proper placement, administration, and reading of TB skin tests including the varying millimeters of induration, "mm" for a positive result for immunocompromised patients, routine nursing facility patients, and individuals identified as low risk. The specifics of the method for reading a TB test were also reviewed. The Hospital's Employee Health Coordinator also reviewed when to conduct a screening form, e.g., past positive, and the facility's policies regarding referral to the Physicians, Medical Director, or Health Department. The Administrator and Director of Nursing have taken complete control of the TB Screening Program effective 01/31/14 for both employees and residents, including administration and reading of TB Skin Tests, Screening Forms, and QI Audits and reports until such time as all Licensed Nurses have successfully completed skills verification related to administration and reading of TSTs and Screening Forms. The Director of Nursing will conduct the TB skin tests and readings until all staff have received re-education and have demonstrated they are knowledgeable. In the absence of the Director of Nursing, the Administrator will observe a licensed nurse who has already been re-educated and demonstrated successful skills to administer and/or read the TB test in order to ensure it is administered/read correctly in the event it is "required" during the absence of the DON. **The surveyors validated the Immediate Jeopardy was removed as follows: A review of the facility's policy entitled, "[MEDICAL CONDITION] Screening and Testing," dated August 2005, revealed all employees upon hire would receive a two-step Mantoux skin test with the first step being given on the first day of work. Employees with a negative skin test would receive a second-step Mantoux skin test within seven to fourteen days, and annually by a one-step method. The policy stated if a new positive occurred, employees would be referred to the local Health Department or to the Medical Director for further diagnostic evaluation and testing to include a chest x-ray. The policy further stated if an employee had a documented positive Mantoux skin test upon hire, a screening for [MEDICAL CONDITION] symptoms would be performed. An employee with negative symptomology would have an annual screening thereafter. If symptomology was present, the employee would be referred to the local Health Department or the Medical Director for further diagnostic evaluation and testing to include a chest x-ray. Review of the facility's policy entitled, "Resident [MEDICAL CONDITION] Testing and Screening Policy," dated August 2005, revealed all residents without a known documented positive PPD reaction would receive [MEDICAL CONDITION] testing upon admission using a two-step method. The first step would be administered on admission and if negative, a second PPD would be administered seven to fourteen days thereafter. The policy stated if the second step was negative, annual testing would occur thereafter using a single-step method. The policy revealed evaluation of residents with a new positive PPD would occur by the attending physician or the Medical Director to determine the presence of active [MEDICAL CONDITION]. The policy also revealed residents with a known documented positive reaction to a Mantoux PPD test would be screened for any history and symptoms of [MEDICAL CONDITION]. A chest x-ray would be obtained for residents with a positive screening, and the attending physician or the Medical Director would be notified to determine if further testing, appropriate treatment, and management were necessary. The policy stated any resident with suspected or probable infectious [MEDICAL CONDITION] would be transferred to an alternate facility for treatment. Review of the facility's policy entitled, "[MEDICAL CONDITION] Testing and Screening Temporary Measures," dated 01/17/14, revealed in the event the [MEDICAL CONDITION] testing agent became unavailable due to the shortage of [MEDICATION NAME] and [MEDICATION NAME], either a BAMT, IGRA, or TST test would be performed. If these tests were not available from the facility's laboratory, the facility would consult with the local Health Department for measures to be taken for [MEDICAL CONDITION] testing and/or screening. Interview with the Administrator on 01/31/14, at 11:35 AM, the DON on 01/31/14, at 11:40 AM, the Corporate Nurse on 01/31/14, at 11:42 AM, and the Vice President of Clinical Operations on 01/31/14 at 1:40 PM, verified they had attended the telephone conference on 01/16/14, and confirmed the group had decided to repeal the interim [MEDICAL CONDITION] policy and revert back to the old [MEDICAL CONDITION] policy dated 2005, for both employees and residents. Interview conducted with the Administrator on 01/31/14, at 11:35 AM and 1:20 PM, revealed he had contacted the local Hospital as well as the local pharmacies, and obtained enough [MEDICATION NAME] to last at least 60 days based on the facility's average admission and new hire rate. The Administrator stated he had met with all administrative nurses, as well as the DON, to discuss the [MEDICAL CONDITION] testing policy. The Administrator stated they decided that the Staff Development Coordinator (SDC) would begin testing all employees on 01/16/14 and 01/17/14, the administrative nurses began testing residents on 01/17/14, and testing was completed by 01/17/14. The Administrator further stated the facility would revert to using the BAMT, IGRA, or TST in the event [MEDICATION NAME] was not available. The Administrator stated if the laboratory tests were not available at the facility's laboratory, he or the DON would consult the local Health Department for guidance. Interview conducted with the DON on 01/31/14, revealed either she or the Administrator would notify the local Health Department in the event the facility did not have [MEDICATION NAME] or [MEDICATION NAME] available to perform PPDs. The DON stated she had developed training and had trained all facility nurses on what to do in the event [MEDICATION NAME] or [MEDICATION NAME] was unavailable and all facility nurses had been trained on the policy and procedure. Review of in-services entitled, "Nurse Education of TB Screening Policy," revealed the DON educated staff on the new policy that required nursing staff to notify the DON should testing be required. The in-service was initiated on 01/17/14 and completed on 01/23/14. Review of an in-service roster entitled, "Administrator Review of [MEDICAL CONDITION] Test Issues," dated 01/16/14, revealed all administrative nurses attended an in-service regarding the facility's [MEDICAL CONDITION] policy, State Regulations concerning [MEDICAL CONDITION] testing, and [MEDICAL CONDITION] testing for all residents and staff. Interview conducted with QI Nurse #2 on 01/31/14, at 11:45 AM, and QI Nurse #1 on 01/31/14, at 1:00 PM, revealed they made and distributed a copy of the Resident [MEDICAL CONDITION] Testing Policies to all licensed nurses in the facility. The policy was used to retrain all nursing staff. The training was completed on 01/23/14. Observation of the facility's [MEDICATION NAME] in the facility on 01/30/14 revealed the facility had enough [MEDICATION NAME] on hand to provide 150 PPD tests. Review of an e-mail sent to the Administrator by the Health Department Medical Director dated 01/24/14, at 8:12 AM, revealed the Administrator had consulted with the Medical Director, who advised the facility to start all staff and resident annual testing. The e-mail revealed any staff or resident who had previously been tested would not require a two-step, and those staff members or residents who have had a previous positive PPD required a [MEDICAL CONDITION] assessment. The e-mail stated residents who did not have symptoms would not need a chest x-ray. Interview conducted with the local Health Department Medical Director on 01/30/14, at 2:50 PM, revealed she had consulted with the Administrator and had advised him to begin [MEDICAL CONDITION] testing for employees and residents. The Medical Director stated she had advised the Administrator to begin using the two-step method, unless the resident or staff member had already had a two-step TB test; and in that case, just to begin the annual testing. The Medical Director stated any staff or resident who had a past positive PPD would require a screening and would only require a chest x-ray if the resident or employee had a symptom of [MEDICAL CONDITION]. The physician stated she told the Administrator that waiting until the employee's next scheduled shift would be sufficient to do the PPD or screening. A review of signed physician's orders [REDACTED]. The physician's orders [REDACTED]. Interview conducted with Unit Coordinator #1 on 01/31/14, at 12:10 PM, Unit Coordinator #2 on 01/31/14, at 12:15 PM, and Unit Coordinator #3 on 01/31/14, at 12:20 PM revealed PPD skin tests or screenings for residents with a history of a positive PPD were completed on 01/17/14. The Unit Coordinators stated they had attended the in-service given by the Administrator and had discussed the repeal of the [MEDICAL CONDITION] policy and going back to the previous policy. The Unit Coordinators stated in the future, all residents without a known past positive would receive a two-step PPD upon admission and a one-step annually. If after receiving the first PPD the resident had a reaction, the physician would be notified for further orders, including a chest x-ray. The Unit Coordinators stated all employees would be given a PPD as well, unless they had a positive past PPD, and in that case a screening would be completed. If the employee documented symptoms, the employee would be referred to the Health Department or the Medical Director for further testing including a chest x-ray. The Unit Coordinators each stated all resident PPDs were negative and they had reported that information to the DON, and would be sending a report to the DON after reading the second step PPDs on 02/07/14. Interview with the weekend House Supervisor on 01/31/14, at 1:30 PM, revealed she had been assigned to the time clock on 01/18/14 and 01/19/14, to administer PPD skin tests or complete screenings for employees. Employees were not allowed to work until after the PPDs or screenings were done. Interview with Quality Improvement (QI) Nurse #2 on 01/31/14, at 12:47 PM, revealed she had been assigned to the time clock on 01/17/14, 01/18/14, and 01/19/14, to administer PPDs or complete screenings for employees. Employees were not allowed to work until after the PPDs or screenings were done. Interview conducted with Registered Nurse (RN) #3 on 01/30/14, at 4:30 PM, Licensed Practical Nurse (LPN) #4 on 01/30/14, at 4:40 PM, LPN #2 on 01/30/14, at 4:45 PM, LPN #3 on 01/30/14, at 4:50 PM, and LPN #1 on 01/30/14, at 5:05 PM revealed they had attended an in-service regarding the [MEDICAL CONDITION] policy and were knowledgeable of the facility's TB testing policy and the policy regarding the skin testing agent not being available. The nurses stated every resident had to have a two-step PPD on admission and a one-step annually. If the resident had a past positive history of PPD or [MEDICAL CONDITION], the physician or Medical Director must be notified for any additional testing and a chest x-ray must be obtained. If a resident had a positive PPD or had symptoms of TB, the physician or Medical Director, the Administrator, and the DON must notified immediately. The nurses stated no nurse was allowed to admit residents until after they were trained on the [MEDICAL CONDITION] policy. The nurses further stated they were aware they had to notify the DON and the Unit Coordinator if [MEDICATION NAME] was not available and if the laboratory was not able to conduct BAMT, IGRA, or TST testing. Interview conducted with the Admissions Coordinator on 01/31/14, at 1:02 PM, revealed she was responsible for assigning beds to residents upon admission, and had been assigned by the Administrator to notify QI Nurse #1 or QI Nurse #2 of any scheduled admissions. Interview conducted with QI Nurse #2 on 01/31/14, at 11:45 AM, and QI Nurse #1 on 01/31/14, at 1:00 PM, revealed they had reviewed all resident TB skin tests to ensure they were conducted per policy and administered by a nurse who had been re-educated on the policy. There had been no new admissions to the facility. Review of [MEDICAL CONDITION] screenings and PPD test results for all residents dated 01/17/14, revealed all residents with a history of a positive PPD had been screened and all other residents received a PPD skin test on 01/17/14. All PPDs were negative and no resident had signs or symptoms documented on the screening form. The PPDs were read on 01/20/14. Review of PPD test results for all employees revealed all employees received a TB skin test on 01/16/14 or 01/17/14. All TB skin tests were documented as being zero (0) millimeters of induration (negative for [MEDICAL CONDITION]). The TB skin tests were read on 01/19/14 or 01/20/14. Review of Quality Improvement Documentation revealed QI Nurse #1 documented she reviewed three new employee health files. QI Nurse #1 stated the new employees were not nurses. The documentation revealed the employees began employment on 01/28/14, QI Nurse #1 reviewed the health files on 01/29/14, and found no concerns, and the policy was being followed. Interview conducted with QI Nurse #1 on 01/31/14, at 1:15 PM, revealed she was required to review all new employee health files within 24 hours to ensure any symptoms of [MEDICAL CONDITION] were followed up on per facility policy. Interview conducted with the DON on 01/31/14, at 1:15 PM, revealed she checked the computer daily, and reviewed all new admissions to ensure the policy was being followed and had not identified any concerns. Interview conducted with the weekend Nursing Supervisor on 01/31/14, at 1:30 PM, revealed she reviewed any new admissions daily on the weekend to ensure the [MEDICAL CONDITION] policy was being followed and had not identified any concerns. Review of an Absence/Vacation Report dated 01/30/14, revealed Employee #2 and Employee #51 had both been placed on Administrative Leave of Absence until further notice. Interview conducted with the facility's Medical Director on 02/01/14, at 9:30 AM, revealed he had been contacted by the facility and had given the DON an order to obtain chest x-rays for both employees and had been notified that the x-rays were negative for [MEDICAL CONDITION]. Review of chest x-ray reports for Employee #2 and Employee #51 dated 01/31/14, revealed both were negative for [MEDICAL CONDITION]. Review of an e-mail and an in-service roster sent to the Administrator from the local Hospital Employee Health Nurse on 01/31/14, revealed the Administrator, DON, and Corporate Nurse, all attended an in-service provided by hospital staff regarding Centers for Disease Control (CDC) guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of PPDs. Interview conducted with the Corporate Nurse on 02/01/14, at 9:00 AM, revealed she had attended the in-service on 01/31/14, by the local hospital employee health nurse on CDC guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of a PPD. Interview conducted with the DON on 02/01/14, at 9:05 AM, revealed she had attended an in-service on 01/31/14, by the local hospital employee health nurse regarding CDC guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of a PPD. The DON stated as of 01/31/14, she was responsible for administering all PPDs and reading all PPDs until nurses were re-educated on administration and reading of a PPD and the facility's policy on [MEDICAL CONDITION] testing for both employees and residents. The DON stated if she was not available, the Administrator was required to supervise a nurse who had been re-educated on administering and reading of a PPD. Interview conducted with the Administrator on 02/01/14, at 9:45 AM, revealed he had attended an in-service on 01/31/14, by the local hospital employee health nurse on CDC guidelines for [MEDICAL CONDITION], administration of a PPD, and reading of a PPD. The Administrator stated as of 01/31/14, the DON was responsible for administering all PPDs and reading all PPDs until nurses were re-educated. The Administrator stated if the DON was not available; the Administrator would supervise a nurse who had been re-educated on administering and reading a PPD.

Based on interview, record review, facility policy review, and review of notifications from the Kentucky Department of Public Health (DPH), the Office of Inspector General, and the Centers for Disease Control (CDC) it was determined the facility failed to have an effective quality assessment and assurance committee to identify quality deficiencies related to infection control and to develop and implement plans of action to correct infection control practices. On 02/19/13, the facility was notified by the Office of Inspector General and the Kentucky DPH regarding a shortage of [MEDICATION NAME] (a protein derivative used to test for [MEDICAL CONDITION] TB) and on 03/08/13, the facility developed a temporary policy to address the shortage of [MEDICATION NAME]. Although the policy was changed on 03/08/13, residents and staff continued to receive [MEDICATION NAME] skin tests until 07/02/13. On 07/02/13, the facility began conducting a [MEDICATION NAME] screening assessment for residents and staff to evaluate for risk factors and signs/symptoms of TB, per the facility's temporary policy. However, the facility failed to develop a plan of action to monitor the effectiveness and efficiency of the newly developed policy/procedure and failed to evaluate and monitor residents and staff for possible infection of [MEDICAL CONDITION] in accordance with the Kentucky DPH and CDC. The facility assessed thirty-three (33) residents as having signs and symptoms and/or risk factors for [MEDICAL CONDITION] which required additional testing per the facility's temporary policy; however, there was no documented evidence the testing was completed. In addition, the procedures the facility developed for TB screening were not in accordance with recommendations from the Kentucky Department of Public Health (DPH) and the Centers for Disease Control (CDC) regarding screening of residents and employees for [MEDICAL CONDITION]. This failure affected a total of eighty-seven (87) of one hundred fifty-nine (159) residents at the facility and one hundred seven (107) staff members who did not receive a TB skin test or laboratory blood testing from 07/02/13 through 01/17/14 as recommended by the Department of Public Health and the CDC (refer to F441). The facility's failure to have an effective quality assurance program to identify concerns/deficiencies related to Infection Control and the testing of residents and employees for possible [MEDICAL CONDITION] infections was likely to cause serious injury, harm, impairment, or death to residents in the facility. Immediate Jeopardy was identified on 01/17/14 and was determined to exist on 07/02/13, and is ongoing. The facility was notified of the Immediate Jeopardy on 01/17/14. The findings include: Review of the Quality Improvement policy (dated January 2011) revealed the Quality Improvement Committee was responsible to determine if changes in plans of action were required to improve outcomes, if action plans needed to be formed or modified, and if increased monitoring of resident care was required. On 02/19/13, all long-term care facilities were notified by the Kentucky Department of Public Health and the Office of Inspector General of a shortage in the manufacturing of [MEDICATION NAME] (a protein derivative used to test for [MEDICAL CONDITION]). The letter recommended a Blood Assay for [DIAGNOSES REDACTED] (BAMT) be used as an option for TB screening in long-term care facilities until the [MEDICATION NAME] shortage was resolved. Review of the facility's "[MEDICAL CONDITION] Testing and Screening -Temporary Measures" policy dated 03/08/13 and revised on 07/02/13 revealed a "Complete [MEDICAL CONDITION] Screening User Defined Assessment" would be conducted for all residents and staff. The policy directed upon completion of the assessment, no further testing would be required if residents or newly hired employees were assessed to have negative responses to all questions on the assessment. The policy noted if residents or employees were assessed to have a positive response to "Signs and Symptoms," further medical evaluation was to include a chest x-ray. Further, the policy noted residents and employees assessed to have a negative response to "Signs and Symptoms," but a positive response to the "[MEDICAL CONDITION] Risks" would receive a [MEDICATION NAME] skin test unless written documentation of a prior positive skin test and negative chest x-ray was available. Review of a Health Alert Network from the Centers for Disease Control (CDC) dated 04/12/13 revealed the CDC recommended substituting a type of blood test for a [MEDICATION NAME] skin test or substituting [MEDICATION NAME] (another solution that can be used for TB skin tests) for [MEDICATION NAME] for skin testing. The CDC health alert stated [MEDICATION NAME] skin tests could be allocated to priority indications, such as TB investigations. Review of the medical records for 14 of 24 sampled residents and 73 of 75 unsampled residents revealed these residents required either an admission or annual TB skin test; however, there was no documented evidence the facility had administered the TB skin test or any blood testing as recommended from the Kentucky Department of Public Health and the CDC for these residents. In addition, the facility assessed 33 of the 87 affected residents to have signs and symptoms and/or risk factors for [MEDICAL CONDITION] which required either a chest x-ray or [MEDICATION NAME] skin test. Review of the newly hired employees from 07/02/13 through 01/17/14 revealed the facility had hired 50 new employees. Forty-nine of the 50 employees did not receive a TB skin test or blood test to determine the presence of [MEDICAL CONDITION]. Two of the 49 employees were assessed to have a past exposure to [MEDICAL CONDITION]; however, there was no documented evidence the employees received further testing for [MEDICAL CONDITION] per the facility's policy and as required by the Kentucky Department of Public Health, the CDC, and the Office of Inspector General. The facility also identified 57 employees who were due to receive an annual TB skin test; however, none of these employees received the TB skin test or the recommended blood testing recommended by the Department of Public Health and the Office of Inspector General. Interview conducted with the Quality Assurance (QA) Coordinator on 01/17/14 at 3:30 PM, revealed the newly adopted policy/procedure regarding [MEDICATION NAME] testing had not been monitored through the QA program because the policy was temporary. The QA Coordinator stated the Unit Coordinators (UCs) were responsible for monitoring to ensure residents and staff received the designated TB screening and had not reported any problems to her related to the completion of the screenings. The QA Coordinator stated the facility had not monitored the effectiveness of the new policy and had not monitored to ensure all residents and employees received the recommended TB skin testing or blood testing, per the facility's policy. Interview with the Administrator on 01/17/14, at 3:00 PM revealed audits were conducted to ensure the newly developed TB screening assessment was conducted for residents and employees. However, the Administrator stated monitoring had not been conducted through the QA program to evaluate the effectiveness and efficiency of the new TB screening policy. Therefore, residents and employees requiring additional testing, per the TB screening assessment, were not identified and the testing was not provided.