Every finding on record at Stanford Crossing

Based on observation, interview, record review, and review of the facility's policies, the facility failed to immediately inform the resident's physician and the resident's representative when there was a significant change in the resident's physical and mental status for one (1) of 51 total sampled residents, Resident (R) 19. The facility assessed R19 to have decreased meal and fluid intake on [DATE] through [DATE]. Per interview, R19 also had a change in level of consciousness on [DATE] and [DATE]. However, there was no documented evidence the staff notified the resident's physician or representative from [DATE] through [DATE] of the resident's changes. R19 expired on [DATE]. The facility's failure to have an effective system to ensure each resident's physician and resident's representative were notified of significant changes in the resident's physical and mental status is likely to cause harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR S483.25 Quality of Care, F684, and 42 CFR S483.10 Resident Rights, F580, at the highest scope and severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR S483.10 Resident Rights. On [DATE], the Administrator was provided a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and notified of the failure to ensure each resident's physician and representative were notified of acute changes in the resident's condition is likely to cause serious injury, harm, impairment, or death to a resident. This failure constituted IJ at 42 CFR S483.10 Resident Rights, F580. The IJ at F580 also constituted Substandard Quality of Care (SQC) at 42 CFR S483.10. The IJ was determined to exist on [DATE] when R19 had a decline in meal and fluid intake and level of consciousness. The facility provided an acceptable IJ removal plan on [DATE]. This plan alleged the IJ was removed on [DATE]. An Extended Survey and IJ Removal validation were conducted on [DATE]-[DATE]. The State Survey Agency (SSA) validated the IJ's Removal Plan on [DATE]. The SSA validated the immediacy of the IJ had been removed on [DATE] as alleged.The findings include: Review of the facility's policy, Notification of Changes, revised [DATE], revealed the facility was to promptly inform the resident's physician and representative when there was a change requiring notification. The policy defined circumstances requiring notification included a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status, which might include life-threatening conditions or clinical complications. Review of R19's admission Sheet, located in the medical record, revealed the facility admitted the resident on [DATE]. R19's diagnoses included diabetes and atherosclerotic heart disease. Review of R19's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed R19's Brief Interview for Mental Status (BIMS) score to be 14. This score indicated R19 was cognitively intact. Review of R19's Comprehensive Care Plan, revised [DATE], revealed the facility assessed R19 to have a full code status. Interventions included to keep the family informed of changes in condition. Record review revealed the facility assessed R19 to have decreased meal and fluid intakes from [DATE] - [DATE]. R19 refused breakfast and lunch on [DATE], consumed 0-25% of dinner on [DATE] and [DATE], refused all meals on [DATE], consumed 0-25% of breakfast and lunch on [DATE], and refused dinner on [DATE]. Further review revealed the facility assessed R19 to have consumed total fluid intake of 700 ml (milliliters) on [DATE], 120 ml on [DATE], and 420 ml on [DATE]. However, there was no documented evidence the facility notified the R19's physician or representative of the resident's decline in intake. During an interview, on [DATE] at 6:00 PM, Certified Nursing Assistant (CNA) 10 stated she notified nursing staff on the night shift of [DATE] that R19 would not open her eyes but did clamp her mouth closed during oral care. CNA 10 stated the nurse obtained vital signs and told her they were normal. However, there was no evidence the nurse notified R19's physician or representative. CNA 10 stated she had received in report on [DATE] night shift that R19 had not eaten or drank anything on the [DATE] day shift. During an interview, on [DATE] at 12:20 PM, Licensed Practical Nurse (LPN) 4 stated she was R19's nurse on [DATE] day shift. LPN 4 stated R19 did not eat or drink and was sleeping a lot during her shift, but she did not notify the physician or R19's representative. LPN 4 stated, during report, she was informed that R19 did not eat or drink anything on the [DATE] night shift. During an interview, on [DATE] at 12:40 PM, RN 6 stated R19 slept quite a bit on day shift on [DATE] which was not normal for R19. RN 6 stated the Certified Nursing Assistants (CNAs) reported that R19 was sleepy during the shift. However, there was no documented evidence RN 6 notified R19's physician or representative of the changes. During an interview, on [DATE] at 6:30 PM, RN5 stated she was the nurse responsible for 50 residents on [DATE] night shift. RN5 stated her shift started at 6:30 PM and she did not visualize or assess R19 until she was notified by another staff member (Kentucky Medication Aide/KMA or a CNA as she could not remember) of R19's change in level of consciousness just prior to calling 911. RN5 stated she notified Advanced Practice Registered Nurse (APRN) 1 after her assessment and was told to call Emergency Medical Services (EMS) to transfer R19 to the hospital. Review of the hospital record revealed R19 was seen in the Emergency Department on [DATE] at 1:29 AM. The hospital diagnosed R19 with intracerebral hemorrhage, sepsis, and pneumonia. Further review revealed R19 was intubated and transferred to a Level 1 Trauma Center for further treatment on [DATE]. During an interview, on [DATE] at 4:59 PM, APRN 1 stated she had worked in the facility for approximately three (3) weeks and had not met R19. The APRN stated she was in the facility on [DATE], [DATE], and [DATE]. APRN 1stated she had not been notified of R19's condition until she was called by RN5 during night shift on [DATE], at which time she was notified R19 had a change in her level of consciousness, was not responsive to sternal rubs, and had fixed and pinpoint pupils. APRN 1 stated she instructed RN5 to transfer R19 to the hospital at that point. Additionally, APRN 1 stated she expected to be notified of a patient's (resident's) decline in appetite and refusal of medications for two (2) days because it sometimes means other things are going on. APRN 1 stated she expected to be notified of a resident's change in level of consciousness or mental status change because it could be indicative of an infection. and she would order labs and X-rays to determine if a resident had an infection. During an interview, on [DATE] at 9:28 AM, the Medical Director (MD) stated he had not been informed of R19's condition at any point and it was his expectation the APRN be notified of a resident's change in condition and the APRN would contact him if needed. The Medical Director stated he would expect the APRN or MD to be notified if a patient (resident) with a Full Code Status did not eat or drink for 24 hours. During an interview, on [DATE] at 4:05 PM, R19's Family Member 1 stated she visited R19 on a regular basis and had been to visit R19 on [DATE] or [DATE], at which time R19 seemed fine and was sitting up watching television, eating pie, and joking. Family Member 1 stated she did not get any phone calls from the facility regarding a change in R19's condition until the night of [DATE], sometime around 11:00 PM or 12:00 AM, at which time she was informed by facility staff that R19 had trouble breathing and had not been eating. Family Member 1 stated facility staff asked her if she wanted R19 sent to the hospital, and she stated yes. Additionally, Family Member 1 stated she drove immediately to the hospital and was told by hospital staff that R19 was unresponsive and had not eaten in three (3) days according to the report they received from the facility. Family Member 1 stated the Emergency Department (ED) physician said there was no choice but to put R19 on a ventilator because her oxygen level was at 70%, she had pneumonia really bad, and a brain computer tomography (CT) revealed a brain bleed. Family Member 1 stated R19 was intubated and transferred to a Level 1 Trauma Center. Resident 19 expired on [DATE].

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan and failed to implement care plan interventions. Additionally, the facility failed to identify, assess, and intervene for an acute change in the resident's condition related to decreased appetite and level of consciousness for one (1) of 51 sampled residents, Resident (R) 19. The facility assessed R19 to have decreased meal and fluid intake on 11/24/2025 through 11/27/2025. Per interview, R19 also had a change in level of consciousness on 11/26/2025 and 11/27/2025. However, there was no evidence the staff completed a thorough nursing assessment from 11/24/2025 through 11/27/2025. The facility's failure to have an effective system to ensure each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 12/06/2025 and was determined to exist on 11/24/2025 in the areas of 42 CFR S483.25 Quality of Care, F684, and 42 CFR S483.10 Resident Rights, F580, at the highest scope and severity (S/S) of a J. Substandard Quality of Care (SQC) was also identified at 42 CFR S483.25 Quality of Care, F684. On 12/07/2025, the Administrator was provided a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template and notified of the facility's failure to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, failure to implement care plan interventions, and failure to identify, assess, and intervene for an acute change in the resident's condition. The Administrator was notified that IJ at F684 also constituted Substandard Quality of Care (SQC) at 42 CFR S483.25. The facility provided an acceptable IJ removal plan on 12/08/2025. This plan alleged the IJ was removed on 12/07/2025. An Extended Survey and IJ Removal validation was conducted 12/07/2025-12/08/2025. The State Survey Agency (SSA) validated the IJ Removal Plan and determined the immediacy of the IJ had been removed on 12/07/2025 as alleged. The findings include: Review of the facility's policy, Notification of Changes, revised 03/20/2025, revealed the facility was to promptly inform the resident's physician and representative when there was a change requiring notification. The policy defined circumstances requiring notification included a significant change in the resident's physical, mental, or psychosocial condition such as deterioration in health, mental, or psychosocial status. Review of the facility's policy, Activities of Daily Living (ADLs), revised 03/20/2025, revealed care and services would be provided for eating to include meals and snacks. Further review of the policy revealed a resident who was unable to carry out the activities of daily living would receive the necessary services to maintain good nutrition and oral hygiene. The facility had no nutrition policy. However, during interviews with the dietician, she stated that everyone was supposed to have at least 1500 milliliters (ml) fluid per day, or it should be reported. Advance Practice Registered Nurse (APRN) 1 stated she wanted to be notified if a resident had less than 500 ml per 12-hour shift. Review of R19's admission Sheet revealed the facility admitted R19 on 01/13/2016. R19's diagnoses included diabetes and atherosclerotic heart disease. Review of R19's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed R19's Brief Interview for Mental Status (BIMS) score to be 14. This score indicated the resident was cognitively intact. Review of R19's care plan, revised 09/17/2025, revealed the facility assessed R19 to be at nutrition and hydration risk related to diabetes, dementia, and protein-calorie malnutrition with a goal to be at reduced risk for dehydration. Further review revealed interventions which included to assess for signs and symptoms of dehydration such as elevated temperature and change in mental status, encourage additional 240 milliliters (ml) fluid four times a day (QID), medication as ordered, monitor by mouth (po) intakes, and monitor/document/report as needed (prn) any signs and symptoms of dysphagia such as refusing to eat. Continued review revealed a care plan, revised 08/10/2021, for Long Term Care with a goal that R19 would be provided with quality care which met physical and mental needs with interventions which included monitor for physical/mental improvement or decline and provide care as needed to maintain or improve R19's current functional level. Additionally, the facility would keep R19's family informed of a change in condition. Review of R19's care plan, revised 09/10/2025, revealed the facility care planned R19 for diabetes with a goal that R19 would have no complications related to diabetes. Further review revealed interventions which included to monitor/document/report PRN (as needed) any signs or symptoms of hyperglycemia (high blood sugar) which included Kussmaul breathing (rapid, deep breaths), stupor (a state of near-unconsciousness or insensibility), or coma. However, there was no evidence the facility implemented these interventions. Record review revealed the facility assessed R19 to have decreased meal and fluid intakes from 11/24/2025 - 11/27/2025. R19 refused breakfast and lunch on 11/24/2025, consumed 0-25% of dinner on 11/24/2025 and 11/25/2025, refused all meals on 11/26/2025, consumed 0-25% of breakfast and lunch on 11/27/2025, and refused dinner on 11/27/2025. Further review revealed the facility assessed R19 to have consumed a total fluid intake of 700 ml on 11/24/2025, 120 ml on 11/26/2025, and 420 ml on 11/27/2025. However, there was no documented evidence the facility conducted a thorough assessment related to R19's decline in food/fluid intake. In addition, there no documented evidence that staff notified the physician of R19's decreased appetite or fluid intake. During an interview, on 12/05/2025 at 6:00 PM, Certified Nursing Assistant (CNA) 10 stated she notified nursing staff on the night shift of 11/26/2025 that R19 would not open her eyes but did clamp her mouth closed during oral care. CNA 10 stated the nurse obtained vital signs and told her they were normal. However, there was no documented evidence the nurse completed a thorough assessment or documented R19's vital signs in the medical record. During further interview, on 12/05/2025 at 6:00 PM, CNA10 stated that she notified Registered Nurse (RN) 5 on 11/27/2025, around 12:30 AM, just prior to RN5 assessing R19's vital signs and notifying the physician, that R19 was not responsive, and her breathing was abnormal with heavy, fast breathing. CNA 10 stated RN5 obtained vital signs and obtained an oxygen level of 65% for R19. CNA 10 stated she had received in report from the prior shift that R19 had not eaten or drank anything on the prior shift. However, there was no documented evidence that RN5 assessed R19 fast abnormal breathing and responsiveness from 11/27/2025 at 6:30 PM until 11/28/2025 at 12:30 AM when she was notified by CNA10. During an interview, on 12/05/2025 at 12:20 PM, Licensed Practical Nurse (LPN) 4 stated she was R19's nurse on 11/27/2025 day shift. LPN 4 stated R19 did not eat or drink and was sleeping a lot during her shift, but she did not notify the physician. LPN 4 stated during report, she was informed that R19 did not eat or drink anything during the 11/26/2025 night shift. However, there was no documented evidence LPN 4 completed an assessment on R19. During an interview, on 12/04/2025 at 11:14 AM, Kentucky Medication Aide (KMA) 1 stated she told the nurse on 11/27/2025 night shift that R19 was not responding like she normally does because she always notifies the nurse of any changes. During an interview, on 12/05/2025 at 12:40 PM, RN 6 stated R19 slept quite a bit on day shift on 11/27/2025 which was not normal for R19. RN 6 stated the Certified Nursing Assistants (CNA) reported that R19 was sleepy during the shift. However, there was no documented evidence RN 6 completed a thorough assessment on R19 or notified the physician of the resident's change in level of consciousness. Review of the schedule revealed both LPN4 and RN 6 were scheduled on R19's unit 11/27/2025 day shift and were both notified by CNAs of R19's change in condition. However, there was no documented evidence that RN19 and LPN4 assessed R19's change in condition during the 11/27/2025 day shift. During an interview, on 12/05/2025 at 6:30 PM, RN5 stated she was the nurse responsible for 50 residents on 11/27/2025 night shift. RN5 stated her shift started at 6:30 PM. However, RN5 stated she had not visualized or assessed R19 until she was notified by another staff member of R19's change in level of conscious just prior to the 911 call. RN5 notified Emergency Medical Services (EMS) to transfer R19 to hospital but could not recall what time the call was made. Review of the EMS (Emergency Medical Services) run sheet and 911 recording, dated 11/28/2025, revealed Registered Nurse (RN)5 called 911 on 11/28/2025 at 12:46 AM and asked for EMS to transfer R19 to the hospital. During the 911 call, RN5 reported that the resident had decreased intake since 11/24/2025, and had agonal (gasping, abnormal) breathing, and staff could not arouse the resident with painful stimuli. Further review of the EMS run sheet revealed R19 was hot to touch. During an interview, on 12/05/2025 at 2:45 PM, Paramedic 1 stated he responded to the 911 call for R19 on 11/28/2025 at 12:56 AM. Paramedic 1 stated he could hear R19's labored breathing from the hallway before he entered R19's room. Review of the hospital record revealed R19 was seen in the Emergency Department on 11/28/2025 at 1:29 AM. The hospital diagnosed R19 with intracerebral hemorrhage, sepsis, and pneumonia. Further review revealed R19 was intubated and transferred to a Level 1 Trauma Center for further treatment on 11/28/2025. R19 expired on 12/04/2025. During an interview, on 12/06/2025 at 11:55 AM, the DON stated the facility used machines that connected to their charting system for any behaviors, medications, meals, and vital signs. He further stated this system sends alerts daily to the Unit Managers. He stated no alerts were triggered on R19 even though she had documentation of multiple missed meals and low intake. Additionally, he stated their Tapestry system was installed above residents' beds and monitored residents' breaths, heart rates, and movements. He stated the Tapestry system has been in use since March or April 2025. However, he stated it did not send any alerts on R19 during 11/24/2025 - 11/27/2025. During an interview, on 12/05/2025 at 9:48 AM, the Director of Nursing (DON) stated it was his expectation nurses did bedside rounding at the beginning of each shift. The DON stated every nurse should lay eyes on their residents before they accept assignments to make sure each resident was alive and had no immediate needs. During an interview, on 12/05/2025 at 12:18 PM, the DON stated residents' needs were identified through the charting system and daily meetings. The DON stated that not checking on a resident for four to five (4-5) hours was not acceptable, and every resident should be checked on every two (2) hours. The DON stated nurses should report if a resident was not eating and document this in the follow up report. Additionally, the DON stated if a resident could not be aroused, an assessment should be done and the provider notified. During an interview, on 12/06/2025 at 2:17 PM, the Administrator stated it was her expectation nurses documented refusal of meals and would inform the next shift in report if a resident was not eating or drinking. She further stated she expected assessments to be completed per policies.

Based on observation, interview, record review, and policy review, it was determined the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for one (1) of 51 total sampled residents, Resident (R) 19. The facility failed to document assessments for R19 from 11/24/2025 to 11/27/2025 when R19 had a decline in intake and level of consciousness. R19 was transferred to the hospital on [DATE]. R19 expired on 12/04/2025.The findings include:The facility did not provide a policy for nursing documentation. Review of the facility's position description, Licensed Practical Nurse (LPN), dated 02/2025, revealed the LPN's essential functions included observing, recording, and reporting changes in residents' condition to the supervisor and attending physician and maintaining residents' medical record by way of documentation. Review of the facility's position description, RN (Registered Nurse), dated 02/01/2024, revealed the RN's major duties and responsibilities included assessing for changes in residents' status, notifying the physician and resident's family or representative, and documenting accordingly. Review of R19's admission Sheet revealed the facility admitted R19 on 01/13/2016. R19's diagnoses included diabetes and atherosclerotic heart disease. Review of R19's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed R19's Brief Interview for Mental Status (BIMS) score to be 14. This score indicated R19 was cognitively intact. Review of R19's care plan, revised 09/17/2025, revealed the facility assessed R19 to be at nutritional and hydration risk related to diabetes, dementia, and protein-calorie malnutrition with a goal to reduce the risk for dehydration. Further review revealed interventions which included to assess for signs and symptoms of dehydration such as elevated temperature and change in mental status, encourage additional 240 milliliters (ml) fluid four times a day (QID), administer medication as ordered, monitor by mouth (po) intakes, and monitor/document/report as needed (prn) any signs and symptoms of dysphagia such as refusing to eat. Continued record review revealed the facility care planned that R19 would be provided with quality care which met physical and mental needs with interventions which included monitor for physical/mental improvement or decline and provide care as needed to maintain or improve R19's current functional level. Additionally, the facility assessed R19, on 10/02/2019 to have a full code status with a goal that R19's wishes would be honored and an intervention to keep family informed of any change in condition. Review of R19's care plan, revised 09/10/2025, revealed the facility assessed R19 had diabetes with a goal that R19 would have no complications related to diabetes and an intervention which included to monitor/document/report any signs or symptoms of hyperglycemia (high blood sugar) which included Kussmaul breathing (rapid, deep breaths), stupor (a state of near-unconsciousness or insensibility), or coma. However, there was no evidence the facility implemented these interventions. Record review revealed the facility assessed R19 to have decreased meal and fluid intakes from 11/24/2025 - 11/27/2025. R19 refused breakfast and lunch on 11/24/2025, consumed 0-25% of dinner on 11/24/2025 and 11/25/2025, refused all meals on 11/26/2025, consumed 0-25% of breakfast and lunch on 11/27/2025, and refused dinner on 11/27/2025. Further review revealed the facility assessed R19 to have consumed a total fluid intake of 700 ml (milliliters) on 11/24/2025, 120 ml on 11/26/2025, and 420 ml on 11/27/2025. However, there was no documented evidence the facility assessed R19 due to the declines in food/fluid intake. Additionally, there was no documentation of nursing assessments or notes from 11/24/2025 through 11/27/2025. During an interview, on 12/05/2025 at 6:00 PM, Certified Nursing Assistant (CNA) 10 stated she notified nursing staff on the night shift of 11/26/2025 that R19 would not open her eyes but did clamp her mouth closed during oral care. CNA 10 stated the nurse obtained vital signs and told her they were normal. However, there was no documented evidence the nurse completed an assessment or documented R19's vital signs in the medical record. During an interview, on 12/05/2025 at 12:20 PM, Licensed Practical Nurse (LPN) 4 stated she was R19's nurse on 11/27/2025 day shift. LPN 4 stated R19 did not eat or drink and was sleeping a lot during her shift and was informed during report that R19 did not eat or drink anything during the 11/26/2025 night shift. However, there was no documented evidence LPN 4 completed or documented an assessment on R19. During an interview, on 12/05/2025 at 12:40 PM, RN 6 stated R19 slept quite a bit on day shift on 11/27/2025 which was not normal for R19. RN 6 stated the Certified Nursing Assistants reported that R19 was sleepy during the shift. However, there was no documented evidence RN 6 completed or documented an assessment on R19. During an interview, on 12/05/2025 at 6:30 PM, RN5 stated she assessed R19 on 11/27/2025 night shift when she was notified by another staff member that R19 had a change in level of consciousness. RN5 stated she could not recall the time, but it was shortly before she called 911 to transport R19 to the hospital. However, there was no documented evidence RN5 had completed or documented an assessment on R19 between 11/27/2025 at 6:30 PM, at the beginning of her shift, until she entered a note on 11/28/2025 at 12:30 AM. Review of R19's Progress Notes, dated 11/28/2025 at 12:30 AM, charted by RN5, revealed R19 had a temperature of 97.5 degrees Fahrenheit. Review of the EMS (Emergency Medical Services) run sheet, dated 11/28/2025 at 1:04 AM, revealed Paramedic 1 assessed R19's temperature to be 104.2 degrees upon arrival to the facility. Further review of the EMS run sheet revealed Paramedic 1 documented the resident was noted to be hot to touch. R19 was transferred and admitted to the hospital on [DATE]. The hospital diagnosed R19 with intracerebral hemorrhage, sepsis, and pneumonia. R19 expired on 12/04/2025. However, review of R19's medical record revealed no documented evidence of the resident's change in condition. R19 expired on 12/04/2025. During an interview, on 12/05/2025 at 12:18 PM, the Director of Nursing (DON) stated residents' needs were identified through the charting system. The DON stated nurses should document if a resident was not eating. Additionally, the DON stated if a resident could not be aroused, an assessment should be completed and documented. During an interview, on 12/06/2025 at 2:17 PM, the Administrator stated it was her expectation nurses documented refusal of meals.

Based on observation, interview, and facility policy review the facility failed to provide housekeeping services to ensure a clean and sanitary environment for eight of 51 sampled residents (R) Residents ((R) 6, R7, R64, R37, R58, R70, R72, and R92). The findings include: Review of the facility's undated policy titled, Resident Rights, revealed the resident had a right to a safe, clean, comfortable and homelike environment. Review of the facility's housekeeping policy titled, Housekeeping Daily Duties, dated 12/2001, revealed a schedule of what housekeeping would do on each day of the week. The policy stated All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corners, problems occur.1. On 12/04/2025 at 9:18 AM, observation of R6's room revealed a tile in the doorway that was cracked and potentially a fall hazard. Continued observation revealed that a handrail in the bathroom next to the toilet was loose and missing one of four screws. 2. On 12/04/2025 at 9:26 AM, observation of R7's room revealed five cracked tiles in the doorway of the resident's room. 3.Observation on 12/04/2025 at 9:39 AM, of R64's room revealed two cracked tiles in the doorway of the resident's room. Continued observation revealed a black substance on the base board in the resident's room next to the entrance to the bathroom.Interview with R64 on 12/04/2025 at 9:46 AM revealed the black substance had been there for a long time. R64 stated, I used to keep my house very clean. I don't like that they have not fixed this. It makes me feel dirty.4. On 12/04/2025 at 10:04 AM, observation of R37's room revealed two cracked tiles in the doorway. Further observation revealed a two-inch hole in the wall behind the resident's bed. 5. On 12/04/2025 at 10:12 AM, observation of R58's room revealed that the overbed table had the rubber missing around the top which exposed a sharp edge. 6. On 12/04/2025 at 10:28 AM, observation of R70's room revealed a broken tile in the middle of the room. In an interview with R70 on 12/04/2025 at 10:46 AM, the resident stated This tile has been broken since the first day I was here. I sit in my wheelchair a lot and sometimes the wheel of my wheelchair will get stuck in the hole in the tile and I am not strong enough to push myself out of it.7. On 12/04/2025 at 10:46 AM, observation of R72's room revealed two cracked tiles in the floor in the bathroom. Continued observation revealed a one-inch gap in the drywall around the sink in the bathroom. 8. On 12/04/2025 at 11:08 AM, observation of R92's room revealed numerous holes in the drywall on all four walls of the room. Continued observation revealed a trash can sitting underneath the sink. In an interview with R92 on 12/04/2025 11:18 AM, the resident stated They put that trash can underneath the sink to catch the dripping water. I don't know when they are going to fix this.The Maintenance Director stated in interview on 12/04/2025 at 11:42 AM, that they use a system called Tails, and anyone could put a work order in. He stated, Everyone knows that they can put a work order in, and we will make sure it gets done. The Maintenance Director stated there were no active work orders currently and he has not been made aware of anything that needs repaired In an interview with the Director of Nursing (DON) on 12/04/2025 at 12:13 PM, he stated that he was unaware of any black substance on the walls or baseboards of any of the residents' rooms. The DON stated that if there was something like that growing on the walls and baseboards, housekeeping should notify him, and they would have someone come in and look at it and find out what it was and how to treat it. During an interview with the Housekeeping Manager on 12/04/2025 at 1:12 PM, she stated, Every resident room gets a deep clean once a week and on the days we don't deep clean, we spot clean. The Housekeeping Manager stated that she was not aware of any black substance on the baseboards in any room. During observation of R64's room with the housekeeping manager, she observed the black fuzzy substance. She stated that there was a black fuzzy substance. The Housekeeper stated that she had never been notified of this.During the interview with the Administrator on 12/04/2025 at 1:38 PM she stated that anyone in the facility could put a work order in and it would get sent to maintenance and they would prioritize it. She stated, We have a good system in place, and everyone has the capacity to place a work order. We encourage everyone to put a work order in the system if they see anything that needs fixed. When asked if she was aware of any cracked tiles or black substances on the base boards, she stated, I am not aware of anything like that. If there are cracked tiles in the floor, we need to get them fixed immediately. This could cause a resident to fall and get hurt and that is not what any of us want to happen.

Number of residents sampled:11Number of residents cited: 7 Based on observations, interviews, record review, review of facility staffing documentation, and review of the facility's Payroll Based Journal (PBJ) report, the facility failed to ensure it had an effective system to provide sufficient numbers of qualified nursing staff to meet the needs of 6 of 51 sampled residents (Resident (R) 8, 18, 30, 68, 94 and 117). The findings include: Review of the facility's policy titled, Staffing, implemented 03/20/2025, revealed the purpose was to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Further review of the facility's staffing policy revealed the facility must ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. Review of the Payroll Based Journal (PBJ) the facility has a one-star staffing rating. The one-star staffing rating means that a LTC facility has not met the minimum staffing set by the Centers of Medicare and Medicaid Services. 1.During an interview with Resident (R) 94 on 12/03/2025 at 9:50 AM, R94 stated that she takes a fluid pill and required multiple bathroom trips during the night. R94 stated she had to wait longer for assistance which was not comfortable. R94 stated, They don't have enough workers. 2.During an interview with R8 on 12/03/2025 at 5:00 PM, he stated that he sometimes received his medications later than the scheduled time. R8 stated getting his medications late was due to a lack of staff. 3. During an interview with R30 on 12/04/2025 at 8:50 AM, R30 stated that he liked living in the facility but did not believe there was enough staff. R30 stated that the staff always appeared rushed. He stated that this made him feel like staff did not have time to provide his care. R30 stated staff were not compassionate or friendly with him when care was provided. 4. During an interview with R18 on 12/04/2025 at 10:30 AM, R18 stated that he often waited a long time for his call light to be answered. R18 explained that he required assistance with the activities of daily living and became frustrated when he was left waiting for his needs to be met. He stated that staff should answer call lights regardless of what they assume he may need. R18 stated that at times he observed aides sitting in the dining area having what he described as a [NAME] party instead of answering call lights. 5. During an interview with R68 on 12/04/2025 at 10:35 AM, R68 stated that he became aggravated when he had to wait for assistance. He stated that the previous night he walked into the hallway seeking help for his roommate because the call light had been activated for a while without response. 6. During an interview with R117 on 12/04/2025 at 10:40 AM, she stated that she frequently received her nighttime snacks very late. R117 stated she believed this occurred due to insufficient staffing. On 12/04/2025 at 12:18 PM, an observation on the 100 Hallway revealed a resident's call light that remained illuminated for 24 minutes before Certified Nursing Assistant (CNA) 6 responded and entered the resident's room. When interviewed at 12:50 PM on 12/04/2025, CNA 6 stated that she was busy with another resident and was unable to answer the call light. On 12/05/2025 at 11:14 AM, an additional observation on the 100 Hallway revealed a call light that remained illuminated for 18 minutes before CNA 4 responded. When interviewed at 11:40 AM, CNA 4 stated that she thought that someone else had answered the call light. During an interview on 12/04/2025 at 4:05 PM, CNA 4 stated she had been employed for one month and believed the facility was short staffed. CNA 4 explained that she often was responsible for up to 25 residents per shift and had difficulty finding assistance to turn residents who required a two-person assist. She stated that some residents wait long periods to be changed. CNA 4 further stated that although she reported concerns to the Director of Nursing and Administrator, her concerns go in one ear and out the other. During an interview with CNA 5 on 12/04/2025 at 4:15 PM she stated that staffing levels did not allow her sufficient time to provide the care to the residents without her feeling rushed. CNA 5 stated that she often could not follow the assigned shower schedule due to lack of time and stated, I do what I can. CNA 6 was interviewed on 12/04/2025 at 4:20 PM. She stated that she worked as a float across all shifts/units and believed that all units were understaffed. CNA 6 stated that she must prioritize care tasks and was often unable to complete all required care. During an interview with the Director of Nursing (DON) on 12/05/2025 at 12:00 PM, she stated that there were a lot of call ins, but the facility took an all-hands-on deck approach by having all department heads, including himself, to help provide resident care. The DON stated that there have been complaints brought to him that the facility was short staffed, and they did not have enough help on the floor to provide resident care needs. He stated that he discussed the CNA to resident ratio with the staff at the time the complaint was voiced. The DON stated there was enough staff to provide care to residents despite staff complaints. During an interview with the Administrator on 12/05/2025 at 11:35 AM, she stated the facility averaged 38 staff call-ins per month and required employees to give at least two hours' notice prior to calling in. She stated that when an employee called in, mass text messages were sent to all staff, and the scheduler began calling employees to cover the shift. The Administrator stated that department heads were required to fall in and cover shifts when necessary. She stated the facility did not mandate overtime. During the interview, the Administrator explained that staff often grumble about staffing when she passed them in the hallway, but she had not received what she considered legitimate complaints. She stated that each CNA was assigned between 6 and 12 residents depending on the acuity (level of assistance needed). The Administrator acknowledged that residents had raised concerns during the Resident Council meetings regarding call-light response times. She stated her expectation was that call lights be answered within 5 to 10 minutes or acknowledged by staff with an attempt to locate someone who could provide the needed care.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four (4) of 51 sampled residents (Resident (R)7, R28, R42 and R50).The findings include:Review of the facility's policy, titled Enhanced Barrier Precautions (EBP), dated 03/08/2024, revealed the EBP policy was implemented to reduce the transmission of multidrug-resistant organisms (MDROs) within the facility. The policy stated EBP would be utilized in conjunction with standard precautions to provide targeted gown and glove use during high-contact resident care activities. The policy stated high contact care activities included assisting with and providing hands on care.Review of the facility's policy titled Infection Control dated 03/10/2024, revealed that all nebulizer tubing should be in a sealed bag when not in use. The policy stated that it was okay to take the tubing out of the bag to be used, but it should be in a bag when not in use. 1. Observation on 12/24/2025 at 3:12 PM, revealed Certified Nursing Assistant (CNA)2 failed to don (put on) Personal Protective Equipment (PPE) prior to providing care for R7 who was on Enhanced Barrier Precautions (EBP). Additionally, CNA2 failed to wash or sanitize his/her hands upon exiting R7's room after providing care.Observation of R7 on 12/04/2025 at 11:12 AM revealed a nebulizer machine with tubing laying on the overbed table. The tubing was not in use and not in a bag.Review of R7's Physician's Orders dated 10/10/2024, revealed orders for Enhanced Barrier Precautions (EBP- infection control intervention designed to reduce transmission of multidrug-resistant organisms) related to a history of Methicillin-resistant Staphylococcus aureus (MRSA) found in the wound.Observation on 12/04/2025 at 3:42 PM, revealed a sign on the door to R7'a room that stated, enhanced barrier precautions. Further observation revealed there was a cart at the door of R7's room that contained boxes of gloves and disposable gowns.2. Observation of R28's room on 12/04/2025 at 11:36 AM revealed a nebulizer machine with tubing touching the floor. The machine was not in use, and the nebulizer kit was laying on the floor. The tubing was not in use and was not stored in a bag.3. Observation of R42's room on 12/04/2025 at 11:58 AM revealed a nebulizer kit laying on the overbed table, not in use. The nebulizer kit was not stored in a bag.4. Observation of R50's room on 12/04/2025 at 12:14 PM revealed a nebulizer kit sitting on the nightstand. The nebulizer was not in use, and the nebulizer kit was not stored in a bag. During an interview with CNA2, on 12/04/2025 at 9:22 AM, she stated if PPE was not donned appropriately for Enhanced Barrier Precautions (EBP), it placed the resident, other residents and staff at risk for spread of infection. CNA 2 stated all residents on EBP should not be touched by staff unless staff was wearing gloves and a disposable gown.During continued interview with CNA2, she stated, she always tried to don appropriate PPE prior to entering R7's room. She stated she knew she should wash or sanitize her hands upon exiting the room. CNA2 stated, I must have been in a hurry. I would never put any of my residents at risk for getting an infection or bacteria.During interview with Registered Nurse (RN) 1, on 12/04/2025 at 3:12 PM, she stated all staff had been educated on infection control policies and a sign on the door indicated the resident was on EBP. RN1 stated all staff should be aware they were to don the appropriate PPE before providing any type of care for residents on EBP. The RN stated she monitored as she was going down the halls and if staff were identified as not wearing appropriate PPE, she would immediately educate them. RN1 stated the Infection Preventionist (IP) completed daily rounds to monitor for infection control measures as well.During an interview with the IP on 12/05/2025 at 1:46 PM, she stated she expected nursing staff to follow the facility's policies regarding PPE and EBP. The IP stated if she ever saw any staff not following proper infection control procedures, she would immediately provide them education on what they did wrong, and the corrective actions needed. The IP stated following infection control policies and procedures for a resident on EBP was important to prevent other residents or staff from being exposed. Further, the IP stated it was important to use good hand hygiene after providing care, and upon exiting a resident's room. She stated she tried to make daily rounds and educate staff regarding infection control procedures as needed. The IP stated that per their policy, all nebulizer tubing should be stored in a bag at the resident's bedside when not in use. During an interview, on 12/04/2025 at 2:32 PM, the Administrator, stated general hand washing was number one, and donning PPE as indicated was expected of all staff. The Administrator stated she left it to the clinical management staff to make rounds to ensure there were no infection control concerns. She stated that the facility's policy was that all nebulizer tubing should be stored in a bag, and this was her expectation. The Administrator stated she expected all staff to follow the facility's infection control policies.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a care plan was developed and implemented for two of 51 sampled residents (Resident (R5 and R90). The findings include: 1.Review of the facility's policy titled, Comprehensive Care Plans, dated 04/06/2015 and revised 02/09/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. Closed record review of R5's face sheet revealed the facility admitted the resident on 04/22/2024. R5's readmission on [DATE] included diagnoses that included subsequent encounter for closed fracture with routine healing; personal history of Transient Ischemic Attack (TIA/stroke); and cerebral infarction without residual deficits, and difficulty in walking, not elsewhere classified. Review of the admission Minimum Data Set (MDS) Assessment, dated 04/25/2024, revealed the facility assessed R5 to have a Brief Interview for Mental Status (BIMS) score of four out of 15. This score indicated the resident was not cognitively intact. Record review revealed no documented evidence the facility developed a Comprehensive Care Plan for R5 that was resident specific. R5's care plan had interventions in place such as Encourage resident to not yell at other residents and Encourage resident to voice their feelings. However, the facility had assessed R5 to be cognitively impaired. Record review reveals that R5's care plan was not updated quarterly.2. Closed record review of R90's face sheet revealed the facility admitted the resident on 10/29/2024 for short term rehabilitation following an ischemic stroke. Further review of the closed record revealed no documented evidence the facility developed and revised a comprehensive care plan for R90 that was personalized. Record review revealed the facility developed a goal for R90 to Return to home. However, R5 had been homeless before being admitted to facility. In an interview with the MDS Coordinator on 12/04/2025 at 12:34 PM, she stated R90's care plan should have a goal that was tailored to them. She stated the care plan should stated, return to community instead of return to home. In addition, the facility failed to update R90's care plan quarterly. During an interview with the Minimum Data Set (MDS) Coordinator on 12/05/2025 at 11:12 AM, she stated R5 and R90 should have had a Comprehensive Care Plan implemented when they were admitted to the facility. The MDS Coordinator stated that she was in charge of implementing and updating care plans. During an interview with the Director of Nursing (DON) on 12/04/2025 at 10:06 AM, he stated each resident should have a person-centered Comprehensive Care Plan and the MDS Coordinator was responsible for implementing the care plans. The DON stated his expectations were for each resident to have the appropriate care plan implemented. During an interview with the Administrator on 12/04/2025 at 10:41 AM, she stated she expected all residents to have a comprehensive care plan and for staff to follow the facility's policies. She stated that all care plans should be revised and reviewed quarterly, at minimum.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide safe medication administration for one of 12 sampled residents. The findings include: Review of the undated facility policy titled Resident Rights revealed the resident had the right to be free from any medication errors and to receive the correct medication. Review of the undated facility policy Medication Administration revealed that the resident had the right to receive the correct medication at the correct time, and the correct dose. Review of the facilities investigative report revealed that Resident (R) 3 and R12 were housed in a room together and on 02/24/2025 they decided that they wanted to switch A bed and B bed positions. The facility switched the two bed positions and did not update the residents bed transfer in the computer system until the next day. On 02/24/2025 at medication pass Registered Nurse (RN)1 gave R3 medications that were supposed to be given to R12 due to failure to properly identify the correct resident. R3 received the following medications that were ordered for R12: 90 units of long-lasting glargine insulin (used to control Diabetes), Xanax 0.25 mg (Used to treat anxiety), Atorvastatin 80 mg (used to reduce cholesterol), Donepezil 10 mg (used to treat Alzheimer's Disease), Duloxetine 60 mg (used to treat Depression/Anxiety Disorders), Eliquis 2.5 mg (a blood thinner), Acetaminophen 500 mg(a pain/fever reducing medication), Ropinirole 0.5 mg (used to treat Parkinson's Disease), Simethicone 80 mg (used to relieve gas), and Trazodone 50 mg (used to treat Depression). In an interview with RN1 at 12:14 PM on 05/14/2025, RN1 stated that it was his first shift working on the floor without a preceptor. RN1 stated that he did not properly identify R3 by her picture, name and date of birth. RN 1 stated that he had been properly trained on how to identify correct residents but only utilized the resident room numbers that night to administer resident medications. RN1 stated he identified the error and reported it to the supervisor and Director of Nursing (DON). RN1 stated the outcome of administering wrong medications to a resident could include, Coma or even death is possible. In an interview with the DON on 05/15/2025 at 12:34 PM he stated that he had not started working for the company as the DON when the incident happened. He stated that they had an interim DON from regional. When contact information was asked for the regional DON, it was not provided to the surveyor and the surveyor was told that they could not find any contact information for them. According to the DON, coma or even death to a resident could result due administering a wrong medication. The DON stated that he expected that all residents should be properly identified before administering any medication. In an interview with the Administrator on 05/15/2025 at 1:18 PM she stated that she was made aware of the incident on 02/24/2025 around 7:30 PM and that she came to the facility. The Administrator continued to state that RN1 was pulled off the floor immediately and was replaced with another nurse. According to the Administrator, vital signs were obtained for resident #3, the resident was in no distress and the Medical Director/Responsible Party was notified. The Administrator stated that death could be a potential outcome of a resident receiving the wrong medications and her expectations were that everyone will be properly identified each time that a medication was administered. During an interview with the Medical Director on 05/15/2025 at 4:08 PM, he was unable to remember the incident and would have to refer to his notes and continued to state, I am very busy, and it would have to be later in the evening. The surveyor attempted to call back later in the day to contact the Medical Director on 05/15/2025 at 1:48 PM, 2:12 PM, and 2:49 PM. All three attempts received no answer and no call back from the Medical Director.

Based on observation, interview, record review, facility document and policy review, it was determined the facility failed to ensure residents' comprehensive care plans were developed and implemented for one (1) of six (6) sampled residents (Resident #7). The facility assessed Resident #7 to be a risk for elopement and care planned him/her for the risk with interventions which included: to distract from wandering by being offered pleasant diversions which included: structured activities, food, conversation, television, or a book. On 05/16/2023, the resident was observed to push on the exit door handle and press the door code box to exit the facility. The resident was provided a Wandergaurd at that time; however, the resident's person-centered care plan failed to address the resident pressing the code box and/or provide increased supervision or monitoring for the safety of the resident. Therefore, on 07/15/2023 at 6:40 PM, Resident #7 was able to exit the facility undetected by staff, by entering the code observed by a staff member who entered the code for the resident's viewing. The resident was unsupervised for approximately five (5) minutes. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 08/31/2023, alleging removal of the Immediate Jeopardy on 07/22/2023, prior to the State Survey Agency's (SSA's) investigation. The SSA validated the facility's IJ Removal Plan, on 09/07/2023, and determined the deficient practice was corrected as alleged on 07/22/2023, prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility's policy titled, Comprehensive Care Plan, dated 01/13/2018, revealed the purpose of the Comprehensive Care Plan was to ensure the resident or resident representative was included in all aspects of person-centered care planning which included the provision of services to enable the resident to live with dignity and supported the resident's goals, choices, and preferences. Continued review revealed a comprehensive care plan was to be developed for each resident within twenty-one (21) days and no more than seven (7) days after the completion of the Minimum Data Set (MDS) Assessment. Per review, the comprehensive care plan must be prepared with input from the facility's Interdisciplinary Team (IDT). Further review revealed care plans were to be reviewed and updated when there had been a significant change in the resident's condition; when the desired outcome was not met; when the resident was readmitted to the facility; and reviewed and revised at least quarterly. Review further revealed the subsequent care plan meetings were to be documented in the care conference notes by Social Services or his/her designee. Review of facility policy titled, Elopement Management Program, dated 12/26/2016, revealed the facility's Elopement Risk Management Program's purpose was to provide the resident with an environment that remained as free from accidents and hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Continued review revealed in order to identify residents at risk for elopement, an assessment was performed before and during the admission process, daily, weekly, and quarterly according to the MDS Assessment schedule or as needed (PRN) based on the observation and evaluation of the resident. Review revealed the IDT developed an individualized care plan to prevent elopement for which the nurse determined the resident's risk factors. Per review, the nurse was to document the intervention on the resident's care plan, and communicate the new interventions to staff members providing care shift-to-shift. Further review revealed the entire IDT must ensure all planned interventions were carried out as written in the care plan and communicated the care plan to the resident's family. Review further revealed the IDT was to review and educate the resident, family, or responsible party about the individualized interventions put in place to ensure the resident's safety. In addition, the care plan was to be reviewed for effectiveness, and the resident monitored daily for any new behaviors and changes in existing behaviors so appropriate interventions could begin as soon as possible. Record review revealed the facility admitted Resident #7, on 02/01/2023, with diagnoses that included Vascular Dementia, Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction without Residual Deficits, and Encephalopathy, Unspecified. Review of Resident #7's Quarterly MDS Assessment, dated 06/09/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), which indicated he/she was severely cognitively impaired. Review of the Progress Note, dated 05/12/2023, revealed Resident #7 had been assessed as an elopement risk due to his/her diagnosis of Dementia, history of being impulsive, ability to ambulate and self-propel in a wheelchair within the building and his/her hovering around exits. Review further revealed a Wander Guard was placed on Resident #7. Review of Resident #7's Elopement Care Plan revealed it was initiated on 05/12/2023, with interventions which included interventions implemented on 05/16/2023: to distract the resident from wandering by offering pleasant diversions, structured activities, a book, conversation, television, or food, Continued review revealed additional interventions to monitor the resident for fatigue and weight loss, toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes, and applying a wandering device to his/her ankle and check the placement and function. Further review of the record revealed however, no documented evidence Resident #7 was care planned for increased supervision, even though the facility assessed him/her to be at risk for elopement on 05/12/2023. Review of the Progress Note dated 05/16/2023, revealed Resident #7 had been observed at an exit door pushing on the handle and pressing the door code box. Continued review revealed however, no documented evidence to support the facility updated Resident #7's care plan with increased supervision and/or monitoring of the resident at the code box, to ensure his/her safety. Review of the Facility's Investigation revealed on 07/15/2023, a staff member punched the door code in to allow someone to exit, and Resident #7 watched the staff member enter the code to the door. Continued review revealed after watching the staff member punch in the code, Resident #7 punched in the code and exited the facility without staff supervision. Review further revealed Resident #7 was found by a staff member sitting outside, for approximately five (5) minutes, by the fence thirty-four (34) feet from the facility's front entrance. In a telephone interview, on 08/30/2023 at 8:11 PM, LPN #17 stated she had been the previous 300 Hall Unit Manager. She stated Resident #7 would dress daily and appeared not to look like a resident at times, so she did not trust the resident not to try and elope. She stated that was why she decided to make him/her an elopement risk. LPN #17 stated the process on care plans was for her to email the MDS Nurse and tell her what she had done, and the MDS Nurse was ultimately responsible for updating the care plans with input from the IDT team. She stated it was always a big deal if they did the care plans and the MDS Nurse did not. The LPN stated she could update a baseline care plan; however, the MDS Nurse had the responsibility to ensure the care plans were updated. She stated on 5/12/2023, she entered the progress note, received a Physician's order for a undergird device which she was to place on Resident #7. LPN #17 further stated she initiated the elopement care plan for Resident #7 then sent the MDS Nurse an email telling her what she had done, so the resident's care plan could be modified and updated. In an interview on 08/29/2023 at 2:00 PM, the MDS Nurse stated resident care plans were reviewed quarterly and whenever an assessment occurred. She stated the care plan could be reviewed more frequently if a resident was being monitored due to being at risk for conditions such as infections, falls, etc., and checked to see if the interventions which had been chosen needed updating. The MDS Nurse stated Social Services would update residents' elopement care plan because they assessed for mood and behaviors. She stated residents were assessed for elopement every quarter or whenever a resident displayed behaviors. The MDS Nurse stated any nurse could add an intervention to the care plan after discussing the matter with the Director of Nursing (DON) and the Executive Director (ED). She further stated the responsibility for updating the care plan after a resident displayed exit-seeking behaviors fell to whoever was working at the time the behaviors occurred. In an interview on 09/07/2023 at 8:43 AM, the DON stated the nurse on duty was responsible for updating a resident's care plan if an event occurred during their shift. In an interview on 09/07/2023 at 10:18 AM, the ED stated care plans were updated as needed. She stated the facility's process for updating care plans was for the floor nurse to initiate a conference call with her, the DON, the Nursing Supervisor on duty and/or the Regional Corporate Nurse Consultant at the time of the incident. The ED stated during that call they discussed the situation and came up with interventions. She stated someone on the conference call was assigned to update the resident's care plan and she or the Regional Nurse Consultant would confirm that the care plan had been updated. The ED further stated the charge nurse on duty was ultimately responsible for making sure the care plans were updated at the time of the event. The facility alleged it had taken the following actions: 1. Corrective Action for Resident #7 who had been affected by the deficient practice for F 689: Resident #7 was wearing tan jogging pants, a T-shirt, and shoes at the time he/she was found outside of the facility. Continued review revealed the weather was 82.4 degrees, wind was at three (3) miles per hour (mph), with 79% humidity, according to the website local conditions.com at 7:00 PM for the facility's location. 2. Corrective action included a head-to-toe skin assessment of Resident #7 that was completed with no injury noted. Further review revealed the action also included a check of Resident #7's Wander Guard alert bracelet to ensure it was in place to his/her right ankle on 07/15/2023. 3. Corrective action for Resident #7 included Resident #7 being placed on one to one (1:1) supervision on 07/15/2023, and his/her care plan updated to reflect the increased supervision by the Registered Nurse (RN). No further care plan revisions were completed as the resident remained 1:1 with facility staff at all times and was to do so for the remainder of time he/she resided in the facility or was no longer able to be independently mobile. 4. Corrective action also included notification of Resident #7's Physician (MD) and responsible party (RP) on 07/15/2023. 5. Further corrective action (for Resident #7) included a new BIMS assessment and St. Louis University Mental Status (SLUMS) assessment which was a test for Dementia that measured aspects of cognition on a scale from 0-30, given to Resident #7 by the Speech Therapist on 07/16/2023. A score of 0-30 indicated Dementia. 6. Corrective action included a new elopement assessment completed on Resident #7 on 07/15/2023, which identified him/her as at risk for elopement. 7. Further corrective action included a head count of facility residents performed by each unit nurse on 7/15/2023. All residents residing in the facility were accounted for and present. 8. Corrective action also included the residents residing in the facility that have been identified as risk for elopement had wander guards in place. Wander Guards were checked for functioning and placement by the charge nurses on 07/15/2023. 9. Corrective action included door codes changed by the Plant Operations (Ops) Director on 07/15/2023. Key pad covers were ordered and placed by the Plant Ops Director on the two (2) main exit doors on 07/21/2023. 10. Further corrective action included checking all doors and windows in the facility by Plant Ops Director on 7/15/2023 to ensure all doors/windows were locked, secured, and that delayed egress was functioning properly. 11. Corrective action also included all current residents being reassessed for elopement potential by the DON, Unit Manager, Infection Control/Risk Manager, Wound Nurse, MDS Coordinators and charge nurse starting on 07/15/2023 and completed on 07/16/2023. 12. Corrective action included all residents currently residing in the facility that had been identified at risk for elopement had care plans reviewed or implemented to reflect current needs of the residents on 07/16/2023 by the MDS Nurse and/or Regional Nurse. 13. Further corrective action included a review of the elopement binders for accuracy by the Social Services Director (SSD) on 07/16/2023. 14. Corrective action included a thirty (30) day look back in the electronic medical record operating system, point click care (PCC), on all events that had occurred in the facility and 24-hour report for exit seeking behavior; this was started on 07/15/2023 and competed on 07/16/2023. 15. Corrective action included the DON, Unit Manager, Assistant Director of Nursing (ADON), MDS Coordinators and Regional Nurse Consultant completing a thirty (30) day look back of nurses' notes for exit seeking behaviors and/or elopements with wandering behavior identified on residents in the facility currently identified as at risk for elopement. This was started on 07/15/2023 and completed on 07/16/2023. 16. Corrective action included providing education to Administrative staff on 07/16/2023 by the Nurse Consultant on the policies for implementing and following care plans. Care Plan Policy and Procedure education was to include the following: Elopement/wandering care plan interventions, creating, reviewing, implementing, and following the care plan and updating care plan with changes in condition. All staff receiving education could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. That process continued until all managers obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Nurse Consultant. 17. Corrective action also included re-educating facility staff to include as necessary (PRN) and Agency as well as licensed nurses and nurse aides, dietary, therapy, housekeeping and administrative staff on following policies and procedures to include elopement, missing resident, safety and supervision, accident and incident, behavior management and care planning, resident rights, Dementia, abuse and neglect, facility administration, Quality Assurance and Process Improvement (QAPI), and the Change of Condition policy and procedure per the IDT team, and communicating these specific interventions to all relevant staff which was started on 07/15/2023 and was completed for all current staff which included taking a post-test and scoring 100%, on the current working schedule by 07/21/2023. Staff not on the current schedule will receive education and be required to take a post-test and score 100%, before being permitted to work starting on 7/21/2023. 18. Corrective action included covering the exit door keypads to the main entrance and exit doors for the facility that would prevent residents or visitors from visualizing the key pad when code was being entered. 19. Further corrective action included starting on 07/15/2023, all doors were to be continued to be checked for proper function daily to ensure the delayed egress was functioning properly and the alarms were audible to alert staff, by members of the IDT team. 20. Corrective action included an elopement drill that was completed on 07/16/2023 by the Plant Operations manager. Elopement drills were to be conducted twice a day on day and night/ shifts, for one (1) week and weekly for four (4) weeks by Administrator, DON, or Department Head Managers. Then were to be conducted quarterly, thereafter. 21. Corrective action included the DON, RM, Wound Nurse, MDS or Regional Nurse were to monitor all residents, as well as new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decrease to Monday through Friday for three (3) months to determine if there were any new exit seeking behaviors and to ensure appropriate interventions have been implemented to ensure the safety of the residents. 22. Corrective action also included beginning on 07/16/2023, the following was to be reviewed daily by a member or members of the IDT team: Events in Risk Management, Clinical Summary 24-hour report, review new and readmissions for elopement assessments and updated care plans and elopement book as needed, Nurses notes, new or worsening exit seeking and/or wandering behavior tracking, care plan interventions for any identified new or worsening exit seeking and/or wandering behavior and Medication Administration Record (MAR) monitoring. 23. Corrective action included beginning on 07/16/2023, an elopement test that included questions regarding our policies on elopement, Dementia, QAPI, abuse reporting, change of condition, care plans, accidents and incidents, and safety and supervision. The testing was to be completed by employees and the employee must make a 100%, if not they must be re-educated and re-tested until 100% obtained. Staff not working on 07/17/2023 were to be educated upon return to work and a post test administered. 24. Corrective action included a nurse from the regional team or corporate office and/or the [NAME] President (VP) of Operations being available on site or by phone starting 07/15/2023. A member of the regional team was providing regional oversight from 7/15/2023 until immediacy was lifted either in person or by phone to ensure continued compliance with audits established by QAPI Committee. 25. Corrective action included a QAPI meeting conducted on 07/16/2023 to discuss the pending deficiencies with F656 in regards to care planning. QAPI was to continue to be ongoing weekly for four (4) weeks and the DON was to report the findings of all audits to QA. An immediate action plan was implemented and discussed to ensure compliance and any changes needed to the facilities plan were completed. The State Survey Agency validated the facility had taken the alleged actions: 1. In interview on 08/24/2023 at 10:52 AM, SRNA #17 stated on 07/15/2023 around 6:30 PM or so, she found Resident #7 sitting outside of the facility at the end of the sidewalk beside the fence after she clocked out of work for her shift. She stated she along with the nightshift nursing supervisor and another SRNA, brought Resident #7 back inside the facility and returned him/her to his/her unit. In an interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she worked the evening shift on the night of Resident #7's elopement incident 07/15/2023. She stated she provided 1:1 supervision for Resident #7 after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. 2. Record review of Resident #7's progress note dated 07/15/2023, revealed Resident #7 had a head to toe skin assessment performed by LPN #5 and his/her Wander Guard bracelet was removed and replaced with a new one. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated once Resident #7 was brought back to the 300 unit, she performed a head to toe skin assessment of him/her. She further stated she also checked Resident #7's Wander Guard bracelet and replaced it with a new one. 3. Review of Resident #7's care plan revealed the resident had been care planned for 1:1 supervision on 07/15/2023. In interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she provided 1:1 supervision for Resident #7 on 07/15/2023, after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. Observation of Resident #7 from 08/22/2023 through 09/07/2023, revealed Resident #7 currently remained on 1:1 supervision. 4. Review of Resident #7's progress noted dated 07/15/2023, revealed Resident #7's MD and RP were notified of the elopement event on 07/15/2023 at 6:45 PM. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated she contacted Resident #7's MD and RP to notify them of the elopement event on 07/15/2023. 5. Record review revealed a SLUMS Assessment had been completed for Resident #7 on 07/16/2023, by the Director of Rehab/Speech Therapy. Continued review revealed Resident #7 was assessed to have SLUMS Assessment score of twenty (20) out of thirty (30) on the SLUMS scale, which indicated he/she had Dementia (a SLUMS score of one [1] to twenty [20] indicated Dementia). In interview on 09/07/2023 at 12:12 PM, the Director of Rehab/Speech Therapy revealed she completed the SLUMS Assessment of Resident #7 on 07/16/2023. 6. Review of Resident #7 progress note dated 07/15/2023 revealed an elopement risk assessment was completed of the resident by LPN #5. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she performed a new elopement risk assessment on Resident #7 immediately after the elopement event on 07/15/2023. 7. In a telephone interview with the Weekend Nightshift Nursing Supervisor on 09/07/2023 at 3:28 PM, she stated, she along with each unit charge nurse, performed a head count of all residents in the facility, and each resident was accounted for. Review of the facility's Elopement Binder revealed all residents that resided in the faciltiy were accounted for by nursing staff on 07/15/2023. 8. In a telephone interview on 09/07/2023 at 3:28 PM, the Weekend Nightshift Nursing Supervisor stated she also performed the placement and function checks on the Wander Guard bracelets for all residents at risk for elopement on 07/15/2023. Observation on 08/25/2023 at 11:25 AM, revealed Unit Manager #1 demonstrated the testing and function of Resident #7's Wanderguard Bracelet, which was observed to be functioning properly. 9. In an interview on 08/22/2023 at 9:25 AM, the facility's Maintenance Director stated he changed the door keypad codes and placed covers over the keypads by 07/21/2023. Observation of the facility's exit doors on 09/01/2023 at 4:00 PM, revealed covers over all the egress doors keypads as alleged. 10. In continued interview on 08/22/2023 at 9:25 AM, the facility Maintenance Director stated he checked all the facility's doors and windows on 7/15/2023 to ensure all doors/windows were locked, secured, and the delayed egress was functioning properly. 11. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she assisted in performing the new elopement assessment risks on all residents along with the other unit charge nurses, MDS Nurse, and the Regional Nurse Consultant onsite after the elopement incident on 07/15/2023 through 07/16/2023. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated the completion of the new elopement assessment risks of all residents had been conducted and the results of the assessments were located in the Elopement Binders. Review of facility's F656 Care Plan Binder on 09/07/2023 at 1:30 PM revealed residents had been reassessed for elopement. 12. In an interview with the facility MDS Nurse on 08/29/2023 at 2:00 PM, she stated she reviewed and updated the care plans for all residents deemed at risk for elopement on 07/16/2023. 13. In an interview on 09/07/2023 at 9:49 AM, the Social Services (SS) Assistant stated she, along with the Social Services Director, updated the elopement binders and care plans on 07/16/2023. She stated they updated the list of residents at risk for elopement and placed the new updated copies in all areas. The SS Assistant further stated they reviewed the elopement binders monthly to ensure that they were up to date. On 08/30/2023 at 10:30 AM, the SSA Surveyor went to each unit in the facility and located the Orange Elopement Binder at each nurses' station behind the desk. 14. In a telephone interview with Regional Corporate Nurse Consultant #1 on 09/01/2023 at 9:03 AM, she stated she performed audits of all nurses notes, 24 hour reports and documentation, and checked for other potential residents that were at risk for exit seeking behavior from 07/15/2023 to 07/16/2023. 15. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she completed a thirty (30) day audit from 07/15/2023 to 07/16/2023, of the nurses notes for residents at risk for elopement to see if there were any exit seeking behaviors documented. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation present of the thirty (30) day audit no other exit seeking behaviors were documented. 16. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided education regarding care plans to the administrative staff on 07/15/2023 and administered post tests to them. She stated that all staff made 100% scores and if they had not the staff member was reducated and had to retake the posttest until 100% was achieved. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation of all staff education and their post tests. 17. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided elopement education to facility staff along with Regional Corporate Nurse Consultant#1 beginning on 07/15/2023 and administered post tests to them. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation noting all staffs' education and posttests. In interview on 08/31/2023 at 4:10 PM and 4:15 PM with RN #3; and at 4:30 PM with LPN #16 revealed they stated they received education on elopement. In interview on 09/06/2023 at 10:20 AM, Staff Developement Coordinator/Infection Preventionist stated he received the education and took the post tests. In interview on 09/01/2023 at 2:20 PM, Dietary Aide #1 stated she received the education and had taken a post test on elopement. 18. Observation of the facility front door and staff exit door on 08/22/2023 revealed the keypads were covered with a plastic privacy cover to obstruct viewing of the code being entered. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he installed the covers to the door keypads shortly after the elopement event on 07/15/2023. 19. In an interview with the Maintenance Director on 08/22/2023 at 9:25 AM, he stated the exit doors were checked daily for proper functioning and returned demonstration of how the doors function at that time. He stated he and the ED, DON and some nurses performed the checks. In interview on 09/01/2023 at 9:03 AM, Regional Nurse Consultant #1 and at Executive Director both stated they assisted with checking the exit doors starting on 07/15/2023, and the door checks were continuing to be performed. 20. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he conducted the elopement drills for facility staff on 08/16/2023. The Maintenance Director stated the elopement drills were conducted twice a day, and occurred at least once on each shift for four (4) weeks after the event, then the drills were conducted weekly and PRN. In interview on 09/07/2023 at 8:43 AM, the DON stated she the elopement drills were being conducted as required. In an interview on 09/07/2023 at 10:18 AM, the ED stated the elopement drills had been conducted as required. Review of Elopement Binder on 09/06/2023 revealed elopement drills were being conducted on each shift starting 07/16/2023 for next four (4) weeks. Interview on 08/24/2023 at 10:52 AM, with SRNA #17; on 08/25/2023 at 8:55 AM with SRNA #15; and on 08/25/2023 at 8:50 AM with LPN #6 they all stated they participated in elopement drills and the education provided. 21. In an interview on 08/29/2023 at 2:00 PM, the MDS Nurse stated she along with Regional Corporate Nurse Consultants #1 and #2 had been providing monitoring of residents for exit seeking behaviors. In an additional interview on 09/01/2023 at 9:03 AM, Regional Nurse Consultant #1 stated she audited nurse notes, 24 hr reports and all other pertinent documentation and checked other potential residents that might be at risk for elopement. Observations during the SSA onsite survey 08/22/2023 through 09/07/2023, revealed staff were observed rounding each hallway and performing every fifteen (15) minute checks of all residents at risk for elopement. 22. In an interview 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she audited nurses' notes, and 24 hour reports. In interview on 09/01/2023 at 9:42 AM, the Social Services (SS) Assistant and Social Services Director stated they put the elopement binders together, and updated them and the residents' elopement care plans as needed. 23. In interview on 08/31/2023 at 4:10 PM, with RN #3; at 4:30 PM, with LPN #16; and at 4:15 PM, with LPN #10 they all stated they were provided education on facility policies to include the following: change of condition, elopement, Dementia, QAPI, abuse reporting, care plans, accidents and incidents, and safety and supervision. They all stated they were educated by the Regional Nurse Consultant. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she had provided elopement education to facility staff. 24. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she along with Regional Corporate Nurse Consultant #2 and the VP of Operations had all either been in the building or available by telephone to provide oversight and ensure audits were performed, since the elopement incident on 07/15/2023. 25. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she attended QAPI meetings along with the facility's IDT team on 07/16/2023 and the facility had held QAPI meetings weekly since then. In an interview on 09/01/2023 at 10:43 AM, the MDS Nurse stated she updated the care plans for newly identified elopement risk residents on 07/16/2023 and has participated in QAPI. In an interview on 09/07/2023 at 8:43 AM, the DON stated she performed elopement audits and she also checks and audits of the medication carts. She further stated she attended the IDT meetings Monday-Friday, held twice a day. The DON additionally stated she reported her audit findings in the QAPI meetings. In a telephone interview on 09/06/2023 at 3:27 PM, the facility's Medical Director stated he had been made aware of the deficiencies and was participating in the QAPI meetings, which he attended in person.

Based on observation, interview, record review, review of facility documents and policy, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of six (6) sampled residents assessed as an elopement risk (Resident #7). The facility assessed Resident #7 as at risk for elopement and care planned the resident to be distracted from wandering by being offered pleasant diversions, structured activities, food, conversation, television, or a book. However, the resident was able to exit the facility undetected by staff on 07/15/2023 at 6:40 PM, based on a review of the facility's Final Investigation Report. The resident was found located outside the building unsupervised for approximately five (5) minutes. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 08/31/2023, alleging removal of the Immediate Jeopardy on 07/22/2023, prior to the State Survey Agency's (SSA's) investigation. The SSA validated the facility's IJ Removal Plan, on 09/07/2023, and determined the deficient practice was corrected as alleged on 07/22/2023, prior to the initiation of the investigation. Therefore, the IJ was determined to be Past Immediate Jeopardy. The findings include: Review of the facility policy titled, Increased Supervision, undated, revealed its purpose was to ensure necessary supervision was provided and continued through the interdisciplinary team (IDT) assessment. Per policy review, the IDT was to consult with the attending Physician, resident, and/or responsible party prior to removing the increased supervision. Continued review of the policy revealed Increased Supervision referred to the supervision of the resident by staff to prevent opportunities for the resident to harm themselves or others. Further review revealed staff assigned to conduct increased supervision were to complete monitoring forms and provide adequate supervision to mitigate incident risk. Review of the facility policy titled, Elopement Management Program, dated 12/26/2016, revealed the Elopement Risk Management Program's purpose was to provide residents with an environment that remained as free from accidents and hazards as possible, and received adequate supervision and assistance devices to prevent accidents. Per policy review, in order to identify residents at risk for elopement, an assessment was performed before and during the admission process, daily, weekly, and quarterly according to the Minimum Data Set (MDS) Assessment schedule or as needed (PRN). Continued review revealed based on the observation and evaluations performed of the resident, the IDT developed an individualized care plan to prevent elopement. Review revealed the nurse determined the resident's risk factors and documented interventions on the resident's care plan. Per review the licensed nurse also communicated the new interventions to the staff members who provided care shift-to-shift. Review of the policy revealed an Elopement Binder was to be kept at each nurses' station and at the receptionist's desk, which contained an elopement risk identification form on residents at risk for elopement. According to review of the policy, care plans were to be reviewed for effectiveness, and the resident was to be monitored daily for any new behaviors and changes in existing behaviors so appropriate interventions could begin as soon as possible. Further review revealed maintenance was to test and document that exit doors were secured and that alarms or electronic locks/keypads functioned as designed. Review further revealed the licensed nurse on every shift was to check the placement and function of the resident's electronic alarm devices and document the results on the resident's Treatment Administration Record (TAR). Review revealed if the electronic device did not function the licensed nurse was to immediately replace it with an operational device and communicate the changes via shift-to-shift report. In addition, the policy review revealed if a resident was identified to be at risk for elopement, an exit-seeking tracking form was to be implemented. Review further revealed when the IDT determined the resident was no longer at risk for elopement, treatment goals and approaches could be removed from the resident's care plan, a team member was to note the date of discontinuance on the resident's Care Plan and was to write a short narrative in the interdisciplinary notes indicating the rationale for the decision. Review of facility policy titled, Golden Alert, undated, revealed when the door alarm was sounding, someone must go to the door that was alarming and do an outside perimeter check, and if no resident was observed outside, the person responding was to go back inside and deactivate the alarm. Continued review revealed staff were to page Golden Alert- which alerted the units to conduct a head count of all residents, and if all residents were accounted for then they were to page, All Clear. Further review revealed if a resident was considered missing, staff was to immediately page Golden Alert and announce the resident's room number, which alerted all staff there was a missing resident. Additionally, the review revealed staff were to follow the facility's elopement guidelines located in the elopement binder. Review of Resident #7's medical record revealed the facility admitted him/her on 02/01/2023, with diagnoses including: Personal History of Transient Ischemic Attack (TIA), Cerebral Infarction without Residual Deficits, Vascular Dementia and Encephalopathy, Unspecified. Review of Resident #7's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. Review of Resident #7's Elopement Assessment Risk, dated 05/12/2023, revealed the facility assessed the resident as being at risk for elopement based on his/her ability to self-propel in a wheelchair independently. Continued review revealed Resident #7 was an elopement risk also due to: being ambulatory; his/her diagnosis of Dementia; history of wandering or hovering near exits; and history of being impulsive. Review of the Progress Note, dated 05/12/2023, revealed Resident #7 had been assessed to be an elopement risk due to his/her ability to ambulate and self-propel in a wheelchair within the building and hovering around exits. Further review of the Progress Note revealed an Undergird bracelet (a monitoring device which alarmed monitored doors and alerted staff) was applied to Resident #7. Review of the Progress Note, dated 05/16/2023, revealed Resident #7 was observed at an exit door pushing on the handle and pressing the door code box. Continued review revealed no documented evidence the facility provided increased supervision and/or monitoring of Resident #7 at the code box, to ensure his/her safety. Review of the Facility's Investigation, dated 07/15/2023 revealed on that date, Resident #7 entered the code to the door at the front entrance exit door after watching a staff member punch in the code on the key pad. Continued review revealed Resident #7 exited the facility without staffs' supervision, and was found by a staff member sitting outside, approximately five (5) minutes after exiting the facility, by the fence thirty-four (34) feet from the facility's front entrance. Further review revealed the facility based the timeframe of the resident's being found on staff interviews. Review of the facility's Final Investigation dated 07/21/2023 revealed on 07/15/2023, the [NAME] President (VP) of Clinical Operations interviewed Resident #7 at 7:30 PM, and the resident stated he/she was going to check on his/her truck. Continued review revealed when the VP of Clinical Operations asked Resident #7 how he/she got out of the facility, the resident stated I watched them punch the code in. Further review of the investigation revealed Resident #7 had been able to recall two (2) of the five (5) digit code sequence for the door at the time of the interview. Per the DON's written statement in the facility's Final Investigation documentation dated 07/21/2023 at 3:47 PM, revealed she identified Resident #7 during the root cause analysis as the resident had a variable BIMS score ranging from five (5) to nine (9) out of 15 and a history of being a special operations agent in the armed forces, and presented himself/herself as a cognizant person. Observation of Resident #7, on 08/22/2023 at 10:16 AM, revealed the resident was sitting up on his/her bed painting suncatchers, and on 1:1 supervision with facility staff at that time. Observation of Resident #7, on 08/23/2023 at 2:00 PM, revealed Resident #7 was up in his/her wheelchair with State Registered Nursing Assistant (SRNA) at his/her side for 1:1 supervision while in line waiting to enter the facility's dining hall to participate in an afternoon activity. In an interview with Licensed Practical Nurse (LPN) #8, on 08/24/2023 at 3:30 PM, she stated she had last seen Resident #7, on 07/15/2023 between 5:00 PM and 5:30 PM, on the 300 Hall hallway. LPN #8 stated she was giving shift report when the girls from the 100 Hall came to the 300 unit to bring Resident #7 back and told her the resident had been found outside. She further stated that shocked her because the resident had never tried to exit seek before. In an interview with SRNA #14, on 08/24/2023 at 3:13 PM, she stated she had last seen Resident #7 around 6:15 PM to 6:20 PM on 07/15/2023. She stated Resident #7 had been in his/her room when she last saw the resident as she was picking up his/her dinner tray. In an interview with SRNA #22, on 08/30/2023 at 8:25 AM, he stated he had last seen Resident #7 self-propelling in his/her wheelchair on the 300 Hall around the nurses' station at 6:30 PM as he was going to get ice. In an interview on 08/24/2023 at 10:52 AM, SRNA #17 stated she was the staff member who found Resident #7 sitting outside the facility after she clocked out of work from her shift. She stated she had not heard a door alarm going off, but heard what might have been Resident #7's Undergird alarm sounding. SRNA #17 stated when she left the facility she happened to see Resident #7 sitting beside the fence near the front entrance as she walked by. She stated she then asked another SRNA, whose name she could not recall, to check and see if Resident #7 was allowed to be outside or if he/she was their own power of attorney (POA). The SRNA stated Resident #7 did not say anything to her or tell her why he/she was outside. She further stated she stayed with Resident #7 while the other SRNA went inside to check and got LPN #13 and they all three (3) escorted Resident #7 back inside the facility and returned him/her to his/her unit. Review of SRNA #17's timecard revealed she clocked out of work on 07/15/2023 at 6:40 PM. In an interview with LPN #5 on 08/24/2023 at 9:05 AM, she stated she had last seen Resident #7 self-propelling past the 300-unit nurses' station during shift change. The LPN stated none of the staff on the 300 unit where Resident #7 resided had been aware the resident was missing until he/she was brought back to the unit after his/her elopement. He further stated that had been around 6:30 PM, before Resident #7 was brought back to the 300 unit by the 100 Hall staff. During an interview with LPN #13, she stated she last saw Resident #7 in the front lobby of the facility sitting next to her at the beginning of her shift, right after she clocked in, on 07/15/2023, as she was punching in the door code to let a family member out of the facility. She stated she had clocked in for work at 6:38 PM. LPN #13 stated she should have been careful to not reveal the door code when entering it on the keypad; however, at the time she did not have any concerns about Resident #7 having exit-seeking behaviors. She further stated Resident #7 had not been exit-seeking in the past and was always going all over the facility and went back to his/her room without any issues. In addition, LPN #13 stated the facility's process before Resident #7's elopement had been to change the door codes when needed. Review of LPN #13's timecard revealed the LPN clocked in a 6:38 PM on 07/15/2023. In an interview with the Director of Nursing (DON), on 09/07/2023 at 8:43 AM, she stated she was notified by the night shift supervisor that Resident #7 had been found sitting outside the facility. She stated she did not have to respond though because the Corporate Nurse, who lived nearby the facility, responded to the event, and therefore, never went to the facility that day. The DON stated she assisted with the facility's investigation beginning on 07/16/2023. In an interview with the Executive Director (ED), on 09/07/2023 at 10:18 AM, she stated she had been notified of the elopement event involving Resident #7 immediately after it happened by the Nightshift Nursing Supervisor at 6:30 PM. She stated she then notified the Regional Nurse Consultant because she only lived five (5) minutes from the facility. The ED stated the Regional Nurse Consultant went to the facility to make sure Resident #7 was okay and everything that needed to be done was put in motion, and she arrived at the facility shortly after that. She further stated Resident #7 was placed on 1:1 supervision at that time. The facility alleged it had taken the following actions: 1. Corrective Action for Resident #7 who had been affected by the deficient practice for F 689: Resident #7 was wearing tan jogging pants, a T-shirt, and shoes at the time he/she was found outside of the facility. Continued review revealed the weather was 82.4 degrees, wind was at three (3) miles per hour (mph), with 79% humidity, according to the website local conditions.com at 7:00 PM for the facility's location. 2. Corrective action included a head-to-toe skin assessment of Resident #7 that was completed with no injury noted. Further review revealed the action also included a check of Resident #7's Wander Guard alert bracelet to ensure it was in place to his/her right ankle on 07/15/2023. 3. Corrective action for Resident #7 included Resident #7 being placed on one to one (1:1) supervision on 07/15/2023, and his/her care plan updated to reflect the increased supervision by the Registered Nurse (RN). No further care plan revisions were completed as the resident remained 1:1 with facility staff at all times and was to do so for the remainder of time he/she resided in the facility or was no longer able to be independently mobile. 4. Corrective action also included notification of Resident #7's Physician (MD) and responsible party (RP) on 07/15/2023. 5. Further corrective action (for Resident #7) included a new BIMS assessment and St. Louis University Mental Status (SLUMS) assessment which was a test for Dementia that measured aspects of cognition on a scale from 0-30, given to Resident #7 by the Speech Therapist on 07/16/2023. A score of 0-30 indicated Dementia. 6. Corrective action included a new elopement assessment completed on Resident #7 on 07/15/2023, which identified him/her as at risk for elopement. 7. Further corrective action included a head count of facility residents performed by each unit nurse on 7/15/2023. All residents residing in the facility were accounted for and present. 8. Corrective action also included the residents residing in the facility that have been identified as risk for elopement had wander guards in place. Wander Guards were checked for functioning and placement by the charge nurses on 07/15/2023. 9. Corrective action included door codes changed by the Plant Operations (Ops) Director on 07/15/2023. Key pad covers were ordered and placed by the Plant Ops Director on the two (2) main exit doors on 07/21/2023. 10. Further corrective action included checking all doors and windows in the facility by Plant Ops Director on 7/15/2023 to ensure all doors/windows were locked, secured, and that delayed egress was functioning properly. 11. Corrective action also included all current residents being reassessed for elopement potential by the DON, Unit Manager, Infection Control/Risk Manager, Wound Nurse, MDS Coordinators and charge nurse starting on 07/15/2023 and completed on 07/16/2023. 12. Corrective action included all residents currently residing in the facility that had been identified at risk for elopement had care plans reviewed or implemented to reflect current needs of the residents on 07/16/2023 by the MDS Nurse and/or Regional Nurse. 13. Further corrective action included a review of the elopement binders for accuracy by the Social Services Director (SSD) on 07/16/2023. 14. Corrective action included a thirty (30) day look back in the electronic medical record operating system, point click care (PCC), on all events that had occurred in the facility and 24-hour report for exit seeking behavior; this was started on 07/15/2023 and competed on 07/16/2023. 15. Corrective action included the DON, Unit Manager, Assistant Director of Nursing (ADON), MDS Coordinators and Regional Nurse Consultant completing a thirty (30) day look back of nurses' notes for exit seeking behaviors and/or elopements with wandering behavior identified on residents in the facility currently identified as at risk for elopement. This was started on 07/15/2023 and completed on 07/16/2023. 16. Corrective action included providing education to Administrative staff on 07/16/2023 by the Nurse Consultant on the policies for implementing and following care plans. Care Plan Policy and Procedure education was to include the following: Elopement/wandering care plan interventions, creating, reviewing, implementing, and following the care plan and updating care plan with changes in condition. All staff receiving education could not return to work until the education was provided, post-test administered related to elopement policy and procedures and 100% score obtained. If manager did not score 100% on post-test, then manager was immediately re-educated and post-test re-administered. That process continued until all managers obtained a 100% score on post-test. All post-tests were reviewed for compliance by the Nurse Consultant. 17. Corrective action also included re-educating facility staff to include as necessary (PRN) and Agency as well as licensed nurses and nurse aides, dietary, therapy, housekeeping and administrative staff on following policies and procedures to include elopement, missing resident, safety and supervision, accident and incident, behavior management and care planning, resident rights, Dementia, abuse and neglect, facility administration, Quality Assurance and Process Improvement (QAPI), and the Change of Condition policy and procedure per the IDT team, and communicating these specific interventions to all relevant staff which was started on 07/15/2023 and was completed for all current staff which included taking a post-test and scoring 100%, on the current working schedule by 07/21/2023. Staff not on the current schedule will receive education and be required to take a post-test and score 100%, before being permitted to work starting on 7/21/2023. 18. Corrective action included covering the exit door keypads to the main entrance and exit doors for the facility that would prevent residents or visitors from visualizing the key pad when code was being entered. 19. Further corrective action included starting on 07/15/2023, all doors were to be continued to be checked for proper function daily to ensure the delayed egress was functioning properly and the alarms were audible to alert staff, by members of the IDT team. 20. Corrective action included an elopement drill that was completed on 07/16/2023 by the Plant Operations manager. Elopement drills were to be conducted twice a day on day and night/ shifts, for one (1) week and weekly for four (4) weeks by Administrator, DON, or Department Head Managers. Then were to be conducted quarterly, thereafter. 21. Corrective action included the DON, RM, Wound Nurse, MDS or Regional Nurse were to monitor all residents, as well as new admissions for evidence of new or worsening exit seeking and/or wandering behaviors daily for two (2) weeks, then decrease to Monday through Friday for three (3) months to determine if there were any new exit seeking behaviors and to ensure appropriate interventions have been implemented to ensure the safety of the residents. 22. Corrective action also included beginning on 07/16/2023, the following was to be reviewed daily by a member or members of the IDT team: Events in Risk Management, Clinical Summary 24-hour report, review new and readmissions for elopement assessments and updated care plans and elopement book as needed, Nurses notes, new or worsening exit seeking and/or wandering behavior tracking, care plan interventions for any identified new or worsening exit seeking and/or wandering behavior and Medication Administration Record (MAR) monitoring. 23. Corrective action included beginning on 07/16/2023, an elopement test that included questions regarding our policies on elopement, Dementia, QAPI, abuse reporting, change of condition, care plans, accidents and incidents, and safety and supervision. The testing was to be completed by employees and the employee must make a 100%, if not they must be re-educated and re-tested until 100% obtained. Staff not working on 07/17/2023 were to be educated upon return to work and a post test administered. 24. Corrective action included a nurse from the regional team or corporate office and/or the [NAME] President (VP) of Operations being available on site or by phone starting 07/15/2023. A member of the regional team was providing regional oversight from 7/15/2023 until immediacy was lifted either in person or by phone to ensure continued compliance with audits established by QAPI Committee. 25. Corrective action included a QAPI meeting conducted on 07/16/2023 to discuss the pending deficiencies with F656 in regards to care planning. QAPI was to continue to be ongoing weekly for four (4) weeks and the DON was to report the findings of all audits to QA. An immediate action plan was implemented and discussed to ensure compliance and any changes needed to the facilities plan were completed. The State Survey Agency validated the facility had taken the alleged actions: 1. In interview on 08/24/2023 at 10:52 AM, SRNA #17 stated on 07/15/2023 around 6:30 PM or so, she found Resident #7 sitting outside of the facility at the end of the sidewalk beside the fence after she clocked out of work for her shift. She stated she along with the nightshift nursing supervisor and another SRNA, brought Resident #7 back inside the facility and returned him/her to his/her unit. In an interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she worked the evening shift on the night of Resident #7's elopement incident 07/15/2023. She stated she provided 1:1 supervision for Resident #7 after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. 2. Record review of Resident #7's progress note dated 07/15/2023, revealed Resident #7 had a head to toe skin assessment performed by LPN #5 and his/her Wander Guard bracelet was removed and replaced with a new one. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated once Resident #7 was brought back to the 300 unit, she performed a head to toe skin assessment of him/her. She further stated she also checked Resident #7's Wander Guard bracelet and replaced it with a new one. 3. Review of Resident #7's care plan revealed the resident had been care planned for 1:1 supervision on 07/15/2023. In interview on 08/24/2023 at 1:55 PM, SRNA #16 stated she provided 1:1 supervision for Resident #7 on 07/15/2023, after the elopement incident until the end of her shift on 07/16/2023 at 6:30 AM. Observation of Resident #7 from 08/22/2023 through 09/07/2023, revealed Resident #7 currently remained on 1:1 supervision. 4. Review of Resident #7's progress noted dated 07/15/2023, revealed Resident #7's MD and RP were notified of the elopement event on 07/15/2023 at 6:45 PM. In an interview on 08/24/2023 at 9:05 AM, LPN #5 stated she contacted Resident #7's MD and RP to notify them of the elopement event on 07/15/2023. 5. Record review revealed a SLUMS Assessment had been completed for Resident #7 on 07/16/2023, by the Director of Rehab/Speech Therapy. Continued review revealed Resident #7 was assessed to have SLUMS Assessment score of twenty (20) out of thirty (30) on the SLUMS scale, which indicated he/she had Dementia (a SLUMS score of one [1] to twenty [20] indicated Dementia). In interview on 09/07/2023 at 12:12 PM, the Director of Rehab/Speech Therapy revealed she completed the SLUMS Assessment of Resident #7 on 07/16/2023. 6. Review of Resident #7 progress note dated 07/15/2023 revealed an elopement risk assessment was completed of the resident by LPN #5. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she performed a new elopement risk assessment on Resident #7 immediately after the elopement event on 07/15/2023. 7. In a telephone interview with the Weekend Nightshift Nursing Supervisor on 09/07/2023 at 3:28 PM, she stated, she along with each unit charge nurse, performed a head count of all residents in the facility, and each resident was accounted for. Review of the facility's Elopement Binder revealed all residents that resided in the faciltiy were accounted for by nursing staff on 07/15/2023. 8. In a telephone interview on 09/07/2023 at 3:28 PM, the Weekend Nightshift Nursing Supervisor stated she also performed the placement and function checks on the Wander Guard bracelets for all residents at risk for elopement on 07/15/2023. Observation on 08/25/2023 at 11:25 AM, revealed Unit Manager #1 demonstrated the testing and function of Resident #7's Wanderguard Bracelet, which was observed to be functioning properly. 9. In an interview on 08/22/2023 at 9:25 AM, the facility's Maintenance Director stated he changed the door keypad codes and placed covers over the keypads by 07/21/2023. Observation of the facility's exit doors on 09/01/2023 at 4:00 PM, revealed covers over all the egress doors keypads as alleged. 10. In continued interview on 08/22/2023 at 9:25 AM, the facility Maintenance Director stated he checked all the facility's doors and windows on 7/15/2023 to ensure all doors/windows were locked, secured, and the delayed egress was functioning properly. 11. In interview on 08/24/2023 at 9:05 AM, LPN #5 stated she assisted in performing the new elopement assessment risks on all residents along with the other unit charge nurses, MDS Nurse, and the Regional Nurse Consultant onsite after the elopement incident on 07/15/2023 through 07/16/2023. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated the completion of the new elopement assessment risks of all residents had been conducted and the results of the assessments were located in the Elopement Binders. Review of facility's F656 Care Plan Binder on 09/07/2023 at 1:30 PM revealed residents had been reassessed for elopement. 12. In an interview with the facility MDS Nurse on 08/29/2023 at 2:00 PM, she stated she reviewed and updated the care plans for all residents deemed at risk for elopement on 07/16/2023. 13. In an interview on 09/07/2023 at 9:49 AM, the Social Services (SS) Assistant stated she, along with the Social Services Director, updated the elopement binders and care plans on 07/16/2023. She stated they updated the list of residents at risk for elopement and placed the new updated copies in all areas. The SS Assistant further stated they reviewed the elopement binders monthly to ensure that they were up to date. On 08/30/2023 at 10:30 AM, the SSA Surveyor went to each unit in the facility and located the Orange Elopement Binder at each nurses' station behind the desk. 14. In a telephone interview with Regional Corporate Nurse Consultant #1 on 09/01/2023 at 9:03 AM, she stated she performed audits of all nurses notes, 24 hour reports and documentation, and checked for other potential residents that were at risk for exit seeking behavior from 07/15/2023 to 07/16/2023. 15. In a telephone interview on 09/01/2023 at 9:03 AM, Regional Corporate Nurse Consultant #1 stated she completed a thirty (30) day audit from 07/15/2023 to 07/16/2023, of the nurses notes for residents at risk for elopement to see if there were any exit seeking behaviors documented. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation present of the thirty (30) day audit no other exit seeking behaviors were documented. 16. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided education regarding care plans to the administrative staff on 07/15/2023 and administered post tests to them. She stated that all staff made 100% scores and if they had not the staff member was reducated and had to retake the posttest until 100% was achieved. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation of all staff education and their post tests. 17. In an interview on 08/31/2023 at 3:00 PM, Regional Corporate Nurse Consultant #2 stated she provided elopement education to facility staff along with Regional Corporate Nurse Consultant#1 beginning on 07/15/2023 and administered post tests to them. Review of the facility's Elopement Binders on 08/31/2023 at 3:20 PM revealed documentation noting all staffs' education and posttests. In interview on 08/31/2023 at 4:10 PM and 4:15 PM with RN #3; and at 4:30 PM with LPN #16 revealed they stated they received education on elopement. In interview on 09/06/2023 at 10:20 AM, Staff Developement Coordinator/Infection Preventionist stated he received the education and took the post tests. In interview on 09/01/2023 at 2:20 PM, Dietary Aide #1 stated she received the education and had taken a post test on elopement. 18. Observation of the facility front door and staff exit door on 08/22/2023 revealed the keypads were covered with a plastic privacy cover to obstruct viewing of the code being entered. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he installed the covers to the door keypads shortly after the elopement event on 07/15/2023. 19. In an interview with the Maintenance Director on 08/22/2023 at 9:25 AM, he stated the exit doors were checked daily for proper functioning and returned demonstration of how the doors function at that time. He stated he and the ED, DON and some nurses performed the checks. In interview on 09/01/2023 at 9:03 AM, Regional Nurse Consultant #1 and at Executive Director both stated they assisted with checking the exit doors starting on 07/15/2023, and the door checks were continuing to be performed. 20. In an interview on 08/22/2023 at 9:25 AM, the Maintenance Director stated he conducted the elopement drills for facility staff on 08/16/2023. The Maintenance Director stated the elopement drills were conducted twice a day, and occurred at least once on each shift for four (4) weeks after the event, then the drills were conducted weekly and PRN. In interview on 09/07/2023 at 8:43 AM, the DON stated she the elopement drills were being conducted as required. In an interview on 09/07/2023 at 10:18 AM, the ED stated the elopement drills had been conducted as required. Review of Elopement Binder on 09/06/2023 revealed elopement drills were being conducted on each shift starting 07/16/2023 for next four (4) weeks. Interview on 08/24/2023 at 10:52 AM, with SRNA #17; on 08/25/2023 at 8:55 AM with SRNA #15; and on 08/25/2023 at 8:50 AM with LPN #6 they all stated they participated in elopement drills and the education provided. 21 [TRUNCATED]

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure its pharmaceutical services, to include procedures which assured the accurate acquiring and receiving of all controlled drugs, implemented its policy to prevent diversion for one (1) of thirty-five (35) sampled residents (Resident #49). Resident #49 was found to have missing controlled substance medications which could not be accounted for, and the facility was unable to locate them. The findings include: Review of the facility's policy titled, Controlled Substances, dated 06/21/2017, revealed the facility was to maintain a record and signed scheduled medication count at each change of shift (the Shift Count) by the on-coming nurse or authorized individual with off-going nurse or authorized individual, using a Controlled Drug Count Verification Form or using a facility approved form. Continued policy review revealed any discrepancies in the Shift Count must be immediately reported to the Director of Nursing (DON) for further action. Review of the facility's Final Investigation Report, undated, revealed on 06/25/2023 it was identified Resident #49's controlled substance medication was not located in the medication cart. Per review, when the pharmacy was contacted it was discovered the medication had been sent to the facility. Review of the Report revealed Licensed Practical Nurse (LPN) #9, who was working as charge nurse on the date pharmacy confirmed delivery of the medication, was suspended on 06/25/2023. Continued review revealed LPN #11, who was also working on the date of pharmacy delivery, and who signed in the delivery for all the unit medications on 06/21/2023, was also suspended on 06/25/2023 pending the investigation. Further review of the Final Investigation Report, undated, revealed both employees were drug tested and their results were negative, and the facility initiated an investigation which included the conduction of a facility-wide audit to ensure all current narcotics were accounted for with no discrepancies identified. Review of LPN #9's written statement revealed it stated, On June twenty-first (21st), I was on both med carts passing medications. Continued review of the LPN's statement revealed during the medication (med) pass LPN #9 received narcotics along with narcotic sheets, and LPN #9 had signed one (1) sheet, she thought. Review of LPN #9's statement revealed, However, the majority of the narcotic sheets had not been filled out. Further review of the LPN's statement revealed she filled the sheets out and signed them even though she did not put the (medication) card in the box. At the end of the shift, the count was correct for both carts. Further review of the facility's Final Investigation Report revealed on 06/25/2023, in the Administrator's interview with LPN #11 she was asked about events on 06/21/2023 when medications were delivered from pharmacy. Continued review revealed LPN #11 stated she signed for the medications and she and LPN #9 placed the medications in the cart together. Per review, when the Administrator asked specifically about Resident #49's medications, LPN #11 stated she remembered seeing the resident's name on the medication cards and talking to the delivery person about medication cards that had thirty (30) count and fifteen (15) count cards. Review of the investigation revealed a written statement dated 06/25/2023, noted by LPN #7 which indicated a KMA reported to the LPN Resident #49 was out of a narcotic medication dose. Continued review of LPN #7's written statement revealed LPN #7 called the pharmacy to get the delivery status, and pharmacy told the LPN Resident #49's controlled substance medication had been sent out (to the facility) on 06/21/2023 and had been signed for by LPN #11. Review of LPN #7's written statement further revealed pharmacy stated it was forty-five (45) pills on two (2) cards, one (1) card of thirty (30) pills and one (1) card of fifteen (15) pills. During an interview on 08/31/2023 at 9:29 AM, the Pharmacy Delivery Service's Manager stated it was his company's expectation for the courier service delivery driver to wait until the facility's nurses had reconciled the medications to ensure they had received what they were supposed to receive. Review of the police report, CAD Detail Incident #2023-00054991 dated 06/25/2023, revealed the facility's Executive Director (ED) called to report a drug investigation and theft of narcotics. Continued review revealed the medication had been delivered by pharmacy and two (2) nurses had been suspended. Review of the police report, CAD Detail Incident #2023-00056954 dated 06/30/2023, revealed the facility's ED reported again to the police on 06/30/2023, she believed it was an issue on the pharmacy's part, as the nurse had never signed for the medication. Review of the Packing Slip dated 06/20/2023 revealed a quantity of fifteen (15) pills and thirty (30) pills of Resident #49's controlled substance medication was documented as packaged by the pharmacy for delivery. Continued review revealed a statement at the bottom of the Packing Slip which read, By signing below you acknowledge that the items above have been received; however, there was no documented evidence the Packing Slip had been signed. Review of an untitled document, dated 06/21/2023, revealed handwritten notes that read Packing Slip from pharmacy delivery person stated verified with LPN #11 on 06/21/2023. Further review of the untitled document revealed no documented evidence it had been signed by anyone and did not list the name or quantity of narcotic medications received. Review of the facility's, Controlled Medication Shift Change Log Unit/Med Cart 300 Cart Two (2) revealed no documented evidence a nurse had recorded any controlled medications as being received by the facility on 06/21/2023. During an interview on 08/22/2023 at 9:55 AM, Resident #49 stated he/she received his/her medications on time and never had any medications missing. Resident #49 stated he/she took Gabapentin (an anticonvulsant and nerve pain medication) every day, he/she knew what medications he/she took and had taken the same medications at home. During an interview on 08/29/2023 at 4:10 PM, Kentucky Medication Aide (KMA) #3 stated he did not recall seeing the missing medications during the period from 06/21/2023 through 06/23/2023. Further interview revealed the normal controlled substances medication shift count came up correct on 06/23/2023, the day he worked. Review of the Controlled Medication Shift Change Log, Unit/Med Cart 300 Cart 2 form dated 06/19/2023, revealed on 06/21/2023 between 7:00 AM and 7:00 PM, two (2) controlled substance count sheets were added, which had been signed by LPN #7 and LPN #9. Continued review of the form revealed it stated, Note additions and deletions on the reverse side. However, the reverse side of the form revealed no documented evidence medications were recorded as received on 06/21/2023, by either the off-going nurse, LPN #7, or the on-coming nurse, LPN #9. During an interview on 08/30/2023 at 2:25 PM, LPN #7 stated she never saw Resident #49's missing medication and called pharmacy when she noticed that Resident #49 was going to run out of the medication the evening of 06/25/2023. During an interview on 08/29/2023 at 4:10 PM, Kentucky Medication Aide (KMA) #5 stated he worked two (2) days after Resident #49's medication was discovered missing. Further interview revealed the shift count on that day (06/23/2023) was normal and the count came up correct. He further stated he did not recall ever seeing Resident #49's missing medication during his shift. During an interview on 08/30/2023 at 3:15 PM, LPN #17 stated she worked on 06/24/2023, on the unit where Resident #49's medication had been missing. She stated the residents she cared for on 06/24/2023, had not been missing any medication that day. LPN #17 further stated she did not know anything regarding the whereabouts of Resident #49's missing medication. During an interview on 08/30/2023 at 2:18 PM, LPN #9 stated she was not there on 06/21/2023 when pharmacy delivered Resident #49's medication, as she was on the cart passing medications. She stated she believed the pharmacy had not sent the package of medications that had been discovered missing. During an interview on 08/26/2023 at 5:07 PM, LPN #11 stated on 06/21/2023 she worked at the facility as the Unit Manager (UM) and she did not remember what pharmacy had delivered that day. She stated she received controlled substance medications from pharmacy and placed the meds in her UM's office, and closed and locked the door to go to morning meeting. LPN #11 stated she had not logged in the medications she had received onto the Controlled Medication Shift Change Log. She further stated after morning meeting she came back to the unit, put the controlled medications on the cart in the lockbox, and let LPN #9 know the medications were in the cart. During an interview on 08/30/2023 at 10:41 AM, the Director of Pharmacy Services stated the pharmacy used a courier service to deliver controlled substances to the facility. The Director of Pharmacy Services stated the courier service drivers had a clear understanding of the Pharmacy's controlled substance delivery process. The Director of Pharmacy Services stated the courier services driver knew the pharmacy's substance delivery process included the pharmacy's expectation for the courier drivers to wait until the nurses receiving the medications reconciled the medications to ensure they had received what they were supposed to receive. During an interview on 08/30/2023 at 2:18 PM, LPN #9 stated when controlled substances were delivered by pharmacy, nurses who received the medications must be counted with the pharmacy delivery person to make sure what was on the medication packing slip were the actual medications received. LPN #9 stated she signed the Controlled Medication Shift Change Log as an on-coming or off-going nurse that meant the count of all the controlled substances was correct. LPN #9 further stated she did not receive medications from the pharmacy on 06/21/2023. During an interview on 08/29/2023 at 3:30 PM, Regional Nurse Consultant #2 stated Resident #49's one (1) medication was the only thing missing from the 06/21/2023 pharmacy delivery, and that was why the facility reported it. During an interview on 08/29/2023 at 3:40 PM, the ED stated she did not know what happened to Resident #49's missing medication; however, thought pharmacy had not really ever delivered the medication to the facility. The facility implemented the following actions prior to the State Survey Agency (SSA) investigation: 1. A count of all active prescribed narcotic medication for all residents on all units was completed on 06/25/2023 by the DON. No additional missing medications (meds) were identified from cart. The ED ensured notifications were made to the Police, Ombudsman, Adult Protective Services (APS), State, Responsible Party, Physician, Medical Director, and Regional Nurse. 2. Audit of all residents' active orders for narcotics for the past thirty (30) days to ensure all controlled drug records present by regional nurse was started on 06/26/2023 and completed by 06/29/2023. Resident pain levels were completed on unit by licensed nurses for residents on unit. Pain interviews were completed by licensed nurses on all residents by 06/30/2023. For any residents whose pain was not controlled either by interview or assessment, nurse was to complete notification to the physician (MD) and responsible party (POA). 3. The Regional Nurse in-serviced the DON on the Narcotic policy and procedure including the proper storage of medications, proper signing of narcotics on receipt, staff to notify the DON of inaccurate counts during shift change, and for the DON or nurse manager to do a weekly audit of narcotics received at the facility. The DON in-serviced the ADON and Unit Managers (UMs) on the narcotic policy and procedure. The DON/ADON/UM in-serviced current licensed nurses and medication aides on the Narcotic policy and procedure including proper signing of narcotics on receipt on the narcotic record and on the shift count log, and notification to the DON for any inaccurate counts during shift change. 4. Quality Improvement (QI) review was completed weekly by the DON/ADON/UM to ensure the narcotic packing slip with drug(s) received had been signed by two (2) nurses, the medication written on the count sheet, medication added to the count of cards/sheets, and Controlled drug record was in the narcotic book. Any issues identified were to be addressed immediately. The DON brought the results to the Quality Assessment and Performance Improvement (QAPI) meeting monthly. The State Survey Agency (SSA) verified the facility implemented the corrective actions alleged:. 1. During an interview on 08/29/2023 at 3:30 PM, Regional Nurse Consultant #2 stated on 06/26/2023, she went to all the medication carts and copied all the controlled substances sheets. She stated she pulled the pharmacy report of the past thirty (30) days of controlled substances dispensed and validated the current supply of controlled substances was all delivered, and nothing had been misappropriated. Regional Nurse Consultant #2 stated she also performed a visible inventory of every controlled substance. She stated she believed Resident #49's controlled substance medication never showed up at the facility from pharmacy. The Regional Nurse Consultant further stated, we had a process problem, and we did education. During an interview on 08/29/2023 at 3:40 PM the Administrator stated she informed the Medical Director on 06/25/2023, of the education and ongoing audits the facility was doing as a result of Resident #49's medication that pharmacy stated was delivered on 06/21/2023 but the facility could not locate. 2. During an interview on 08/29/2023 at 3:30 PM the Regional Nurse Consultant #2 stated on 06/26/2023 she went to all the medication carts, copied all the controlled substances sheets, pulled the pharmacy report of the past thirty days' controlled substances dispensed. She stated she then validated the current supply of controlled substances were all delivered, and nothing had been misappropriated. The Regional Nurse Consultant stated she performed a visible inventory of every controlled substance. 3. During an interview on 08/31/2023 at 3:55 PM, UM #2 stated she received education and then provided education to her staff about opening and counting narcotics delivered from pharmacy. She stated two (2) nurses must sign off verifying what was delivered had been received. Observation on 08/31/2023 at 4:00 PM, revealed the facility document .Care and Rehab Education Recap was taped to the medication cart of the unit where the medications had been discovered missing. Review of the Narcotic Medication section of the document revealed it stated two (2) nurses, or one (1) nurse and one (1) Kentucky Medication Aide (KMA) was to receive, count, sign and store the narcotics behind two (2) locks in the medication cart. Continued review revealed the two (2) nurses were to sign the delivery manifest sheet, the Controlled Drug Record, add the card/sheet to the narcotic shift count and to the log on the back of the shift count record. In addition, review revealed the nurses were to notify the DON immediately for any discrepancy, and the nurses/KMA may not leave until reconciled. Review of the document titled, Nurses and KMA's Narcotic Process Test revealed question number two (2) asked When pharmacy delivered the (narcotic) medication, two (2) nurses, or one (1) nurse and KMA should sign the delivery sheet/manifest, sign the controlled Drug Sheet for the resident, and complete and sign the Narcotic Shift Log. True or False. The test key indicated True was the correct answer. Review of the facility document titled, Nurses and KMA's Narcotic Policy and Procedure as follows, undated, revealed it stated when pharmacy delivered narcotic medications, two (2) nurses, second (2nd) person might be a med aide, were to verify medications were received and place the signed (not initialed) manifest (packing slip) in the UM box. Continued review revealed the nurses then placed the medication on the correct med cart. Further review revealed both nurses were to add the medication to the controlled drug log/book and sign (not initial) the log and controlled drug record. During an interview on 08/30/2023 at 2:18 PM, LPN #9 stated when controlled substances were delivered by Pharmacy, nurses who received the medications must count the med with the Pharmacy delivery person to make sure what was on the medication packing slip was the medications received. LPN #9 stated she signed the Controlled Medication Shift Change Log as an on-coming or off-going nurse which meant the count of all the controlled substances was correct. During an interview on 08/29/2023 at 3:40 PM, the Administrator stated the Nurses and KMA's Narcotic Policy and Procedure, undated, was implemented after Resident #49's medications were discovered missing. During an interview on 08/30/2023 at 11:59 AM, LPN #7 stated she received education on the new narcotics process that when medication came in from the pharmacy the medication packages were opened up and were checked against the white paper packing slip and two (2) nurses were to sign. She stated the two (2) nurses signatures indicated the narcotics on the packing slip were what the pharmacy delivered. LPN #7 stated the pharmacy delivery person was not to leave until the nurses verified receipt of any narcotic medications. During an interview on 08/31/2023 at 4:20 PM, LPN #6 stated when pharmacy delivered medications earlier that day, she and UM #2 went through the bag and compared the packing slip with what the facility had received. She stated once she and another nurse ensured the facility had received all medications on the packing slip, she signed pharmacy's electronic receipt on the pharmacy delivery person's phone. LPN #6 further stated if a discrepancy between pharmacy's packing slip and the medications received was discovered, she would notify the DON immediately. 4. During interview on 08/31/2023 at 3:55 PM, UM #2 stated the narcotic medication process and education was discussed in the facility's QAPI meetings. UM #2 stated, We talk about it all the time. During an interview 08/29/2023 at 3:40 PM, the Administrator stated the Nurses and KMA's Narcotic Policy and Procedure as follows:, undated, had been implemented after Resident #49's medications were discovered missing. Review of the document titled, Nurses and KMA's Narcotic Policy and Procedure as follows:, undated, revealed it stated at shift change or any time keys were exchanged, the off going and oncoming nurse/medication aide were to count all drugs, cards and sheets, and verify the count matched what was on the controlled drug record/sign out sheet. Continued review revealed the nurse was also to validate the cards and sheets added number at the time of the count matched the cards/sheets logged were added during that shift. Review revealed if a medication was on the packing slip, but not received, the nurses was to make a notation on the manifest (packing slip) and notify pharmacy immediately. Per review, the nurses were to also notify the DON, and the DON/ADON/UM were to review the Narcotic book weekly. Further review revealed the DON/ADON/UM were to ensure the order matched the prescription on hand, the supply in cart was sufficient for the next week, and were to reorder narcotics as applicable. Review additionally revealed at that time the Narcotic shift change sheets and Controlled Drug Records were to be reviewed for any illegible entries, patterns of administration, wasted medications or any issues. During an interview on 08/30/2023 at 4:15 PM, the DON stated medication misappropriation was discussed in QAPI and the medication misappropriation audits were ongoing.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a person-centered Comprehensive Care Plan (CCP) which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for six (6) of forty-seven (47) sampled residents (Residents #1, #16, #17, #18, #19 and #88). 1. Review of Resident #1's CCP revealed the facility assessed Resident #1 as a fall risk, on 05/29/2018, with a history of impaired cognition and restless/anxious behaviors, balance problems of which resident required extensive assistance with bed mobility, transfers, and toileting. On 01/01/2020, the resident was ordered a low air loss (LAL) mattress (alternating pressure system) developed for the comfort of the resident and related to risk for pressure ulcers; however, the resident was not care planned for the air mattress. Resident #1's care plan provided no evidence of ordered guidelines to ensure appropriate settings that correlated with the resident's weights or documented evidence of a monitoring system in place to ensure proper functioning of the air mattress and safety of the resident. On 02/16/2022, Resident #1 had an unwitnessed fall with an injury, whose root cause was determined to be the air mattress, which caused the resident to roll out of the bed and onto the floor. Continued review of Resident #1's CCP revealed care plan interventions for staff to observe for any moods/behaviors that might contribute to falls when the resident was restless in the wheel chair, and to offer position changes, to include increased supervision of visual checks when the resident was up in his/her wheel chair; however, no specific guidelines were provided. On 02/29/2020, the facility initiated the intervention for staff to ensure resident to be up only one (1) to two (2) hours as tolerated in the reclining wheelchair, and to include increase visual checks when resident was up in chair. However, Resident #1 sustained a second fall with injury on 07/08/2022 from his/her wheelchair, while in the lounge area without supervision. It was reported Resident #1 was trying to get up and screaming that he/she just wanted to go back to bed. Resident #1's record review and staff interviews revealed the resident had been in the wheelchair for approximately four (4) hours with multiple requests and attempts to return to bed during that time; therefore, staff failed to implement the resident's care planned interventions while up in the wheelchair. 2. Review of Resident #16's medical record revealed the facility assessed the resident to be a risk for falls related to gait/balance problems since admission. Resident #16's Physical Therapy (PT) discharge recommendations, dated 04/27/2023, revealed the resident was to ambulate with no assistive device, stand by assist (SBA)/contact guard assist (CGA) while observing oxygen saturation. However, the resident's care plan dated 04/26/2023, revealed the resident was independent in the room with a walker, and interventions included the resident to wear proper non-skid footwear when up and practice oxygen tube safety. Resident #16 stated he/she was in the bathroom on 05/04/2023, without wearing nonskid footwear, stepped over oxygen tubing, lost his/her balance, and fell hitting his/her left shoulder. However, staff failed to implement proper nonskid footwear or address the PT's discharge recommendations to ensure the resident's safety. 3. Review of Resident #17's medical record revealed the facility assessed the resident to be a risk for falls due to weakness, impaired cognition, and decreased mobility. Review of Resident #17's care plan dated 03/29/2023, revealed the resident required a contour mattress to prevent falling out of bed. On 04/01/2023 interventions added included extensive assistance of two (2) staff members for bed mobility, transfers, and bathing, and the resident was non-ambulatory. Resident #17 experienced a fall on 04/17/2023 by rolling out of bed and did not have a contour mattress on the bed. This care plan intervention had not been implemented. 4. Review of Resident #18's medical record revealed the facility assessed the resident to be a high risk for falls due to gait and balance issues related to a Cardiovascular Accident (CVA) with right side hemiplegia. Review of Resident #18's fall investigations revealed the resident had a fall on 04/08/2023 and another fall on 04/17/2023, and both involved the resident falling out of bed. Interventions in the care plan for the first fall, such as ensure the urinal was at the bedside was not developed, and staff did not assist the resident to the bathroom as per the care plan. For the second fall, interventions were developed of fall mat to the side of the bed, and move the resident closer to the nurses' station. However, per observation and interviews, staff failed to implement fall safety interventions as Resident #18 was not moved closer to the nurses' station and did not have a mat placed to the side of his/her bed. 5. Review of Resident #19's care plan revealed the resident was dependent on a two (2) person physical assistance for bathing, bed mobility, toileting, and transfers. The resident was placed on a Low Air Loss (LAL) mattress since date of admission; however, no resident specific guidelines were provided to ensure safety of the mattress. Resident #19 rolled from the bed to the floor while Certified Nursing Assistant (CNA) #7 was performing personal care. CNA #7 stated she did not look at the Kardex (nurse aide care plan) to see the resident required a two (2) person assistance with personal care. 6. Review of Resident #88's care plan revealed CNA #4 failed to implement the care plan for residents at risk for behaviors, and the resident exhibited abusive behaviors to include verbal and physical aggression toward staff during personal care. Consequently, CNA #4 failed to implement behavioral interventions and cursed at the resident. The facility's failure to ensure residents' care plans were resident specific related to their physical needs, behaviors and required supervision as well as guidelines to address the settings and required staff for assisting residents on LAL mattresses with interventions implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K; 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K; 42 CFR S483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR 483.75 Quality Assurance and Performance Improvement (F867), at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. The facility was notified of the Immediate Jeopardy on 05/26/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, with the facility alleging removal of the Immediate Jeopardy on 06/01/2023. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 06/01/2023, prior to exit on 06/10/2023, which lowered the scope and severity (S/S) to an E 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 Comprehensive Care Plan, dated 01/13/2018, revealed staff members were to ensure the resident or his/her representative was included in all aspects of the person-centered care plan. Per the policy, the planning was to include the provision of services to enable the resident to live with dignity and support the resident's goals, choices, and preferences which included, but were not limited to, goals related to the resident's daily routines. The policy stated care plans must be prepared with input from the Interdisciplinary Team (IDT), which included, but was not limited to the Physician, a Registered Nurse (RN), and a Nurse Aide with responsibility for the resident. The policy also stated staff should include input from the resident and his/her representative to the extent practicable. Per the policy, the care plan would describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. 1. Review of Resident #1's closed medical record revealed the facility admitted the resident, on 05/11/2018, with diagnoses that included Unspecified Dementia without Behavioral Disturbance, Need for Assistance with Personal Care, Age-Related Osteoporosis without Current Pathological Fracture, and Specified Disorders of Bone Density. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 01/11/2022, revealed the resident had no history of falls since admission and was not interviewable, with a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), which indicated severe cognitive impairment. The assessment also indicated Resident #1 was at risk for pressure ulcer/injury, but had no unhealed pressure ulcers; however, the resident was currently treated with a pressure reducing device for chair and bed. The assessment also indicated the resident required extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. Review of Resident #1's CCP, initiated 05/29/2018, revealed staff identified that the resident was at risk for falls related to the fall risk score, balance problems, weakness, restless/anxious behaviors at times, required assistance with transfers and bed mobility, and possible side effects of medication. Interventions implemented since admission included staff to ensure one-half (1/2) side rails while in bed for turning and repositioning, bed in lowest position, mechanical lift for transfers, call light in reach, and promote use of appropriate footwear when up. Additional interventions were added on 06/13/2018, to include increased supervision of visual checks when resident was up in his/her chair; however, no resident guidelines were provided. Additionally, interventions added on 02/29/2020, indicated staff was to ensure resident to be only up one (1) to two (2) hours as tolerated in the reclining wheelchair, and to increase visual checks when resident was up in the chair; however, no resident guidelines were provided to explain the type of supervision, such as one-to-one (1:1) and the time frame of visual checks. Review of Resident #1's Physician's orders for January 2020, revealed an order for an air mattress (alternating pressure system developed for the comfort of the resident) every day and night shift. However, the resident was not care planned for the air mattress, as no ordered setting guidelines were provided based on the resident's weight or documented evidence of a monitoring system in place to ensure the safety and functioning of the air mattress and to ensure proper settings to correlate with the resident's weight. Review of Resident #1's Incident Audit Report, dated 02/16/2022 at 9:35 PM, revealed the resident was found on the floor next to his/her bed, and the resident stated he/she did not know what happened or how he/she ended up on the floor. Resident #1 was sent to the Emergency Department (ED), and the Computed Tomography (CT) scan showed an acute fracture of the anterior/posterior C2 (cervical) vertebrae. The Interdisciplinary Team (IDT) concluded the root cause of the fall was from the air mattress (the resident rolled out of the bed). Therefore, a new intervention was to discontinue the air mattress and apply a contour mattress (edges on the mattress were built higher than the center to keep the resident from rolling out/off the bed). Review of Resident #1's Incident Audit Report, dated 07/08/2022 at 2:30 PM, revealed the resident was found lying in the floor next to his/her wheelchair in the lounge on the 200 Unit. The resident was trying to get up and screaming that he/she just wanted to go back to bed. The IDT concluded the root cause of the fall was the resident desired a position change. The resident was sent to the hospital. Resident #1's hospital record, dated 07/08/2022 revealed x-ray imaging showed Resident #1 had an acute nondisplaced fracture of the proximal tibial metaphysis; bilateral tibial fracture, and right distal fibula avulsion fractures, with no surgical intervention recommended. Review of Resident #1's care plan updated 07/13/2022, after Resident #1's second fall on 07/08/2022, revealed interventions to include when resident was restless in the bed or chair, offer position change, and every fifteen (15) minute supervision checks. However, the interventions that were in place before the fall to ensure resident to be only up one (1) to two (2) hours as tolerated in the reclining wheelchair, and to increase visual checks when resident was up in the chair were not implemented. During an interview on 05/18/2023 at 2:25 PM with Licensed Practical Nurse (LPN) #9, she stated air mattresses would increase residents' risk for falls, and she would expect staff to increase supervision with residents on air mattresses, ensure the bed was in the lowest position, and bed rails were in place, if ordered. She stated interventions should be implemented to prevent falls and care planned appropriately. She stated, if this was not done, residents could fall again with an adverse outcome, as Resident #1 did, with his/her second fall. LPN #9 stated there should have been one-to-one (1:1) supervision, and the resident should only have been up in the chair for two (2) hours, as care planned. During an interview on 05/19/2023 at 12:15 PM with CNA #34, he stated he did not receive any type of training or education from the facility. However, he stated he knew if a resident was up and requested to go back to bed, it was the resident's right to be placed back to bed. He said this was especially true if the resident was attempting to get up on his/her own and was care planned with guidelines when up in a wheelchair. Further, he stated most of the time when residents were in the dayroom/lounge, there was no supervision, no one-to-one (1:1) monitoring, or staff to sit with the residents. He added related to air mattresses, he believed they put the residents at risk for falls, due to their body alignment, and it could push the resident out of the bed. Therefore, he stated training and education should be done to ensure resident safety. During an interview on 05/22/2023 at 4:45 PM with LPN #4, she stated she had worked at the facility since June 2021, and since that time, no staff members had stayed in the dayroom/lounge/dining room on the 200 Unit to supervise residents. She added, if a resident was eating, the resident might have a staff to monitor; however, there was no schedule for monitoring. She stated, staff will take turns and work together to ensure resident safety. Further, LPN #4 stated there was no documentation log and/or charting system to ensure residents' siderails were in place, the bed in the lowest position, and air mattress settings were accurate. She stated it was the nurse's responsibility to ensure resident safety and ensure care plans were being implemented accurately, and if not, it could put residents at risk of having a negative outcome, such as falls with or without injuries. During an interview on 05/24/2023 at 4:45 PM with RN #7, she stated she was aware Resident #1 had fallen prior to the current fall, and the resident had requested to go back to bed approximately thirty (30) minutes prior to this fall. She stated, however, she was not familiar with Resident #1's care plan, interventions, or that the resident was a fall risk. Therefore, RN #7 stated this put the resident at danger for an injury. In addition, RN #7 stated the facility did not provide the education needed for residents at risk, the investigation process, or updating the care plan. She added, the facility did not do a thorough investigation, which was the resident's right. She stated if staff was not familiar with the resident, not getting educated on the care plan put the resident at risk. During an interview on 05/18/2023 at 3:53 PM with the Assistant Director of Nursing (ADON), she stated air mattresses increased a resident's risk for falls, and she expected staff to increase supervision with residents that had an air mattress. The ADON stated she did not recall Resident #1's second fall; however, she would expect staff to implement the care plan interventions, because she said, They are a safeguard for the residents, and I would have expected my staff to assist the resident back to bed, it is the residents right. In addition, the ADON stated she did not recall any education that was provided to staff or any discussion related to the resident's second fall, as she stated, I might not have been there, not involved. During an interview on 05/24/2023 at 9:30 AM with the Director of Nursing (DON), she stated she had not been monitoring the air mattresses, and she did not check the care plans to ensure the air mattresses were care planned with the setting accuracy. Therefore, the DON stated, if the setting was not correct and monitored, the mattress would be of no benefit to the resident, putting him/her at risk. In addition, the DON stated supervision meant direct visualization of the resident, into the room to see the resident to ensure resident safety. She added, in the 200 Unit dayroom/lounge, it was right outside of the nurses' station; however, staff could not see the resident unless inside the room. Further, the DON stated she expected staff to supervise and listen to the residents and their requests, to always ensure resident safety, and to have a staff member in the dining room/lounge, not just at mealtimes. She stated at other times, residents should expect staff to monitor them due to potential choking, falls, and/or other incidents. During an interview on 05/24/2023 at 10:22 AM with Advanced Practice Registered Nurse (APRN) #1, related to Resident #1's second fall, the APRN stated she would expect the resident to be monitored in the dining room related to his/her history in order to prevent another injury. She stated, per the resident request's and the intervention to be up in the wheelchair as tolerated, obviously, the resident was not tolerating being up and should have been put back to bed. She stated this resulted in a negative outcome that could have been prevented. 2. Review of Resident #16's medical record revealed the facility admitted the resident, on 06/29/2022, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia/Hypercapnia, and Dependent on Oxygen (O2). Review of Resident #16's Quarterly MDS Assessment, dated 03/14/2023, revealed the resident had no history of falls since admission was assessed to have a BIMS score of fifteen (15) of fifteen (15), which indicated the resident had intact cognitive response. The assessment also indicated Resident #16 was assessed for oxygen therapy; was independent with bed mobility, personal hygiene, transfers, and toileting; was independent with set up assistance with dressing and eating; and was independent with walker in room for ambulation. Review of Resident #16's CCP, initiated on 06/30/2022, revealed staff identified that the resident had an activities of daily living (ADL) self-care performance deficit related to weakness, impaired mobility, impaired gait/balance, pain, and shortness of air (SOA). Interventions indicated the resident was independent with a walker in the room for ambulation, to give assistance upon request for locomotion, and was independent with bed mobility, personal hygiene, transfers, and toileting. Additional interventions were added on 07/01/2022 for staff to assist with ADLs per resident's request and when there was increased SOA. Additionally, on 07/01/2022, the resident was care planned as at risk for falls related to gait/balance problems and medication regimen. Interventions indicated staff was to be sure the resident's call light was within reach, encourage the resident to always wear nonskid footwear, and Physical Therapy (PT) to evaluate and treat as ordered or as needed (PRN). Review of Resident #16's Incident Audit Report, dated 05/04/2023 at 8:07 PM, revealed the resident was found sitting in the bathroom floor with his/her back against wall, and the resident was not wearing nonskid socks. The resident stated he/she tripped over the oxygen tubing and hit his/her head on the wall. Per Resident #16's hospital medical record diagnostic imaging of the left shoulder, dated 05/05/2023, the resident had a chronic left clavicle fracture with displacement. Review of Resident #16's care plan, updated on 05/04/2023, after the resident's fall on 05/04/2023, revealed interventions for staff to ensure the resident was educated on wearing proper nonskid footwear and oxygen tubing safety. An additional intervention, on 05/30/2023, revealed the resident was ordered retractable oxygen (O2) tubing. Review of Resident #16's Physical Therapy discharge summary recommendations, dated 04/27/2023, revealed the resident's maximum potential had been achieved as he/she was able to tolerate prolonged ambulatory distance with no assistive device (AD). The discharge summary stated the resident continued to require stand by assist (SBA)/contact guard assist (CGA) while observing oxygen saturation. However, the resident's care plan, dated 04/26/2023, revealed the resident was independent in the room with the walker. During an interview on 05/24/2023 at 8:30 AM, Restorative Aide (RA) #1 stated there was an issue with the PT discharge plan not matching the resident's Kardex and care plan. 3. Review of Resident #17's medical record revealed the facility admitted the resident, on 03/13/2023, with diagnoses that included Alzheimer's Disease with Dementia, Atrial Fibrillation (on Plavix, an anticoagulant), and COPD. Resident #17 was assessed to be a risk for falls due to weakness, impaired cognition, and decreased mobility. Review of Resident #17's Admission MDS Assessment, dated 03/17/2023, revealed the resident had no history of falls since admission. Further, the resident was assessed to have a BIMS score of ninety-nine (99), which indicated the resident could not complete the BIMS assessment tool. The assessment also indicated Resident #17 triggered for mood and behavioral symptoms. The assessment also indicated the resident required extensive assistance of two (2) staff members for bed mobility, bathing, transfers, and toileting, and the resident was non-ambulatory. Review of Resident #17's CCP, dated 03/13/2023, revealed the resident required extensive assistance with Activities of Daily Living (ADL); required assistance of two (2) staff for bed mobility, transfers, and bathing; and the resident was non-ambulatory. In addition, staff identified that the resident was at risk for falls related to new environment, balance problems related to weakness, use of psychotropic medication, poor safety awareness, and behaviors. Interventions indicated staff was to ensure call light within reach when in room, hands on assist with transfers, and observe for any fall related side effects from psychotropic medications, such as increased drowsiness or dizziness and staggering gait. Continued review revealed Resident #17 was care planned for altered psychosocial needs related to dementia with interventions for staff to monitor behavior every shift and document if noted; provide non-pharmacological interventions such as one-to-one (1:1) supervision (specify); however, no one-to-one (1:1) resident guidelines were provided to ensure the resident's safety. According to Resident #17's plan of care, dated 03/29/2023, an intervention was added for a contour pressure reducing mattress; however, the resident had not been care planned for another type of mattress prior to this intervention. Review of Resident #17's Incident Audit Report, dated 04/17/2023 at 12:49 AM, revealed the resident was lying in the floor, on his/her back beside the bed. The report stated the resident had rolled out of bed, hitting his/her face on the floor, with lacerations and hematoma to the forehead and bridge of the nose. Review of Resident #17's hospital medical record revealed a CT scan showed the resident had an acute minimally displaced nasal/septum fracture. Review of Resident #17's plan of care updated on 04/17/2023, after resident fall on 04/17/2023, revealed interventions for an additional contour pressure reducing mattress to define parameters of mattress; although, the resident had been care planned for a contour mattress dated on 03/29/2023. Additional interventions initiated on 04/17/2023 to include fall mat to the left side of the bed, and per family request, the right side of the bed was to be against the wall. The Executive Director (ED) stated, in an interview on 05/23/2023 at 11:10 AM, she did not know how the fall could have been prevented unless staff would have put the contour mattress on sooner (which was care planned on 03/29/2023 but not done). She stated the reason for the mattress change was to have a barrier to help prevent the resident from falling from the bed. She further stated, Resident #17 did fine when up in a wheelchair because he/she was not as fidgety. 4. Review of Resident #18's medical record revealed the facility admitted the resident, on 02/15/2023, with diagnoses that included Alzheimer's Disease with Dementia, Cardiovascular Accident (CVA) with Right Side Hemiplegia and Depression. Review of Resident #18's Quarterly MDS Assessment, dated 04/03/2023, revealed the resident was assessed with a BIMS score of twelve (12) of fifteen (15), which indicated moderate cognitive impairment. The assessment also indicated Resident #18 had a history of falls since admission with injury. According to the MDS assessment, Resident #18 required the extensive assistance of two (2) persons, and physical assistance for transfers, bed mobility, bathing, and toileting. However, the assessment for how the resident walked between locations in his/her room indicated activity did not occur. Additionally, the assessment indicated the resident was incontinent of bowel and bladder, with no toileting program currently being used to manage the resident's bowel/bladder incontinence. Review of Resident #18's CCP, initiated on 03/07/2023, revealed staff identified that the resident was at risk for falls related to gait/balance problems, use of antidepressant medication, and the resident would raise and lower height of bed on his/her own. According to the plan of care related to the resident's risk for falls, interventions indicated staff was to ensure the resident's reacher was close to him/her to grasp items; the resident wore appropriate footwear; and staff was to observe for fall related side effects from antidepressants, such as increased drowsiness, dizziness, or a staggering gait. Continued review of Resident #18's plan of care revealed the resident had functional bladder incontinence related to dementia and impaired mobility with interventions as indicated for staff to encourage and assist the resident with transferring to the bathroom commode during rounds and would need to stay with the resident and check every two (2) to three (3) hours and as required for incontinence. Further review revealed an additional intervention added on 03/22/2023, for standard mattress changed to forty-two (42) inch wide mattress. Review of Resident #18's Incident Audit Report, dated 04/08/2023, revealed between 4:00 PM to 5:00 PM the resident was found on floor at the foot of both beds in his/her room; the fall was unwitnessed; and no injury resulted from the fall. Per the report, the resident was attempting to transfer self to the bathroom when the fall occurred. The report stated Resident #18 was noted to have incontinence when assessed post-fall. Review of Resident #18's plan of care revealed an update on 04/10/2023, which indicated for staff to keep urinal within reach when the resident was in bed. However, in the resident's care plan, prior to the fall, staff had failed to develop this intervention to address the resident's functional bladder incontinence and had failed to assist the resident to the bathroom. Review of Resident #18's Incident Audit Report, dated 04/17/2023, revealed at 7:50 PM, Resident #18 sustained another fall within nine (9) days from the initial fall on 04/08/2023; however, this unwitnessed fall resulted in the resident having a nasal/septum fracture and fracture of the anterior maxillary process. Resident #18 was found on his/her stomach lying in the floor beside the bed. Resident #18 stated, I fell out of bed. Further review of the report revealed on 04/18/2023, the IDT reviewed and concluded the root cause was that the resident lies on his/her side in bed when resting. Since the resident was currently on a wider mattress, new interventions were to consider moving the resident to a room closer to the nurses' station and place a fall mat to the left side of the bed. Review of Resident #18's plan of care updated on 04/17/2023, after the resident's second fall with a major injury, revealed interventions to include to consider moving the resident to a room closer to the nurses' station, bilateral pivot assist bars to assist with bed mobility and transfers, and a fall mat to the left side of the bed when the resident was in the bed. However, observations revealed Resident #18 had not been moved to a room closer to the nurses' station and did not have a mat placed to the left side of the bed on 05/19/2023 or 05/22/2023. During an interview on 05/23/2023, with the Social Services Director (SSD), she stated Resident #18 did not have a mat on the morning of 05/23/2023, and she requested a fall mat be brought to the room. During an interview on 05/23/2023, with the Maintenance Supervisor, he stated Resident #18, for over a month, did have a fall mat in the room. However, he stated it was folded up and against the wall. 5. Review of Resident #19's record revealed the facility admitted the resident, on 09/10/2021, and the resident was assessed to be a high risk for falls due to muscle rigidity secondary to Parkinson's Disease with other diagnoses that included Unspecified Dementia and Aphasia. Review of Resident #19's Quarterly MDS Assessment, dated 03/14/2023, revealed the resident had no history of falls since admission and was not interviewable, with a BIMS score of ninety-nine (99), which indicated the resident was unable to complete the BIMS assessment instrument. The assessment also indicated Resident #19 required extensive assistance of two (2) staff members for bed mobility, transfers, dressing and toileting (incontinent of bowel and bladder), but was not on a toileting program. According to the assessment, Resident #19 was at risk for pressure ulcers (PU) and was assessed to need a pressure reducing bed/mattress. Review of Resident #19's CCP, initiated 09/22/2021, revealed staff identified that the resident was at risk for falls related to balance problems, due to weakness, impaired vision, incontinence, and impaired cognition. Interventions indicated staff was to ensure the resident was centered in the bed after providing care. Continued review revealed Resident #19 was care planned for altered psychosocial needs related to dementia with interventions for staff to monitor behavior every shift and document if noted, provide non-pharmacological interventions such as redirect with activity, offer fluid/food, offer reassurance/conversation, one-to-one (1:1) supervision (specify); however, no specific one-to-one (1:1) guidelines were provided for staff, and it was not specified. Ongoing revie [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices to prevent accidents or hazards. In addition, the facility failed to conduct a thorough fall investigation that led to a root cause determination; along with the development and implementation of an action plan after each fall for five (5) of forty-seven (47) sampled residents (Residents #1, #16, #17, #18 and #19). 1. On [DATE], Resident #1 was ordered an air mattress (alternating pressure system) for his/her comfort, without assessing the resident's needs and safety for the device. Review of the manufacture's recommendation for the air mattress revealed that to avoid the risk of death or injury from falling, staff were to read the user manual prior to its use. Continued review of the manufacture's recommendation revealed it was the requirement that the residents would be assessed and monitored for its use, for the resident's safety. Subsequently, on [DATE], the resident experienced a fall from his/her air mattress and sustained injuries which resulted in a Cervical (neck) Fracture. In addition, Resident #1 sustained a second fall on [DATE] from his/her wheelchair while in the lounge area. Resident #1, prior to his/her fall, told staff he/she wanted to go to bed. Interviews and record review revealed Resident #1 was in his/her wheelchair for approximately four (4) hours without staff acknowledging the resident's request. As a result, the resident attempted to stand from his/her wheelchair and fell on the floor. The resident sustained a Displaced Fracture of the Proximal Tibial Metaphysis Bilaterally. The resident returned to the facility on [DATE], with Hospice/Palliative care services and expired on [DATE]. 2. On [DATE], Resident #16 stated he/she was in the bathroom, stepped over his/her oxygen tubing, and lost his/her balance. The resident fell and hit his/her left shoulder on the wall of his/her bathroom. The resident sustained a Chronic left Clavicle Fracture with Displacement. The facility identified the root cause of the resident's fall was the lack of the non-skid footwear. However, the facility failed to implement changes to the resident's oxygen tubing, to reduce the resident's falls risk. 3. On [DATE], Resident #17 was found lying on the floor, on his/her back, beside his/her bed. Further review revealed Resident #17 hit his/her face on the floor. The resident sustained injuries to include a nasal bone and Septum Displaced Fracture. Review of the facility's falls incident report revealed the facility failed to complete a thorough investigation to support the determination of the root cause of restless. 4. On [DATE], Resident #18 sustained a fall out of his/her bed and the Hospital Record revealed, the facility had removed the resident's bed railings due to safety concerns. The facility's investigation revealed the resident fell out of bed. However, there was no other investigation completed to determine the root cause of the resident's fall to ensure appropriate interventions were in place to prevent the resident's falls. The resident sustained injuries which included a Nasal Septum Fracture and Fracture of the Anterior Maxillary process. 5. On [DATE], Certified Nursing Assistant (CNA) #7 performed incontinence care without another staff member. Resident #19 rolled from his/her bed to the floor during incontinence care. The root cause was determined to be the resident was on an air mattress; however, the facility failed to determine within the root cause analysis that the resident was assessed to have two (2) staff to assist with his/her bed mobility. The resident sustained injuries to include a nasal bone fracture with a 9 centimeter (cm) facial laceration . The facility's failure to have an effective system to ensure adequate supervision and monitoring to prevent falls/accidents has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K; 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K; 42 CFR S483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR S483.75 Quality Assurance and Performance Improvement, at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on [DATE], prior to exit on [DATE]. The findings include: Review of the facility's policy titled Fall Management, dated [DATE], revealed a fall was an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface, which included onto a bed, chair, or bedside mat. The policy stated injury related to a fall was any documented injury that occurred as a result of or was recognized within a short period of time (hours or to a few days) after the fall and attributed to the fall. According to the policy, a major injury included bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. Continued review of the policy also revealed a fall risk observation was completed on admission, quarterly, and annually, with any significant change in condition, and with any fall, and was utilized to identify individuals who were at high risk for falls. Further review of the policy revealed fall prevention was achieved through an interdisciplinary approach to managing risk factors and implementing appropriate interventions to reduce the risk of falls. Continued review of the policy revealed staff were to develop a plan of care, which included general and specific interventions to reduce fall risk. The policy further revealed staff were to investigate falls and complete a root cause analysis and determine an intervention based on information gathered from the investigation of the falls. The policy also stated the investigation and root cause analysis of a fall may include medications that place a resident at risk for falls, intrinsic/extrinsic fall risk factors, time of day, and devices used at the time of the fall. Review of the Low Air Loss Mattress owner's manual titled Invacare Micro Air MA65 Series, dated [DATE], revealed to avoid the risk of death or injury from falling: Invacare suggested staff read and used the User Manual prior to using the product. Further, rails were to be in the raised position whenever a {resident} patient was in the bed, proper {resident}patient assessment and monitoring was required to prevent injury, variations in bed rail dimensions, and mattress thickness, size, or density would increase the risk of injury. Further review revealed staff were to work with a therapist, physician, and other medical staff to perform assessments to complete {resident} patient monitoring, to avoid death, injury. 1. Review of Resident #1's Closed Medical Record revealed the facility admitted the resident on [DATE] with diagnoses that included: Unspecified Dementia without Behavioral Disturbance, Age Related Osteoporosis without current Pathological Fracture, and Fatigue. Continued review revealed the resident was placed under hospice/palliative care on [DATE] and expired at the facility on [DATE]. Review of Resident #1's Physician Orders for [DATE] revealed an air mattress (alternating pressure system) was ordered for the comfort of the resident; every day/night shift. Review of Resident #1's Admission Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had no history of falls since admission. Continued review revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severe cognitive impairment. Further review revealed the resident was at risk for pressure ulcer/injury and was assessed to have had no unhealed pressure ulcers. Review of Resident #1's Comprehensive Care Plan initiated on [DATE] revealed the resident was care planned for at risk for falls related to: his/her fall risk score, balance problems, weakness, restless/anxious behaviors, required assistance with transfers, bed mobility, and possible side effects of his/her medication. Interventions implemented since admission included staff were to ensure one-half (,d+[DATE]) side rails while in bed for turning and repositioning, bed in the lowest position, mechanical lift for transfers, call light in reach, and promote the use of appropriate footwear when up. Additional interventions were added on [DATE], to include increased supervision of visual checks when the resident was up in his/her chair. Additionally, interventions were added on [DATE], indicating staff were to ensure the resident was to only be up one (1) to two (2) hours as tolerated in a reclining wheelchair. The facility failed; however, to ensure the resident was assessed and monitored for his/her air mattress, to ensure the safety of the resident to prevent injury, as well as, failed to care plan for and manage for the risk factors and implementation of the intervention to reduce the risk of falls while utilizing the air mattress, as per the facility's policy. 1 a.) Review of the facility's Incident Audit Report dated [DATE] at 9:35 PM revealed the resident was found on the floor next to his/her bed, with his/her feet towards the head of the bed and his/her head next to the wall. The resident was noted to have had a knot on his/her left side of his/her scalp. The resident stated he/she did not know what happened or how he/she ended up on the floor. According to the incident report, there were no witnesses to the incident and the resident was assessed to have no injuries. Continued review of the incident report, revealed the resident's pain level was not assessed, and the predisposing environmental/situational factors were not documented. Further review of the facility's incident report revealed on [DATE], the facility's Interdisciplinary Team (IDT) met and concluded the root cause was that the resident was unable to provide a description of his/her fall related to impaired mental status due to his/her diagnosis of Dementia. Review of the Nurse's Progress Note, dated [DATE] at 10:00 PM, revealed the resident had a change in condition; a fall with a hematoma to the left side of his/her scalp. Review of the Nurse's Progress Note, dated [DATE] at 09:30 AM, revealed the resident complained of neck and left arm pain upon movement. Further review of the Note revealed an order was obtained to send Resident #1 to the emergency room (ER) for an evaluation. Review of Resident #1's Hospital Medical Record, dated [DATE], revealed the resident had an admitting diagnosis of an initial fall encounter, a Nondisplaced Fracture of the second Cervical Vertebrae (vertebrae of the neck, immediately below the skull) related to a fall. During a telephonic interview on [DATE] at 10:25 AM, with Certified Nursing Assistant (CNA) #33, she stated she no longer worked at the facility. CNA #33 stated she was familiar with Resident #1 and recalled working the day Resident #1 was found on his/her floor. According to the CNA, she was working the 6:00 PM -6:00 AM shift and as she was walking up the hallway, she observed Resident #1 on the floor of his/her room with other staff at the resident's side. CNA #33 could not recall the exact date and/or time; however, she recalled Resident #1 to be fidgety and squirming around a lot. Further, she stated the resident had body alignment issues and the resident received a new fall mattress after his/her fall. CNA #33 stated that it was the facility's practice to provide an air mattress to the residents that tried to move around a lot. She further stated that if the air mattress was not straight or properly inflated, it could easily, at any time, cause the resident to fall off the mattress. CNA #33 stated residents deserve to have proper interventions and implemented procedures to ensure their safety and to prevent falls. In an interview, on [DATE] at 2:25 PM, with Licensed Practical Nurse (LPN) #9, she stated on [DATE], she was completing her rounds at approximately 10:00 PM to 11:00 AM, when she found Resident #1 on the floor, next to the side of the bed between the wall and the bed. The LPN stated Resident #1 could not recall what happened. LPN #9 stated the physician was notified and she was instructed not to send the resident out, but to continue to monitor the resident. Further interview with the LPN revealed the resident began to complain of pain in the early morning and was sent to the emergency room (ER) for evaluation. LPN #9 stated there was no night shift supervisor at that time; however, the Executive Director (ED) started the investigation process when she came in the next morning. LPN #9 further stated, on [DATE] at 2:25 PM, Resident #1 favored his/her right side and was on an air mattress; however, LPN #9 could not recall the resident's fall risk precautions at the time of the fall, but stated that after the resident's fall, his/her air mattress was switched out to a contour mattress and the resident was on every fifteen (15) minute checks upon return from the hospital. LPN #9 revealed the air mattresses would increase the resident's risk for falls and she would have expected staff to increase supervision with residents on air mattresses. LPN #9 stated interventions should have been put in place and implemented to prevent falls. In an interview, on [DATE] at 1:05 PM, with the Maintenance Supervisor, he stated he was responsible for setting up the air loss mattresses and that he would apply the settings, as per the nurses' instructions. The Maintenance Supervisor stated he did not follow a written physician's order, nor did he utilize the manufacturer's recommendation related to the low Air Loss mattresses. Further, the Maintenance Supervisor revealed he was not part of the Interdisciplinary Team (IDT) meetings, until recently, to discuss the facility's equipment. He stated the air mattresses were a risk factor for residents, especially those residents with mental impairments. In an interview on [DATE] at 3:53 PM with the Assistant Director of Nursing (ADON), she stated during the time of Resident #1's fall on [DATE], she was the Director of Nursing (DON), and she was made aware of the incident on [DATE], at approximately 10:00 PM. The ADON stated she was informed the resident had fallen out of bed and hit his/her head. She stated Resident #1 denied pain but displayed some disorientation. She stated at that time there was no procedure in place; she did not have a working list of residents on air mattresses, or staff that were responsible to monitor the airflow of the mattresses, nor a night shift supervisor to assist with falls investigation. She stated the Interdisciplinary Team (IDT) met the next morning with the Executive Director (ED) and discussed any incidents and changes of condition overnight and IDT, as a team determined the root cause was the resident's air mattress chambers could get full of air and repositioning the resident, increasing the resident's risk for falling out of his/her bed, therefore, new interventions were updated to discontinue the resident's air mattress and apply the contour mattress. Additionally, the ADON stated the air mattresses increased the resident's risk for falls. 1 b.) Review of Resident #1's Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident was assessed for a history of falls, with major injury. Further review of the MDS revealed the resident continued to require extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. Review of Resident #1's Nurse's Progress Notes dated [DATE] at 1:10 PM revealed the resident was up in a chair after lunch per the resident's request. Further review of the Note revealed ten (10) to fifteen (15) minutes later, the resident was asking to go back to bed. The resident kept trying to scoot himself/herself out of the chair. Review of the facility's Incident Audit Report dated [DATE] at 2:30 PM revealed the resident was found lying on the floor next to his/her wheelchair. Continued review revealed the resident was trying to get up and screaming that he/she just wanted to go back to bed. The resident had been in the lounge on the 200 Unit, visiting with his/her sister after lunch. Further, the resident stated, I fell out of my chair, wanna go to bed. According to the incident report, there were no witnesses to the incident, the resident was assessed for injuries, his/her pain was addressed, and no documentation of the resident's environmental assessment was reported. A continued review of the report revealed the resident's physiological factors included confusion, impaired memory, and incontinence. Further review of the facility's incident report revealed on [DATE], the facility's Interdisciplinary Team (IDT) met and discussed the resident's fall with injury. The IDT concluded the root cause of the resident's fall was the resident's desire for a position change. A continued review of the Nurse's Progress Notes, dated [DATE] at 3:05 PM, revealed the nurse heard someone yelling for help from the dining room. The resident was found lying on his/her right side, with his/her wheelchair beside him/her. The resident was observed to have a skin tear with bleeding from his/her left lower extremity. Further review revealed the resident's legs were contracted or smaller than the other leg. Review of Resident #1's Hospital Admission Record, dated [DATE], revealed the resident was admitted with his/her status post fall from a wheelchair. Continued review revealed the resident was highly demented and x-ray imaging revealed a nondisplaced fracture of proximal tibial metaphysis; bilateral tibial fracture, and right distal fibula avulsion fractures. Further review of the hospital records revealed no surgical intervention was recommended. An additional review revealed the resident was positive for a Urinary Tract Infection (UTI). Review of Resident #1's Physician Orders, dated [DATE], revealed the resident was ordered to receive Hospice Services beginning [DATE]. Certified Nursing Assistant (CNA) #35, in a telephonic interview, on [DATE] at 8:15 PM, stated she worked for the facility in 2022. She stated she did not provide direct care to Resident #1; however, she recalled the resident yelling in the dining room, and he/she was found on the floor with a skin tear to his/her head. She stated another resident stated Resident #1 had requested to go back to bed for several hours, scooting himself/herself down in his/her wheelchair. CNA #35 added, if a resident was attempting to get up on their own and requesting to go back to bed, there would be a greater risk of a fall when the care plan was not followed. Interview on [DATE] at 5:00 PM with CNA #11, stated she worked the 200-unit and was familiar with Resident #1. She stated she believed he/she was the type of resident that tried to get up on his/her own and attempted to get out of bed and his/her wheelchair. CNA #11 recalled staff had gotten the resident up in a wheelchair sometime before lunch, that was all she could recall. Further, she stated if a resident requested to go back to bed, staff, should be proactive and respect the resident's request. She stated it was the resident's right and the staff's responsibility to promote and ensure resident safety to prevent injuries. During an interview on [DATE] at 8:53 PM with Nurse Aide (NA) #1, she stated she worked at the facility from [DATE] thru [DATE]. NA #1 stated she was familiar with Resident #1 and recalled the resident liked to get up and eat breakfast in the dining room with his/her sister, who was also a resident at the facility. She added, on the day of the incident, Resident #1 was up in his/her wheelchair for both breakfast and lunch and the resident was fine for a while as he/she napped in his/her wheelchair, then around lunch between 12:00 PM to 12:30 PM, a CNA told the resident she was going to change the resident and put him/her back to bed. NA #1 recalled pulling Resident #1 up in his/her chair numerous times, due to the resident wiggling in his/her wheelchair and recalled the resident asking to go back to bed about twenty (20) minutes prior to lunch. NA #1 stated the resident fell in the dining room later that afternoon. NA #1 stated all the staff was trying to monitor the residents in the dining room, with no specific designated staff to monitor. Additionally, NA #1 stated staff heard the resident hit the floor, he/she yelled as the wheelchair hit the dining room table. NA #1 stated Resident #1 was put at risk for a fall from the beginning when he/she had requested to go back to bed and demonstrated restless/anxious behavior. In an interview, on [DATE] at 4:45 PM, with Registered Nurse (RN) #7, she stated she was employed at the facility from [DATE] thru [DATE]. She stated she had only worked on the 200-unit a couple of days when Resident #1 had a fall. RN #7 stated Resident #1 was up in his/her wheelchair between 11:00 AM to 3:30 PM. RN #7 stated she was monitoring/watching the resident, in the dining room; however, the resident had requested to go to bed, but RN #7 was in/out of the resident's rooms, passing medications and informed the resident, just a second, let me get a CNA to put you back to bed. RN #7 stated, she looked around and found a student to locate a CNA to assist with putting the resident back to bed. She stated, I was afraid the resident would get up and fall, and instructed the resident to not get up because she knew the resident had a fall prior. RN #7 stated she was the only nurse on the floor as the other nurse had gone on lunch break. She stated she continued to pass out medications to other residents. 2. Review of Resident #16's Admissions Medical Record revealed the facility admitted the resident on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia/Hypercapnia, Anxiety, and Depression. Review of Resident #16's Quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed the resident had no history of falls since admission and was assessed to have a Brief Interview of Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact. The assessment also indicated Resident #16 was assessed for oxygen therapy. Continued review of the MDS assessment revealed the resident was independent with bed mobility, personal hygiene, transfers, and toileting. Continued review revealed the resident was assessed to require one (1) person assistance with bathing and one (1) person assistance with a walker out of his/her room for ambulation. Review of Resident #16's Comprehensive Care Plan initiated [DATE] revealed the resident was care planned for Activities of Daily Living (ADL), self-care performance deficit related to weakness, impaired mobility, impaired gait/balance pain, and shortness of air (SOA). Further review revealed interventions included: the resident was independent with his/her walker in his/her room for ambulation, assistance upon request for locomotion, independent with bed mobility, personal hygiene, transfers, and toileting. Additional interventions were added on [DATE] for staff to assist with ADLs per the resident's request and when increased SOA. A continued review of the resident's Comprehensive Care Plan revealed the resident was care planned to be at risk for falls related to gait/balance problems, and medication regimen. Further review revealed interventions included: staff was to ensure the resident's call light was within reach, encourage resident to always wear nonskid footwear and Physical Therapy (PT) was to evaluate and treat as ordered or as needed (PRN). Review of the facility's Incident Audit Report, dated [DATE] at 8:07 PM, revealed Resident #16's roommate yelled for help. Review of the report revealed the Kentucky Medication Aide (KMA) was walking down the hallway and went into the resident's room. Resident #16 was noted sitting on his/her buttock on the bathroom floor with his/her back against the wall. A continued review of the report revealed Registered Nurse (RN) #1 noted the resident had his/her socks on that was not his/her nonskid socks. The resident stated he/she tripped over his/her oxygen cord. Further review of the report revealed the resident hit his/her head on the wall. He/she further stated his/her oxygen cord pulled causing the resident to trip over it. Review of the immediate action taken revealed an order was received to send the resident to the emergency room (ER). Additional review of the incident report, dated [DATE] at 8:07 PM, revealed the resident refused to go to the ER. Further review of the Report revealed a new order to send the resident to the ER if the resident changed his/her mind and the resident was educated on the proper footwear, and safety with oxygen tubing. Continued review of Resident #16's incident report revealed improper footwear was noted as predisposing situational factors. On [DATE] IDT reviewed the resident incident form and concluded the root cause of the resident's fall was the Lack of non-skid footwear. Further, interventions revealed staff were educated on the nonskid footwear for the resident. The facility; however, failed to address the resident's concern with tripping over his/her oxygen tubing. Review of Resident #16's Hospital emergency room Record, dated [DATE] at 4:01 PM, revealed an emergency room (ER) Primary Impression/Diagnosis was a Displaced Fracture of shaft of the left clavicle related to an unspecified fall, initial encounter. Review of Resident #16's Diagnostic Imaging plain film of his/her left shoulder impression, dated [DATE], revealed a chronic left Clavicle Fracture with displacement. Review of Resident #16's Comprehensive Care Plan was updated on [DATE], after the resident's fall, to include interventions for staff to ensure the resident was educated on the resident wearing proper nonskid footwear. The facility identified the root cause of the resident's fall on [DATE] and ordered the resident a retractable oxygen (O2) tubing. 3. Review of Resident #17's Admission Medical Record revealed the facility admitted the facility on [DATE] with diagnoses that included Alzheimer's with Dementia, Asthma, Atrial Fibrillation, and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #17's Minimum Data Set Assessment (MDS), dated [DATE], revealed the resident had no history of falls since admission. Further, the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of 99, which indicated the resident's interview was unsuccessful. Continued review of the MDS revealed the resident was assessed to require an extensive assistance of two (2) staff members for bed mobility, bathing, transfers, and toileting. Review of Resident #17's Comprehensive Care Plan, dated [DATE], revealed the resident required extensive assistance with Activities of Daily Living (ADL's); required assistance of two (2) staff for bed mobility, transfers, and bathing. The resident was Care Plan for being non-ambulatory. Review of the resident's care plan related to falls revealed the resident was care planned to be a falls risk related to his/her new environment, balance problems related to weakness, use of psychotropic medication, poor safety awareness and behaviors. Interventions included staff were to ensure the resident's call light was within reach when in his/her room, hands-on assistance with transfers, and observe for falls related to his/her side effects from psychotropic medications such as increased drowsiness or dizziness, and staggering gait. Continued review revealed Resident #17 was care planned for altered psychosocial needs related to dementia with interventions for staff to monitor the resident's behavior every shift and document if noted, provide non-pharmacological interventions such as 1:1 supervision. Review of Resident #17's facility Incident Audit Report dated [DATE] at 12:49 AM revealed the resident was lying on the floor, on his/her back beside the bed. Further review, revealed the resident rolled out of the bed, hitting his/her face on the floor, with lacerations and a hematoma to his/her forehead. The resident complained of increased pain. Further review revealed the resident reported rolling out of bed face first, hitting his/her nose and forehead. The incident report revealed the resident remained oriented to person and situation. Continued review revealed confusion and impaired memory were noted as predisposing physiological factors with no evidence of other predisposing environmental, nor situational factors, and/or documented interviews to demonstrate a thorough investigation. A continued review of the incident report revealed the immediate action taken was to assist the resident to bed, apply pressure to the resident's wound, and the resident was sent to the emergency room (ER) for an evaluation. Review of Resident #17's Hospital Medical Record, dated on [DATE] at 12:37 AM, revealed the resident was triaged with a complaint of a fall with facial lacerations. A review of the resident's ED Disposition after Triage dictated by the emergency room (ER) Physician at 12:37 AM on [DATE] revealed the resident fell at approximately 12:10 AM and it was an unwitnessed fall with lacerations noted to his/her forehead and the bridge of the resident's nose was bleeding but was stopped prior to his/her arrival to the hospital. Review of the physician's documentation also revealed the resident had a vertical directed forehead laceration which measured 2.5 centimeters (cm) in length. The physician further documented that the forehead skin laceration was repaired with skin glue. Continued review of Resident #17's hospital record revealed a Preliminary Radiology Report for a CT scan revealed an acute minimally displaced nasal fracture and nasal septum. 4. Review of Resident #18's Admission Medical Record revealed the facility admitted the resident on [DATE] with diagnoses that included Atrial Fibrillation, Alzheimer's/Dementia, Cardiovascular Accident (CVA) with right side hemiplegia, Depression, Diabetes Mellitus Type II, and Chronic Renal Failure (CRF) without dialysis. Review of Resident #18's Quarterly Minimum Data Set Assessment (MDS) dated [DATE], revealed the resident was assessed with a Brief Interview for Mental Status (BIMS) score of twelve (12), which indicated the resident was moderately impaired. The assessment also indicated Resident #18, had a history of falls since admission with injury. Further review of the MDS assessment revealed the resident required extensive assistance of two (2) persons physical assistance for transfers, bed mobility, bathing, and toileting. Review of Resident #18's Comprehensive Care Plan, initiated [DATE], revealed staff identified that the resident was at risk for falls related to gait/balance problems, and use of antidepressant medication. Further review revealed the resident was able to raise and lower the height of his/her bed on his/her own. Further review revealed the resident was a falls risk with interventions to include: staff to ensure the resident to keep his/h [TRUNCATED]

Based on interview, record review, review of the facility's policy, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled its effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility was cited at the S/S of Immediate Jeopardy during the 06/10/2023 survey. Review of the 02/10/2020 Recertification Survey's Plan of Correction (POC), and the Abbreviated Survey's POC revealed the facility was previously cited at actual harm and Immediate Jeopardy (IJ). The 06/10/2023 survey had repeat deficiencies that had been cited on the 02/10/2020 survey. Review of the fall tracker revealed the facility had a total of one-hundred and eight (108) falls within a four (4) month time period. Of the 108 falls, thirty-three (33) falls resulted in injuries. The facility's Administrator failed to have an effective system in place to investigate the root cause of the residents' falls; failed to develop and implement an action plan after each fall or when there was a change in the resident's condition; and failed to accurately assess the resident and/or residents' environment to determine whether adequate supervision and/or assistive devices necessary to prevent accidents. In addition, the facility was cited six (6) Immediate Jeopardy deficiencies and Substandard Quality of Care (SQC) during this survey. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices; 42 CFR 483.21 Comprehensive Person-Centered Care Plans ( F656), 42 CFR 483.70 Administration (F835), 42 CFR 483.70 Governing Body (F837), 42 CFR 483.75 Quality Assurance and Performance Improvement QAPI/QAA program (F867) and at 42 CFR 483.70 Medical Director (F841). Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care; (F689) Free from Accidents/Hazards/Supervision/Devices. The facility was notified of the Immediate Jeopardy on 05/26/2023. An acceptable removal plan was received on 06/07/2023. The State Survey Agency determined the immediacy had been removed, 06/01/2023, as alleged, prior to exit on 06/10/2023. Non-compliance remained in the areas of 42 CFR 483.25 Quality of Care (F689) at a S/S of an E; 42 CFR Comprehensive Person-Centered Care Plans (F656) at a S/S of an E; 42 CFR 483.70 Administration (F835) at a S/S of an E; 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI) Program (F867) at a S/S of an E; 42 CFR 483.70 Governing Body (F837) at a S/S of an E; and 42 CFR 483.70 Medical Director (F841) at a S/S of an E. Additional deficient practice was also identified at F583 at a S/S of an E; F600 at S/S of a D; and F602 at S/S of a D; and F761 at a S/S of an E. Refer to F656; F689; F837; F841; and F867. The findings include: Review of the facility's policy titled, Administrator, revised April 2007, revealed the licensed Administrator was responsible for the day-to-day functions of the facility. Continued review revealed the facility's governing body had appointed the Administrator who was dually licensed in accordance with current federal and state requirements. The Administrator was responsible for: Management of day-to-day functions in the facility; residents' rights to fair and equitable treatment, self-determination, individuality, etc.; implementation of established resident care policies and other operational policies and procedures necessary to maintain compliance with current laws, regulations and guidelines governing long-term care facilities; liaison to the governing board, medical staff; and other professional and supervisory staff; evaluation and implementation of recommendations from the facility's committees (Quality Assessment and Assurance); ensure adequate number of personnel employed to meet residents' needs; and, ensuring the facility admitted residents whom it could provide adequate care. Review of the facility's, Job Description for the Administrator, undated, revealed the Administrator directed and performed quality assessment and assurance functions, oversight of the facility's Quality assurance process, including but not limited to regulatory compliance rounds to monitor performance and to continuously improve quality. Implementation of programs to gather and analyze data for trends and to institute actions to resolve problems promptly. Further review revealed the Administrator reported and made recommendations to appropriate committees to include the Governing Body and Medical Director. Continued review revealed the Administrator ensured adherence to proper safety procedures, including but not limited to, prompt investigation and reporting of injury. Ensured proper documentation was maintained, including but not limited to, documentation of investigations, incidents, meetings, staff training and education, to include QAPI improvement plans. The job description further revealed the Administrator developed and updated policies and procedures to reflect the philosophy of the facility, professional standards, and legal requirements. Review of the 02/20/2020, Recertification Survey's POC revealed previously cited deficiencies, included F689, Quality of Care: Free from Accidents/Hazards/Supervision/Devices. The facility failed to have an effective system in place to investigate the root cause of the residents' falls, failed to develop and implement an action plan after each fall or when there was a change in the resident's condition, and failed to accurately assess the resident and/or residents' environment to determine whether adequate supervision and/or assistive devices necessary to prevent accidents associated with falls. Based on observations, interview and record review throughout the survey, revealed the Administrator failed to develop and/or implement an effective system to ensure person-centered Comprehensive Care Plans (CCP) which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment related to falls and supervision; failed to develop and implement care plans related to resident specific guidelines of equipment; (LAL) mattresses and oxygen tubing. Further, the facility failed to provide effective Administrative and Governing body oversight of day-to-day operations of the facility and failed to ensure an effective Quality Assurance Program to provide quality care and services to meet the needs of the residents. During interview on 05/24/2023 at 9:30 AM, with the Director of Nursing (DON), she stated she had been in the DON role since March 2023, and since the last month or so (no specific date provided), she directly reported to the Executive Director (ED). She stated she was involved with care conferences (morning clinical meeting) related to residents' falls and incidents; observe the environment and update the care plan with resident involvement. The DON stated falls were QA'd (Quality Assurance) and discussed, all the data would continue to be QA'd, once a month on Thursday with the physician's involvement. She stated that however, the normal previous routine/procedure, the QA process was to conduct a through chart review and room check; no resident specific discussion. The DON stated her job was to provide oversight to the nursing department and report any concerns to the Administrator. Additionally, she stated she was responsible for the care needs of the facility's residents and supervision of its nursing staff. The DON stated she ensured residents received the necessary care and services and provided the supervision of nursing staff. Further interview revealed the [NAME] President of Clinical Operations and the [NAME] President of Operations (VPO) had been present in the building daily and provided support, education and resources. The Medical Director (MD), stated during interview on 05/05/2022 at 2:30 PM, that in his role as the Medical Director he would coordinate care and if issues were discovered, he would communicate with the Executive Director (ED). The MD further stated that he would expect the staff to follow the residents' plans of care and implement the interventions as ordered. He stated they knew what the problems were, as well as the residents' patterns; unfortunately, they did not follow through. In addition, the MD stated the facility had a high turnover rate and it was difficult to build a system with inconsistent staffing, that was not trained nor educated on the proper care needs of the residents. He further stated this contributed to the increase in falls. However, the MD stated he was engaged in the Quality Assurance Performance Improvement (QAPI) metrics related to falls trending upwards. During interview on 06/10/2023 at 9:44 AM, with the Executive Director (ED), she stated she had been in the role since July 2022 and was responsible for the day-to-day functioning of the facility and was responsible to ensure the facility operated within the state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. She also stated she was the Quality Assurance Coordinator and was responsible for the program. In addition, she stated she was required to ensure the ongoing audits related to previously cited deficiencies were reviewed, and if any concerns were identified, they were corrected immediately. The ED stated the facility had put audits in place; however, the facility was focused on the tracking and trending of previous falls specific to the facility's percentages and numbers, not resident specific as to the change with the current Plan of Correction (POC). The ED stated, We were not establishing the actual root cause, neglecting the overall 'resident specific' picture/part, nor the collaborative involvement that was needed, in order to get down to the actual root cause of the fall; therefore, missing the most important parts and potentially putting the residents at higher risk. Currently, a more specific procedure was in place to ensure an immediate and thorough investigation starting with staff education. This included agency staff and a more in-depth education process prior to working, more thorough interviews, resident environmental aspect, resident behaviors, fall risk/history starting from admission and most importantly, to ensure the correct interventions for the right resident. Consequently, if these factors were not addressed as previous, it put the resident at risk with a negative outcome, that could have been prevented. Interview on 06/10/2023 at 10:28 PM, with the [NAME] President of Operations (VPO) revealed he started with the corporation on 05/30/2023. He stated he provided in person oversight to include the Executive Director (ED) and [NAME] President of Clinical Operations (VPCO) starting 05/31/2023. He stated he was involved with the revisions of the POC on 06/05/2023. The VPO stated his role was to provide general operational oversight; policy review and revision, preventive measures to ensure understanding with standards of care, policies and implementation. The VPO stated, the difference in the facility corrections from 2020 falls plan of correction (POC) compared to the current POC, was education with the importance and focus of the root cause analysis; looking into the injuries, appropriate risk factors, starting from the admission process and ensuring proper resident specific preventive measures were in place and sustained. He added, these preventive measures should have already been implemented and a part of the process. However, the procedure moving forward was now to promote resident reviews with the audit and reeducate the staff to include Agency, prior to onboarding, thorough evaluations of risk and appropriateness of interventions, and of importance to look at the resident and address the injuries. In addition, he added the facility's number one goal was to educate at the best of their ability, try to reduce Agency staffing; make accountable for their actions and dismiss the wrong, control the environment, reeducate staff daily and prioritize importance of resident safety and quality of care. Interview on 06/09/2023 at 1:40 PM, with [NAME] President of Clinical Operations (VPCO) revealed she was a member of the facility's Governing Body (GB), which included the ED and VPO, per policy. The VPCO stated her role was to provide facility oversight and ED guidance and education of policies and procedures. She stated she was onsite beginning 05/17/2023, to provide support to staff while the State Survey Agency was in the building with concerns. Additionally, since 05/17/2023 she had been in the facility, periodically attended QAPI, provided a lot of on the spot training; researched QAPI tools to provide education and procedure with root cause analysis, facility trending to increase resident supervision, initiate proper procedure for staff to notify the ED, DON and self, to ensure the investigation was proper. The VPCO stated the facility's failure related to falls, was because there was no system in place. She stated she felt the facility was looking at contributing factors instead of the root cause of the fall, neglecting the resident's needs and not investigating the why did the fall happen, in order to promote a thorough investigation. The VPCO stated the staff were attempting to identify the root cause; however, they needed to provide a more appropriate root cause. She stated there was the need for education on the importance of a system wide approach and how to improve the interviews; the nurse would include their part, but now we need to include the pre-fall with other staff and ensure an immediate investigation/action was performed related to the root cause, with appropriate immediate interventions, and more supervision. Additionally, a new Performance Improvement Plan (PIP) committee was initiated. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, alleging removal of the Immediate Jeopardy on 06/01/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Beginning 05/19/2023, the [NAME] President of Clinical Services (VPCS) re-educated the Executive Director (ED), the Director of Nursing (DON) and the staff Development Coordinator (SDC) on the facility's fall policy. This education included: ensure completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition; ensure that care plans interventions were implemented based on findings of the fall risk assessment; implement an immediate intervention following each fall including a root cause analysis; and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. 2. a.) On 05/19/2023, the Executive Director (ED) and Director of Nursing (DON) ensured that the Staff Development Coordinator (SDC) started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy. The education included, but was not limited to initiating an investigation as to the cause of the fall, implementing an immediate intervention with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattress settings would be compatible with resident's weight, comfort and appropriate functioning of the mattress. c.) Documentation was added to the electronic medical record (EMR) for verification of low air loss mattress settings every shift to ensure that it remained at the appropriate level for each resident. d.) Staff was educated that residents who required the use of an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the Nurse Manager if changes were needed regarding the support surface. e.) Newly hired staff, agency staff and staff who had not been educated by 05/31/2023 would receive this education prior to working their next shift. 3. Beginning 05/22/2023, a post education test was administered by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Unit Managers (UM) for all current Licensed Nurses and Certified Nursing Assistants (CNAs) following education to ensure care plan interventions were in place. a.) If a score of 100 percent (100%) was not obtained, re-education would be completed until proficiency was obtained, until score of 100%. b.) Staff members not working on 05/22/2023 would have the education provided and a post-test completed prior to working in the facility. c.) Agency staff and staff on leave of absence would have the education provided and be required to complete the post-test prior to working in the facility. d.) Findings of the tests would be reviewed by the Executive Director (ED) and/or Director of Nursing (DON) to ensure compliance. 4. a.) On 05/22/2023, the Executive Director (ED) and Director of Nursing (DON) ensured the DON/ADON/UM/Nursing Supervisor/Licensed Nurse would complete visual observation rounds on six (6) residents daily across all shifts and all units including weekends and holidays, to ensure care plan interventions were in place to decrease the risk of falls/injuries times two (2) weeks, then six (6) observations three (3) times a week for two (2) weeks, then six (6) observations weekly times four (4) weeks, then six (6) residents monthly until further recommendations by the QAPI committee. The QAPI Committee include: the Executive Director (ED), the Director of Nursing (DON), Infection Preventionist (IP), Maintenance Director, Human Resource Business Partner (HRBP) and the Medical Director (MD). b.) Findings would be reported by a member of the IDT as listed above and would report daily in the QAPI meeting to the Director of Nursing and/or Executive Director to ensure compliance and that corrective actions had been initiated. c.) Residents would be selected by the [NAME] President of Clinical Services (VPCS) and/or DON to ensure residents identified at high risk for falls would be reviewed at least once in the two (2) week cycle. d.) Corrective action would be completed immediately and staff would be reeducated to ensure care plan interventions were in place to decrease the risk of falls/injuries. 5. On 05/23/2023, the Executive Director (ED) ensured that a review was conducted by the [NAME] President of Clinical Services (VPCS), Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Manager (UM) for all current residents' who have experienced a fall within the last 90 days to ensure appropriate notification of physician, responsible party, completion of a root cause analysis, care plan interventions were updated to reflect current needs identified during the root cause analysis, and completion of neurological checks as indicated. Corrective actions were completed as indicated. 6. On 05/23/2023, Managers and Department Leaders, consisting of the ED, DON, ADON, SDC, Activities Director (AD), Business Office Manager (BOM), Social Services Director (SSD), Social Services Coordinator/Assistant (SSA), Unit Manager (UM), Medical Records Coordinator (MRC), and the [NAME] President of Clinical Services (VPCS) completed visual rounds to compare and ensure the residents' care plans/Kardex falls interventions were in place for residents with falls in the last 90 days and ensure interventions were identified and placed on the Certified Nursing Assistants (CNAs) Kardex and were implemented to decrease the risk of falls. 7. a.) Beginning 05/23/2023, the DON, ADON, or Unit Manager (UM) would perform Quality Assurance review audits for residents who experienced a fall to ensure a root cause analysis had been completed with appropriate interventions implemented, the care plan was reviewed/updated, ensure interventions in place and listed on the CNAs Kardex or Point of Care (POC) documentation in electronic medical record (EMR), and follow up documentation was completed by the end of the 72 hours post fall period daily in the QAPI meeting. b.) Areas of concern would be addressed immediately or education or increase in audits. c.) Findings would be reported to the Executive Director (ED) and the Quality Assurance Performance Improvement Committee daily times two (2) weeks, then weekly times four (4) weeks, then monthly thereafter or as determined by the QAPI committee. 8. On 05/29/2023, the Executive Director (ED) and Director of Nursing (DON) received education provided by the Chief Operating Officer (COO) regarding their responsibility to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. 9. On 05/29/2023, the Executive Director (ED) and Director of Nursing (DON) received education by the [NAME] President of Clinical Services (VPCS) on the past three (3) year's survey history; the policies for falls; accident investigation to include root cause analysis utilizing CMS five (5) Whys, care plan development, care plan revision; the roles and expectations of the administration of the facility; the roles and responsibility of the Governing Body (GB); the roles and responsibilities of the Medical Director (MD), and roles and responsibilities of the Quality Assurance and Improvement (QAPI) committee. 10. a.) On 05/29/2023, the Executive Director (ED) ensured that the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), and the [NAME] President of Clinical Services (VPCS) conducted a review of the falls for Residents #16, #17, #18, and #19 within the last 90 days with a root cause analysis completed or updated as indicated. b.) Review of each resident included an assessment of the resident and the resident's environment to determine the need for increased supervision and/or assistive devices were needed to avoid further accidents. c.) Updated interventions were added to the care plans for Residents #16, #17, #18, and #19 related to the findings of the root cause analysis as indicated on 05/30/2023. 11. a.) Beginning 05/29/2023, an Ad hoc (prime contractor for CMS Website Development Support (CMS WDS) program, which covered many public-facing portions of HealthCare.gov.) A QAPI meeting by the ED, DON, VPCS, Infection Preventionist (IP), Social Service Director (SSD), and Licensed Nurse, was held with the Medical Director (MD) on 05/29/2023 to discuss the above stated plan to ensure care plan interventions were implemented and continued to be in place for residents to decrease the risk of falls/injuries. b.) Findings of audits and corrective actions were discussed, no further recommendations were made by the MD at that time. 12. On 05/29/2023, a Stand-down QAPI meeting was held daily by the Executive Director to review the above stated, to discuss findings of audits of plans for F656, F657, F689, F835, F837, F841, and F867, and determine concerns that may require immediate action. Corrective actions would be initiated immediately. 13. Starting 05/29/2023, a QAPI meeting was held daily times two (2) weeks, then weekly for four (4) weeks, then monthly to ensure continued compliance with the above stated plan with follow-up and recommendations by the governing body, appropriate interventions by the Medical Director (MD), and an effective QAPI to decrease the risk of falls/injuries, for recommendations and further follow-up as indicated. 14. a.) On 05/29/2023, the Executive Director (ED) and Director of Nursing (DON) initiated the plan that beginning 05/25/2023, the Clinical Interdisciplinary Team would review residents who experienced a fall during the morning clinical meeting to ensure a Root Cause Analysis (RCA) was determined, all appropriate interventions to include: consideration of the need for increased supervision and/or assistive devices as deemed appropriate were implemented to assist in preventing further falls, review and update the care plan as appropriate, and ensure intervention was on the Care Plan/CNA Kardex. b.) The DON/ADON/SDC/UM would make an IDT Nurse's Note with the root cause of the fall and intervention that was in place, and add any further interventions recommended by IDT. If further recommendations were suggested, the Licensed Nurse would add to the care plan. c.) A Nurse Manager would validate that the intervention was in place daily in the QAPI meeting. The IDT would evaluate the effectiveness of the intervention(s) and for latent injuries related to the fall daily in the QAPI meeting. d.) The Director of Nursing (DON) would be responsible for ensuring the above meeting was completed as per the plan. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 06/01/2023: 1. Interview on 06/09/2023 at 1:40 PM, with the VPCS indicated on 05/19/2023, the [NAME] President of Clinical Services (VPCS) re-educated the Executive Director (ED), the Director of Nursing (DON) and the staff Development Coordinator (SDC) on the facility's fall policy to include ensuring completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition, ensuring that care plan interventions were implemented based on the findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. 2. a.) Review of staff education sheets and staff interviews revealed on 05/19/2023, the Executive Director (ED) and Director of Nursing (DON) ensured that the Staff Development Coordinator (SDC) started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy, including but not limited to initiating an investigation as to the cause of the fall, implementing an immediate intervention with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattress settings were compatible with resident's weight, comfort and appropriate functioning of the mattress. c.) Observation and record review revealed documentation was added to the electronic medical record (EMR) for verification of low air loss mattress settings every shift to ensure that it remained at the appropriate level for each resident. d.) Staff was educated that residents who required the use of an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the Nurse Manager if changes were needed regarding the support surface. e.) Newly hired staff, agency staff and staff who had not been educated by 05/31/2023 received this education prior to working their next shift. 3. Review of staff education sheets and interview on 06/09/2023 at 3:05 PM, with the SDC revealed that beginning 05/22/2023, a post education test was administered by the Director of Nursing (DON), Assistant Director of Nursing (ADON) and Unit Managers (UM) for all current Licensed Nurses and Certified Nursing Assistants (CNAs) following education to ensure care plan interventions were in place. a.) If a score of 100 percent (100%) was not obtained, re-education was completed until proficiency was obtained, until score of 100%. b.) Staff members not working on 05/22/2023, had the education via in-person or phone communication provided and a post-test was completed and verified prior to working in the facility. c.) Agency staff and staff on leave of absence had the education provided via in-person or phone communication and required completed post-test prior to working in the facility was verified and validated on 06/09/2023. d.) Findings of the tests were reviewed by the Executive Director (ED) and/or Director of Nursing (DON) to ensure compliance. Interview on 06/09/2023 at 3:05 PM, with the SDC stated she had been re-educated on the Care Plan policy per the VPCS and explained the importance of care plan interventions to decrease the risk of resident falls. 3. Review of staff education sheets revealed on 05/19/2023, the SDC started re-educating all the current Licensed Nurses and Certified Nurse Assistants (CNAs) on the facility's care plan policy, to include ensuring that interventions were implemented and in place to decrease the risk of falls. Staff interviews on 06/09/2023 and 06/10/2023 revealed the staff were educated prior to working in the facility. Interview with LPN #15 on 06/09/2023 at 3:45 PM, revealed she had received education on fall risk, accidents/incidents, abuse, low air loss mattress, correct orders with settings and Kardex training in-services to ensure safety for fall risk residents. Interview with Registered Nurse (RN) #6, on 06/09/2023 at 5:00 PM, revealed she had recent education on 06/04/2023 on fall risk residents related to care plan interventions in place and correct documentation. This included resident rights and low air loss mattress orders and settings to ensure resident safety. Interview with Certified Nurse Aide #4 on 06/09/2023 at 4:07 PM, revealed recent training on falls risk; low air loss mattress; abuse; and residents' rights on 06/04/2023. The training also included to ensure the Kardex was to be looked at every for resident's needs and to verify fall risk residents. 4. a.) Review of the facility's documentation to include meeting minutes revealed on 05/22/2023, the Executive Director (ED) and the Director of Nursing (DON) ensured the DON/ADON/UM/Nursing Supervisor/Licensed Nurses completed visual observational rounds on six (6) residents daily across all shifts and all units including weekends and holidays, to ensure care plan interventions were in place to decrease the risk of falls/injuries times two (2) weeks, then six (6) observations three (3) times a week for two (2) weeks, then six (6) observations weekly times four (4) weeks, then six (6) residents monthly until further recommendations by the QAPI committee consisting of the Executive Director (ED), the Director of Nursing (DON), Infection Preventionist (IP), Maintenance Director, Human Resource Business Partner (HRBP) and with the Medical Director (MD). b.) Findings were reported by a member of the IDT as listed above and were reported daily in the QAPI meeting to the Director of Nursing and/or Executive Director to ensure compliance and that corrective actions had been initiated. c.) Residents were selected by the [NAME] President of Clinical Services (VPCS) and/or the DON to ensure residents identified at high risk for falls were reviewed at least once in the two (2) week cycle. d.) Corrective actions were completed immediately, and staff were reeducated to ensure care plan interventions were in place to decrease the risk of falls/injuries. Interview on 06/09/2023 at 4:00 PM, with the SSD stated there were daily QAPI meetings with the ED and VPCS to go over falls, governing body, and care plans. She stated she received education on falls/incidents/air mattress/PIP, and QAPI. The SSD stated she felt it had been beneficial. She stated the QAPI and PIP were not well known to staff, now there was much more communication with more participation with PIP. The SSD stated she audited fall care plans in the recent last week and went through

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure its Governing Body was actively engaged in ensuring its policies were effectively implemented regarding the management and operation of the facility. The facility's Governing Body failed to ensure the facility sustained substantial compliance in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices, F689; 42 CFR 483.70 Administration, (F835); 42 CFR 483.75 Quality Assurance and Performance Improvement (QAPI), F865; 42 CFR 483.70 Governing Body, F837; and 42 CFR 483.70 Medical Director, F841. In addition,, review of the facility's fall tracker documentation revealed the facility noted a total of one-hundred and eight (108) falls occurred within a four (4) month time period. Of the one-hundred and eight (108) falls, thirty-three (33) of the falls resulted in injuries to the resident. (Refer to F656, F689, F835, and F867) The facility's failure to have an effective system to ensure its Governing Body was actively engaged in ensuring its policies were effectively implemented regarding the management and operation of the facility has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Develop/Implement Person-Centered Comprehensive Care Plans, (F656) at a S/S of a K; 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689) at a S/S of a K; 42 CFR 483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867) at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689). The facility was notified of the Immediate Jeopardy on 05/26/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, with the facility alleging removal of the Immediate Jeopardy on 06/01/2023. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 06/01/2023, prior to exit on 06/10/2023. The findings include: Review of the facility's policy titled, Governing Body, undated, revealed the Governing Body in accordance with 42 CFR Section 483.70(d), appointed the designated Administrator. Per review, the Administrator, who was licensed by the State, was responsible for the management of the facility and was to report to and be accountable to the Governing Body. Continued review revealed the policy stated the Governing Body was responsible for and accountable for the facility's QAPI Program. The policy further noted the Governing Body was to fulfill its referenced duties through a combination of onsite visits; Zoom or telephonic conferences; and performance of audits, performed on a scheduled and/or an as-needed basis In addition, the policy revealed the facility's Governing Body was responsible for and accountable for its QAPI Program. During the Recertification Survey, dated 03/05/2020 the facility was cited at 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656 and 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices, F689, at a Scope and Severity (S/S) of a K. During the current survey Immediate Jeopardy was again identified in the areas of 42 CFR 483.21 Develop/Implement Comprehensive Care Plan, F656 and 42 CFR 483.25 Quality of Care, Free from Accidents/Hazards/Supervision/Devices, F689, at a S/S of a K. In an interview on 05/05/2022 at 2:30 PM, the Medical Director stated his role as Medical Director was to coordinate care and if issues were discovered, he communicated with the facility's Executive Director (ED). The Medical Director stated he expected facility staff to follow residents' plans of care and implement their interventions as ordered. He stated staff knew what residents' problems were, as well as the resident's patterns; unfortunately; however, the facility had not followed through with necessary interventions. Per the Medical Director, the facility had a high staff turnover rate and it was difficult to build an effective system with inconsistent staffing, who were not trained nor educated on the proper care needs of the residents. He further stated the high turnover rate and inconsistent staffing who were not trained and educated on residents' care needs contributed to the increase in falls. The Medical Director stated however, he was engaged in the facility's QAPI metrics regarding residents' falls trending upwards. In an interview on 06/10/2023 at 9:44 AM, the ED stated she was responsible for the facility's day to day functioning and was responsible for ensuring it operated within state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. She stated she was the facility's Quality Assurance (QA) Coordinator and was responsible for the QA program. The ED stated she was required to ensure ongoing audits related to previously cited deficiencies were reviewed, and if any concerns were identified, they were corrected immediately. According to the ED, the facility had implemented audits and revealed the facility had been focused on tracking and trending previous falls specific to the facility's percentages and numbers, and not on resident specific falls. Per the ED, currently, a more specific procedure has been initiated to ensure an immediate and thorough investigation starting with staff education, to include agency staff and a more in-depth education process prior to working, more thorough interviews, reviewing resident environmental factors, resident behaviors, fall risk/history starting from admission and most importantly, to ensure the correct interventions for the right resident. The ED further stated consequently, due to those factors not being addressed as previously, it put the resident at risk for a negative outcome, which could have been prevented. In an interview on 06/10/2023 at 10:28 PM, the [NAME] President of Operations (VPO) stated he started with the corporation on 05/30/2023. He stated he provided in person oversight to the facility's Governing Body, to include the ED and [NAME] President of Clinical Operations (VPCO) starting 05/31/2023, and had been involved with the revisions of the POC on 06/05/2023. The VPO stated his role was to provide general operational oversight; policy review and revision; and preventive measures to ensure understanding with standards of care, policies and implementation. He stated the difference in the facility's corrections from the 2020 falls POC was the education; focusing on the importance of ensuring a root cause analysis and looking into injuries; assessing appropriate risk factors starting from the admission process and ensuring proper resident specific preventive measures were in place and sustained. According to the VPO, those preventive measures should have already been implemented by the facility previously and been a part of its process. He stated however, the procedure moving forward was now to promote resident review with audits; and reeducation of staff to include all agency staff prior to beginning work, regarding thorough evaluations of residents' risk and appropriateness of their interventions, and of the importance of assessing the resident and addressing their injuries. In addition, he stated the facility's number one (1) goal was educating staff to the best of its ability on a daily basis; trying to reduce the use of agency staffing; having accountability for its actions and controlling the environment, and prioritizing the importance of resident safety and quality of care. In an interview on 06/09/2023 at 1:40 PM, the VPCO stated she was a member of the facility's Governing Body which also included the ED and VPO, as per policy. The VPCO stated her role was to provide oversight of the facility and guidance for the ED and education regarding policies and procedures. She stated she had been onsite beginning 05/17/2023, to provide support for staff while Surveyors were in the building. The VPCO stated on 05/19/2023, she identified there were no orders in place and had performed an audit of residents on air mattresses. She stated after the audit two (2) residents on Low Air Loss (LAL) mattresses had those mattresses discontinued. Per the VPCO, since 05/17/2023 she had been present in the facility providing a lot of on the spot training; periodically attending QAPI meetings; researching QAPI tools to use to provide education and procedure with root cause analysis. She stated she also assisted with facility trending to increase resident supervision; initiating a proper procedure for staff to notify the ED, DON and herself, to ensure the facility's investigation were proper. The VPCO stated the facility's failure related to falls, directly having no system in place, she felt had been from looking at contributing factors instead of the root cause of the falls; neglecting the resident needs; and not investigating the why the fall had happened, in order to promote a thorough investigation. She stated staff had attempted to identify the root cause; however, they needed to provide a more appropriate root cause. The VPCO stated there was a need for education on the importance of a system wide approach and improving interviews. Per the VPCO, nurses had their part; however, now the facility needed to include pre-fall education with other staff and ensure an immediate investigation/action was performed related to the root cause, with appropriate immediate interventions implemented, and more supervision provided. Additionally, she further stated a new Performance Improvement Plan (PIP Committee had been initiated. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, alleging removal of the Immediate Jeopardy on 06/01/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1. Beginning on 05/17/2023, a member of the Governing Body would do the following: onsite at a minimum of four (4) days a week and available by phone twenty-four (24) hours a day seven (7) days a week. (a). Audit incidents and accidents. (b). Complete a review of investigations of incidents and accidents. (c). Ensure QAPI processes and procedures that included results of all audits, analysis of audits, identification of Root Cause of system failures, implementation of corrective actions, and tracking and trending of the facility's processes. 2. On 05/19/2023, the ED and DON received education given by the [NAME] President of Clinical Services (VPCS) on the policies for falls, and accident investigation. The education included: root cause analysis; care plan development; and care plan revisions. 3. On 05/29/2023, the VPCS, a member of the Governing Body, reviewed the removal plans with the ED for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and to ensure adherence to the plan(s) to decrease the risk of potential injuries to residents related to falls. 4. (a). Beginning 05/29/2023, a review was to be completed with the ED by a member of the Governing Body that included the VPCO. The VPCS, each week beginning 05/29/2023, would follow up to include audits and plans initiated to correct identified concerns. (b). The process also included follow-up with staff members, department heads, external consultant, residents and/or families to assist in evaluating ongoing compliance or deficient practices with the removal plan and/or facility processes regarding the regulatory intent of F656, F657, F689, F835, F837, F841, and F867. (c). Any concerns identified regarding review with the ED were to be immediately addressed/corrected by the ED and discussed with another member of the Governing Body (VPCS or VPCO). (d). Immediate actions were to be taken to ensure the residents' well-being and compliance with the identified regulatory violations. The findings were to be reported to the Chief Operating Officer (COO) starting on 05/29/2023 by the VPO or VPCO weekly. 5. Beginning 05/29/2023, the COO completed education with the members of the Governing Body regarding their roles and responsibilities to provide oversight of the management and operation of the facility to ensure the facility was administered effectively, and to ensure the facility had an effective QAPI program. 6. (a). On 05/29/2023, the ED and DON received education by the VPCS on the roles and expectations of: the administration of the facility, the Governing Body, the Medical Director, and the QAPI Committee. (b). The VPCS re-educated the ED, DON, and Medical Director on the revised Accidents and Incidents/Falls, Investigating and Reporting policies to include notification of the ED and DON. (c). On 05/29/2023, a post test was administered to the ED and DON by the VPCS to validate understanding of the above education. 7. (a). Beginning 05/23/2023, an Ad hoc QAPI meeting was held with the Medical Director regarding the plan for consistent reviews by the Governing Body to ensure the removal plans were followed consistently and to discuss the weekly review with the ED as stated above. No further recommendations were made by the Medical Director regarding the plan. (b). A stand down QAPI meeting was to be held daily by the ED to review the above stated plan, to discuss findings of audits, and determine concerns which might require immediate action. 8. Starting 05/29/2023, a QAPI meeting was to be held daily for two (2) weeks, then weekly times four (4) weeks, then monthly thereafter to ensure continued compliance with the above stated plan to ensure continued compliance with follow-up and recommendations by the Governing Body. 9. (a). On 05/30/2023, the ED provided education to the Department managers which included: the DON, ADON, SDC, UM, MDS Coordinator, SSD, SSC, BOM, AD, DD, RSD, HKS, and MA regarding the roles and responsibilities of the Governing Body. (b). The education included the availability of the Governing Body with concerns, grievances, or need of resources to assist in ensuring the highest level of care and services to the residents in the facility. 10. (a). On 05/30/2023, the education was initiated with facility staff by the SDC, DON, ADON, Nursing Supervisor or VPCS regarding the roles and responsibilities of the Governing Body. (b). The education included the availability of the Governing Body with concerns, grievances, or need of resources to assist in ensuring the highest level of care and services to the residents in the facility. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 06/01/2023 as alleged: 1. Per observation and interview, beginning 05/17/2023, a member of the Governing Body was onsite daily at the facility, at a minimum of four (4) days a week and available by phone twenty-four hours a day seven (7) days a week as alleged. (a). Review of the facility's documentation revealed on 05/17/2023, an audit was conducted of residents' incidents and accidents. Continued review revealed the audit encompassed the investigations and review of the investigation process to ensure the QAPI processes and procedures which included results of all audits, analysis of audits, identification of Root Cause of system failure and implementation of corrective actions, and tracking and trending of the facility's processes were completed. (b). In an interview on 06/09/2023 at 1:40 PM, the VPCS stated when the State Survey Agency (SSA) Surveyors entered the building on 05/17/2023, with concerns, an audit of residents with falls/incidents/accidents was initiated and conducted. The VPCS stated concerns had been identified regarding no Physician's Orders related to the mattresses. The facility began a thorough audit review at that time to address the concerns. (c). In continued interview on 06/09/2023 at 1:40 PM, the VPCS stated she ensured QAPI processes and procedures that included results of all audits, analysis of audits, identification of Root Cause of system failures, implementation of corrective actions, and tracking and trending of facility processes were completed. 2. In interview on 06/09/2023 at 1:40 PM, the VPCS stated on 05/19/2023, she educated the ED and DON on the policies for falls, accident investigation to include root cause analysis, care plan development, and care plan revision. 3. On 05/29/2023, the VPCS, a member of the Governing Body, reviewed the removal plans with the ED for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and ensure adherence to the plan(s) to decrease the risk of potential injuries to residents related to falls. 4. (a). In interview on 06/09/2023 the VPCS and VPCO stated beginning 05/29/2023, a review was completed with the ED by a member of the Governing Body, which included the VPCO, and VPCS. They stated the review was to continue to be completed each week beginning 05/29/2023, for actions with follow up including audits and plans which had been initiated to correct identified concerns. (b). In continued interview on 06/09/2023 the VPCS and VPCO stated the process also included follow-up with staff members, department heads, the external consultant, residents and/or families to assist with evaluating ongoing compliance or deficient practices regarding the removal plan and/or the facility's processes related to the regulatory intent of F656, F657, F689, F835, F837, F841, and F867. The VPCS and VPCO stated any concerns identified regarding the review with the ED were to be immediately addressed/corrected by the ED and discussed with another member of the Governing Body (VPCS or VPCO). (d). In additional interview on 06/09/2023 the VPCS and VPCO stated immediate actions were taken to ensure residents' well-being and compliance with the identified regulatory violations. They stated the findings were to be reported to the COO starting on 05/29/2023 by the VPO or VPCO weekly. In an interview on 06/10/2023 the facility's COO, VPCO and SVPCS stated the ED and DON received education on the facility's past three (3) year's survey history, the facility's policies for falls, and accident investigation to include root cause analysis utilizing the Centers for Medicare and Medicare Services (CMS) five (5) Whys. They further stated the education included Care Plan development, Care Plan revision, the roles and expectations of: administration of the facility; the Governing Body; the Medical Director; and the QAPI Committee. 5. In an interview on 06/10/2023 the COO stated beginning 05/29/2023, his role included completing the education with the members of the Governing Body regarding their roles and responsibilities to provide oversight to the management and operation of the facility to ensure it was administered effectively, and to ensure the facility had an effective QAPI program. 6. (a). In interview on 06/10/2023 with the ED and DON they stated they both received education on 05/29/2023, provided by the VPCS on the roles and expectations of administration of the facility, the Governing Body, the Medical Director; and the QAPI Committee. (b). In interview on 06/09/2023 at 1:40 PM, the VPCS stated she had re-educated the ED, DON, and Medical Director on the revised Accidents and Incidents/Falls, Investigating and Reporting policies which included notification of the Administrator (ED) and DON. In continued interview on 06/09/2023 at 1:40 PM, the VPCS stated she re-educated the ED, DON, and SDC on 05/19/2023, on the facility's fall policy, and ensuring completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition. She stated the re-education also included ensuring care plan interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions that included the need for increased supervision or assistive devices as deemed necessary. In interview on 06/09/2023 at 1:40 PM, the VPCS stated the facility's QAPI met daily specifically for falls, to look at all falls, for prevention, root cause identification, behaviors and risk prone residents and interventions. She stated this was to be included on weekends and holidays, and the Medical Director was to be notified to keep him updated. The VPCS stated the communication had been enhanced, firsthand and had increased her awareness regarding the importance of frequent communication and having a continued onsite presence. (c). Review of the facility's documentation and staff educational personnel files revealed on 05/29/2023, a post test was administered to the ED and DON by the VPCS to validate their understanding of the above education. 7. (a). Review of the facility's documentation and meeting minutes revealed beginning 05/23/2023, an Ad hoc QAPI meeting was held with the Medical Director regarding the plan for consistent reviews by the Governing Body to ensure the removal plans were followed and to discuss the weekly review with the ED. Further review revealed no additional recommendations were made by the Medical Director regarding the plan. Review of the QAPI meeting minutes revealed the ED, DON, VPCS, Infection Preventionist (IP), SSD, Licensed Nurse, and Medical Director met on 05/29/2023 to discuss the facility's plan to ensure care plan interventions were implemented and continue to be in place for residents to decrease the risk of falls/injuries. Further review revealed findings of audits and corrective actions were discussed, with no further recommendations made by the Medical Director at that time. (b). Review of the facility's documentation and meeting minutes revealed a stand down QAPI meeting was held daily by the ED to review the plan, discuss findings of the audits, and determine concerns which might require immediate action. Review of the facility's documents and meeting minutes revealed the follow-up with staff members, department heads, external consultant, residents and/or families to assist in evaluating ongoing compliance or deficient practices with the removal plan and/or the facility's processes regarding the regulatory intent of F656, F657, F689, F835, F837, F841, and F867. Review of the facility's documentation revealed beginning 05/29/2023, a review was completed with the ED by a member of the Governing Body to include the VPCO, and VPCS each week beginning 05/29/2023, for actions with follow up to include audits and plans which had been initiated to correct identified concerns. 8. Review of the facility's documentation revealed starting 05/29/2023, a QAPI meeting was to be held daily for two (2) weeks, then weekly times four (4) weeks, then monthly thereafter to ensure continued compliance with the above stated plan to ensure continued compliance with follow-up and recommendations by the governing body. In interview on 06/09/2023 at 1:40 PM, the VPCS stated the QAPI had been meeting daily specifically regarding falls, looking at prevention, root cause identification, resident behaviors and risk prone residents and interventions. The VPCS stated the Medical Director was to be notified and be kept updated. She further stated communication had been enhanced, which had increased her awareness of the importance of frequent communication and having a remaining onsite presence. In interview on 06/10/2023, the COO, VPCO and Senior [NAME] President of Clinical Services (SVPCS) stated education had been provided to the ED and DON as alleged specific to their roles and responsibilities to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. 9. (a). Review of the facility's documentation, and staff educational training sheets revealed on 05/30/2023, the ED provided education to the Department Managers which included the DON, ADON, SDC, UM, MDS Coordinator, SSD, SSC, BOM, AD, DD, RSD, HKS, and MA regarding the roles and responsibilities of the facility's Governing Body. In interview on 06/09/2023 at 4:00 PM, the SSD stated daily QAPI meetings occurred with the ED and VPCS to go over falls, Governing Body, and care plans. She stated she received multiple educations on falls/incidents/air mattress/PIP, and QAPI. The SSD stated she felt the education had been beneficial, and the QAPI and PIP were not well known to staff; however, now much more communication was occurring and more participation with the PIP. The SSD stated staff were educated on the residents' care plans and how to correct it if something was incorrect, and to perform visual rounds. She further stated all departments had been educated which included ensuring family notifications, care plan editing, medication reviews, psychiatric involvement and appointments. (b). Review of the staff educational training sheets revealed the education included the availability of the Governing Body for concerns, grievances, or the need of resources to assist in ensuring the highest level of care and services to the residents in the facility. In interview on 06/09/2023 at 3:05 PM, the SDC stated the team identified the facility's failure regarding the citations were related to the the importance of air mattress education needed to be provided, importance of one-on-one (1:1) supervision and other increased supervision of residents at high risk for falls, care plans needing to be updated and followed up on by the Interdisciplinary Team (IDT). The SDC stated the importance of proper care of residents, specific to the facility's systems failure was to ensure residents were toileted, repositioned, their pain addressed and personal items were in reach. She stated to ensure necessary follow through: more education of staff was needed to make them more observant; investigation of the root cause of incidents was needed; and ensuring appropriate fall interventions were in place and implementing them. The SDC stated the facility initiated increased QAPI education with staff, education with all departments and explained the QAPI process. According to the SDC, the IDT was now to evaluate to reduce residents' falls, other accidents/falls and provide a better quality of care, and staff were to be involved and have input with the PIP. She stated there had been a team meeting specific to falls and actual floor staff involvement/input to work more cohesively and improve resident safety. The SDC stated her involvement with the removal plan included education per the VPCS on all the implementations to improve resident quality of care and ensure their safety. She stated she performed all trainings of the QAPI, Fall/Accidents, low air loss mattress with required two (2) assistants, settings and checking a resident's coccyx, and ongoing education of abuse. The SDC stated she ensured all staff were educated one-on-one (1:1) in person, and/or via phone to perform competency testing. She further stated all current agency staff were educated, and new onboarding staff, had an introduction orientation packet that must be performed prior to working the floor with testing required. 10. (a). Review of the facility's documentation, review of the educational training sign-in sheets revealed on 05/30/2023, education had been initiated with staff by the SDC, DON, ADON, Nursing Supervisor or VPCS regarding the roles and responsibilities of the Governing Body. (b). Review of the facility's educational documentation revealed the education included the availability of the Governing Body for concerns, grievances, or need of resources to assist in ensuring the highest level of care and services to the residents in the facility. In interview on 06/10/2023 the COO, VPCO and SVPCS stated the ED and DON received education on the facility's past three (3) year's survey history, the facility's policies for falls, accident investigation to include root cause analysis utilizing the CMS five (5) Whys, Care Plan development, Care Plan revision, and the roles and expectations of: the administration of the facility; the Governing Body (RGB); the Medical Director (MD); and the QAPI Committee. In interview on 06/09/2023 at 4:00 PM, the SSD stated daily QAPI meetings with the ED and VPCS had been held to go over residents' falls, Governing Body, and care plans. She stated she received multiple educations on falls, incidents, air mattresses, PIP, and QAPI. According to the SSD, she felt it had been beneficial, as the QAPI and PIP had not been well known to staff, and now there was more communication and participation in the PIP. The SSD stated all departments were educated on the required items including ensuring family notification, care plans, editing care plans, medication reviews, psychiatric involvement, appointments, and fixing something if it was incorrect.

Based on interview and record review, it was determined the facility failed to have an effective system in place to investigate the root cause of the resident's falls. The Medical Director was responsible for providing the staff direction related to the facility's policy and the current professional standard of practice and failed to ensure the coordination of medical care in the facility. As a result, five (5) of forty-seven (47) sampled residents experienced falls with major injuries. The facility's failure to have an effective system to ensure the Medical Director provided oversight of the residents medical care and failure to implement polices that was reflective of the current professional standards of practice has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE] in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), Develop/Implement Person-Centered Comprehensive Care Plans, at a S/S of a K; 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision at a S/S of a K; 42 CFR S483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR S483.75 Quality Assurance and Performance Improvement, at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care (F689), Accidents and Supervision. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on [DATE], prior to exit on [DATE]. The scope and severity (S/S) of the IJ deficiencies was lowered to an E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. (Refer to F656, F689, F835, F837, and F867) The findings include: Review of the Medical Director's responsibilities, dated [DATE], revealed the Medical Director was responsible for administrative decisions including recommending, developing, and approving facility policies related to residents' care, providing medical and clinical leadership in a multidisciplinary approach to resident care and care planning within the skilled long-term setting. Further review of the Medical Director's responsibilities revealed he was to assist the facility with the identification, evaluation, and resolution or medical and clinical concerns affecting resident care or quality of life. Review of the facility policy titled Fall Management, dated [DATE], revealed a fall was an unintentional change in position coming to rest on the ground, floor or onto the next lower surface, which included onto a bed, chair, or bedside mat. The policy stated injury related to a fall was any documented injury that occurred as a result of or was recognized within a short period of time (hours or to a few days) after the fall and attributed to the fall. According to the policy, a major injury included bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. Review of the policy also revealed a fall risk observation was completed on admission, quarterly, annually, with any significant change in condition, and with any fall, and was utilized to identify individuals who were at high risk for falls. Further review of the policy revealed fall prevention was achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce risk for falls. Review of the facility Low Air Loss Mattress owner's manual titled INVACARE Micro AIR MA65 Series dated [DATE], revealed to avoid risk of death or injury from falling: Invacare suggest read and use the User Manual prior to using the product, rails be in the raised position whenever a patient is on the bed, proper patient assessment and monitoring is required to prevent injury, variations in bed rail dimensions, and mattress thickness, size or density could increase the risk of injury, work with therapist, physician and other medical staff to perform assessment and patient monitoring, to avoid death, injury, or damage due to improper maintenance and inspection, always maintain and inspect equipment. Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, effective date [DATE], revealed the purpose of QAPI was to ensure the mission of the facility was actualized through the establishment of resident centered quality management processes, to ensure that proactive quality care and services were provided to each resident on a continuous basis, to ensure compliance with regulations and standards of practice and to provide timely solutions to spontaneous events. Further review of the policy revealed objectives of the QAPI program included a systemic process designed to ensure that care practices were consistently applied, and the facility met or exceeded an expected standard of quality. Review of the facility's Quality Assurance Performance Improvement (QAPI) Program review for [DATE], [DATE], [DATE] and [DATE] report revealed the QA committee failed to review the Plan of Correction (PoC) from the Recertification Survey with exit date of [DATE], in which the facility was cited at an Immediate Jeopardy (IJ), related to falls. Further review of the of the QAPI Program revealed there was no documentation to support the committee continued with Quality Measured comments or action plan for improvement. Continued review revealed there was no evidence the committee developed plans of action to correct identified quality deficiencies based on the root cause analysis and prioritization of topics of identified issues/concerns related to resident falls with major injury, and failed to maintain formal written documentation as evidence of ongoing quality management to promote and ensure the resident's safety. 1. Review of the facility's Incident Audit Report dated [DATE] at 9:35 PM, for Resident #1 revealed the resident was found on the floor next to his/her bed, with his/her feet towards the head of the bed and his/her head next to the wall. The facility identified the resident fell out of his/her low air lost (LAL) mattress. The resident was noted to have had a knot on his/her left side of his/her scalp. Further review revealed the resident did not know what happened or how he/she ended up on the floor. Continued review of the incident report, revealed the resident's pain level was not assessed, and the predisposing environmental/situational factors were not documented. Review of the Hospital Medical Record, dated [DATE], revealed the resident was admitted with diagnosis of a Nondisplaced Fracture of the second Cervical Vertebrae. Review of the QA minutes revealed no recommendation from the Medical Director, to include the review of the facility's policy or discussion of the standards of practice to assist with interventions to prevent the resident's fall, as per the facility's policy and the Medical Directors Job Responsibilities. Subsequently, on [DATE], Resident #1 experienced a second fall. Review of the facility's Incident Audit Report, revealed the resident was found lying on the floor next to his/her wheelchair. Continued review revealed the resident was trying to get up and screaming that he/she just wanted to go back to bed. The resident had been in the lounge on the 200 Unit, visiting with his/her sister after lunch. Further, the resident stated, I fell out of my chair, wanna go to bed. Review of the resident's Hospital Medical Record revealed the resident was diagnosed with a nondisplaced fracture of the proximal tibial methaphysis; bilateral tibial fracture, and right distal fibula avulsion fractures. Review of the QA minutes revealed no recommendation from the Medical Director, to include the review of the facility's policy or discussion of the standards of practice to assist with interventions to address the adequate supervision required to assist the resident to his/her bed. As a result, the resident was placed on Hospice Care. The resident expired on [DATE]. 2. Review of the facility's Incident Audit Report, dated [DATE] at 8:07 PM, revealed Resident #16's roommate yelled for help. Review of the report revealed the Kentucky Medication Aide (KMA) was walking down the hallway and went into the resident's room. Resident #16 was noted sitting on his/her buttock on the bathroom floor with his/her back against the wall. A continued review of the report revealed Registered Nurse (RN) #1 noted the resident had his/her socks on that was not his/her nonskid socks. The resident stated he/she tripped over his/her oxygen cord. Further review of the report revealed the resident hit his/her head on the wall. He/she further stated his/her oxygen cord pulled causing the resident to trip over it. Review of the immediate action taken revealed an order was received to send the resident to the emergency room (ER). Review of Resident #16's emergency room (ER) Record, dated [DATE], revealed the resident's primary impression/diagnosis was a displaced fracture of his/her shaft of the left clavicle related to an unspecified fall. Review of the QA committee minutes revealed no documentation to support the Medical Director offered recommendations to the facility staff to include a review of the facility's policy related to falls and/or care plan review. The facility failed to address the resident's concern related to the resident's oxygen tubing, which caused the resident's fall. 3. Review of the facility's Incident Audit Report dated [DATE] at 12:49 AM, revealed Resident #17 was found lying on the floor, on his/her back beside his/her bed. Further review, revealed the resident rolled out of the bed, hitting his/her face on the floor, with lacerations and a hematoma to his/her forehead. Continued review revealed confusion and impaired memory were noted as predisposing physiological factors with no evidence of other predisposing environmental, nor situational factors, and/or documented interviews to demonstrate a thorough investigation. A continued review of the incident report revealed the immediate action taken was to assist the resident to bed, apply pressure to the resident's wound, and the resident was sent to the emergency room (ER) for an evaluation. The Medical Director; however, failed to provide recommendation to the facility to include: reviewing the facility's policy related to falls, to assist with determining the root cause of the resident's fall, through an investigation, and failed to gather information from the investigation to develop an intervention that would be person-centered specific. Continued review of the incident report revealed the resident was sent to the hospital were it was documented the resident had facial laceration from his/her fall. 4. Review of the facility's Incident Audit Report dated [DATE], revealed Resident #18 was found on the floor at the foot of both beds in his/her room. Continued review of the incident report revealed that when staff asked the resident, What he/she was trying to do? The resident stated, pee. Further review of the incident report revealed that numerous episodes of urinary incontinence was noted in the resident's brief. The incident report revealed the resident only verbalized pee numerous times. Further review of the incident report revealed the resident attempted to transfer self to the bathroom. The incident report revealed there were no predisposing factor for the resident's environment, and the resident's psychological factors included confusion, weakness, and gait imbalance. Further review of the facility incident report revealed on [DATE], the facility's Interdisciplinary Team (IDT) reviewed the resident's fall and concluded the root cause analysis identified and documented as, resident with urgency to urinate, with the intervention provided to be incontinence care, and keep urinal in reach. The Medical Director; however, failed to provide recommendation to the facility to include: reviewing the facility's policies related to falls and care plans. Review of the resident's care plan revealed staff were to check on the resident every two (2) to three (3) hour to assist with transferring the resident to the bathroom and commode. Staff documented the resident had numerous episodes of urinary incontinence and the resident stated he/she had to pee; however, the Medical Director failed to offer a recommendation to the facility staff, to include increased supervision with transferring the resident to the bathroom, to prevent additional falls. Additionally, Resident #18 had a second (2nd) fall on [DATE]. Review of the facility's Incident Audit Report, dated [DATE], revealed Resident #18 was noted to be lying on his/her stomach on the floor beside his/her bed. The resident stated, 'I fell out of bed. Resident #18 was sent to the emergency room (ER) for evaluation and was found to have a nasal/septum fracture and fracture of the anterior maxillary process. Further review of the facility incident report revealed the Interdisciplinary Team (IDT) reviewed and concluded the root cause analysis was identified and documented as, the resident lies on his/her side in his/her bed when resting. However, there was no documentation to support the Medical Director provided a resolution, identification, or an evaluation to assist the facility staff developed appropriate interventions to prevent or reduce the resident's falls. Further review of the resident's Medical Record revealed the resident reported to the emergency room (ER) staff, on [DATE], that the facility removed the resident's bed railings from his/her bed, which caused the resident's fall. Additional review of the resident's record revealed the resident was not assessed or evaluated for bedrails, prior to his/her fall on [DATE]. Continued review of the resident's medical record revealed the Medical Director failed to address in the QA committee meeting the concern of the bedrails noted in the resident's hospital records. 5. Review of the facility's Incident Audit Form dated [DATE], revealed Resident #19 rolled from his/her bed on to the floor during incontinence care. Review of the witness statement revealed the Certified Nursing Assistant (CNA) #7 said she rolled the resident away from her and the resident rolled out of bed. Continued review of the incident form revealed incontinent was noted to be the only predisposing physiological factors listed on the form. IDT determined the root cause of the fall was determined to be the air mattress and the resident rolled on the opposite of staff. Review of the resident's care plan revealed the resident was assessed to have two (2) person assist with bed mobility; however the CNA who performed the resident's care worked independently. The IDT did not address this concern as part of the root cause nor was there documentation to support the Medical Director offered the facility staff a recommendation. On [DATE], IDT reviewed the incident report and determined the root cause analysis was determined and documented as the resident was on an air mattress and the resident rolled opposite staff. Further review revealed the intervention was to change the air mattress to contour mattress, and side rails were placed to use during care. However, the facility failed to determine within the root cause analysis that the resident was assessed to have two (2) staff to assist with his/her bed mobility. Review of Resident #19's Hospital Record, dated [DATE] at 9:52 AM, revealed the resident had a fall with laceration/hematoma. Continued review of the hospital record revealed the {resident} patient fell from bed without loss of consciousness. Further review revealed the {resident} patient had a 4 to 5-centimeter (cm) skin tear to his/her right jawline with no bleeding noted. The hospital record also revealed the resident had a moderate size blue hematoma with swelling to his/her right lateral elbow area and a smaller blue hematoma to his/her forearm. Further review of the hospital record revealed nasal bone fracture with a 9 cm facial laceration and contusion of the head and right forearm. In addition, review of the fall tracker revealed the facility had a total of one-hundred and eight (108) falls within a four (4) month time period, [DATE] thorough [DATE]. Of the 108 falls, thirty-three (33) falls resulted in injuries In an interview, on [DATE] at 4:45 PM, with the Minimum Data Set (MDSC) Coordinator, she stated she had been in the MDS role for one (1) year and was actively involved in the daily clinical meetings. Per the interview, she stated the IDT would discuss the recent falls and review the interventions in place and determine any new, needed interventions; however, she was not aware who was ultimately responsible to ensure the interventions were being implemented. Further, she stated she did not recall any interventions with Resident #1 being discussed or implemented. She added, previously she would just care plan the type of mattress, not include guidelines of weights and/or specifics. Continued interview with MDSC revealed if the resident's air mattress settings were not based on current weight and not accurate, it could cause a danger to the resident with a potentially dangerous outcome. She stated the bed rails would also now be care planned and the unit managers would be responsible for the bedrail assessments. The MDS Coordinator stated she often communicated with the Therapy Director (TD) to discuss changes to the resident's care plan, related to falls. Interview on [DATE] at 10:22 AM with the Advanced Registered Nurse Practitioner (ARNP), stated she was in house daily for more acute visits, and the Medical Director (MD) would see the more chronic residents two (2) times a month; however, stated the MD would begin seeing the resident's more often. The ARNP stated, typically, if a fall/incident occurred, she would assess the resident and implement orders immediately. She stated all staff should be familiar with the residents' plan of care and interventions for the safety and appropriateness of care for the resident. In an interview on [DATE] at 9:44 AM with the Executive Director (ED), she stated she had been in the role since [DATE] and was responsible for the day-to-day functioning of the facility and was responsible to ensure the facility operated within the state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. She stated she was the Quality Assurance Coordinator and was responsible for the program. In addition, she stated she was required to ensure the ongoing audits related to previously cited deficiencies were reviewed, and if any concerns were identified, they were corrected immediately. The ED stated the facility had put audits in place; however, the facility was focused on the tracking and trending of previous falls specific to the facility percentages and numbers, and was not resident specific. In an additional interview, on [DATE] at 2:45 PM with the Executive Director on [DATE] at 2:45 PM, she stated the Medical Director communicates with staff when he made his rounds; however, there was no formal education/training specific to falls with staff. In an interview, on [DATE] at 2:30 PM, the Medical Director (MD), stated his role as the Medical Director was to coordinate care and if issues were discovered, he would communicate with the facility Executive Director (ED). Further interview revealed he would expect staff to follow the residents plan of care and implement the interventions as ordered. Per the interview, the MD stated the facility had a high turnover rate and it was difficult to build a system with inconsistent staffing. He further stated the inconsistent staffing contributed to the increase in the residents falls as the staff were unfamiliar with the resident and their behaviors. The MD further stated he was involved with the QA process; however, the facility focused more on percentage of falls the residents had and were not focus on the specific resident. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1.a.) Beginning on [DATE], the Executive Director (ED) reviewed the responsibilities of the Medical Director (MD) with him. The Medical Director's responsible included: administrative decisions, recommending, developing, and approving the facility's policies related to the residents' care; and providing medical and clinical leadership in a multidisciplinary approach to resident care planning within the skilled long-term care facility. b.) The falls policy was reviewed, revised and approved on [DATE]. 2. a.) On [DATE], the Executive Director reviewed the removal plans with the Medical Director for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and to request recommendations for further interventions to decrease the risk of potential injuries to residents related to falls/injuries in the facility. b.) The Medical Director stated he understood the plans and made no recommendations. 3. On [DATE], the Executive Director (ED) reviewed the education provided to the Director of Nursing (DON) and the Staff Development Coordinator (SDC) provided by the [NAME] President of Clinical Services (VPCS) on [DATE], regarding the facility's fall policy. a.) To include ensuring completion of fall risk assessments on admission, quarterly, and with a change in a resident's condition, ensuring that care plan interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall, completion of a thorough investigation following each fall, including a root cause analysis. b.) Discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. c.) The Medical Director made no further recommendations regarding this education. 4. a.) On [DATE], the Executive Director informed the Medical Director that on [DATE], the SDC started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy, including but not limited to initiating an investigation as to the cause of the fall, implementing immediate interventions with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattresses settings would be compatible with resident's weight, comfort and appropriate functioning of the mattress. c.) Documentation was added to the Electronic Medical Record (EMR) for verification of low air mattress settings every shift to ensure that it remained at the appropriate level for each resident. d.) Staff were educated that residents who required an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the nurse manager if changes were needed regarding the support surface. e.) The Nurse Manager would utilize the support surface algorithm from New Source Medical. f.) Newly hired staff, agency staff and staff who had not been educated would receive this prior to working their next shift. g.) The Medical Director made no further recommendations regarding the education of staff members. 5. a.) On [DATE], the Executive Director discussed with the Medical Director that beginning [DATE], the Licensed Nurse would initiate and investigate all falls, implement an immediate intervention and update the care plan. b.) The Clinical Interdisciplinary Team would review residents who had experienced a fall during the morning clinical meeting to ensure a Root Cause Analysis (RCA) was determined, all appropriate interventions to include consideration of the need for increased supervision and/or assistive devices as deemed appropriate were implemented to assist in preventing further falls, review and update the care plan as appropriate, and ensure the intervention was on the Care Plan/CNA Kardex. c.) The DON/ADON/SDC/UM would make an IDT Nurses' Note with the root cause of the fall and intervention that was in place, add any further interventions recommended by IDT. If further recommendations were suggested, the Licensed Nurse would add to the care plan. 6. On [DATE], the Executive Director (ED) informed the Medical Director (MD) that a stand down QAPI meeting would be held daily by the ED to review the above stated, to discuss findings of audits, and determine concerns that may require immediate action. Any adverse findings would be shared with the Medical Director by the Executive Director or Director of Nursing daily for recommendations. 7. a.) On [DATE], an Ad hoc Quality Assurance Process Improvement (QAPI) meeting was held by the Executive Director, the Director of Nursing, Infection Preventionist, Licensed Nurse, and with the Medical Director to discuss the plan initiated to decrease the risk of falls. b.) The method of ensuring that a root cause analysis was completed as part of the investigation following a fall, that consideration was given to the need for increased supervision to decrease the risk of further falls/injuries, that consideration was discussed regarding the need for a change in the resident's environment, the potential need for assistive devices, education provided to staff, and audits for monitoring compliance with fall interventions. c.) No further recommendations were made by the medical director related to this plan. 8. On [DATE], an Ad hoc QAPI meeting would be held daily times two (2) weeks, then weekly for four (4) weeks to discuss the plan, review findings of the above stated audits, and to request the need for further actions and/or modifications to the plan. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy by [DATE]: 1.a.) Facility documentation review and interview with the Executive Director (ED), she stated on [DATE] she went over the responsibilities of the Medical Director (MD) with the Medical Director to include the responsibility for administrative decisions. b.) Facility documentation revealed on [DATE], the falls policy was reviewed, revised and approved on [DATE], by the Medical Director. 2. a.) Facility documentation and during interview with the Executive Director (ED), on [DATE], she stated on [DATE], she reviewed the removal plans with the Medical Director for F656, F689, F835, F837, F841, and F867 to ensure understanding of the requirements of each plan and to request recommendations for further interventions to decrease the risk of potential injuries to residents related to falls/injuries in the facility. b.) Facility documentation revealed the Medical Director stated understanding of the plans and made no recommendations. 2. Facility documentation and during interviews on [DATE] and [DATE],the ED stated on [DATE], that she had reviewed the education provided to the Director of Nursing (DON) and the Staff Development Coordinator (SDC) provided by the [NAME] President of Clinical Services (VPCS) on [DATE], regarding the facility's fall policy. a.) The education included: ensuring completion of fall risk assessments on admission, quarterly, and with a change in a resident's condition, ensuring that care plan interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall, completion of a thorough investigation following each fall, including a root cause analysis. b.) Discussion by the Interdisciplinary Team (IDT) included to review/update the resident's care plan following each fall for further interventions that may require the need for increased supervision or assistive devices as deemed necessary. c.) The Medical Director made no further recommendations regarding this education. During interview on [DATE] at 3:05 PM, with the SDC, she stated she had been re-educated on the Care Plan policy per the VPCS. She stated she explained the importance of care plan interventions to decrease the risk of residents' falls. During interview on [DATE] at 1:40 PM, with the VPCS, she stated on [DATE], she re-educated the Executive Director (ED), the Director of Nursing (DON) and the staff Development Coordinator (SDC) on the facility's fall policy, to ensure completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition, ensuring that care plans interventions were implemented based on findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions. 3. On [DATE], the VPCS, SDC and the DON stated re-education was provided per the VPCS on [DATE]. During interviews on [DATE] thru [DATE], related to the facility's fall policy, the VPCS, SDC and the DON stated education began [DATE] and consisted of the importance to ensure completion of fall risk assessments on admission, quarterly, and with significant change in the resident's condition were completed. They also stated that the reeducation included to ensure that care plan interventions were implemented based on the findings of the fall risk assessment, implementing an immediate intervention following each fall including a root cause analysis, and discussion by the Interdisciplinary Team (IDT) to review/update the resident's care plan following each fall for further interventions to include the need for increased supervision or assistive devices as deemed necessary. 4. a.) Facility documentation and review of staffs' personnel records specific to education and sign-in sheets revealed on [DATE], the Executive Director informed the Medical Director that on [DATE], the SDC started re-educating all current Licensed Nurses and Certified Nursing Assistants (CNAs) on the facility's fall policy, including but not limited to initiating an investigation as to the cause of the fall, implementing an immediate intervention with consideration of the need for increased supervision or the addition of assistive devices, and reviewing/updating the care plan with each fall. b.) Education also included that low air loss mattresses settings would be compatible with the resident's weight, comfort and appropriate functioning of the mattress. c.) Documentation was added to the Electronic Medical Record (EMR) for verification of low air mattress settings every shift to ensure that it remains at the appropriate level for each resident. d.) Staff were educated that residents who required an air loss mattress would require two (2) staff members to assist with turning and repositioning in bed to decrease the risk of falls, and to notify the nurse manager if changes were needed regarding the support surface. e.) The Nurse Manager would utilize the support surface algorithm from New Source Medical. f.) Newly hired staff, agency staff and staff who had not been educated would receive this prior to working their next shift. g.) The Medical Director made no further recommendations regarding the educa [TRUNCATED]

Based on interview, record review, review of the facility's policies, documents, Executive Director's Job Description, and Plan of Correction (PoC) submitted for the 03/05/2020 Recertification Survey, it was determined the facility failed to have an effective process in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track adverse resident events, analyze their causes, and implement effective preventive action. The facility failed to ensure there was an effective system in place to regularly review and analyze audit data, including data collected under the QAPI program, and act on available data to make improvements and maintain substantial compliance. In addition, review of the facility's documentation revealed fall tracker information noting the facility had a total of one-hundred and eight (108) falls within a four (4) month timeframe, 01/01/2023 through 04/30/2023, of which thirty-three (33) of those fall resulted in injuries. However, there was no documented evidence the facility discussed the one-hundred and eight (108) falls, nor reviewed the resident's previous falls, analyzed the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered interventions to prevent further falls. Interview and record review revealed the facility had no system in place to thoroughly investigate the root cause of residents' falls. Additionally, there was no documented evidence to support the facility's QAPI analyzed the data collected to decrease the occurrence of residents' falls. The continued failure of the facility to utilized the data collected resulted in a lack of action to correct the systemic, high-risk issue of residents' falls. The facility's failure to have an effective system in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) process has caused or is likely to cause serious harm or serious injury to the residents. Immediate Jeopardy (IJ) was identified on 05/26/2023 and was determined to exist on 07/08/2022 in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Develop/Implement Person-Centered Comprehensive Care Plans, (F656) at a S/S of a K; 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689) at a S/S of a K; 42 CFR 483.70 Administration (F835, F837, and F841), at a S/S of a K; and 42 CFR 483.75 Quality Assurance and Performance Improvement, (F867) at a S/S of a K. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, Accidents and Supervision (F689). The facility was notified of the Immediate Jeopardy on 05/26/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, with the facility alleging removal of the Immediate Jeopardy on 06/01/2023. The State Survey Agency (SSA) validated removal of the Immediate Jeopardy, as alleged on 06/01/2023, prior to exit on 06/10/2023. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement Program, effective date of 03/19/2018, revealed the purpose of its QAPI was to ensure the mission of the facility was actualized through the establishment of resident centered quality management processes, and to ensure that proactive quality care and services were provided to each resident on a continuous basis. Continued review revealed the policy's purpose also included allowing access of direct care givers, manager, and customers to quality improvement mechanisms, ensuring compliance with regulations and standards of practice and providing timely solutions to spontaneous events. The policy noted the Executive Director (ED) was to be devoted to continuous quality assurance and improvement. Further review of the policy revealed the objectives of the facility's QAPI program included a systemic process designed to ensure care practices were consistently applied, and the facility met or exceeded an expected standard of quality. In addition, the facility's QAPI program developed and implemented appropriate plans of action to correct identified quality deficiencies based on root cause analysis and prioritization of topics identified and maintained formal written documentation as evidence of ongoing quality management. Review of the Executive Director's Job Description, undated, revealed the ED directed and performed quality assessment and assurance functions, including but not limited to: regulatory compliance rounds to monitor performance and to continuously improve quality. According to the job description, implementation of programs to gather and analyze data for trends and to institute actions to resolve problems promptly was a duty of the ED. In addition, per the job description, the ED was to ensure proper documentation was maintained, including but not limited to, meetings and QAPI improvement plans. Review of the facility's acceptable Plan of Correction (PoC) for the Recertification Survey, dated 03/05/2020, revealed for the substandard deficient practice which had been cited at F689, the facility had educated all licensed staff, the ED, Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Minimum Data Set (MDS) Coordinator, and the Staff Development Coordinator (SDC) on the Falls Management Policy which included completing the Morse Falls Risk Evaluation (a tool developed for assistance in identifying residents at risk for falling). Continued review of the PoC revealed education was completed for the ED, DON, ADON, and SDC regarding utilizing the Stop and Watch form, a communication form developed by the Centers for Medicare and Medicaid Services (CMS). Further review revealed the education also encompassed communicating a change in a resident's condition including, but not limited to, pain, concerns related to sleep changes, and/or needing increased help from staff. The education additionally included developing, implementing, and revising care plans to include appropriate interventions based on root cause analysis and review of previous falls to identify trends and assist in determining the most appropriate interventions. Additional review of the acceptable PoC, for the Recertification Survey dated 03/05/2020, revealed the Interdisciplinary Team (IDT) was to review in the facility's daily clinical meeting (Monday through Friday) each fall in the nursing shift report to ensure the falls risk evaluation had been completed for the resident involved. Continued review revealed the IDT was to review the involved resident's recent fall history, to include the five (5) Why's (a tool approved by CMS for identifying root cause analysis), completed by licensed nurses, to assist in determining the appropriate intervention at the time of the fall. Per review of the PoC, beginning on 01/20/2020, the Nursing Consultant, ED, DON, ADON, and Assistant Administrator were to be onsite at the facility to monitor the process related to adequate supervision to prevent accidents/incidents until the Immediate Jeopardy (IJ) was removed and substantial compliance had been achieved, and pending QAPI Committee review. PoC review revealed any concerns identified were to be addressed immediately and reported to the QAPI Committee weekly for review and for further recommendations. The PoC stated the QAPI Committee meeting was to be held at least bi-weekly to discuss issues with the Medical Director and also on an as needed basis. In addition, the PoC noted the IDT was to meet daily to discuss the findings and progress; review all falls daily with the Physician to ensure appropriate interventions were implemented. Review further revealed the PoC noted the ED, ADON Assistant Administrator, and DON were to ensure all newly hired staff and agency staff received education on New Hire Orientation or prior to working the floor. Review of the facility's fall tracker documentation revealed the facility noted a total of one-hundred and eight (108) falls occurred within a four (4) month time period, 01/01/2023 through 04/30/2023. Continued review revealed of the one-hundred and eight (108) falls, thirty-three (33) of the falls resulted in injuries to residents, which included twenty-three (23) residents who sustained repeated falls, and three (3) residents who had sustained fractures from falls. However, there was no documented evidence the facility's QAPI Committee discussed the one-hundred and eight (108) falls, nor reviewed the resident's previous falls, analyzed the time of day and staff patterns for each fall in order to determine the root cause of the falls and to implement person centered interventions to prevent further falls. Review of the facility's monthly QAPI Committee meeting minutes, from 02/28/2022 to 04/30/2023, revealed the Committee members noted as present were: the Social Services Director (SSD), the Medical Director (MD) via phone; Licensed Practical Nurse (LPN) #8; MDS Coordinator; Activities Director (AD); ED; Human Resources Director; Director of Nursing (DON); Advanced Practice Registered Nurse (APRN); Assistant Director of Nursing (ADON); and Unit Manager (UM). Continued review of the QAPI meeting minutes for the dates of 02/28/2022, 03/31/2022, 07/14/2022, and 04/20/2023 revealed no documented evidence the minutes included discussion of residents' falls (with or without injuries), reviewing residents' previous falls, performed a root cause analysis of the falls and/or implemented appropriate person-centered care plan interventions as per the PoC. Review revealed however, on 07/14/2022, the Quality Measures review which included falls indicated the facility's falls for June 2022, was noted as 49.1 %; for May 2022 as 66%; and for April as 70%, with the National average noted as 43.7%, and the State average as 47.3%. Per review, even though there was the Quality Measures review there were no comments, notes and/or an action plan documented, nor review of the PoC regarding the facility's noncompliance related to falls. Further review of the facility's last year of QAPI notes dated 02/28/2022 through current, 04/20/2023, revealed the facility's QAPI Committed failed to develop and implement appropriate plans of action to correct identified quality deficiencies based on root cause analysis and prioritization of topics of identified issues/concerns related to residents' falls with major injury. In addition, the facility's QAPI Committed failed to maintain formal written documentation as evidence of ongoing quality management to promote and ensure resident safety. During an interview on 05/23/2023 at 1:05 PM, the Maintenance Supervisor stated he had not been involved in the facility's morning IDT meetings and QAPI Committee meetings until this month. He stated his recent attendance was due to the recent need and question of equipment related to residents' accidents and falls. The Maintenance Supervisor stated that week he removed two (2) low air loss (LAL) mattresses from residents' beds due to recent auditing/monitoring of residents. He stated if a resident was mobile, then the resident did not need an air mattress. He further stated he could see the LAL mattresses being a risk factor for causing residents to fall, especially those residents with mental issues. During an interview on 05/24/2023 at 9:30 AM, the DON stated she had been in her role since March 2023. She stated in the last month or so (no specific date provided), she had been involved with care conferences related to resident falls and incidents, and had observed the environment and updated care plans with resident involvement. The DON stated information on falls was brought to the QAPI meetings and discussed. However, she stated she had not attended recent QAPI meetings. According to the DON, all the data related to residents' falls was to continue to be brought to the monthly QAPI Committee meetings, with the Medical Director's involvement: to discuss residents' history of falls since admission, behaviors and/or any contributing factors to include medications, residents environment and to discuss interventions with the QAPI team. She further stated however, the facility's normal previous routine, had been for the QA process to be done through chart reviews and room checks. In addition, she stated there had previously been no resident specific discussions related to falls. During an interview on 05/05/2022 at 2:30 PM, the Medical Director stated in his role he coordinated resident care, and if issues were discovered, he communicated with the ED. He stated he expected staff to follow resident's plans of care and implement the interventions as ordered. Per the Medical Director, staff knew what residents' problems were, as well as the resident's patterns; however, unfortunately, staff had not followed through. The Medical Director stated the facility had a high staff turnover rate which caused inconsistent staffing that made it difficult to build a system because the staff members were not trained or educated on the proper care needs of the residents. He stated all of that contributed to the increase in residents' falls. The Medical Director stated he was engaged in the facility's QAPI metrics related to falls, which had been trending upward in numbers. During an interview on 06/10/2023 at 9:44 AM, the ED stated she had been in her role since July 2022 and was responsible for ensuring the facility operated within state and federal guidelines and maintained regulatory compliance regarding previously cited deficiencies. The ED stated she was also responsible for the facility's day-to-day functioning, and was the Quality Assurance Coordinator and responsible for that program. She stated she was required to ensure the facility's ongoing audits related to previously cited deficiencies were reviewed, and any concerns identified were immediately corrected. The ED stated the facility had implemented audits; however, had focused on tracking and trending previous falls specific to the facility's percentages and numbers, and not onresident specific requirements as to the change with the current PoC. According to the ED, the facility's Interdisciplinary Team (IDT) had not been establishing the actual root cause of residents' falls and neglected the overall resident specific picture/part. She stated the collaborative involvement needed, in order to get down to the actual root cause of a resident's fall was missing. Therefore, she stated the falls review which occurred had been missing the most important parts and potentially had placed residents at higher risk of falls and/or injuries. She further stated if all risk factors were not addressed, it did put residents at risk of having a negative outcome which could have been prevented. During an interview on 06/10/2023 at 10:28 PM, the [NAME] President of Operations (VPO) stated he started working for the corporation on 05/30/2023. He stated he provided in person oversight to the facility's Governing Body which included the ED and [NAME] President of Clinical Operations (VPCO), starting on 05/31/2023, and had been involved with the revisions of the facility's PoC on 06/05/2023. The VPO stated his role was to provide general operational oversight of the facility; performing policy review and revision; and ensuring preventive measures for the understanding of standards of care, policies, and their implementation. He stated the difference in the facility's corrections from the 2020 falls PoC compared to the current PoC being developed was related to the education. He stated now the importance and focus was on root cause analysis, looking into the injuries, appropriate risk factors, starting from the admission process, and ensuring proper resident specific preventive measures were in place and sustained. The VPO stated those preventive measures should have already been implemented and a part of the facility's process. During an interview on 06/09/2023 at 1:40 PM, the [NAME] President of Clinical Operations (VPCO), stated she was a member of the facility's Governing Body (GB), which also included the ED and the VPO. The VPCO stated her role was to provide oversight of the ED and facility, guidance for the ED and education regarding policies and procedures. She stated beginning on 05/17/2023, she had been onsite to provide staff support while the State Survey Agency was in the building. The VPCO stated she identified on 05/19/2023, that no orders were in place for air mattresses, and she performed an audit of residents who had an air mattress. She stated the results of that audit resulted in her discontinuing two (2) residents' low air loss (LAL) mattresses. Per the VPCO, throughout that time she communicated with the Senior [NAME] President of Clinical Operations (SVPCO), and the SVPCO had been in agreement with her. She stated she periodically attended QAPI, performed a lot of on the spot training, and researched QAPI tools to provide education of root cause analysis and the facility's trending to increase resident supervision. The VPCO stated the facility's failure related to residents' falls had been that there was no system in place to determine the root cause of the falls, which resulted in neglecting the residents' needs. She stated that investigating the why of the fall happening, in order to promote a thorough investigation. She stated prior to the the deficiencies and auditing of residents' medical records, staff members attempted to identify the root cause of residents' falls. The VPCO stated however, staff had required additional education regarding root cause analysis, and explanation of the process of identifying the appropriate root cause. She stated audits revealed the need for staff education and the importance of a system-wide approach. According to the VPCO, it was determined there needed to be a procedure to improve the interview process, which included pre-fall resident information containing staff interviews/involvement. She stated there needed to be an immediate investigation/action implemented and followed through related to the actual root cause, of falls/incidents to promote an appropriate immediate intervention, such as increased supervision of the involved resident. The facility provided an acceptable Immediate Jeopardy Removal Plan on 06/07/2023, alleging removal of the Immediate Jeopardy on 06/01/2023. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following. 1. On 05/23/2023, the facility did not have documentation to support there was an effective QAPI Program to investigate the root cause of falls for Residents #1, #16, #17, #18, and #19. (a). Resident #1 no longer resided in the facility. (b). Falls for Residents #16, #17, #18, and #19 were reviewed by the QAPI Committee on 05/23/2023. A root cause analysis (RCA) was performed for each of the resident's falls, and care plan interventions were implemented related to findings of the RCA for each resident. 2. (a). On 05/23/2023, an audit of falls in the facility for the last ninety (90) days was conducted by the ED, DON, Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and [NAME] President of Clinical Services (VPCS). (b). Care plans were reviewed for residents who experienced a fall in the last three (3) months to ensure an appropriate intervention was in place to decrease the risk of falls. Corrective actions were completed as indicated. 3. (a). On 05/29/2023, the ED, DON, and Medical Director, through the QAPI Committee, initiated a performance improvement project (PIP) sub-committee comprised of the DON, ADON, SDC, Unit Manager (UM), Charge Nurse, Certified Nursing Assistant (CNA), Director of Rehabilitation Services, Activity Director (AD), and Housekeeping Supervisor. (b). The ED charged the PIP sub-committee team with analyzing the falls data, completing a trending of the data, completing a root cause analysis of falls in the facility, interviewing residents and staff regarding fall risk, utilizing feedback and information to develop a plan, and reporting the findings to the QAPI Committee by 05/30/2023. The facility's plan was to decrease the number of falls; and therefore, reduce the risk of injury from falls. 4. (a). On 05/29/2023, education was provided for the ED, DON, and Medical Director by the VPCS, regarding the requirement to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focused on indicators of the outcomes of care and quality of life. (b). Included in the education were the five (5) elements of QAPI and making the process an active part of identifying concerns and initiating PIPs to collect and analyze data, complete root cause analysis, develop a plan, and monitor the effectiveness of the plan. 5. On 05/29/2023, a Stand-down QAPI Committee meeting would be held daily by the ED to review the above, to discuss findings of audits of plans for F656, F689, F835, F837, F841, and F867 and determine concerns which might require immediate action. Corrective actions were to be initiated immediately. 6. On 05/29/2023, an Ad Hoc QAPI Committee meeting was held by the ED, DON, Infection Preventionist, Licensed Nurse, and Medical Director to discuss the plans initiated to decrease the risk of falls. (a). In the meeting they determined a method for ensuring a root cause analysis would be completed as part of the investigation following a fall; that consideration was given to the need for increased supervision to decrease the risk of further falls/injuries; that consideration was discussed regarding the need for a change in the resident's environment; the potential need for assistive devices; education provided to staff; and audits for monitoring compliance with fall interventions. (b). Discussion with the QAPI Committee included the development of a PIP to decrease the number of injuries related to falls and ensure an effective plan with monitoring was initiated. 7. Starting 05/29/2023, a QAPI Committee meeting was to be held daily times two (2) weeks, then weekly for four (4) weeks, then monthly to ensure continued compliance with the above stated plan to ensure continued compliance with follow-up and recommendations by the Governing Body. 8. Beginning 05/30/2023, education was conducted by the VPCS for the QAPI Committee, which included the DON, ADON, SDC, UM, Dietary Manager (DM), and Social Services Director (SSD) on the QAPI program. (a). Education included QAPI goals, elements of the QAPI program, facility implementation of the QAPI program, staff's role in the QAPI program, and how to communicate concerns, problems, or opportunities for improvement to the QAPI Committee. (b). Also discussed was the facility's current PIP, with a goal of reducing falls and injuries related to falls, and the role of staff in the PIP. Staff including agency staff and volunteers not in the facility on 05/31/2023, were to receive education prior to working in the facility. 9. (a). On 05/30/2023, education was initiated by the SDC for facility staff, agency staff, and volunteers on the QAPI program. (b). Education included QAPI goals, elements of the program, facility implementation of the QAPI program, staff's role in the QAPI program, and how to communicate concerns, problems, or opportunities for improvement to the QAPI Committee. (c). Also discussed was the facility's current Performance Improvement Project (PIP), with a goal of reducing falls and injuries related to falls, and the role of staff in the PIP. Staff including agency staff and volunteers not in the facility on 05/31/2023 would receive education prior to working in the facility. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on 06/01/2023 prior to exit on 06/10/2023. 1. Review of the facility's documentation confirmed the facility's conclusion its QAPI had not been effective in investigating the root cause of Residents #1, #16, #17, #18, and #19's falls. (a). Review of Resident #1's closed record review confirmed the resident no longer resided in the facility. (b). Review of Residents #16's, #17's, #18's, and #19's records and review of the facility's QAPI Committee minutes dated 05/23/2023, confirmed the QAPI Committee performed a root cause analysis (RCA) of the residents' falls, and implemented care plan interventions related to the findings of the RCA for each resident. 2. (a). Review of the facility's falls audit documentation and tracking/trending report confirmed on 05/23/2023, the audit of falls was conducted for the past ninety (90) days by the ED, DON, ADON, SDC, and the VPCS. (b). The records of residents noted as having experienced a fall in the past ninety (90) days were reviewed, including their care plans and Kardex and corrective actions alleged were confirmed. In an interview on 06/09/2023 at 4:00 PM, the SSD stated she audited fall care plans last week. She stated she went through the care plans with an IDT note to audit the resident's fall risk and develop appropriate interventions as a team with the ED, Supervisors, Unit Managers, ADON, and DON. The SSD further stated the IDT identified and updated residents' fall risks and ensured appropriate interventions were developed for each fall risk resident's care plan. In an interview on 06/09/2023 at 3:05 PM, the SDC stated the IDT realized the facility's failures with the citations, which revealed the importance of air mattress education that needed to be provided for staff. The SDC stated the IDT also realized the importance of the need for increased supervision for residents at high risk for falls, including one-to-one (1:1) supervision, and the importance of updating care plans and the IDT following-up on care plans. She stated a system failure had been identified by the IDT specific to the importance of proper care for the residents. The SDC stated proper care for residents included ensuring residents were toileted timely, were repositioned as necessary, had their pain addressed, and had their personal items within reach. She stated staff members must ensure follow through with such actions, and have more education: on being observant, investigating the root cause of falls, updating the care plan with appropriate fall interventions, and implementing those interventions. Per the SDC, the facility's QAPI initiated actions were to increase QAPI education with staff and explain the QAPI process. She stated the IDT was now evaluating falls indepth to reduce the falls and providing a better quality of care to residents. The SDC stated staff were having input in the QAPI Performance Improvement Project (PIP) on falls initiated on 05/30/2023 and team meetings were being held, specific to falls, with floor staff involvement and input for staff to work more cohesively and improve resident safety. 3. (a). Review of the facility's QAPI Committee documentation revealed a meeting was held on 05/29/2023, in which the ED, DON, and MD, initiated a PIP sub-committee comprised of the DON, ADON, SDC, Unit Manager, Charge Nurse, CNA, Director of Rehabilitation Services, Activity Director, and Housekeeping Supervisor. (b). Continued review of the facility's QAPI Committee documentation revealed the ED charged the PIP sub-committee team with analyzing falls data, completing a trending of the data, and completing root cause analysis of falls. Review additionally revealed the ED also charged the PIP sub-committee with interviewing residents and staff regarding fall risk, utilizing the feedback and information to develop a plan, and reporting the plan to the QAPI Committee by 05/30/2023. Review further revealed the plan initiated on 05/30/2023, was to decrease the number of falls, and therefore the risk of residents' injury from falls. In interview on 06/09/2023 at 4:00 PM, the SSD stated the staff education on the QAPI process regarding the PIP was more beneficial now, as previously the QAPI and the PIP had not been very well known by staff. However, she stated now from the QAPI meetings and discussion of the PIP process to decrease the number of falls/injuries had promoted increased staff communication and participation with the PIP. 4. In an interview on 06/10/2023 at 9:33 AM, with the DON and at 9:40 AM, with the ED, they stated on 05/29/2023, they were provided education by the VPCS, and the Medical Director was also present for the education. They stated the education was regarding the requirement for developing, implementing, and maintaining an effective, comprehensive, and data driven QAPI program for the facility that focused on indicators of the outcomes of care and quality of life for residents. The ED stated the education also included identifying concerns, the five (5) elements of QAPI, initiating PIPs to collect and analyze data, completing root cause analysis, developing a plan, and monitoring the effectiveness of the plan. In an interview on 06/10/2023 at 1:40 PM with the facility's Corporate Operations Officer (COO), [NAME] President of Clinical Operations (VPCO) the COO stated education had been provided to the ED and DON specific to their roles and responsibilities to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident. 5. Review of the facility's QAPI Committee documentation revealed a Stand-down QAPI meeting was held daily beginning on 05/29/2023. Review of the minutes for the 05/29/2023 Stand-down QAPI meeting held at 3:00 PM, revealed the meeting was held to discuss the plans for the deficiencies identified at F656, F689, F835, F837, F841, and F867. Further review of the facility's QAPI Committee documentation revealed Stand-down QAPI meeting were held daily as alleged. In interview on 06/10/2023 at 9:44 AM, the ED stated on 05/29/2023, a Stand-down QAPI meeting was held and continued to be held daily in order to complete a comprehensive review of the plan of correction to include action taken for in-house cited resident(s); review of actions taken for residents not cited; and education plan and audit tools and schedule for completion. The ED stated a root cause analysis, Comprehensive Care Plan review for falls and IDT review of current and newly developed interventions occurred. He stated consultation with Therapy Services and/or Medical Director, and/or family/responsible party for cited residents as well as other residents at risk for falls was conducted as a portion of the review. Per the ED, facility staff were interviewed to elicit feedback on the care and services of the cited residents as well as encouraged to bring concerns to the QAPI Committee as it related to falls. 6. Review of the QAPI Committee minutes from the 05/29/2023 meeting revealed an Ad Hoc meeting was held to discuss the plans initiated to decrease the risk of falls. In attendance was the ED, DON, Infection Preventionist, Licensed Nurse, and the Medical Director. (a). Continued review of the 05/29/2023 Ad Hoc QAPI Committee minutes revealed the method determined to reduce falls was to ensure a root cause analysis (RCA) was completed as part of the investigation following a resident's fall, and for consideration to be given to the need for increased supervision of residents to decrease the risk of further falls/injuries. Review of the minutes further revealed it was additionally determined consideration was discussed regarding the need for a change in environment of a resident who sustained a fall; for

Based on observation, interview, record review, and policy review, it was determined the facility failed to store all drugs and biologicals in locked compartments and under proper temperature control. In addition, the facility failed to ensure all medications and/or biological supplies stored on the 200 Hallway medication storage room had not expired. On 05/31/2023, 06/01/2023, and again on 06/09/2023, three (3) licensed nurses assigned to medication (med) carts on the 100 and 200 hallways failed to lock their med carts when away from the carts. On 06/07/2023, the thermometer in the medication refrigerator on the 300 Hallway, registered 64 degrees Fahrenheit.(F). However, according to the log posted on the refrigerator door, the refrigerator temperature should be below 41 degrees Fahrenheit. Further review of the log posted on the refrigerator indicated temperatures had not been measured and documented twice daily in the month of June 2023. Observation, on 06/09/2023 of the 200 Hallway medication storage room revealed there were expired products available for use. The findings include: Review of the facility's policy titled, Storage of Medications, revised November 2020, revealed: The facility stored all drugs and biologicals in a safe, secure, and orderly manner. Bullet number three (3) of the policy indicated the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Bullet six (6) of the policy indicated compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals were locked when not in use. Unlocked medication carts were not left unattended. Observations, on 05/31/2023 at 8:53 AM and again at 9:17 AM, revealed an unlocked, unattended medication cart parked between the main hallway and the 100 Hall resident care area. Further observation revealed the drawers faced outward and were accessible to anyone passing by. In an interview with Licensed Practical Nurse (LPN) #4 on 06/01/2023 at 2:05 PM, LPN #4 stated on 05/31/2023 she was not aware that she walked away and left the cart unlocked. However, she should have locked the medication cart when she walked away from it. LPN #4 said before leaving the cart, the nurse and/or medication aide should always lock the cart. She stated leaving the medication cart unlocked was unsafe because wandering and confused residents could possibly access the contents of the cart. She stated there were some confused and wandering residents living on the 100 Hallway, and she specifically mentioned Residents #36, #46, and #65. During an observation of the 200 Hallway on 06/01/2023 at 8:46 AM, revealed an unlocked, unattended medication cart parked outside of room [ROOM NUMBER] with the drawers facing outward, accessible to anyone passing by the cart. In an interview, on 06/01/2023 at 1:45 PM, with LPN #11, he stated he was an agency nurse, and this was his second time working at the facility. The LPN stated he was aware he left his medication cart unlocked while he was in resident room [ROOM NUMBER]. He stated he thought as long as he could reach out from the resident's room and touch the cart, then it was okay to leave it unlocked. LPN #11 stated he was in the room administering Resident #88's medications, but realized he had forgotten to bring in the resident's inhaler and a cup of water, so he returned to the medication cart to get the items. LPN #11 stated the medication cart should remain locked, when unattended, so that no one else could get into it and take the residents' medications. He stated the 200 Hallway Unit Manager (UM) informed him there were three (3) residents who tended to wander about the unit, and that he should keep an eye on them. However, at the time of the interview, he stated he could not remember their names. He stated he had not received any education/training on securing residents' medications since he had worked at the facility. During an observation on the 200 Hallway, on 06/09/2023 at 8:10 AM, an unlocked medication (med) cart was parked near the 200 hallway nurses' station. Further observation revealed the cart was not visible to the nurse who was assigned to the cart. Observation revealed LPN #12 was standing at the nurses' station, but a tall divider/computer shelf prevented the LPN from seeing the unlocked cart. The medication drawers were facing outward, and accessible to passersby. One resident was seated in his/her wheelchair near the cart. Before entering the 200 Hallway medication storage room with the State Survey Agency (SSA) Surveyor, the LPN briefly stepped outside the nurses' station to speak with with a resident, and then noted and locked the medication cart. In an interview, on 06/09/2023 at 12:50 PM, LPN #12 stated she was an agency nurse, and it had been about a year since she had worked at the facility. She stated she received some training that morning before starting her shift, and she thought the instruction on keeping medications locked and secured had been discussed during that brief training session. The LPN stated she was unsure why she had left the medication cart unlocked. LPN #12 stated medication carts should remain locked when not in sight of the nurse who was assigned to the cart, because one never knew who might get into the cart and remove the medications. The LPN stated if a confused resident opened the cart he/she could potentially ingest some of the medications. She stated since she had not worked on the unit until today. The LPN stated she would be unable to identify residents on the unit who might be confused or disoriented. Observation on 06/07/2023 at 2:45 PM, revealed the thermometer inside the 300 Hallway medication refrigerator read sixty-four (64) degrees Fahrenheit. Review of the refrigerator temperature log posted on the outside door of the refrigerator, titled Cooler/Freezer Temperature Log, June 2023, 300; Med Room, indicated the refrigerator temperatures were to be checked in the AM and in the PM (twice) over a twenty-four hour period, seven (7) days per week. The directions indicated the medication refrigerator should be below 41 degrees F. However, review of the log for the month of June 2023 revealed the temperature readings were missing for the PM reading on 06/ 01/2023; the AM and PM readings on 06/02/2023; the AM temperature reading on 06/03/2023; the AM reading on 06/04/2023; and the AM and PM readings on 06/05/2023. Observations on 06/07/2023 at 2:45 PM, of the contents of the refrigerator included: one (1) Novolog Insulin Pen for Resident #23, one (1) Insulin Glargine (Lantus) Solostar Insulin Pen for Resident #44; three (3) full boxes of Arformoterol Tartrate Inhalation Solution packets, thirty (30) per box, and one (1) additional box with twenty-three (23) packets remaining. Additional contents of the refrigerator included Emergency Drug Kit (EDK) medications that included: one (1) bottle of Lorazepam 2 milligrams (mgs)/milliliter (ml); two (2) Levemir Insulin Flex Pens 100 mg/ml; 2 Lantus Insulin Solostar pens 100 units/ml; four (4) Humalog Insulin Flex Pens 100 units/ml; and 3 Novolog insulin pens, 100 units/ml. In interview, on 06/07/2023 at 2:45 PM, the 300 Hallway Unit Manager (UM) stated she thought the medication refrigerator temperature range should stay around thirty-six (36) to forty-six (46) degrees. She stated medications must be stored at the appropriate temperatures to ensure the medications remained effective for use. The Unit Manager stated a licensed nurse on each twelve (12) hour shift should read and record the refrigerator temperature on the paper log posted on the front of the medication refrigerator. She stated if she happened to see any missing temperature readings, she would have the nurses fill in the temperature reading on the log. The 300 Hallway UM stated she had been the UM for about 2 to 3 weeks, and had not noticed that several refrigerator temperatures had not been recorded twice daily as, required. In an interview on 06/09/2023 at 3:50 PM with Kentucky Medication Aide (KMA) #24, the KMA stated she worked night shift on 06/07/2023, and noted that some of the refrigerator temperatures had not been recorded as expected, but she did not report that to the 300 Hallway UM. She stated she told the nurse on duty, but the nurse said staff could not go back in and document temperatures after the fact. KMA #24 stated staff was supposed to check the temperature in the refrigerator, and document the result on the paper log every shift. She stated monitoring and recording the refrigerator temperatures would help staff identify any issues with the function of the medication refrigerator, and prevent medications from becoming ineffective or unsafe for resident use. During an observation, on 06/09/2023 at 8:14 AM of supplies stored in the 200 hallway medication room the following items were found expired: One (1) Fisherbrand microorganism collection transport system (culture swab set), had an expiration date of 08/17/2022; 2 packaged Heparin Lock flush syringes, five (5) mls each had an expiration date of 06/01/2023; 2 BBL culture swab collection systems, with an expiration date of 08/31/2021, and 1 Secondary Intravenous (IV) administration set 20 drops per ml, with an expiration date of 10/27/2021. In interview on 06/09/2023 at 2:30 PM, the Director of Nursing (DON) stated licensed nurses should know that medication carts must remain locked when they were not attended. The DON stated, when making Unit rounds, the ADON, and the Staff Development Coordinator (SDC) monitored to ensure medication carts were locked, but they had not completed an audit to determine if there was a pattern of unlocked carts on certain hallways, or repeated instances by any particular staff members. She stated when she made rounds and observed an unlocked med cart, she locked it and educated the staff member assigned to that cart. The DON stated medications must always be securely stored because confused residents might access the medications, and might think the pills were candy. She stated a member of the public might try to take the medications from an unlocked cart. Further, the DON stated she would not want the medications to be opened, or moved around in the cart disorganizing or possibly damaging them. During continued interview with the DON, on 06/09/2023 at 2:30 PM, regarding expired products in the 200 Hallway medication storage room, the DON stated all medications and biologicals available for resident care should be in date. She stated staff could not be sure if expired supplies were safe and effective for use. The DON stated staff should measure and record the medication refrigerator temperatures on the log posted on the exterior of the refrigerator to ensure the temperatures remained in range for proper/safe storage of the contents; to detect in any out-of-range temperatures; and in order to report them to the UM. The DON stated the Kentucky Medication Aide should ensure the refrigerator temperatures were recorded on the log each shift. The DON stated the log posted on the 300 Hallway medication refrigerator on 06/07/2023, during the State Survey Agency Surveyor's observation, was a version that the UM posted, but it was not the corporate generated log which indicated the medication refrigerator temperatures should be between 36-46 degrees Fahrenheit, according to the United States Pharmacopoeia Guidelines. In interview with the Executive Director (ED), on 06/10/2023 at 9:34 AM, she stated the UMs should be reviewing the medication refrigerator temperature logs daily to ensure staff were consistently monitoring the temperature to ensure the refrigerator remained at an temperature range for storing medications. She stated the UMs, and other nursing managers should observe the medication carts to ensure they remained locked when not in use. She stated the DON should report any identified staff noncompliance with safe storage of medications, and any expired medications or biologicals found in the medication rooms, because she wanted to participate in corrective action for those types of issues. She stated going forward, managers would increase monitoring on the units to identify noncompliance, and provide additional staff education, as needed. The ED stated if there was continued non-compliance among the staff, then she would have to take other steps to address the issues.

Based on interview, observation, record review and review of the facility's policies, it was determined the facility failed to protect residents from abuse for eight (8) of forty-seven (47) sampled residents (Residents #8, #37, #57,#59, #71, #82 and #95 ). On 06/20/2023, Resident #59 hit Resident #57 on his/her right posterior middle finger, with his/her Reacher. Further review of the facility's investigation revealed Resident #57 reported to staff that he/she wanted to go out into the hallway; however, Resident #59 was sitting in his/her way. Resident #57 further stated he/she grabbed Resident #59's reacher to keep Resident #59 off of him/her, which resulted in a skin tear. On 10/10/2022, Resident #71 struck Resident #82 with his/her reacher (an assistive device used to retrieve items/objects), resulting in Resident #82 striking Resident #71 back with his/her reacher. On 10/05/2022, Resident #8 struck Resident #59. On 10/30/2022, Resident #37 slapped Resident #95 in the face while Resident #95 was sitting in his/her wheelchair in the main hallway. On 02/03/2023, dietary staff reported she overheard a staff member Certified Nursing Aide (CNA #4) curse while providing care to Resident #88. On 06/02/2023, Resident #59 hit Resident #57 with his/her reacher. The findings include: Review of the facility's policy titled, Resident Rights-Kentucky, effective date 01/09/2020, revealed all residents had the right to be free from mental and physical abuse. Review of the facility's policy titled, Freedom from Abuse and Neglect, undated, revealed the facility defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Further review of the policy revealed examples of abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse.' The policy further revealed willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Continued review of the policy revealed the facility was responsible for protecting the residents from harm. Review of the Facility's Investigation, dated 06/02/2023, revealed Resident #59 hit Resident #57 on his/her right posterior middle finger, with his/her Reacher. Further review of the facility's investigation revealed Resident #57 reported to staff that he/she wanted to go out into the hallway; however, Resident #59 was sitting in his/her way. Resident #57 further stated he/she grabbed Resident #59's reacher to keep Resident #59 off of him/her, which resulted in a skin tear. 1 a). Review of Resident #57's Admission Record revealed the facility admitted the resident on 10/01/2021, with diagnoses to include: Alzheimer's Disease, Dementia, and Spinal Stenosis. Review of Resident #57's Quarterly Minimum Data Set (MDS), dated [DATE], revealed, the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) which indicated the resident had moderately impaired cognition. 1 b). Review of Resident #59's Admission record revealed the facility had admitted the resident on 07/08/2021 with diagnoses of heart failure, major depressive disorder, anxiety, atrial fibrillation, and hypothyroidism. Review of Resident #59's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), which indicated the resident had moderately impaired cognition. During an interview, on 06/02/2023 at 2:20 PM, Resident #57 stated Resident #59 was swinging his/her reacher around and when he/she told Resident #59 that he/she was going to tell the nurse, Resident #59 said no and hit him/her with his/her reacher. During interview, on 06/04/2023 at 8:50 PM, Family Member #2 stated Resident #59 told him/her that he/she was sitting in the doorway and Resident #57 was trying to get around him/her. Family Member #2 stated that Resident #57 told him that Resident #59 hit him/her with a reacher. During an interview on 06/08/2023 at 11:00 AM, Certified Nursing Assistance (CNA) #9 stated Resident #57 and Resident #59 were tugging back and forth with the reacher stick when she entered the room. CNA #9 stated Resident #57's hand was bleeding and Resident #57 had reported that Resident #59 had hit her him/her with the reacher. During an interview on 06/08/2023 at 12:37 PM, Registered Nurse (RN) #2, stated she was in her office and heard screaming coming from Resident #57 and Resident #59's room. RN #2 stated when she entered the residents' room, she observed both residents tugging on a reacher. RN #2 stated Resident #57's hand was bleeding and he/she reported that Resident #59 had hit him/her with the reacher. RN #2 stated Resident #59 and Resident #57 were separated and assessed. During an interview, with the Director of Nursing (DON), on 06/08/2023 at 1:02 PM, she stated Resident #59 agreed to and was moved to another room. She also stated she expected staff to separate residents when any incident occurred and notify the DON or Administrator immediately with any allegations of abuse. During an interview on 06/10/2023 at 9:34 AM, the Administrator stated she usually was the person to do the investigations and it was her expectation that the facility's policy be followed with all investigations. Review of the facility's investigation, dated 10/05/2022, revealed Resident #8 entered Resident #59's room and struck Resident #59 on his/her arm and back. Resident #8 and Resident #59 were separated, and Resident #8 was placed on 1:1 supervision. 2 a). Review of Resident #8's Admission Record revealed the facility admitted the resident, on 05/03/2018, with diagnoses of Dementia, Alzheimer's disease with early onset, and unspecified psychosis not due to substance or known physiological condition. Review of Resident #8's Quarterly Minimum Data Set (MDS), dated [DATE] revealed, the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) which indicated severely impaired cognition. 2 b). Review of Resident #59's Admission record revealed the facility admitted the resident on 07/08/2021 with diagnoses of heart failure, major depressive disorder, anxiety, atrial fibrillation, hypothyroidism. Review of Resident #59's Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15), which indicated moderately impaired cognition. Review of the Nursing Progress Note, dated 10/05/2022 at 6:32 PM, entered by Licensed Practical Nurse (LPN) #10 revealed Resident #59 was sitting in her/his room when another resident entered his/her room and struck Resident #59 on the upper left arm and back. Review of the Facility Investigation revealed Resident #57 witnessed Resident #8 hit Resident #59. During an interview on 06/01/2023 at 3:10 PM, LPN #10 stated Resident #59 reported that Resident #8 entered her/his room and struck him/her on the arm and back. During an interview on 06/02/2023 at 1:28 PM, the Administrator stated, Resident #59 had reported that Resident #8 had hit him/her. Furthermore, the Administrator stated that her expectations were that the facility conducted investigations immediately. 3 a). Record review revealed the facility admitted Resident #36 on 09/15/2016 with diagnoses of Alzheimer's Disease Unspecified, Unspecified Dementia Moderate with Mood Disturbance, Psychotic Disorder with Delusions due to Known Psychological Condition, and Diabetes Mellitus with Other Specified Complication. Review of Resident #36's Minimum Data Set (MDS) Quarterly Assessment, dated 10/26/2022, revealed Resident #36 had a Brief Interview for Mental Status Score of eight (8) out of fifteen (15) which indicated moderate cognitive impairment. 3 b). Review of Resident #95's Electronic Medical Record (EMR) revealed the facility admitted Resident #95 on 09/08/2021, with diagnoses of Type 2 Diabetes Mellitus without Complications, Unspecified Psychosis not due to a substance, and Unspecified Dementia of Unspecified Severity. Review of Resident #95's Minimum Data Set (MDS) Quarterly Assessment, dated 10/03/2022, revealed Resident #95 had a Brief Interview for Mental Status Score of 99 which indicated the resident was severely impaired. During a phone interview on 06/03/2023 at 10:25 AM with LPN #1, the nurse who gave the witness statement, dated 10/30/2022, she stated she was not present at the time the incident occurred, but she was around the corner. The LPN stated a Certified Nursing Assistant (CNA) grabbed her and told her about the incident. LPN #1 stated both Resident #36 and Resident #95 were in their wheelchairs in the hall at the time. During an interview, on 05/31/2023 at 2:10 PM with Social Services Director (SSD) and the Social Services Aide (SSA) regarding the incident between Resident #36 and Resident #95 that occurred on 10/30/2022, the SSD stated the investigation was completed per the facility's policy. She also stated residents that were able to be interviewed were interviewed and those that could not be interviewed had skin assessments done. She stated that to her knowledge, no injuries were noted on either Resident #36 or Resident #95. Both the SSD and SSA stated the incident happened on the weekend and they both heard about the incident when they returned on Monday. Resident #95 was moved out of the room he/she and Resident #36 shared. SSD and SSA stated as far as they knew, there had been no further incidents with Resident #36 striking out at anyone. The SSD stated Resident #36 was usually calm and docile. The SSD stated sometimes Resident #95 called or cried out when he/she needed something, and SSD thought that may have possibly agitated Resident #36 at the time. The SSD and SSA both stated no residents should be abused in any way in the facility and it was the facility's responsibility to make sure all residents were safe and free from harm. During an interview with the Assistant Director of Nursing (ADON) on 06/02/2023 at 1:00 PM, she stated she had been the ADON since 09/2021. She also stated she could not remember much about the incident between Resident #36 and Resident #95. She stated when resident to resident altercations occur, the aggressor would be removed and placed on increased observation. The incident would then reported to the abuse coordinator, who was the Administrator. The ADON stated the Administrator was responsible for the facility's report. During an interview with the Administrator on 06/02/2023 at 1:35 PM, she stated she was responsible for the full investigations into facility reported incidents and she would do the interviews and would write the reports. She stated she would interview the residents, staff, and family members if appropriate. The Administrator stated investigations should begin immediately and the facility's policy for reporting incidents should be followed. She also stated staff and family had all been educated to the importance of timely reporting. She further stated it was the ultimate responsibility of the facility to protect residents from abuse and misappropriation. Review of a facility investigation, dated 10/10/2022, revealed at approximately 7:00 PM, Resident #84 came up to the nurses' station and informed LPN #7 that his/her roommate, Resident #71, had accused him/her of huffing paint and had struck Resident #84 on the head several times with his/her reacher. In return, Resident #84 stated he/she struck Resident #71 back in the leg with his/her reacher. Continued review of the facility's investigation revealed both residents were assessed without any injuries noted. Further review revealed Resident #71 was moved to a different room, and Resident #84 was placed on one-on-one (1:1) supervision until he/she was seen by psych. Additionally, both residents' care plans were updated following the incident. 4 a). Review of Resident #71's electronic health record (EHR) revealed the facility admitted Resident #71 on 08/20/2020 with diagnoses to include Peripheral Vascular Disease Unspecified, COPD Unspecified, and Cirrhosis of the Liver. On 03/29/2023, a diagnosis of Vascular Dementia Unspecified Severity without Behavioral Disturbance was added. The facility assessed Resident #71 in a Quarterly Minimum Data Set (MDS), dated [DATE] as 14/15 BIMS, which indicated no cognitive impairment. 4 b). Review of Resident #84's EHR revealed the facility admitted Resident #84 on 03/29/2021 with diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, Hypertension Secondary to Other Renal Disorders, and Hyperlipidemia Unspecified. The facility care planned the resident for history of physical and verbal aggression towards staff and other residents. Review of the care plan revealed Resident #84 was placed on 1:1 supervision on 10/11/2022, which resolved on 10/31/2022. The facility assessed Resident #84 in a Quarterly MDS, dated [DATE] as 15/15 BIMS, which indicated no cognitive impairment. During interview on 05/31/2023 at 9:45 AM, with Resident #71, he/she stated that he/she had been in every room in this place, and when asked about this, the resident stated there were some people he/she could get along with, and some people he/she couldn't get along with. Resident #84 stated during interview on 06/01/2023 at 8:50 AM, that on 10/10/2022 he/she had just finished eating supper in bed, and had gotten up in his/her wheelchair when his/her roommate, Resident #71, started waylaying him/her in the head with a reacher. Resident #84 stated Resident #71 was accusing him/her of huffing red paint. Resident #84 stated he/she took the reacher away from Resident #71 and struck Resident #84 back with it, then went into the hall and let LPN #7 know. Resident #84 stated LPN #7 separated them, moving Resident #71 to a different room. Resident #84 stated nothing like that had ever happened before, and that he/she wasn't injured. Interview on 06/01/2023 at 8:23 AM, with LPN #7, she stated she recalled on 10/10/2022 (could not recall the time) Resident #84 came up to the nurses' station, and stated that Resident #71 had hit him/her and he/she hit Resident #71 back with the grabber. LPN #7 stated she made sure they stayed separated, assessed them both, and called the Administrator. The LPN stated she completed both skin assessments, and pain assessments, and neither resident had issues with skin or pain. She stated Resident #84 stated he/she was getting out of bed, when Resident #71 took his/her reacher and hit him/her. LPN #7 stated Resident #84 told her that he/she took the reacher from Resident #71 and struck Resident #71 back. The LPN stated there was no paint involved. LPN #7 described Resident #71 as quite often confused, although with no prior history of striking anyone. LPN #7 stated there had been no other incidents with either resident. During interview on 06/01/2023 at 1:03 PM, with the Social Services Director (SSD), she stated she was present during the time of the allegation involving Resident #84 and Resident #71. She stated she wasn't sure what provoked Resident #71 to strike Resident #84 with his/her reacher. She stated she recalled Resident #84 was very upset after the incident. She stated Resident #71 gets confused sometimes. Interview with the Administrator on 06/01/2023 at 8:10 AM, and again on 06/02/2023 at 1:29 PM, she stated both Resident #71 and Resident #84 had reachers to get items that they couldn't reach. She stated at the time of the incident, Resident #84 could self-transfer, now he/she was dependent on staff for assistance. The Administrator stated Resident #71 was and remained dependent on staff for transfers and ambulation. She stated prior to the incident, Resident #71 had some cursing and getting frustrated at staff, but nothing physical. The Administrator stated there was no painting going on, and no opportunity for Resident #84 to be huffing paint. 5 a). Observation of Resident #88 on 05/31/2023 at 9:10 AM, revealed the resident was in his/her bed with staff providing personal care. Continued observation revealed no bruises/injuries were noted to the resident. Review of Resident #88's Admission Record revealed the facility admitted Resident #88 on 07/03/2021 with diagnoses of cerebral infarction, vascular dementia, with behavioral disturbance, functional quadriplegia, unspecified psychosis, and impulsiveness. Review of Resident #88's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), which indicated the resident had severe impaired cognition. Continued review revealed Resident #88 required total dependence with two (2) person staff assistance with bed mobility, transfers, and bathing. Review of Resident #88's care plan initiated on 09/14/2021, revealed the resident had mood and behavior problems related to cerebral infarction, and communication deficit. Further review revealed Resident #88 had a history of disrobing, combative with staff, verbally abusive to staff during care; physically aggressive with staff including grabbing/pinching/hitting at staff during personal care. Further review revealed care planned interventions included: staff to encourage diversional acts of choice, when combative with care or verbal behaviors, allow for a brief rest period and attempted care later. On 12/16/2021 a revision was initiated to cue, reorient and supervise resident as needed. Review of the Facility's Investigation, dated 02/03/2023, revealed Resident #88 cursed at staff during care, and dietary staff witnessed Certified Nurse Assistant (CNA) #4 curse at the resident. The staff overheard CNA #4 curse back at Resident #88 as she was providing personal care. The facility suspended CNA #4 pending investigation. Further review of the facility's investigation five (5) day final report revealed the facility determined that abuse could not be validated as CNA #4 cursed in response to pain and it was not directed toward the resident. Interview on 05/31/2023 at 10:20 AM, Resident #88 stated he/she did not recall the incident when CNA #4 verbally cursed at him/her during care. However, the resident stated he/she grabbed, pinched and said inappropriate language to the staff, but denied abuse from staff and/or residents. During interview on 06/01/2023 at 9:12 AM, with Dietary Aide (DA) #1 she stated she would change out daily menus on each unit and on the morning of the incident around 5:30 AM, she was on the 200-Unit when she heard Resident #88, yelling and hollering, stop it. DA #1 stated she observed and overheard CNA #4 inform the resident to shut up, the resident in turn said, Fuck you to CNA #4, and she in turn said Fuck you right back to the resident. During interview with DA #1, she stated she immediately informed LPN #4. She stated LPN #4 responded that she would take care of the situation; however, the LPN did not request her written statement. Also, DA #1 stated at approximately 8:30 AM she reported the incident to her manager, with a written statement. In addition, DA #1 stated CNA #4 was suspended for approximately three (3) days; however, she came back and was currently caring for residents. CNA #4 stated during interview, on 06/01/2023 at 4:45 PM, that she reviewed residents' Kardexes to ensure appropriate care and safety. She stated she was familiar with Resident #88 and the resident could be combative, loose with words and was inappropriate touching staff at times. CNA #4 stated the resident had severe contractures, bad eyesight and when staff turned/rolled him/her, the resident would get upset. She stated Resident #88 could be very inappropriate with sexual verbiage and touching. Continued interview with CNA #4 revealed on 02/03/2023 at approximately 5:00 AM, during last rounds she was providing personal care to Resident #88, as she was turning the resident, he/she grabbed her breast and twisted. She stated it hurt, and instantly, without thinking said fuck, that hurt, and the resident responded with, fuck you . CNA #4 stated she told the resident he/she could not be touching anyone like that, it was very inappropriate. In addition, she stated she did not mean to say it, it was an accident, an immediate response and was not directed towards the resident. The CNA stated she informed the supervisor that morning after rounds, not sure if she reported; however, that morning he received a call from the facility that she was suspended until the incident was fully investigated. She stated she gave an interview statement. Upon returning, prior to resident care, she was educated on abuse and the resident's plan of care. The Dietary Manager (DM) stated during interview, on 06/02/2023 at 10:44 AM, that she came into the facility on [DATE] at 8:30 AM that morning for work. She stated DA #1, informed her that when putting up menus she heard Resident #88 yell out fuck you to CNA #4. The DA told her that CNA #4 in return said, fuck you back to the resident. She stated she informed Licensed Practical Nurse (LPN) #8, who was on the unit, sometime between 5:30 AM and 6:00 AM. However, the DM stated she informed the Administrator at approximately 9:00 AM, before the morning meeting. LPN #9 stated during interview on 06/02/2023 at 1:24 PM, that on 02/03/2023 about 6:30 AM, a dietary staff (DA#1) approached her to inform that she did not like what she heard from another staff member directed towards Resident #88. LPN #7 stated she immediately had her complete a witness statement, and took it to management. She stated they addressed the incident at the Morning Meeting at 9:30 AM. She stated DA #1 informed her that she had already made the house supervisor, LPN #7 aware of the situation and when it happened. LPN #9 stated DA #1 stated she was not sure LPN #7, had informed management of the incident, nor started an incident report. During interview on 06/02/2023 at 2:20 PM, with LPN #7, she stated on 02/03/2023, early morning while doing their rounds, a kitchen staff member (DA #1) came and informed her of a staff member, CNA #4, had said cuss words in Resident #88's room. LPN #7 stated she pulled CNA #4 out of the room, and she told her what happened at the time. The LPN stated she informed CNA #4 that she could not do that. However,she did not do an incident report, nor did she did inform anyone. LPN #7 stated she did not believe the way CNA #4 said it, that it was not intentional. However, looking back and reeducated, she would call the Administrator. The Director of Nursing (DON) stated during interview on 06/08/2023 at 1:10 PM, that staff had been educated on the importance of getting assistance when providing care actions with residents that have aggressive actions/behaviors. She stated she also informed the staff to be cognizant of their speech when in residents' areas. The DON stated she expected staff to notify the her or the Administrator immediately with any allegations of abuse. During an interview with the Executive Director (ED), on 06/02/2023 at 1:35 PM, she stated the Administrator was responsible for the full investigations into facility reported incidents. The ED stated she conducted the interviews and wrote the reports. The ED stated she interviewed residents, staff and family members if appropriate. She stated investigations should begin immediately. The ED stated the facility's policy for reporting incidents should be followed. She stated staff and family had all been educated to the importance of timely reporting. The ED stated it was the ultimate responsibility of the facility to protect residents from abuse. Review of a facility investigation, dated 10/10/2022, revealed at approximately 7:00 PM, Resident #84 came up to the nurses' station and informed LPN #7 that his/her roommate, Resident #71, had accused him/her of huffing paint and had struck Resident #84 on the head several times with his/her reacher. In return, Resident #84 stated he/she struck Resident #71 back in the leg with his/her reacher. Continued review of the facility's investigation revealed both residents were assessed without any injuries noted. Further review revealed Resident #71 was moved to a different room, and Resident #84 was placed on one-on-one (1:1) supervision until he/she was seen by psych. Additionally, both residents' care plans were updated following the incident. 6 a). Review of Resident #71's electronic health record (EHR) revealed the facility admitted Resident #71 on 08/20/2020 with diagnoses to include Peripheral Vascular Disease Unspecified, COPD Unspecified, and Cirrhosis of the Liver. On 03/29/2023, a diagnosis of Vascular Dementia Unspecified Severity without Behavioral Disturbance was added. The facility assessed Resident #71 in a Quarterly Minimum Data Set (MDS), dated [DATE] as 14/15 BIMS, which indicated no cognitive impairment. 6 b). Review of Resident #84's EHR revealed the facility admitted Resident #84 on 03/29/2021 with diagnoses that included Encounter for Orthopedic Aftercare Following Surgical Amputation, Hypertension Secondary to Other Renal Disorders, and Hyperlipidemia Unspecified. The facility care planned the resident for history of physical and verbal aggression towards staff and other residents. Review of the care plan revealed Resident #84 was placed on 1:1 supervision on 10/11/2022, which resolved on 10/31/2022. The facility assessed Resident #84 in a Quarterly MDS, dated [DATE] as 15/15 BIMS, which indicated no cognitive impairment. During interview on 05/31/2023 at 9:45 AM, with Resident #71, he/she stated that he/she had been in every room in this place, and when asked about this, the resident stated there were some people he/she could get along with, and some people he/she couldn't get along with. When asked about any specific conflicts with other residents, Resident #71 became confused, and no information regarding any incidents could be obtained. Resident #84 stated during interview on 06/01/2023 at 8:50 AM, that on 10/10/2022 he/she had just finished eating supper in bed, and had gotten up in his/her wheelchair when his/her roommate, Resident #71, started waylaying him/her in the head with a reacher. Resident #84 stated Resident #71 was accusing him/her of huffing red paint. Resident #84 stated he/she took the reacher away from Resident #71 and struck Resident #84 back with it, then went into the hall and let LPN #7 know. Resident #84 stated LPN #7 separated them, moving Resident #71 to a different room. Resident #84 stated nothing like that had ever happened before, and that he/she wasn't injured. Interview on 06/01/2023 at 8:23 AM, with LPN #7, she stated she recalled on 10/10/2022 (could not recall the time) Resident #84 came up to the nurses' station, and stated that Resident #71 had hit him/her and he/she hit Resident #71 back with the grabber. LPN #7 stated she made sure they stayed separated, assessed them both, and called the Administrator. The LPN stated she completed both skin assessments, and pain assessments, and neither resident had issues with skin or pain. She stated Resident #84 stated he/she was getting out of bed, when Resident #71 took his/her reacher and hit him/her. LPN #7 stated Resident #84 told her that he/she took the reacher from Resident #71 and struck Resident #71 back. The LPN stated there was no paint involved. LPN #7 described Resident #71 as quite often confused, although with no prior history of striking anyone. LPN #7 stated there had been no other incidents with either resident. During interview on 06/01/2023 at 1:03 PM, with the Social Services Director (SSD), she stated she was present during the time of the allegation involving Resident #84 and Resident #71. She stated she wasn't sure what provoked Resident #71 to strike Resident #84 with his/her reacher. She stated she recalled Resident #84 was very upset after the incident. She stated Resident #71 gets confused sometimes. Interview with the Administrator on 06/01/2023 at 8:10 AM, and again on 06/02/2023 at 1:29 PM, she stated both Resident #71 and Resident #84 had reachers to get items that they couldn't reach. She stated at the time of the incident, Resident #84 could self-transfer, now he/she was dependent on staff for assistance. The Administrator stated Resident #71 was and remained dependent on staff for transfers and ambulation. She stated prior to the incident, Resident #71 had some cursing and getting frustrated at staff, but nothing physical. The Administrator stated there was no painting going on, and no opportunity for Resident #84 to be huffing paint. 46651 28707 45113

Based on observation, interview and review of the facility's policy it was determined the facility failed to ensure each resident's right to privacy and confidentiality of his/her personal and medical records for the residents on the 100 Hall. On 05/31/2023, observations during the initial facility rounds, revealed on three (3) occasions, the screen of the computer was sitting on top of the 100 Hall medication cart. The computer had been left open with the resident's information visible to anyone passing by the cart. The findings include: Review of the facility's policy titled, Resident Rights-Kentucky, effective date 01/09/2020, under the section,State Resident Rights, item number seven (7) revealed all residents shall have confidential treatment of their medical and personal records. Observations, on 05/31/2023 at 8:17 AM, 8:53 AM and 9:17 AM, revealed the medication cart, for the residents on the 100 Hall, was stationed across the hall from rooms [ROOM NUMBERS]. Further observations revealed the medication cart was unlocked and unattended. Observations revealed the computer screen was open and the residents' census information was visible. Observation on 05/31/2023 at 9:17 AM, revealed Licensed Practical Nurse (LPN) #4 walked up to cart with the keys. In an interview on 06/01/2023 at 2:05 PM with LPN #4, she stated she left the medication cart unlocked on 05/31/2023. She stated that she left the computer screen up with visible resident information when she was not at her medication cart on the 100 Hallway. LPN #4 also stated when a nurse was standing at the cart it could be unlocked so she could access resident information. The LPN stated she was taught when standing at the cart and accessing the resident's information to set up medications, it was okay to have the computer screen up, but when she walked away from the cart to administer the medications, then she should close the computer screen to prevent a Health Insurance Portability and Accountability ACT (HIPAA) violation. LPN #4 stated it would become a resident privacy issue if the nurse was logged on and the screen was up and she walked away, then the resident's information could be seen by a passerby. However, she stated the person leaving the cart should ensure they closed the screen or logged off between each resident. LPN #4 stated she just shut the screen to prevent having to put in two (2) passwords to access information between resident medication passes. She stated at the end of the medication pass she would then log off. LPN #4 also stated she was taught about the screens and HIPAA in nursing school and got some training at this facility. In an interview with the Director of Nursing, on 06/10/2023 at 10:00 AM, she stated staff assigned to a medication cart must ensure the computer screen was closed, or locked before walking away from the cart. She stated if that was not done, visitors or others would have access to the residents' health information, and that was a violation of their privacy. In an interview, on 06/10/2023 at 9:44 AM with the Administrator, she stated going forward, she would have to round more constantly to ensure staff were protecting resident information. The Administrator stated they do make rounds to try to ensure the computer screens were locked or closed . Further, the Administrator stated it was not acceptable for residents' health information to be visible to anyone passing the medication carts. She stated that would be a violation of a resident's privacy rights.

Based on interview, record review, and review of the facility policy it was determined the facility failed to immediately inform the physician when a significant change in condition occurred for one (1) of thirty-nine (39) sampled residents (Resident #259). Resident #259 was admitted to the facility on [DATE] and had experienced frequent falls since admission. On [DATE] at approximately 7:15 PM, Resident #259 attempted to get out of bed unassisted and was exhibiting symptoms of increased confusion and agitation. Staff assisted the resident out of bed and into his/her wheelchair where staff observed the resident attempt to get up from the wheelchair unassisted multiple times on [DATE] and into the morning of [DATE]. Resident #259 was restless/anxious, and would not calm down and was hallucinating by reaching in the air and leaning forward to touch the floor in front of his/her wheelchair, trying to retrieve objects that were not there. Even though staff informed Licensed Practical Nurse (LPN) #3 that Resident #259's anxiety and confusion, had been worse the past few days, the physician was not notified of the resident's change in condition. Resident #259 continued to be unable to sleep, exhibit signs of anxiety and restlessness, and attempt unsafe transfers from the wheelchair, into the morning of [DATE]. At approximately 1:02 AM on [DATE], Resident #259 was still up in the wheelchair (almost six (6) hours since getting up at 7:15 PM) and continued to be restless, fidgety, and wiggly. On [DATE] at 1:05 AM, Resident #259 was observed on the floor, lying on his/her left side in the hallway of the facility. The resident was transferred to a local hospital on [DATE] and was diagnosed with [REDACTED]. Resident #259 expired on [DATE] as a result of [MEDICAL CONDITION] due to the fall to the floor. The facility's failure to ensure resident physicians were notified of changes in a resident's condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE] prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Notification of Change, dated 2016, revealed the facility must immediately inform and consult with the resident's physician and notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status, which included a deterioration in health, mental status, or clinical complications. Review of Resident #259's record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #259's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of nine (9), and had no behaviors or signs of difficulty sleeping during the assessment period. The MDS also indicated Resident #259 required extensive assistance of two (2) staff members for transfers, bed mobility, and toileting; and had sustained one (1) fall since admission, with no injury. Review of Resident #259's physician orders and his/her Medication Administration Record [REDACTED]. Continued review of the physician orders and Resident #259's MAR indicated [REDACTED]. Review of the physician orders also indicated staff were directed to administer [MEDICATION NAME] 5 mg, every twelve (12) hours as needed for sleep. Further review of Resident #259's MAR indicated [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #8 on [DATE] at 6:00 PM revealed she frequently cared for Resident #259 and was also assigned to care for the resident on [DATE], during the 6:30 PM to 6:30 AM shift. SRNA #8 stated Resident #259 was attempting to get out of bed unassisted on [DATE] at the beginning of the shift at approximately 7:15 PM and staff assisted the resident out of bed, and into his/her wheelchair. SRNA #8 stated Resident #259 was very confused, wild, and wiggly more than normal and she reported the change in the resident's condition to Licensed Practical Nurse (LPN) #3. SRNA #8 stated Resident #259 was going up and down the hallways of the facility, pulling medication carts, and attempting to stand without assistance from his/her wheelchair. The SRNA stated Resident #259 was also reaching in the air for things that were not there, and reaching to the floor in front of his/her wheelchair. She also stated she informed LPN #3 that Resident #259 was having a bad night and reported the resident's behaviors. The SRNA stated that the LPN instructed her to leave the resident where we could see the resident as much as possible. SRNA #8 stated attempts were made to toilet the resident, and a diversional activity was also provided; however, SRNA #8 stated the activities were not effective in addressing the resident's behavior. SRNA #8 stated at approximately 1:02 AM, after the resident had been up in the wheelchair for hours, she observed the resident in his/her wheelchair and the resident continued to be wiggly and fidgety. The SRNA stated she observed the resident approximately three minutes later, and the resident was lying on the floor in front of his/her wheelchair, at approximately 1:05 AM. Interview with Kentucky Medication Aide (KMA) #1 at 6:15 PM on [DATE] revealed she administered medicine on the unit that Resident #259 resided on during the 6:30 PM to 6:30 AM shift that began on [DATE]. KMA #1 stated the resident was up in his/her wheelchair and was fidgety and would not relax enough to go to sleep. The KMA stated she also observed Resident #259 leaning forward, to reach the floor in front of his/her chair in attempts to pick up things that were not there. KMA #1 stated the resident also attempted to move the medication cart and attempted unsafe transfers a few times from the wheelchair during that shift. The KMA administered the resident's 9:00 PM medications and thought the medications would help relax the resident; however, she stated the medications were not effective and the resident continued to be fidgety. According to the KMA, she was not aware that the resident had medication ordered as needed for sleep, and stated she would have administered the medication if she had known. Interview with SRNA #9 on [DATE] at 6:55 PM revealed she assisted in the care provided to Resident #259 during the 6:30 PM to 6:30 AM shift, which began on [DATE]. She stated she assisted SRNA #8 with getting the resident out of bed because the resident was trying to climb out of bed unassisted. SRNA #9 stated Resident #259 was confused and was observed to propel his/her wheelchair up and down the hallways and attempted to stand from the wheelchair. She reported the resident's behaviors to the nurse and had witnessed SRNA #8 inform the nurse that the resident was more confused than usual, and staff was instructed to keep the resident at the nurses' station. SRNA #9 stated she was in a room with another resident and when she came out, Resident #259 was on the floor, in front of his/her wheelchair at the nurses' station and blood was coming nonstop out of the resident's head. Interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 7:10 PM revealed he was pulled to work the unit where Resident #259 resided on [DATE]. He stated that at approximately 7:30 PM on [DATE], he observed the resident in his/her wheelchair. LPN #3 stated the resident was disoriented, saying off the wall stuff, and was yelling out for people that wasn't there. He also stated that a SRNA informed him of the resident's history of falls and that the resident was more confused than normal. Further interview revealed LPN #3 was aware the resident remained up in a wheelchair for many hours into his shift because he/she was confused, disoriented, experienced unrelieved anxiety and restlessness, and couldn't sleep. The LPN also stated he was trained to notify the resident's physician when changes in the resident's condition occurred; however, he did not call the physician with the change in the resident's condition because the SRNA reported that the resident had been different for days. The LPN acknowledged he should have called the resident's physician. Further interview with LPN #3 revealed he was not aware that Resident #259 had as needed medication ordered if he/she was unable to sleep, or I would have given it. The LPN stated he left the unit to get something to drink and returned to the unit at approximately 1:05 AM on [DATE]. He stated he observed Resident #259 on the floor, in front of the nurses' station and blood was everywhere. The LPN transferred the resident to a local hospital for further evaluation and treatment. Review of Resident #259's nurse's notes, completed by LPN #3, revealed at 1:05 AM on [DATE], the resident was found lying on the floor on his/her left side, in the hallway in front of the nurses' station/dining room of the facility. The nurse's notes indicated Resident #259 had a large hematoma to the left temporal area and copious amount of bleeding also present from area; however, staff was unable to determine the exact origin of bleed. According to the nurse's notes, staff contacted Emergency Medical Services (EMS) and a pressure dressing was applied to the resident's left temporal area. Resident #259 was transferred to the local hospital for further evaluation and treatment. Review of Resident #259's hospital record revealed the resident was triaged on [DATE] at 1:50 AM at a local hospital with a complaint of a [MEDICAL CONDITION] to the left temporal area. Review of Resident #259's ED General Exam dictated by the emergency room (ER) Physician at 2:42 AM on [DATE] revealed the resident resided at a nursing home and had trouble sleeping lately. The physician's documentation also revealed Resident #259 was sitting in his/her wheelchair when he/she leaned forward and fell out and hit his/her head on the floor. The physician documentation indicated Resident #259 had a 2 centimeter (cm) laceration to the left forehead that went to the skull, with a small arterial bleed, that was bleeding briskly. The physician also documented he had Nursing put pressure on the area; however, there was already a large hematoma forming. Further review of the record revealed the physician stated, because of the brisk arterial bleeding, smooth pickups were used to grasp the bleeder using high temperature electrocautery, the arterial bleeding was cauterized. The record indicated three (3) sutures were placed to close the wound. Further review of the hospital record revealed a CT was performed on [DATE] and review of the Preliminary Radiology Report dated [DATE] at 2:45 AM indicated Resident #259 had an acute-appearing left frontotemporal subdural hemorrhage, largest component along the left temporal lobe measuring approximately 9 millimeters (mm) in maximal thickness. Continued review of the report revealed Resident #259 also had an acute-appearing left parietal, left posterior temporal, and right posterior temporal subarachnoid hemorrhage. According to the record, Resident #259 was transferred to a larger hospital, under the care of the trauma team on [DATE] at 3:55 AM. Review of a Coroner's Report revealed Resident #259 was pronounced deceased at 6:38 AM on [DATE], due to [MEDICAL CONDITION] due to a fall to the floor as a cause of death. Interview with the Director of Nursing (DON) on [DATE] at 12:45 PM revealed staff were expected to notify a resident's physician when a change in his/her condition was identified. She also acknowledged that approximately six (6) hours was too long for a resident to have exhibited unrelieved anxiety/restlessness without the resident's physician being notified and interventions implemented to assist the resident with the identified concerns. Interview with Administrator #1 on [DATE] at 2:20 PM revealed she expected staff to notify the resident's physician immediately when changes in their condition occur. The Administrator also acknowledged that approximately six (6) hours was too long for a resident to be up in a wheelchair when he/she was unable to sleep, exhibiting restlessness/agitation, confusion, and seeing things that were not there, without an intervention being implemented to assist the resident with their identified concerns. Interview with Physician #1 on [DATE] at 3:25 PM revealed she expected staff to notify her when changes in a resident's condition occurred and when residents experienced bad anxiety that was unrelieved. ***The facility alleged the following was implemented to remove Immediate Jeopardy effective [DATE]: 1. Resident #259 no longer resides at the facility. 2. By [DATE], the Pharmacist will complete a Medication Regimen Review for current residents, which will include psychoactive medications, to ensure there is a supporting diagnosis, and will review for necessity/indication for the medication. The Pharmacist will also review for psychoactive medications that may be contributing to falls. One hundred eleven (111) residents were reviewed. Recommendations to the Medical Director was made for sixty-three (63) residents, six (6) of which were recommendations for a gradual dose reduction of psychoactive medications. 3. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) assessed current residents for potential side effects from psychoactive medication on [DATE], and ensured resident's Medication Administration Records (MAR) reflected the need to monitor for potential side effects of psychoactive medication. 4. The facility held a meeting on [DATE] to evaluate residents receiving psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) was in attendance and the Medical Director attended by phone to review appropriate utilization of psychoactive medications, which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive is achieved. 5. The DON/ADON/Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on [DATE]. The Nurse Consultant/DON/ADON/ Wound Nurse will also review resident falls for the past 30 days to ensure a root cause analysis has been conducted and appropriate interventions are in place. This will include a review of the care plan to ensure updates have been entered. 6. The Social Service Director, Social Service Assistant, and the Clinical Liaison will interview residents with a BIMS of eight (8) and above to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. The interviews were completed by [DATE] and any concerns identified will be reported to the Director of Nursing (DON) and/or Executive Director immediately and addressed by the appropriate department. 7. The Wound Nurse (LPN) and Clinical Liaison (LPN) will complete resident observations by [DATE] for residents with a BIMS score of seven (7) and below to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. Concerns identified will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 8. The Human Resource Director, ADON, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab will interview current staff related to any knowledge of residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. The interviews will be completed by [DATE] and any concerns will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. The DON/ADON and/or designee will review resident interviews, staff interviews, and resident observations by [DATE] to ensure the physician is notified of any change in condition. The DON/ADON/ MDS nurse will review current resident and staff interviews to ensure that appropriate interventions were placed based on falls root cause analysis. 10. On [DATE], the DON/ADON and/or designee will review fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. By [DATE], the MDS Coordinator will review nursing notes for the past 30 days to ensure physician notification and care plan revision to reflect any change, including falls and behaviors. One resident was identified to not have a care plan related to a skin tear; however, the physician had been notified with orders for treatment. 12. By [DATE], the DON and/or the ADON will review the Twenty-Four hour reports to ensure any change in a resident's condition has been addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. The Nurse Consultant/DON/ADON/SDC/RN Charge Nurse will review care plans on current residents to ensure appropriate documentation related to change in conditions, including but not limited to: pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. The reviews were completed by [DATE]. Five resident care plans were revised. 14. By [DATE], the Nurse Consultant educated the ED/DON/ADON/SDC on utilizing Stop and Watch forms, a communication form developed by CMS to communicate changes related to change of condition. Education will include giving the completed Stop and Watch to the nurse and making a copy and leaving for the DON/ADON. The DON/ADON will review Stop and Watches and follow up on possible change of condition during the daily clinical meeting and was completed as appropriate. By [DATE], the ED/DON/ADON/SDC will educate current staff regarding utilizing Stop and Watch forms for any change in condition, giving the completed form to the nurse, and making a copy for the DON. 15. The Nurse Consultant educated the ED/DON/ADON/SDC the DON/ADON on [DATE] to review Stop and Watches forms to ensure they were acted upon appropriately to include physician notification for changes in condition, They were also educated to ensure appropriate interventions were implemented for falls based on root cause analysis of the fall, which includes the 5 Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention at time of fall. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. The SDC/DON/ADON/ED then educated licensed staff by [DATE] regarding the utilization of the 5 Why's tool to determine the root cause of a fall to assist in determining the most appropriate intervention. In addition, current licensed nurses will be educated to notify the on-call Nurse Manager after a fall to review the root cause and the intervention for appropriateness. 16. By [DATE], the ED/DON/ADON/SDC will educate current licensed staff on appropriate documentation including, but not limited to: changes in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or needing increased help from staff. 17. By [DATE], the Nurse Consultant will educate the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and the Wound Care Nurse (LPN) on assuring that residents are assessed for potential medication side effects; to ensure a monitoring order is placed on the MAR indicated [REDACTED]. Education included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate [DIAGNOSES REDACTED]. The review will be conducted during the daily clinical meeting and will be followed-up by the Pharmacy Consultant. Any new medication orders will be reviewed by the DON/ADON/SDC for necessity to include appropriate [DIAGNOSES REDACTED]. 18. The Nurse Consultant will educate the DON/ADON/SDC on ensuring pharmacy reviews have occurred monthly and ensuring timely follow up of recommendations per facility policy, which states the recommendations will be received by the DON within 3 days of completion of review. The recommendations will be sent to the physician and the DON will verify the physician and Medical Director has received the review within 3 days. The DON should receive a response from the physician within 7 days. If a response is not received in 7 days, the DON/ADON will notify the physician for acceptance and/or a response to the recommendations that require action. If no response is received in 14 days, the DON/ADON will notify the Medical Director for further action. The DON/ADON will also notify the Executive Director and the Nurse Consultant. This education will occur on [DATE]. The DON, ADON, or Staff Development Coordinator will then will educate current licensed staff by [DATE] on assuring that residents are assessed for potential side effects of medications, ensuring a monitoring order is placed on the MAR indicated [REDACTED]. 19. The Pharmacy Director will re-educate the Registered Pharmacist by [DATE] on accurately completing a Medication Regimen Review, which will include a supporting [DIAGNOSES REDACTED]. The Pharmacist assigned to the facility at the time of the IJ has been removed as the Pharmacy Consultant. The current Pharmacy Consultant has been educated on the concerns related to regimen reviews, appropriate [DIAGNOSES REDACTED]. 20. For all education, a post education test will be administered by the Nurse Consultant/DON/ADON/SDC following education. If a score of 100% is not obtained, re-education will be completed until proficiency is obtained and their score is 100%. Five tests will be administered daily by ED/Assistant Administrator/ DON/ADON/SDC to ensure retention of education, until IJ is removed and approved through QAPI process. Current staff who have not received education by [DATE] will be mailed a certified letter informing them to contact the Executive Director/DON/SDC prior to working the floor. Staffing Agencies currently being utilized will be mailed a certified letter on [DATE] of the need to contact the ED/DON/SDC for education prior to working. The Executive Director/SDC or designee will ensure all newly hired staff and agency staff will receive education during New Hire Orientation or prior to working the floor. 21. The IDT will review in the daily clinical meeting (Monday through Friday) each fall and nursing shift reports to ensure the following is completed for any resident who sustained a fall: Falls Risk evaluation, to include the 5 Why's; physician notification; and care plan revision. In addition, the IDT will review Stop and Watch forms, progress notes, and physician orders to ensure care plans have been updated appropriately and physicians have been notified. 22. The Executive Director/Assistant Administrator/DON will conduct daily post clinical IDT meetings Monday-Friday for two weeks to review all identified Change of Condition and the effectiveness of medication to ensure notification of residents' physician as required. In addition, the Executive Director/Assistant Administrator/DON will review five (5) random resident records to ensure proper documentation has been completed related to any change in condition, physician notification, and the care plans are appropriate. Any issues identified will be corrected immediately and reported to the QAPI Committee for 3 months for further review and recommendations. 23. The facility will conduct weekly monitoring to evaluate psychoactive medication on residents, residents new prescribed psychoactive medications, and residents that have had medication dose adjustment. This psychoactive meeting will be conducted weekly by the facility IDT, (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and Pharmacist to review appropriate utilization of psychoactive medications which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 24. Beginning [DATE], the Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at facility to monitor processes related to supervision to prevent accidents, care plan development/revision, and physician notification until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. An AD-HOC QAPI meeting is held at least bi-weekly and as needed to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 25. Beginning [DATE], The Director of Nursing, Assistant Director of Nursing, or the Staff Development Nurse will review MAR's daily (Monday through Friday), during the Clinical Meeting, for two weeks, for documentation of side effect monitoring of [MEDICAL CONDITION] medication and appropriate [DIAGNOSES REDACTED]. The Director of Nursing will also review falls to ensure the Medication Regimen Review has been sent to the consultant pharmacist daily (Monday through Friday) during the clinical meeting. The Director of Nursing will contact the Pharmacy Director, in 72 hours, if no communication from the review is received from the consultant pharmacist. Any concerns identified will be corrected immediately, and reported to QAPI committee for further review and recommendations. 26. The Executive Director will ensure the facility has conducted weekly monitoring, month over month, for 3 months to evaluate psychoactive medication on residents newly prescribed psychoactive medications, and residents that have had medication dose adjustments. This psychoactive meeting will be conducted weekly, by the facility IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and the Pharmacist to review appropriate utilization of psychoactive medications, which includes; antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 27. The Nurse Consultant or Director of Nursing will be in the center daily to monitor residents with new [MEDICAL CONDITION] medication orders to ensure side effect monitoring is completed. 28. Beginning [DATE], Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at the facility to monitor process, related to [MEDICAL CONDITION] medications, until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. AD-HOC QAPI meeting is held at least bi-weekly, and as needed, to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 29. The Executive Director will review 5 random Admissions/Readmissions/Falls/New Medication Orders/ Monthly Pharmacy Reviews for timeliness, and to ensure proper documentation has occurred daily. Any issues identified will be corrected immediately, and reported to QAPI Committee for 3 months for further review and recommendations. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on [DATE], as alleged: 1. Review of documentation revealed Resident #259 no longer resided at the facility. 2. Interview with the Administrator on [DATE] at 5:15 PM and review of documentation revealed by [DATE], the Pharmacist completed a Medication Regimen Review for current residents on psychoactive medications, to ensure there was supporting diagnosis, and necessity and indication for the use of the medication. The Pharmacist also reviewed psychoactive medications that could have contributed to falls. Further review of documentation and interview with the Administrator confirmed one-hundred and eleven (111) residents were reviewed by the Pharmacist. Review of facility documentation revealed the Pharmacist m (TRUNCATED)

Based on interview, record review, and a review of the facility policy, it was determined the facility failed to develop a person-centered care plan to ensure services were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (2) of thirty-nine (39) sampled residents (Resident #259 and Resident #84). Interviews with staff revealed Resident #259 experienced [MEDICAL CONDITION] (unable to sleep), attempted to get up from the wheelchair unassisted, and leaned forward in his/her wheelchair in attempts to retrieve objects that were not there. Review of the resident's care plan revealed no evidence the facility developed a care plan that addressed the resident's inability to sleep at times, or that addressed the identified safety concerns when he/she was up in a wheelchair. On [DATE] at approximately 7:00 PM, staff assisted the resident to a wheelchair and the resident remained in the wheelchair for approximately six (6) hours, even though the resident was restless, fidgeting, attempting to get up from the wheelchair, and leaning forward to touch the floor. At approximately 1:05 AM on [DATE], staff found the resident on the floor in a common area of the facility with a large hematoma and bleeding. The resident was transferred to a local hospital on [DATE] and was diagnosed with [REDACTED]. Resident #259 was pronounced deceased at 6:38 AM on [DATE], due to a [MEDICAL CONDITION] as a result of the fall. On [DATE], staff failed to utilize a mechanical lift when transferring Resident #84, and the resident had to be lowered to the floor. The facility's failure to ensure residents' care plans were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE] prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Comprehensive Care Plan, dated [DATE], revealed staff were to ensure the resident or his/her representative was included in all aspects of the person-centered care plan and the planning was to include the provision of services to enable the resident to live with dignity and support the resident's goals, choices, and preferences which included, but were not limited to, goals related to the resident's daily routines. The policy stated care plans must be prepared with input from the Interdisciplinary Team (IDT), which included, but was not limited to the physician, a Registered Nurse (RN), and a nurse aide with responsibility for the resident. The policy also stated staff should include input from the resident and his/her representative to the extent practicable. Per the policy, the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of Resident #259's record revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #259's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she had no signs of difficulty sleeping and had not exhibited behaviors during the assessment period. The assessment indicated Resident #259 required extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. The MDS also revealed the resident had one (1) fall since admission, with no injury, and was interviewable with a Brief Interview for Mental Status (BIMS) score of nine (9). Review of Resident #259's comprehensive care plan initiated [DATE] revealed staff identified that the resident was at risk for falls. Interventions implemented since admission included for staff to anticipate and meet the resident's needs, his/her bed was placed against the wall per resident/family preference, non-slip footwear when ambulating or mobilizing in the wheelchair, offer snack and fluids, and offer the resident to sit in a wheelchair when he/she is restless or cannot sleep. Interview with Resident #259's daughter on [DATE] at 7:30 PM revealed she visited the resident daily; however, she did not recall being included in the development of the resident's care plan. According to the daughter, Resident #259 attempted to get up from the wheelchair unassisted a lot, especially when the resident was anxious/restless; however, no one did anything to keep the resident from doing that. She also stated Resident #259 had fallen so many times in the facility and, Why would they leave, the resident alone up in a chair at that time of night? The resident's daughter stated she admitted the resident to the facility because the resident was unable to sleep and would stay up for two (2) or three (3) days at a time, and she was unable to care for the resident at home. The daughter stated she informed facility staff of the resident's inability to sleep when the resident was admitted to the facility. Interview with LPN #2 on [DATE] at 9:10 PM revealed she was not sure if Resident #259 had sundowners or what but the resident was very fidgety and didn't sleep much. LPN #2 also stated the resident attempted unsafe transfers from the wheelchair and was unable to be redirected. The LPN stated the only way to keep the resident from falling was to keep your eyes on the resident when he/she was in the wheelchair. The LPN stated no interventions had been implemented to prevent the resident from falling when he/she was up in a wheelchair. Interview with LPN #6 on [DATE] at 11:35 AM revealed Resident #259 attempted unsafe transfers from his/her wheelchair and required redirection. The LPN also stated that was normal for the resident. Per LPN #6, she was not aware of any interventions that had been implemented to prevent Resident #259 from falling when he/she was up in a wheelchair. Interview with Occupational Therapist (OT) #1 on [DATE] at 12:30 PM revealed Resident #259 was confused/restless and would attempt unsafe transfers from the wheelchair. Per the OT, she had observed him/her grab hold of the hand rails in attempts to stand by his/herself while up in the wheelchair. The OT was not aware of any fall interventions that had been implemented related to these identified safety concerns. The OT stated she had not discussed the identified concerns with nursing staff because the resident's attempts to stand happened next to the nurses' station and they were there. Interview with the facility Social Worker (SW) on [DATE] at 1:35 PM revealed the resident's daughter informed her on admission that the resident had trouble sleeping and got his/her days and nights mixed up. Further interview revealed the SW completed sections of the resident's MDS that indicated the resident had no difficulty sleeping. However, she stated she had not spoken with the resident's daughter or any direct care staff during the assessment period, and was unaware that the resident had trouble sleeping since admission to the facility. The SW acknowledged she failed to develop a care plan that addressed the resident's sleep pattern disturbances, stating it should have been addressed. Interview with MDS Nurse #1 on [DATE] at 2:05 PM revealed she assisted in the development of Resident #259's care plan; however, she did not recall speaking to the resident's daughter or direct care staff when Resident #259's care plan was developed. The MDS Nurse further stated she was not aware that Resident #259 attempted unsafe transfers from the wheelchair, or that he/she had trouble sleeping. She stated she had not discussed the resident with direct care staff; however, she stated staff should have informed her of the resident's identified concerns so a care plan could have been developed and interventions implemented that addressed the resident's unsafe transfer attempts from the wheelchair and difficulty sleeping. Interviews with State Registered Nurse Aide (SRNA) #8 on [DATE] at 6:00 PM and SRNA #9 on [DATE] at 6:55 PM revealed they cared for Resident #259 during the 6:30 PM - 6:30 AM shift on ,[DATE]-,[DATE]. They stated they assisted Resident #259 out of bed at approximately 7:15 PM on [DATE] because the resident was trying to get out of bed. According to the SRNAs, the resident remained in the wheelchair for approximately six (6) hours. SRNA #9 stated once the resident was in a wheelchair, he/she was confused, looking for car keys and keys to his/her house, rolling up and down the hallways of the facility, and kept trying to stand up from the wheelchair. SRNA #8 stated the resident attempted to stand from the wheelchair, went up and down the hallways, pulled medication carts around, and was hallucinating (reaching in the air and reaching for the floor, attempting to retrieve objects that were not there), and was fidgety and wiggly. SRNA #8 stated she attempted toileting the resident and gave him/her something to look at, a magazine I think, but stated, no matter what we did he/she would not calm down. The SRNAs stated they reported the resident's behaviors to the nurse and the nurse instructed them to leave the resident where they could see the resident as much as possible. According to the SRNAs, they found the resident on the floor in front of the wheelchair at approximately 1:05 AM on [DATE]. Further review of Resident #259's comprehensive care plan initiated on [DATE] revealed no evidence that staff developed a care plan that addressed the resident's unsafe transfer attempts from the wheelchair, or that he/she leaned forward reaching for objects on the floor in front of the wheelchair. Continued review of the care plan revealed no evidence the facility identified or implemented interventions related to the resident's inability to sleep at times. Interview with Licensed Practical Nurse (LPN) #3 on [DATE] at 7:10 PM revealed staff informed him on [DATE] that Resident #259 had a history of [REDACTED]. He stated he was not aware that the resident was attempting to stand from the wheelchair unassisted, but acknowledged that the resident remained up in a wheelchair for many hours due to unrelieved anxiety, restlessness and couldn't sleep. Continued interview with the LPN revealed no interventions were implemented on ,[DATE]-,[DATE] to address the resident's fall risk. He stated that at approximately 1:05 AM on [DATE] the resident was found on the floor in front of the nurses' station and blood was everywhere. He stated he transferred the resident to a local hospital for further evaluation and treatment. Resident #259's hospital record revealed the resident had a 2 centimeter (cm) laceration to the left forehead that extended to the skull, with small arterial bleed that was bleeding briskly. Further review of the hospital record revealed the resident also sustained an acute-appearing left frontotemporal subdural hemorrhage (brain bleed) and an acute-appearing left parietal, left posterior temporal, and right posterior temporal subarachnoid hemorrhage (brain bleeds in three other areas of the brain). Continued review of the hospital record revealed Resident #259 was transferred to a larger hospital, under the care of the trauma team, on [DATE] at 3:55 AM. According to a Coroner's Report, Resident #259 was pronounced deceased at 6:38 AM on [DATE], and his/her cause of death was a [MEDICAL CONDITION] due to a fall to the floor. Interview with the DON on [DATE] at 12:45 PM revealed she was not aware that Resident #259 attempted unsafe transfers from the wheelchair or that he/she had difficulty sleeping. The DON stated a care plan should have been developed and interventions implemented related to the identified concerns for Resident #259. Interview with Administrator #1 on [DATE] at 2:20 PM revealed she attended the Monday-Friday IDT meetings where falls were discussed daily; however, the only fall for Resident #259 that she recalled discussing was the fall that occurred on [DATE]. The Administrator stated she was not aware that Resident #259 had trouble sleeping or that he/she attempted unsafe transfers while up in the wheelchair. She also stated if staff identified these behaviors, a care plan should have been developed and interventions implemented for the resident's identified concerns. The Administrator also stated that being in a wheelchair for approximately six (6) hours was a long time for a resident to be up in a wheelchair and in hind sight an increased level of supervision would have helped him/her. 2. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated [DATE], revealed Resident #84 had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident required extensive assistance of two (2) or more persons for the activity of transfers and the resident was non-ambulatory. Observation of Resident #84 on [DATE] at 3:49 PM, revealed the resident was lying on the left side and the bed was in low position. The resident was lying on a perimeter mattress with eyes closed. Review of a fall investigation dated [DATE] revealed Resident #84 sustained a fall on [DATE] at 2:10 PM when he/she was lowered to the floor by the shower aide, while being transferred from the wheelchair to the shower chair. The report stated the resident suffered no injury. The root cause of the fall was determined to be the resident's weakness and requiring more assistance. The investigation revealed a mechanical lift assessment would be completed. Review of Resident #84's care plan revealed the resident was identified to be at risk for falls on [DATE]. Further review revealed the care plan was revised on [DATE], to include an intervention for the use of a Maxi lift (an electronic, hydraulic lift for transferring persons from one point to another) for transfers. Review of the nurse aide Kardex (care guide for direct care staff), undated, revealed the facility also revised the Kardex to include the requirement for a Maxi lift for transfers. Review of a fall investigation dated [DATE] revealed Resident #84 suffered a fall at 9:10 PM when staff were assisting the resident to bed from the wheelchair. The investigation stated the resident grabbed the wheelchair and would not let go. The staff were not able to convince the resident to let go and had to lower the resident to the floor. The resident suffered no injury as a result of the fall. The investigation revealed the root cause of the fall to be the resident's inability to follow commands and the intervention was education to the staff regarding transfers. The investigation did not address whether staff were utilizing the Maxi Lift during the transfer as required by the resident's care plan. Interview with State Registered Nurse Aide (SRNA) #1 on [DATE] at 1:53 PM revealed at the beginning of each shift, the facility provides a Kardex that defines what level of assistance and support a resident needs to safely perform tasks. Interview with SRNA #2 on [DATE] at 3:48 PM, revealed the Kardex provided the needed information regarding the amount of assistance and support a resident needs. Review of the facility staffing roster, dated [DATE], revealed SRNA #3 and SRNA #17 and Licensed Practical Nurse (LPN) #2 were assigned to the area of the facility where Resident #84 resided on [DATE]. Interview with SRNA #3 on [DATE] at 3:22 PM, revealed she worked on [DATE] and was familiar with Resident #84, but did not recall the resident having any falls or any incidents. Three attempts were made to contact and speak with SRNA #17 but were unsuccessful. The Nurse Consultant stated on [DATE] at 1:28 PM, that the SRNA had left under unpleasant circumstances. Interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 3:52 PM, revealed on [DATE] two SRNAs were attempting to transfer Resident #259, and the resident grabbed onto the wheelchair. The LPN stated the resident did not fall, but was lowered to the floor. She stated she was not aware the resident's care plan had been updated to include a requirement for the extensive assistance of two (2) staff persons and the Maxi lift for transfers. The LPN stated Kardexes are provided to SRNAs at the beginning of their shift and the information regarding how much assistance a resident needs is on the Kardex. Interview with the Director of Nursing on [DATE] at 11:58 AM, revealed the Maxi lift should have been used to transfer Resident #84 on [DATE], as the intervention had been placed on the care plan on [DATE]. ***The facility alleged the following was implemented to remove Immediate Jeopardy effective [DATE]: 1. Resident #259 no longer resides at the facility. 2. By [DATE], the Pharmacist will complete a Medication Regimen Review for current residents, which will include psychoactive medications, to ensure there is a supporting diagnosis, and will review for necessity/indication for the medication. The Pharmacist will also review for psychoactive medications that may be contributing to falls. One hundred eleven (111) residents were reviewed. Recommendations to the Medical Director was made for sixty-three (63) residents, six (6) of which were recommendations for a gradual dose reduction of psychoactive medications. 3. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) assessed current residents for potential side effects from psychoactive medication on [DATE], and ensured resident's Medication Administration Records (MAR) reflected the need to monitor for potential side effects of psychoactive medication. 4. The facility held a meeting on [DATE] to evaluate residents receiving psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) was in attendance and the Medical Director attended by phone to review appropriate utilization of psychoactive medications, which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive is achieved. 5. The DON/ADON/Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on [DATE]. The Nurse Consultant/DON/ADON/ Wound Nurse will also review resident falls for the past 30 days to ensure a root cause analysis has been conducted and appropriate interventions are in place. This will include a review of the care plan to ensure updates have been entered. 6. The Social Service Director, Social Service Assistant, and the Clinical Liaison will interview residents with a BIMS of eight (8) and above to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. The interviews were completed by [DATE] and any concerns identified will be reported to the Director of Nursing (DON) and/or Executive Director immediately and addressed by the appropriate department. 7. The Wound Nurse (LPN) and Clinical Liaison (LPN) will complete resident observations by [DATE] for residents with a BIMS score of seven (7) and below to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. Concerns identified will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 8. The Human Resource Director, ADON, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab will interview current staff related to any knowledge of residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. The interviews will be completed by [DATE] and any concerns will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. The DON/ADON and/or designee will review resident interviews, staff interviews, and resident observations by [DATE] to ensure the physician is notified of any change in condition. The DON/ADON/ MDS nurse will review current resident and staff interviews to ensure that appropriate interventions were placed based on falls root cause analysis. 10. On [DATE], the DON/ADON and/or designee will review fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. By [DATE], the MDS Coordinator will review nursing notes for the past 30 days to ensure physician notification and care plan revision to reflect any change, including falls and behaviors. One resident was identified to not have a care plan related to a skin tear; however, the physician had been notified with orders for treatment. 12. By [DATE], the DON and/or the ADON will review the Twenty-Four hour reports to ensure any change in a resident's condition has been addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. The Nurse Consultant/DON/ADON/SDC/RN Charge Nurse will review care plans on current residents to ensure appropriate documentation related to change in conditions, including but not limited to: pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. The reviews were completed by [DATE]. Five resident care plans were revised. 14. By [DATE], the Nurse Consultant educated the ED/DON/ADON/SDC on utilizing Stop and Watch forms, a communication form developed by CMS to communicate changes related to change of condition. Education will include giving the completed Stop and Watch to the nurse and making a copy and leaving for the DON/ADON. The DON/ADON will review Stop and Watches and follow up on possible change of condition during the daily clinical meeting and was completed as appropriate. By [DATE], the ED/DON/ADON/SDC will educate current staff regarding utilizing Stop and Watch forms for any change in condition, giving the completed form to the nurse, and making a copy for the DON. 15. The Nurse Consultant educated the ED/DON/ADON/SDC the DON/ADON on [DATE] to review Stop and Watches forms to ensure they were acted upon appropriately to include physician notification for changes in condition, They were also educated to ensure appropriate interventions were implemented for falls based on root cause analysis of the fall, which includes the 5 Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention at time of fall. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. The SDC/DON/ADON/ED then educated licensed staff by [DATE] regarding the utilization of the 5 Why's tool to determine the root cause of a fall to assist in determining the most appropriate intervention. In addition, current licensed nurses will be educated to notify the on-call Nurse Manager after a fall to review the root cause and the intervention for appropriateness. 16. By [DATE], the ED/DON/ADON/SDC will educate current licensed staff on appropriate documentation including, but not limited to: changes in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or needing increased help from staff. 17. By [DATE], the Nurse Consultant will educate the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and the Wound Care Nurse (LPN) on assuring that residents are assessed for potential medication side effects; to ensure a monitoring order is placed on the MAR indicated [REDACTED]. Education included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate [DIAGNOSES REDACTED]. The review will be conducted during the daily clinical meeting and will be followed-up by the Pharmacy Consultant. Any new medication orders will be reviewed by the DON/ADON/SDC for necessity to include appropriate [DIAGNOSES REDACTED]. 18. The Nurse Consultant will educate the DON/ADON/SDC on ensuring pharmacy reviews have occurred monthly and ensuring timely follow up of recommendations per facility policy, which states the recommendations will be received by the DON within 3 days of completion of review. The recommendations will be sent to the physician and the DON will verify the physician and Medical Director has received the review within 3 days. The DON should receive a response from the physician within 7 days. If a response is not received in 7 days, the DON/ADON will notify the physician for acceptance and/or a response to the recommendations that require action. If no response is received in 14 days, the DON/ADON will notify the Medical Director for further action. The DON/ADON will also notify the Executive Director and the Nurse Consultant. This education will occur on [DATE]. The DON, ADON, or Staff Development Coordinator will then will educate current licensed staff by [DATE] on assuring that residents are assessed for potential side effects of medications, ensuring a monitoring order is placed on the MAR indicated [REDACTED]. 19. The Pharmacy Director will re-educate the Registered Pharmacist by [DATE] on accurately completing a Medication Regimen Review, which will include a supporting [DIAGNOSES REDACTED]. The Pharmacist assigned to the facility at the time of the IJ has been removed as the Pharmacy Consultant. The current Pharmacy Consultant has been educated on the concerns related to regimen reviews, appropriate [DIAGNOSES REDACTED]. 20. For all education, a post education test will be administered by the Nurse Consultant/DON/ADON/SDC following education. If a score of 100% is not obtained, re-education will be completed until proficiency is obtained and their score is 100%. Five tests will be administered daily by ED/Assistant Administrator/ DON/ADON/SDC to ensure retention of education, until IJ is removed and approved through QAPI process. Current staff who have not received education by [DATE] will be mailed a certified letter informing them to contact the Executive Director/DON/SDC prior to working the floor. Staffing Agencies currently being utilized will be mailed a certified letter on [DATE] of the need to contact the ED/DON/SDC for education prior to working. The Executive Director/SDC or designee will ensure all newly hired staff and agency staff will receive education during New Hire Orientation or prior to working the floor. 21. The IDT will review in the daily clinical meeting (Monday through Friday) each fall and nursing shift reports to ensure the following is completed for any resident who sustained a fall: Falls Risk evaluation, to include the 5 Why's; physician notification; and care plan revision. In addition, the IDT will review Stop and Watch forms, progress notes, and physician orders to ensure care plans have been updated appropriately and physicians have been notified. 22. The Executive Director/Assistant Administrator/DON will conduct daily post clinical IDT meetings Monday-Friday for two weeks to review all identified Change of Condition and the effectiveness of medication to ensure notification of residents' physician as required. In addition, the Executive Director/Assistant Administrator/DON will review five (5) random resident records to ensure proper documentation has been completed related to any change in condition, physician notification, and the care plans are appropriate. Any issues identified will be corrected immediately and reported to the QAPI Committee for 3 months for further review and recommendations. 23. The facility will conduct weekly monitoring to evaluate psychoactive medication on residents, residents new prescribed psychoactive medications, and residents that have had medication dose adjustment. This psychoactive meeting will be conducted weekly by the facility IDT, (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and Pharmacist to review appropriate utilization of psychoactive medications which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 24. Beginning [DATE], the Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at facility to monitor processes related to supervision to prevent accidents, care plan development/revision, and physician notification until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for r (TRUNCATED)

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for five (5) of thirty-nine (39) sampled residents (Residents #259, #35, #24, #84, and #60). Interviews with staff and Resident #259's daughter revealed the resident had [MEDICAL CONDITION] and attempted unsafe transfers from the wheelchair. However, the facility failed to develop care plan interventions to address the resident's behavior. On [DATE] at 7:15 PM, staff assisted Resident #259 out of bed to a wheelchair because the resident was restless and attempting to get out of bed unassisted. While up in the wheelchair, Resident #259 was also observed leaning forward, attempting to stand, and hallucinating (reaching into the air and leaning forward to touch the floor for objects that were not there). However, the facility failed to develop/implement interventions to prevent falls from the wheelchair and failed to administer as needed medication to help the resident rest/sleep. At 1:05 AM on [DATE], after the resident had been in the wheelchair for approximately six (6) hours, Resident #259 was found on the floor, lying on his/her left side in the hallway of the facility, bleeding from the head. The resident was transferred to a local hospital on [DATE] and was diagnosed with [REDACTED]. Review of a Coroner's Report revealed Resident #259 was pronounced deceased at 6:38 AM on [DATE], and his/her cause of death was a [MEDICAL CONDITION] due to a fall to the floor. Resident #35 sustained a fall on [DATE], and the facility documented that the resident would be supervised when up in a wheelchair; however, the facility failed to add the intervention to the resident's care plan and the intervention was never implemented. Subsequently, Resident #35 continued attempts to get up from his/her wheelchair unassisted and sustained six (6) more falls. However, the facility failed to implement interventions addressing the resident's attempts to get out of the wheelchair unassisted. On [DATE] at 6:00 PM, Resident #35 attempted to stand from his/her wheelchair and fell . The resident was transferred to the hospital due to right hip pain and was diagnosed with [REDACTED]. On [DATE] and [DATE], Resident #24 was found on the floor by the bed, incontinent of urine. The facility investigated the falls and determined the cause of the falls was weakness/not calling for assistance/impaired safety awareness. The facility failed to consider that the need for toileting might have been the cause of the falls and failed to implement interventions to address toileting needs/incontinence. On [DATE], the facility failed to utilize a mechanical lift when transferring Resident #84 as required by the resident's care plan. Staff had to lower the resident to the floor. The facility investigated the resident's fall, but failed to identify that the cause of the fall was the failure to follow the resident's care plan. Resident #60 was admitted to the facility on [DATE] after a fall at home that resulted in a Retropharyngeal (throat area) hematoma, Right Traumatic Subdural Hematoma (brain bleed), and a Compression [MEDICAL CONDITION] spine. The resident sustained [REDACTED]. Interviews with staff revealed the only way to keep the resident safe and prevent falls was to provide one-on-one supervision for the resident; however, the facility failed to implement increased supervision to prevent the resident from falling. The facility's failure to ensure each resident received adequate supervision and assistive devices to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE] prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility policy titled Fall Management, dated [DATE], revealed a fall was an unintentional change in position coming to rest on the ground, floor, or onto the next lower surface, which included onto a bed, chair, or bedside mat. The policy stated injury related to a fall was any documented injury that occurred as a result of, or was recognized within a short period of time (hours or to a few days) after the fall and attributed to the fall. According to the policy, a major injury included bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. Review of the policy also revealed a fall risk observation was completed on admission, quarterly, annually, with any significant change in condition, and with any fall, and was utilized to identify individuals who were at high risk for falls, as well as those individuals who have any risk factors for falls. Further review of the policy revealed fall prevention was achieved through an interdisciplinary approach of managing risk factors and implementing appropriate interventions to reduce risk for falls. The policy directed staff to develop a plan of care, which included general and specific interventions to reduce fall risk. The policy also directed staff to investigate falls and complete a root cause analysis and determine an intervention based on that information. The policy also stated the investigation and root cause analysis of a fall may include medications that place a resident at risk for falls, [MEDICATION NAME]/extrinsic fall risk factors, time of day, and devices used at the time of the fall. 1. Review of Resident #259's record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #259's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she had no signs of difficulty sleeping and had not exhibited behaviors during the assessment period. The assessment also indicated the resident required extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. The MDS also indicated Resident #259 had experienced one (1) fall since admission, with no injury, and was interviewable with a Brief Interview for Mental Status (BIMS) score of nine (9). Review of Resident #259's comprehensive care plan initiated [DATE] revealed staff identified that the resident was at risk for falls. Interventions implemented since admission included to anticipate and meet the resident's needs, place the resident's bed against the wall per resident/family preference, non-slip footwear when ambulating or mobilizing in the wheelchair, offer snack and fluids, and offer the resident to sit in a wheelchair when he/she was restless or could not sleep. Review of Resident #259's physician orders for [DATE] revealed staff were directed to administer [MEDICATION NAME] 5 mg, every twelve (12) hours as needed for sleep. Review of Resident #259's Incident Reports and Nurse's Notes revealed the resident sustained [REDACTED]. On each occasion, staff found the resident on the floor by his/her bed. On [DATE], staff observed the resident's call light on, and found the resident on his/her knees by the bed. The nurse's notes also revealed staff asked the resident why he/she was getting out of bed and the resident stated he/she did not know. Continued review of Resident #259's nurse's notes revealed on [DATE] the resident hit the back of his/her head, reddened discoloration to the resident's forehead, redness to the left hip, and a skin tear to his/her left arm. According to the incident report for Resident #259's fall on [DATE], the resident was attempting to get up unassisted to go to the bathroom. Further review of Resident #259's nurse's notes revealed on [DATE], Resident #259 was hollering out and staff found the resident lying on the floor again, in front of his/her bed. Interview with the DON on [DATE] at 12:15 PM revealed the IDT discussed Resident #259's falls and determined the root cause of each fall was Impaired Safety Awareness. The DON stated that after the fall on [DATE], interventions were implemented to assist the resident to a chair when he/she was restless or can't sleep and to offer snacks and fluids to the resident. According to the DON, after the fall on [DATE], the IDT determined that the resident was attempting to get up unassisted and was falling off of the right side of his/her bed. According to the DON, the left side of the bed was placed against the wall and non-skid strips were placed on the floor on the right side of the bed. Further interview with the DON revealed that after the resident fell on [DATE], the facility implemented a toileting program for the resident. Interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 9:00 PM revealed she cared for Resident #259 and was aware the resident had trouble sleeping and was anxious at times. The LPN stated, You could hear the resident yelling from the hallway if the resident was in bed. Interview with LPN #2 on [DATE] at 9:10 PM revealed she cared for Resident #259 and the resident was very fidgety and didn't sleep much. The LPN stated she was not sure if the resident had sundowners or what but the resident frequently attempted to get out of bed unassisted. She stated staff assisted the resident to a wheelchair when he/she was attempting unsafe transfers from the bed. However, according to LPN #2, the resident also attempted unsafe transfers from the wheelchair and was unable to be redirected. LPN #2 stated the only way to keep the resident from falling was to keep your eyes on the resident when he/she was in the wheelchair. Interview with LPN #6 on [DATE] at 11:35 AM revealed for Resident #259 it was normal for the resident to attempt unsafe transfers from his/her wheelchair and required redirection. LPN #6 stated she was not aware of any interventions that had been implemented to prevent Resident #259 from falling when he/she was up in a wheelchair. Review of a list of residents' BIMS scores, provided by the facility, revealed Resident #56, Resident #259's former roommate, was interviewable with a BIMS score of eleven (11). Interview with Resident #56 on [DATE] at 1:50 PM revealed he/she was Resident #259's roommate when he/she resided in the facility. Resident #56 stated Resident #259 didn't sleep much at all. The resident also stated Resident #259 would sleep two hours at a time if he/she slept that much. Interview with Resident #259's daughter on [DATE] at 7:30 PM revealed she visited the resident daily at the facility. She stated she had to admit the resident because he/she would stay up for two (2) or three (3) days at a time and she was no longer able to care for the resident at home. She also stated she informed staff of the resident's inability to sleep when the resident was admitted to the facility. Further review of Resident #259's care plan provided no evidence that staff developed a care plan or implemented interventions that addressed the resident's unsafe transfer attempts from the wheelchair or to address the resident's [MEDICAL CONDITION]. In addition, there was no evidence the facility identified that the care plan intervention to assist the resident to a chair when he/she was restless or can't sleep was not effective, or considered that the intervention placed the resident at increased risk for falls. Interview with State Registered Nurse Aide (SRNA) #8 on [DATE] at 6:00 PM revealed she frequently cared for Resident #259 and was assigned to care for him/her during the 6:30 PM to 6:30 AM shift on ,[DATE]-,[DATE]. The SRNA stated Resident #259 was attempting to get out of bed unassisted on [DATE] at approximately 7:15 PM and she and another SRNA assisted the resident out of bed, the resident used the restroom, and the staff assisted the resident to a wheelchair. SRNA #8 stated staff had been directed to get the resident up to a wheelchair when the resident attempted to get out of bed unassisted. The SRNA stated the resident was very confused, wild, and wiggly more than normal on [DATE]. According to the SRNA, while up in the wheelchair, Resident #259 was observed going up and down the hallways, pulled med (medication) carts around, and was attempting to stand without assistance from his/her wheelchair. She also stated the resident was hallucinating, reaching in the air for things that were not there, and bending forward to the floor in front of his/her wheelchair. The SRNA stated she reported to the nurse (LPN #3) that the resident was having a bad night and reported the ongoing behaviors the resident was exhibiting. According to SRNA #8, the nurse instructed her to leave the resident where staff could see him/her as much as possible. SRNA #8 stated she attempted toileting the resident and gave the resident something to look at, a magazine I think; however, she stated, no matter what we did the resident would not calm down. SRNA #8 stated the nurse had left the unit to get something to drink, and the medication aide and the other SRNA were in another room providing care to another resident. She stated she was charting in a small room over from the nurses' station and observed the resident in his/her wheelchair, wiggly and fidgety, at approximately 1:02 AM on [DATE]. The SRNA stated she looked out of the room to check on the resident again and observed the resident lying on the floor, in front of his/her wheelchair, at approximately 1:05 AM on [DATE]. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 6:15 PM revealed she administered Resident #259's medications on [DATE] at 9:00 PM. She stated she thought the resident's 9:00 PM medications would help relax the resident; however, he/she was still fidgety. The KMA stated Resident #259 was up in his/her wheelchair and would not relax enough to go to sleep. She stated the resident was observed leaning forward in his/her wheelchair, reaching toward the floor in front of his/her chair, and hallucinating, attempting to pick things up that were not there. KMA #1 also stated the resident kept trying to move the medication cart, and tried to stand up unassisted from the wheelchair a few times during the shift. KMA #1 stated she did not administer [MEDICATION NAME] to the resident because she was not aware that it was ordered by the resident's physician. Interview with SRNA #9 on [DATE] at 6:55 PM revealed she assisted SRNA #8 with getting Resident #259 out of bed on [DATE] because the resident kept trying to climb out of the bed. The SRNA stated the resident was confused, hallucinating, looking for car keys and keys to his/her house, rolling up and down the hallways of the facility, and kept trying to stand up from the wheelchair. The SRNA stated she reported the resident's behaviors to the nurse and was instructed to keep the resident at the nurses' station. The SRNA stated she had been in another resident room providing care and when she came out, Resident #259 was on the floor, in front of his/her wheelchair at the nurses' station. SRNA #9 stated, Blood was coming nonstop out of the resident's head. Continued review of Resident #259's care plan revealed no evidence that interventions were developed/implemented to address the resident bending forward/reaching toward the floor while in his/her wheelchair, or the attempts to get up unassisted. Review of the resident's Medication Administration Record [REDACTED]. According to the MAR, staff had only administered the medication on one occasion, [DATE]. Interview with LPN #3 on [DATE] at 7:10 PM revealed when he arrived at the unit where Resident #259 resided on [DATE] at approximately 7:30 PM, the resident was up in a wheelchair. The LPN stated he was assigned to care for the resident for the remainder of the shift, which ended at 6:30 AM on [DATE]. The LPN stated the nurse aide that was most familiar with the resident informed him that Resident #259 had a bunch of falls and was more confused than normal. He stated the resident was disoriented, saying off the wall stuff, and was yelling out for people that wasn't there. LPN #3 stated staff had not reported to him that the resident was attempting to stand up from his/her wheelchair unassisted, but stated he was aware the resident remained up in a wheelchair for many hours due to confusion, disorientation, unrelieved anxiety and restlessness, and couldn't sleep. However, LPN #3 was unaware the resident had [MEDICATION NAME] ordered as needed for sleep. LPN #3 stated he left the unit to get something to drink and when he returned at approximately 1:05 AM on [DATE], Resident #259 was on the floor in front of the nurses' station and blood was everywhere. He stated he transferred the resident to a local hospital for further evaluation and treatment. Review of Resident #259's nurse's notes revealed LPN #3 documented that on [DATE] at 1:05 AM staff observed the resident lying on the floor on his/her left side, in the hallway in front of the nurses' station/dining room of the facility. The nurse's notes also revealed the resident had a large hematoma to the left temporal area and copious amount of bleeding also present from area. The nurse's notes indicated staff was unable to determine exact origin of bleed. According to the nurse's notes, staff contacted Emergency Medical Services (EMS) and applied a pressure dressing to the resident's left temporal area. Resident #259 was transferred to the local hospital for further evaluation and treatment, and was alert and stable when he/she left the facility. Continued interview with Resident #259's daughter on [DATE] at 7:30 PM revealed she was aware that the resident attempted to get up from the wheelchair unassisted a lot, especially when the resident was anxious/restless. The daughter stated, however, no one did anything to keep him/her from doing that. She also stated Resident #259 had fallen so many times in the facility that she could not understand why would they leave, him/her alone up in a chair at that time of night? Interview with Administrator #1 on [DATE] at 2:20 PM revealed she attended morning meetings Monday through Friday, and was a member of the IDT in the facility. She stated falls were discussed daily during the morning meetings; however, the only fall for Resident #259 that she recalled discussing was the one that occurred on [DATE]. She also stated she was not aware that Resident #259 had trouble sleeping or that he/she attempted unsafe transfers while up in a wheelchair. The Administrator also stated if staff identified that the resident had trouble sleeping, and the resident had medication ordered for sleep as needed, she would expect staff to administer and monitor the effectiveness of the medication. She also stated staff should have implemented fall interventions due to his/her unsafe transfer attempts from the wheelchair. The Administrator stated that approximately six (6) hours was a long time for a resident to be up in a wheelchair exhibiting restlessness and agitation. She stated in hind sight an increased level of supervision would have helped the resident. Review of Resident #259's hospital record revealed he/she was triaged at a local hospital on [DATE] at 1:50 AM with a stated complaint of a [MEDICAL CONDITION] to the left temporal area. Review of the resident's ED General Exam dictated by the emergency room (ER) Physician at 2:42 AM on [DATE] revealed the resident was sitting in his/her wheelchair when he/she leaned forward and fell out and hit his/her head on the floor. Review of the physician documentation also revealed the resident had a 2-centimeter (cm) laceration to the left forehead, that went to the skull, with a small arterial bleed noted that was bleeding briskly. The physician further documented that the arterial bleed was cauterized and three (3) sutures were placed to close the wound. Continued review of Resident #258's hospital record revealed a Preliminary Radiology Report for a CT scan dated [DATE] at 2:45 AM indicated Resident #1 had an acute-appearing left frontotemporal subdural hemorrhage, largest component along the left temporal lobe measuring approximately 9 millimeters (mm) in maximal thickness. Further review of the report revealed the resident also had an acute-appearing left parietal, left posterior temporal, and right posterior temporal subarachnoid hemorrhage. Continued review of the hospital record revealed Resident #259 was transferred to a larger hospital, under the care of the trauma team on [DATE] at 3:55 AM. The record also indicated the resident was alert and was able to obey commands when he/she was transferred. Review of a Coroner's Report revealed Resident #259 was pronounced deceased at 6:38 AM on [DATE]. The cause of death was a [MEDICAL CONDITION] due to a fall to the floor. 2. A review of the medical record for Resident #35 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35 was severely impaired for cognition, utilized a wheelchair for mobility, and required the extensive assistance of two staff persons for transfers. A review of the plan of care developed for Resident #35 dated [DATE] revealed Resident #35 was at risk for falls due to balance problems, weakness, and a history of falling. The care plan included fall interventions for a low bed, contour mattress, bolsters (elongated pillows), and mattress on the floor by the bed. A review of fall investigations for Resident #35 revealed on [DATE] at 6:02 AM Resident #35 sustained a fall with injury. The resident was found lying on the floor in the resident's room by the bed with a laceration noted to right side of his/her forehead/hairline. The resident had previously been up in the wheelchair. The resident was transferred to the hospital for evaluation and treatment. Continued review of the fall investigation for Resident #35 revealed no evidence of a root cause analysis conducted to identify the reason Resident #35 was falling. According to the investigation, an intervention was implemented on [DATE] for Resident #35 to be in a supervised area when up in the wheelchair. However, the facility failed to add this intervention to the resident's plan of care. Further review of fall investigations for Resident #35 revealed the resident continued to sustain falls without injury on the following dates: On [DATE] at 8:30 AM, the resident was found sitting on his/her buttocks on the mattress at the side of the bed; on [DATE] at 7:29 PM, Resident #35 attempted to get out of a chair (unclear what type of chair) to get into bed and slid to the floor; on [DATE] at 3:12 AM Resident #35 was found sitting on a mat beside the bed; on [DATE] at 6:00 PM, the resident was observed on his/her knees on the floor in his/her room; on [DATE] at 10:00 AM Resident #35 was observed sitting on his/her buttocks on the floor in the hallway (unclear if this fall was from the wheelchair); on [DATE] at 12:30 PM, the resident was observed sitting on his/her buttocks on a mat in his/her room. Interview conducted on [DATE] at 2:25 PM with SRNA #13 revealed if Resident #35 was in a wheelchair he/she would pull up to the hand rails and attempt to ambulate unassisted in the hallway. According to SRNA #13, staff had to keep an eye on the resident as the resident was unable to ambulate unassisted. Interview with SRNA #8 on [DATE] at 7:20 PM revealed Resident #35 is extremely confused and forgets he/she cannot stand. Further interview revealed if Resident #35 gets to a handrail when in his/her wheelchair, the resident pulls himself/herself up and tries to ambulate. Interview with SRNA #15 on [DATE] at 1:04 PM revealed Resident #35 was a fall risk and would try to get out of bed unassisted. According to the SRNA, once the resident was up in a wheelchair staff had to constantly watch the resident due to the resident attempting to pull himself/herself up using the handrails. The SRNA stated the resident would stand up and try to walk but the resident was unable to walk unassisted. Interview with LPN #9 on [DATE] at 10:50 AM revealed Resident #35 was confused and attempted to get up unassisted. Per the LPN, the resident was not physically able to ambulate unassisted and had a history of [REDACTED]. Interview with LPN #11 on [DATE] at 11:12 AM, revealed Resident #35 attempted to get up unassisted and had a history of [REDACTED]. Interview with LPN #10 on [DATE] at 1:41 PM revealed the LPN had taken care of Resident #35 and the resident attempted to get up unassisted. According to the LPN, the resident cannot stand on his/her own. Further review of the care plan revealed that although the resident had continued to experience falls in the facility and attempted to get up from his/her wheelchair unassisted, the facility failed to implement interventions addressing the resident's attempts to get out of the wheelchair unassisted. Further, there was no evidence the intervention of supervision while up in the wheelchair was added to the care plan even after the repeated falls mentioned above. Additional review of fall investigations for Resident #35 revealed the resident sustained [REDACTED]. Resident #35 was sitting in a wheelchair in the doorway of his/her room. Resident #35 attempted to stand, sustained a fall, and landed on the right side before staff could intervene. Resident #35 complained of right hip pain, was transferred to the hospital, and diagnosed with [REDACTED]. The resident was in the hospital at the time of the survey and had not returned to the facility. Interview with RN #2 on [DATE] at 4:30 PM revealed the RN had witnessed Resident #35 fall on [DATE]. The RN stated she was in the hallway with her medication cart administering resident medications. The RN stated the resident was in a wheelchair, attempted to stand, and fell before she could get to the resident. According to RN #2, she assessed the resident after the fall. The resident complained of right hip pain, was transferred to the hospital, was diagnosed with [REDACTED]. RN #2 stated she could not remember what the resident was doing prior to the fall, but the resident often tried to get up unassisted and had dementia. Interview with the Director of Nursing (DON) on [DATE] at 3:18 PM revealed the DON was the Minimum Data Set (MDS) Nurse in [DATE] when Resident #35 sustained a fall and was responsible for revising the resident's plan of care and was not aware why the intervention (to supervise when up in the wheelchair) was not added to the plan of care. 3. A review of the medical record for Resident #24 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent significant change MDS assessment completed for Resident #24 dated [DATE] revealed the resident had severely impaired cognition with a BIMS score of two (2) and was assessed to require the extensive assistance of two staff persons for transfers. In addition, the resident was assessed to be at risk for falls with a history of falls. A review of the plan of care initiated on [DATE] revealed Resident #24 was at risk for falls with interventions implemented to have a call light in his/her room, educate the resident to call for assistance before transferring, encourage nonskid footwear, give [MEDICAL CONDITION] medication as ordered, and to keep the environment well lit and free of clutter. Review of the fall investigations for Resident #24 revealed the resident had sustained a fall on [DATE] at 12:41 AM. The resident was found on the floor beside the bed, confused, calling for family. On [DATE] at 4:33 AM, Resident #24 sustained a fall and was found on the floor beside the bed. Per the fall investigation, the resident had been incontinent. Further review of fall investigations revealed the resident sustained [REDACTED]. The resident was found lying on the floor in his/her room by the bed. The resident stated he/she was getting out of bed. Again, the fall investigation stated the resident had been incontinent. There was no documented evidence that the facility completed a fall risk assessment as required by their policy. In addition, even though the investigations revealed the resident was incontinent with each fall, the facility documented that the root cause of the falls was weakness did not call for assist and weakness, impaired safety awareness, and there was no evidence interventions were implemented to address the resident's incontinence. Observations on [DATE] at 9:30 AM, 2:35 PM, and 3:21 PM, and on [DATE] at 10:45 AM revealed the resident had a low bed with an air mattress and fall mats on the floor. Interview with SRNA #8 on [DATE] at 7:20 PM revealed the SRNA was not sure what interventions were in place for the resident to prevent falls other than a low bed and fall mats. Interview with LPN #10 on [DATE] at 1:41 PM revealed Resident #24 could not ambulate and was at risk for falls. According to the LPN, at some point the resident's room was changed to be closer to the nurses' station to increase the resident's supervision. However, the LPN was not aware how the facility decided what interventions to implement when a resident sustained [REDACTED]. Interview with LPN #12 on [DATE] at 1:45 PM revealed the LPN could not remember the resident falling on [DATE] and [DATE], but would have assessed the resident and notified the physician and family of any changes and sent the resident to the hospital. The LPN was not aware why she did not consider the resident's incontinence or interventions for the resident to be checked and changed more often to possibly prevent falls. Interview with the MDS Nurse on [DATE] at 11:17 AM revealed she was unsure of the policy for completing fall risk assessments on residents. According to the MDS Nurse, the care plan was reviewed and revised the next day after a resident fall during the morning (TRUNCATED)

Based on interview, record review, and a review of the facility policy, it was determined the facility failed to ensure the Consulting Pharmacist conducted a review of two (2) of thirty-nine (39) sampled residents' medical records (Resident #259 and Resident #2) when conducting the Drug Regimen Review (DRR) to ensure medications were not causing unwanted, uncomfortable, or dangerous effects. Resident #259 was admitted to the facility on [DATE] with physician orders for [MEDICAL CONDITION] medications. Review of Resident #259's medical record revealed the resident sustained [REDACTED]. Interviews with staff revealed the resident also had [MEDICAL CONDITION]. The licensed Pharmacist conducted a Medication Regimen Review (MRR) on [DATE], and indicated the resident's medical record listed potentially inappropriate supporting [DIAGNOSES REDACTED]. However, the pharmacist failed to review the resident's medical record in an attempt to determine whether the [MEDICAL CONDITION] medications contributed to the resident's falls. Resident #259 sustained another fall on [DATE] at 9:26 PM after the pharmacy review was conducted. In addition, on [DATE] at 1:05 AM Resident #259 was found on the floor, lying on his/her left side in the hallway of the facility, and bleeding from his/her head. The resident was transferred to a local hospital on [DATE] and was diagnosed with [REDACTED]. Resident #259 expired at 6:38 AM on [DATE], due to a [MEDICAL CONDITION] from the fall to the floor. In addition, the facility failed to address a pharmacy recommendation dated [DATE], per the facility's policy for Resident #2. The facility's failure to ensure residents' medical records were reviewed to ensure medications were not causing unwanted, uncomfortable, or dangerous effects has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE] prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F580), 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F689), and 42 CFR 483.45 Pharmacy Services (F756) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: 1. Review of the facility's policy, Medication Regimen Review, Facility Process, dated [DATE], revealed the intent of the process was to prevent or minimize adverse consequences related to medication therapy to the extent possible by providing oversight by a licensed pharmacist, attending physician, medical director, and the Director of Nursing (DON). The policy defined adverse consequences as a broad term, which referred to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional/psychosocial status. The policy also indicated that the Medication Regimen Review would be a thorough evaluation of the resident's medication regimen with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The Medication Regimen Review would include a medical record review for the resident in order to prevent, identify, report, and resolve issues, which included medication-related problems, and collaborate with other members of the IDT, including the resident, their family, and/or the resident representative. Review of Resident #259's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #259's Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident displayed no behaviors during the assessment period. The facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated cognitive impairment, and to require extensive assistance of two (2) staff members for toileting, bed mobility, and transfers. The MDS also revealed the resident had experienced one (1) fall since admission, with no injury. Review of Resident #259's physician orders dated [DATE] and [DATE] revealed the resident received the following medications: [REDACTED]. Resident #259 also received [MEDICATION NAME] (antidepressant) 15 mg at bedtime for treatment of [REDACTED]. Review of Resident #259's record revealed the resident experienced falls on [DATE], [DATE], and [DATE], when attempting to get up unassisted. Review of Resident #259's Pharmacy Consultation Report dated [DATE] revealed the pharmacist identified concerns with the [DIAGNOSES REDACTED]. The pharmacist's report indicated the resident's medical record listed potentially inappropriate supporting [DIAGNOSES REDACTED]. The pharmacist's report also cautioned, All [MEDICAL CONDITION] need appropriate indication. Interview with the facility Pharmacist on [DATE] at 9:45 AM revealed when reviewing Resident #259's medications on [DATE], she identified that the resident was receiving [MEDICAL CONDITION] medications without appropriate [DIAGNOSES REDACTED]. The Pharmacist stated she did not usually research the resident's medical record or inquire about falls the resident had sustained, even if a medication prescribed to the resident could potentially contribute to increased falls. The Pharmacist stated she was not aware that Resident #259 had experienced three (3) falls prior to the medication review and had not discussed Resident #259's medication use with the DON or any other member of the Interdisciplinary Team (IDT). In addition, the pharmacist stated she had not observed or spoken with Resident #259 or the resident's family member/representative. Interview with the DON on [DATE] at 2:05 PM revealed the Interdisciplinary Team (IDT) reviewed all newly admitted residents' medications to ensure that residents receiving [MEDICAL CONDITION] medications had the appropriate supporting diagnoses. However, the DON was unable to remember if Resident #259's medications had been reviewed on admission. The DON also acknowledged the facility had no process in place to monitor residents for potential adverse effects of [MEDICAL CONDITION] medications, including the potential for the medication(s) to be a contributing factor for sustained falls. According to the DON, the resident's physician had not reviewed or acted upon the pharmacist's recommendations prior to the resident's transfer from the facility. Interviews on [DATE] with Licensed Practical Nurse (LPN) #5 at 3:00 PM and LPN #2 at 9:10 PM, and on [DATE] at 11:35 AM with LPN #6 revealed the staff had not been instructed to monitor residents for potential adverse effects of [MEDICAL CONDITION] medication. Interview with Physical Therapy Assistant (PTA) #1 on [DATE] at 12:45 PM revealed he provided services to Resident #259 a couple of times; however, he was unable to get the resident to participate well in therapy because the resident was lethargic during each session. Continued review of Resident #259's medical record revealed the resident sustained [REDACTED]. In addition, review of a nurse's note revealed on [DATE] at 1:05 AM staff observed the resident lying on the floor on his/her left side, in the hallway in front of the nurses' station/dining room of the facility. The nurse's notes also revealed the resident had a large hematoma to the left temporal area and copious amount of bleeding also present from area. Resident #259 was transferred to the local hospital for further evaluation and treatment. Review of Resident #259's hospital record for Resident #259 dated [DATE] revealed the resident had a laceration to the left forehead, which extended to the skull, and an arterial bleed was present and bleeding in the brain. The resident expired on [DATE] at 6:38 AM from a [MEDICAL CONDITION] sustained from a fall. 2. Review of the policy, Medication Regimen Review (MRR) Facility Process, dated [DATE], revealed the attending physician is expected to sign the resident's individual MRR and document that he/she reviewed the pharmacist's identified irregularities; document the action taken or not taken, including the rationale for why the recommendation was rejected; and return the signed form to the Director of Nursing or designee within 7 days. If preferred by the physician, instead of signing the MRR form, the physician may document a progress note in the resident's medical record that states he has reviewed the Pharmacist's recommendations and either accepts the recommendations and provides new orders or documents rationale as to why the recommendation is rejected. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident had moderate cognitive impairment. Review of the current physician orders, per electronic medical record (EMR), revealed as of [DATE], Resident #2 had orders for [MEDICAL CONDITION] medications that included [MEDICATION NAME], Trazadone, [MEDICATION NAME], and [MEDICATION NAME]. Review of the pharmacy recommendations revealed a consultation report dated [DATE], which recommended re-evaluation of the combination of [MEDICATION NAME], and [MEDICATION NAME] and to consider dose reduction if appropriate for Resident #2. The physician checked that the recommendation was declined and did not wish to implement any changes due to reasons below. The recommendation was signed by the physician on [DATE]; however, there was no documentation as to the reason the recommendation was declined. Interview with the Director of Nursing (DON) on [DATE] at 11:19 AM, revealed the Assistant Directors of Nursing (ADONs) were responsible for ensuring pharmacy recommendations were acted upon timely. After reviewing Resident #2's pharmacy recommendation dated [DATE], she stated the ADONs and nurses knew they were required to ensure the physician's rationale was documented for declining a recommendation. Interview with ADON #1 on [DATE] at 9:55 AM, revealed she and ADON #2 audited pharmacy consultation reports/recommendations when returned from the physician to ensure they were complete and had a signature. The ADON stated she was not aware the physician had to document a rationale if a recommendation was declined. ***The facility alleged the following was implemented to remove Immediate Jeopardy effective [DATE]: 1. Resident #259 no longer resides at the facility. 2. By [DATE], the Pharmacist will complete a Medication Regimen Review for current residents, which will include psychoactive medications, to ensure there is a supporting diagnosis, and will review for necessity/indication for the medication. The Pharmacist will also review for psychoactive medications that may be contributing to falls. One hundred eleven (111) residents were reviewed. Recommendations to the Medical Director was made for sixty-three (63) residents, six (6) of which were recommendations for a gradual dose reduction of psychoactive medications. 3. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) assessed current residents for potential side effects from psychoactive medication on [DATE], and ensured resident's Medication Administration Records (MAR) reflected the need to monitor for potential side effects of psychoactive medication. 4. The facility held a meeting on [DATE] to evaluate residents receiving psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) was in attendance and the Medical Director attended by phone to review appropriate utilization of psychoactive medications, which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive is achieved. 5. The DON/ADON/Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on [DATE]. The Nurse Consultant/DON/ADON/ Wound Nurse will also review resident falls for the past 30 days to ensure a root cause analysis has been conducted and appropriate interventions are in place. This will include a review of the care plan to ensure updates have been entered. 6. The Social Service Director, Social Service Assistant, and the Clinical Liaison will interview residents with a BIMS of eight (8) and above to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, requiring increased help from staff, or concerns related to increased fall risks. The interviews were completed by [DATE] and any concerns identified will be reported to the Director of Nursing (DON) and/or Executive Director immediately and addressed by the appropriate department. 7. The Wound Nurse (LPN) and Clinical Liaison (LPN) will complete resident observations by [DATE] for residents with a BIMS score of seven (7) and below to identify residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. Concerns identified will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 8. The Human Resource Director, ADON, Medical Records, Registered Dietician, Scheduler, Environmental Service Director, and/or the Director of Rehab will interview current staff related to any knowledge of residents with concerns related to change of condition, including but not limited to: pain, concerns related to sleep changes, needing increased help from staff, or concerns related to increased fall risks. The interviews will be completed by [DATE] and any concerns will be reported to the DON and/or Executive Director immediately and addressed by the appropriate department. 9. The DON/ADON and/or designee will review resident interviews, staff interviews, and resident observations by [DATE] to ensure the physician is notified of any change in condition. The DON/ADON/ MDS nurse will review current resident and staff interviews to ensure that appropriate interventions were placed based on falls root cause analysis. 10. On [DATE], the DON/ADON and/or designee will review fall risk evaluations and pain assessments to determine if a change of condition is indicated and will notify the resident's physician if needed. 11. By [DATE], the MDS Coordinator will review nursing notes for the past 30 days to ensure physician notification and care plan revision to reflect any change, including falls and behaviors. One resident was identified to not have a care plan related to a skin tear; however, the physician had been notified with orders for treatment. 12. By [DATE], the DON and/or the ADON will review the Twenty-Four hour reports to ensure any change in a resident's condition has been addressed appropriately to include physician notification and care plan revision. No concerns were identified. 13. The Nurse Consultant/DON/ADON/SDC/RN Charge Nurse will review care plans on current residents to ensure appropriate documentation related to change in conditions, including but not limited to: pain, concerns related to sleep, changes in behavior, fall interventions, and fall risk. The reviews were completed by [DATE]. Five resident care plans were revised. 14. By [DATE], the Nurse Consultant educated the ED/DON/ADON/SDC on utilizing Stop and Watch forms, a communication form developed by CMS to communicate changes related to change of condition. Education will include giving the completed Stop and Watch to the nurse and making a copy and leaving for the DON/ADON. The DON/ADON will review Stop and Watches and follow up on possible change of condition during the daily clinical meeting and was completed as appropriate. By [DATE], the ED/DON/ADON/SDC will educate current staff regarding utilizing Stop and Watch forms for any change in condition, giving the completed form to the nurse, and making a copy for the DON. 15. The Nurse Consultant educated the ED/DON/ADON/SDC the DON/ADON on [DATE] to review Stop and Watches forms to ensure they were acted upon appropriately to include physician notification for changes in condition, They were also educated to ensure appropriate interventions were implemented for falls based on root cause analysis of the fall, which includes the 5 Why's (a tool approved by CMS for identifying root cause analysis), to assist in determining an appropriate intervention at time of fall. The education also included the need for licensed nurses to submit the 5 Why's form for each fall to DON/ADON for review in clinical meeting. The Nurse Consultant will also re-educated the staff regarding the facility's Falls Management Policy that requires the completion of a Falls Risk Evaluation (utilizing the MORSE fall Scale tool developed for assistance in identifying fall risk residents) after each fall. The SDC/DON/ADON/ED then educated licensed staff by [DATE] regarding the utilization of the 5 Why's tool to determine the root cause of a fall to assist in determining the most appropriate intervention. In addition, current licensed nurses will be educated to notify the on-call Nurse Manager after a fall to review the root cause and the intervention for appropriateness. 16. By [DATE], the ED/DON/ADON/SDC will educate current licensed staff on appropriate documentation including, but not limited to: changes in condition, pain, concerns related to sleep changes, effectiveness of medication, notification of residents' physicians, or needing increased help from staff. 17. By [DATE], the Nurse Consultant will educate the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and the Wound Care Nurse (LPN) on assuring that residents are assessed for potential medication side effects; to ensure a monitoring order is placed on the MAR indicated [REDACTED]. Education included reviewing residents who was newly admitted /readmitted to ensure the resident had an appropriate [DIAGNOSES REDACTED]. The review will be conducted during the daily clinical meeting and will be followed-up by the Pharmacy Consultant. Any new medication orders will be reviewed by the DON/ADON/SDC for necessity to include appropriate [DIAGNOSES REDACTED]. 18. The Nurse Consultant will educate the DON/ADON/SDC on ensuring pharmacy reviews have occurred monthly and ensuring timely follow up of recommendations per facility policy, which states the recommendations will be received by the DON within 3 days of completion of review. The recommendations will be sent to the physician and the DON will verify the physician and Medical Director has received the review within 3 days. The DON should receive a response from the physician within 7 days. If a response is not received in 7 days, the DON/ADON will notify the physician for acceptance and/or a response to the recommendations that require action. If no response is received in 14 days, the DON/ADON will notify the Medical Director for further action. The DON/ADON will also notify the Executive Director and the Nurse Consultant. This education will occur on [DATE]. The DON, ADON, or Staff Development Coordinator will then will educate current licensed staff by [DATE] on assuring that residents are assessed for potential side effects of medications, ensuring a monitoring order is placed on the MAR indicated [REDACTED]. 19. The Pharmacy Director will re-educate the Registered Pharmacist by [DATE] on accurately completing a Medication Regimen Review, which will include a supporting [DIAGNOSES REDACTED]. The Pharmacist assigned to the facility at the time of the IJ has been removed as the Pharmacy Consultant. The current Pharmacy Consultant has been educated on the concerns related to regimen reviews, appropriate [DIAGNOSES REDACTED]. 20. For all education, a post education test will be administered by the Nurse Consultant/DON/ADON/SDC following education. If a score of 100% is not obtained, re-education will be completed until proficiency is obtained and their score is 100%. Five tests will be administered daily by ED/Assistant Administrator/ DON/ADON/SDC to ensure retention of education, until IJ is removed and approved through QAPI process. Current staff who have not received education by [DATE] will be mailed a certified letter informing them to contact the Executive Director/DON/SDC prior to working the floor. Staffing Agencies currently being utilized will be mailed a certified letter on [DATE] of the need to contact the ED/DON/SDC for education prior to working. The Executive Director/SDC or designee will ensure all newly hired staff and agency staff will receive education during New Hire Orientation or prior to working the floor. 21. The IDT will review in the daily clinical meeting (Monday through Friday) each fall and nursing shift reports to ensure the following is completed for any resident who sustained a fall: Falls Risk evaluation, to include the 5 Why's; physician notification; and care plan revision. In addition, the IDT will review Stop and Watch forms, progress notes, and physician orders to ensure care plans have been updated appropriately and physicians have been notified. 22. The Executive Director/Assistant Administrator/DON will conduct daily post clinical IDT meetings Monday-Friday for two weeks to review all identified Change of Condition and the effectiveness of medication to ensure notification of residents' physician as required. In addition, the Executive Director/Assistant Administrator/DON will review five (5) random resident records to ensure proper documentation has been completed related to any change in condition, physician notification, and the care plans are appropriate. Any issues identified will be corrected immediately and reported to the QAPI Committee for 3 months for further review and recommendations. 23. The facility will conduct weekly monitoring to evaluate psychoactive medication on residents, residents new prescribed psychoactive medications, and residents that have had medication dose adjustment. This psychoactive meeting will be conducted weekly by the facility IDT, (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and Pharmacist to review appropriate utilization of psychoactive medications which includes antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 24. Beginning [DATE], the Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at facility to monitor processes related to supervision to prevent accidents, care plan development/revision, and physician notification until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. An AD-HOC QAPI meeting is held at least bi-weekly and as needed to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 25. Beginning [DATE], The Director of Nursing, Assistant Director of Nursing, or the Staff Development Nurse will review MAR's daily (Monday through Friday), during the Clinical Meeting, for two weeks, for documentation of side effect monitoring of [MEDICAL CONDITION] medication and appropriate [DIAGNOSES REDACTED]. The Director of Nursing will also review falls to ensure the Medication Regimen Review has been sent to the consultant pharmacist daily (Monday through Friday) during the clinical meeting. The Director of Nursing will contact the Pharmacy Director, in 72 hours, if no communication from the review is received from the consultant pharmacist. Any concerns identified will be corrected immediately, and reported to QAPI committee for further review and recommendations. 26. The Executive Director will ensure the facility has conducted weekly monitoring, month over month, for 3 months to evaluate psychoactive medication on residents newly prescribed psychoactive medications, and residents that have had medication dose adjustments. This psychoactive meeting will be conducted weekly, by the facility IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian or Dietary Service Manager), residents physician, facility medical director, and the Pharmacist to review appropriate utilization of psychoactive medications, which includes; antipsychotic medications, hypnotic medications, antianxiety medications, and mood altering medications to ensure side effects, medication changes and overall adjustment to psychoactive is achieved. 27. The Nurse Consultant or Director of Nursing will be in the center daily to monitor residents with new [MEDICAL CONDITION] medication orders to ensure side effect monitoring is completed. 28. Beginning [DATE], Nursing Consultant/ED/DON/ADON/Assistant Administrator will be on sight at the facility to monitor process, related to [MEDICAL CONDITION] medications, until IJ is removed and pending QAPI Committee review. Any concerns identified will be addressed immediately and reported to QAPI weekly for review and further recommendations. AD-HOC QAPI meeting is held at least bi-weekly, and as needed, to discuss issues with the Medical Director. The IDT team meets daily to discuss findings and progress. 29. The Executive Director will review 5 random Admissions/Readmissions/Falls/New Medication Orders/ Monthly Pharmacy Reviews for timeliness, and to ensure proper documentation has occurred daily. Any issues identified will be corrected immediately, and reported to QAPI Committee for 3 months for further review and recommendations. ***The State Survey Agency determined that the facility implemented the following to remove Immediate Jeopardy on [DATE], as alleged: 1. Review of documentation revealed Resident #259 no longer resided at the facility. 2. Interview with the Administrator on [DATE] at 5:15 PM and review of documentation revealed by [DATE], the Pharmacist completed a Medication Regimen Review for current residents on psychoactive medications, to ensure there was supporting diagnosis, and necessity and indication for the use of the medication. The Pharmacist also reviewed psychoactive medications that could have contributed to falls. Further review of documentation and interview with the Administrator confirmed one-hundred and eleven (111) residents were reviewed by the Pharmacist. Review of facility documentation revealed the Pharmacist made recommendations to the Medical Director on 63 residents reviewed and six (6) of those recommendations were for gradual dose reductions of psychoactive medications. 3. Interview with the Director of Nursing (DON) on [DATE] at 3:30 PM and review of documentation revealed she and Assistant Director of Nursing (ADON) #1 assessed current residents for potential side effects from psychoactive medication on [DATE]. The DON and ADON #1 reviewed the residents' Medication Administration Records (MAR)'s to ensure it reflected monitoring for potential side effects for residents that received psychoactive medications in the facility. 4. Interview with the DON on [DATE] at 3:30 PM and review of facility documentation revealed a meeting occurred at the facility on [DATE], which evaluated residents that received psychoactive medications, residents with new orders for psychoactive medications, residents that had a medication dose adjustment, and any pharmacy recommendations. Review of documentation also revealed The IDT (Director of Nursing, Social Service Director, Social Service Assistant, Activity Director, Assistant Director of Nursing, Registered Dietitian/Dietary Service Manager) attended the meeting, as well as the Medical Director, which attended the meeting, by phone. Continued interview with the DON and further review of documentation revealed the meeting was conducted to review appropriate utilization of psychoactive medications, antipsychotic medications, hypnotic medications, antianxiety medications, and mood-altering medications to ensure side effects, medication changes, and overall adjustment to psychoactive medications was achieved. 5. Review of documentation and an Interview with ADON #1 on [DATE] at 3:15 PM revealed she and the DON as well as the Wound Nurse completed Falls Risk Assessments (utilizing the MORSE Fall Scale tool) and Pain Evaluations for current residents on [DATE]. Further interview and review of documentation also revealed The Nurse Consultant, the DON, ADON, and the Wound Nurse reviewed resident falls for the past 30 days, to ensure a root cause analysis was conducted and appropriate interventions were in place. Review of documentation and further interview with ADON #1 also revealed resident care plans were also reviewed to ensure care plan updates had been completed as required. 6 (TRUNCATED)

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to revise the comprehensive care plan for three (3) of thirty-nine (39) sampled residents (Residents #35, #24, and #84). Resident #35 had a history of [REDACTED]. The facility investigated the fall and determined the resident required a supervised area when up in a wheelchair. However, the facility failed to revise Resident #35's care plan and include the resident's need for supervision. The resident sustained [REDACTED]. Resident #24 sustained two (2) unwitnessed falls at 12:30 AM and 4:33 AM, and was found to have been incontinent of urine with each fall. The facility failed to consider that the need for toileting may have been the cause of the falls and failed to implement interventions to address toileting needs/incontinence, particularly at night. In addition, the facility failed to revise Resident #84's care plan to address the resident's election for Hospice care. The findings include: Review of the facility policy, Comprehensive Care Plan, dated 01/13/2018, revealed a comprehensive care plan will be developed for each resident within twenty-one (21) days and no more than seven (7) days after the completion of the comprehensive MDS assessment. The policy further stated the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans when there has been a significant change in the resident's condition, when the desired outcome is not met, etc. 1. A review of Resident #35's medical record revealed the facility admitted the resident on 04/06/2019 with [DIAGNOSES REDACTED]. A review of the most recent quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #35 was severely impaired for cognition, utilized a wheelchair for mobility, and required the extensive assistance of two staff members for transfers. A review of the plan of care developed for Resident #35 dated 04/01/2019 revealed Resident #35 was at risk from falls due to balance problems and weakness. Per the care plan, the resident had a history of [REDACTED]. Resident #35 was in the hospital during the survey and was not observed. A review of fall investigations for Resident #35 revealed on 10/13/2019 at 6:02 AM, the resident sustained [REDACTED]. Resident #35 was transferred to the hospital for evaluation and treatment. A review of the fall investigation revealed no evidence of a root cause analysis conducted to identify the reason for Resident #35's fall. The facility's plan to prevent further falls was for Resident #35 to be in a supervised area when up in the wheelchair. However, a review of the resident's plan of care revealed this intervention was not added to the plan of care. Continued review of Resident #35's medical record/fall investigations revealed the resident sustained [REDACTED]. Review of a fall investigation dated 02/13/2020 for Resident #35 revealed the resident sustained [REDACTED]. Resident #35 was sitting in a wheelchair in the doorway of his/her room. Resident #35 attempted to stand, fell , and landed on the right side before staff could intervene. Resident #35 complained of right hip pain, was transferred to the hospital, and diagnosed with [REDACTED]. Interview with Registered Nurse (RN) #2 on 02/18/2020 at 4:30 PM revealed the RN had witnessed Resident #35 fall on 02/13/2020. The RN stated she was in the hallway with her medication cart administering resident medications. The RN stated the resident was in a wheelchair, attempted to stand, and fell before she could get to the resident. According to RN #2, she assessed the resident after the fall. The resident complained of right hip pain. She stated she transferred the resident to the hospital where he/she was diagnosed with [REDACTED]. RN #2 stated she could not remember what the resident was doing prior to the fall, but stated that the resident had dementia and a history of falls, and often tried to get up unassisted. Interview with the Director of Nursing (DON) on 03/04/2020 at 3:18 PM revealed the DON was the Minimum Data Set (MDS) Nurse in October 2019 when Resident #35 sustained a fall and was responsible for revising the resident's plan of care. According to the DON, she was unaware why the intervention for the resident to be in a supervised area when up in the wheelchair was not added to the plan of care. 2. A review of the medical record for Resident #24 revealed the facility admitted the resident on 06/12/2019 with [DIAGNOSES REDACTED]. A review of the most recent significant change MDS assessment completed for Resident #24 dated 02/06/2020 revealed the resident had severely impaired cognition with a BIMS score of two (2), and was assessed to require the extensive assistance of two staff members for transfers. In addition, the resident was assessed to be a fall risk with a history of falls. A review of the plan of care initiated on 07/05/2019 revealed Resident #24 was at risk for falls with interventions to have a call light in his/her room, educate the resident to call for assistance before transferring, encourage non-skid foot wear, give [MEDICAL CONDITION] medication as ordered, and to keep the environment well lit and free of clutter. A review of a fall investigation completed for Resident #24 revealed the resident had sustained a fall on 11/30/2019 at 4:33 AM. The resident was found sitting on the floor beside the bed and had an incontinence episode. Further review of fall investigations revealed the resident sustained [REDACTED]. The resident was observed lying on the floor by his/her bed and the resident was incontinent. A review of the root cause analysis revealed the cause of the fall was weakness, impaired safety awareness. According to the investigation, the intervention implemented was to move the resident closer to the nurses' station. There was no evidence the facility considered that the resident might have been attempting to toilet when he/she fell and developed care plan interventions to address toileting needs at night. Observations on 02/16/2020 at 9:30 AM, 2:35 PM, and 3:21 PM, and on 02/17/2020 at 10:45 AM revealed the resident had a low bed with an air mattress and fall mats to the floor. Interview with Licensed Practical Nurse (LPN) #12 on 03/05/2020 at 1:45 PM revealed the LPN could not remember the resident falling on 11/30/2019 and 12/01/2019, and was unsure why she did not consider the resident's incontinence or consider including interventions for the resident to be checked and changed more often to possibly prevent further falls. Interview with the Minimum Data Set (MDS) Nurse on 02/21/2020 at 11:17 AM revealed after a resident sustained [REDACTED]. She stated the facility tried to develop interventions to prevent further falls, but was not aware why toileting or checking and changing the resident was not considered as possible interventions for Resident #24 to prevent further falls. 3. Observation of Resident #84 on 02/17/2020 at 3:49 PM, revealed the resident was lying on his/her left side in bed with his/her eyes closed. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #84's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment. Continued review revealed an incomplete significant change assessment dated [DATE]. Continued review of Resident #84's medical record revealed the resident elected for Hospice care on 01/28/2020. Continued review revealed an incomplete significant change assessment dated [DATE]. Subsequently, review of the comprehensive care plan for Resident #84 revealed no evidence that the resident was receiving Hospice care. Interview with the MDS Coordinator on 02/19/2020 at 3:49 PM, revealed she had been in the position since 01/20/2020, and had prior MDS experience. The Coordinator stated she had calculated that Resident #84's care plan should have been completed by 03/03/2020. However, upon review of the date of Hospice election, 01/28/2020, she agreed the significant change comprehensive assessment should have been completed by 02/11/2020 and the care plan updated by 02/18/2020.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to notify the physician of a change in condition and need to alter treatment for one (1) of three (3) sampled residents (Resident #5). The facility readmitted Resident #5 on 09/27/19 after a hospital stay. Staff interviews revealed the resident's physician was notified on 09/27/19 of the scabbed areas to the resident's lower extremities and right ankle. The physician had instructed staff to leave the scabbed areas open to air and to monitor them. However, review of the nurse's notes from 09/28/19 thru 10/07/19 and staff interviews revealed no evidence of monitoring of the scabbed areas on Resident #5's legs and ankle. Observation during a skin assessment on 10/07/19 with staff revealed a Stage 3 Pressure Ulcer (PU) on Resident #5's right outer ankle that was not previously identified by nursing staff. The facility failed to notify Resident #5's physician of the decline in the condition of the wound to the right ankle or of the development of the Stage 3 PU to the resident's right ankle. The findings include: Review of the facility's policy, Change in a Resident's Condition or Status, revised on 12/01/16, revealed staff shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition. Further review of the policy revealed a significant change of condition is a major decline or improvement in the resident's status that requires interdisciplinary review and/or revision to the care plan. Review of the facility's policy, Skin Integrity Management, not dated revealed when a new wound has been identified staff will notify the resident's physician and family. Review of the facility's Policy, Reducing Pressure Ulcers, not dated, revealed the nursing assistants should check the resident's skin each time they provide care to a resident and note/report redness, especially over a bony area. Record review revealed on 09/27/19, the facility readmitted Resident #5 after a hospital stay for a Urinary Tract Infection [MEDICAL CONDITIONS], Acute Kidney Failure, and Dehydration. Further review of the medical record revealed Resident #5 had [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was severely cognitively impaired. Further review of the quarterly MDS revealed Resident #5 required extensive assistance with bed mobility from staff. Review of the Nurse's Notes from 09/27/19 thru 10/06/19 revealed on 09/27/19 the Assistant Director of Nursing (ADON) readmitted Resident #5 to the facility and documented that the resident had scabbed areas noted on (his/her) bilateral lower extremities, and right outer ankle. The ADON further documented that the resident's physician was notified; however, there was no documentation in the nurse's notes of what the physician instructed the ADON to do about the scabbed areas on Resident #5's lower extremities or right ankle. Further review of the staff nurse's notes revealed no other documentation from 09/27/19 through 10/06/19 concerning Resident #5's scabbed area/PU on (his/her) right outer ankle in the nurse's notes. Interview with the ADON on 10/08/19 at 10:45 AM revealed on 09/27/19 after she readmitted Resident #5 to the facility, she notified the resident's physician concerning the scabbed area on the resident's right ankle and lower extremities. She stated Resident #5's physician instructed her to leave the scabbed areas on the resident's right ankle and lower extremities open to air and to monitor them. The ADON verbalized she did not write an order or document the physician's instructions in the nurse's notes or on the 24-Hour Report/Change of Condition Report concerning Resident #5's scabbed areas. Review of the active physician orders [REDACTED].#5's right outer ankle. Review of Resident #5's Treatment Administration Record (TAR) dated 09/27/19 through 10/06/19 revealed there were no orders from the resident's physician for monitoring or wound treatment for the resident's right outer ankle. Review of the Comprehensive Care Plan, with a revision date of 09/16/19, revealed staff needed to observe the resident's skin daily, while providing care, and notify Resident #5's physician with any skin changes. However, there were no additions or revisions to the plan of care related to monitoring of the scabbed areas to the resident's lower extremities and ankle. Review of the Skin Inspection Form, dated 10/04/19 and signed on 10/07/19 by the Director of Nursing (DON), revealed the DON documented that Resident #5 had no new observed skin issues. Review of the Skin Monitoring Comprehensive Shower Forms dated 09/28/19, 10/02/19, and 10/05/19 revealed there were no skin issues to report by the State Registered Nurse Aides (SRNAs). Review of the 24-Hour Report/Change of Condition Report dated 09/27/19 through 10/07/19 revealed there was no evidence of documentation on Resident #5 concerning monitoring or treatment to the scabbed area/PU on the resident's right ankle. Observation during a skin assessment with Licensed Practical Nurse (LPN) #3 on 10/07/19 at 7:35 PM revealed Resident #5 had a bloody bandage on (his/her) right outer ankle, and after LPN #3 removed the bandage, an open area with a large amount of redness around the open area was identified by LPN #3. Observation with the Wound Care Nurse on 10/07/19 at 7:40 PM revealed she assessed the wound on Resident #5's right outer ankle, staged the wound as a Stage 3 PU, cleansed the PU with wound cleanser, and applied a border foam dressing. Interview with LPN #3 on 10/08/19 at 4:00 PM revealed she was Resident #5's nurse on 09/29/19, 09/30/19, 10/04/19, and 10/07/19. The LPN stated she was not told anything about monitoring Resident #5's scabbed areas on his/her lower extremities or on the resident's ankle. LPN #3 verbalized that the first time she saw the PU on Resident #5's ankle was on 10/07/19, during a skin assessment with the state surveyor. Interview with SRNA #7 on 10/08/19 at 2:13 PM revealed on 10/06/19, he observed blood on Resident #5's bed linens that was leaking from a bandage on the resident's right ankle. After requesting assistance from Kentucky Medication Aide (KMA) #1, SRNA #7 stated they removed the bandage from Resident #5's right ankle, cleansed the open area with wound cleanser, and applied a border foam dressing over the resident's right outer ankle. SRNA #7 verbalized that when KMA #1 went to obtain the wound care supplies, she also brought heel protectors to apply on Resident #5's heels. SRNA #7 stated he informed Licensed Practical Nurse (LPN) #5 about Resident #5's open area on his/her right ankle and stated he gave report to the on-coming SRNA at 10:30 PM. Further interview with SRNA #7 revealed there was a little bit of redness around the open area on Resident #5's right outer ankle on 10/06/19. SRNA #7 stated he gave Resident #5 a shower on 10/05/19 and noticed that the resident had a bandage on his/her right ankle. Interview with KMA #1 on 10/08/19 at 3:20 PM revealed she reported an open area on Resident #5's right outer ankle on 10/06/19 to LPN #5, who instructed the KMA to remove the bandage from the resident's right ankle, apply a border foam dressing over the open area, and apply air boots. She revealed there was blood on the resident's bed linens and a crumpled, bloody bandage was on the resident's right ankle. KMA #1 revealed she could not remember if she cleaned the open area on Resident #5's right outer ankle; however, she did remove the bloody bandage and applied a new border foam dressing over the open area on Resident #5's right ankle. Further interview with KMA #1 revealed when she removed the old dressing from the resident's ankle the wound was bleeding, and Resident #5 had blood on his/her bed linens. Interview with LPN #5 on 10/08/19 at 11:13 AM revealed she was Resident #5's nurse on 10/05/19 and 10/06/19. LPN #5 stated that she did not notice anything unusual about the resident's ankles and that the only thing reported to her was when a SRNA reported on 10/06/19 that she was having a hard time keeping (Resident #5's) ankle boots on because (the resident) was crossing (his/her) legs a lot. LPN #5 verbalized if she had seen an open area on Resident #5's ankle she would have assessed the ankle and notified the resident's physician. Further interview with LPN #5 on 10/08/19 at 11:25 AM revealed on 10/06/19 KMA #1 reported to her that Resident #5 had a little bit of bloody drainage and a little bit of redness around an open area on his/her ankle. LPN #5 stated she assessed the open area, notified Resident #5's physician on 10/06/19 at approximately 10:30 PM, and received a phone order to cleanse the open area on Resident #5's right ankle with wound cleanser every day for three (3) days and apply a border foam dressing. LPN #5 verbalized she did the wound care treatment on Resident #5's right outer ankle and wrote the verbal order for wound treatment on 10/06/19. LPN #5 stated she reported to the on-coming shift nurse, LPN #2, on 10/07/19 that Resident #5 had an open area on his/her right outer ankle and that the resident's physician had ordered treatment for the open area. Further interview with LPN #5 revealed she forgot to fill out the Change in Condition Form and forgot to put the new treatment order for Resident #5 on the 24-Hour Report/Change of Condition Form. Interview with LPN #2 on 10/08/19 at 11:40 AM revealed she was Resident #5's nurse on 09/28/19, 09/29/19, 10/02/19, 10/03/19, and 10/07/19, from 6:30 AM to 6:30 PM. LPN #2 stated that the resident did not have a bandage on his/her ankle, or heel boots on, from 09/28/19 through 10/03/19. LPN #2 stated she was not told anything about monitoring the resident's scab areas or wound treatment on the resident's ankle until the morning of 10/08/19. Further interview with LPN #2 revealed if a new order was written for Resident #5's ankle on 10/06/19, for wound treatment for three (3) days, the order would have showed up on the resident's Treatment Administration Record (TAR) on 10/07/19. Interview with the Wound Care nurse on 10/08/19 at 9:10 AM revealed when a new wound is identified, the nurse fills out a Change of Condition Form, notifies the resident's physician, and receives new treatment orders for the wound. The Wound Care Nurse stated, The nurse then notifies the POA, ensures the wound treatment is in place, and then notifies me. She verbalized that she documents the measurements/describes the wounds weekly and if the wound does not show any progress or gets worse, she notifies the resident's physician. Further interview with the Wound Care Nurse revealed she did not find out about Resident #5's Stage 3 PU until 10/07/19, when staff told her the state surveyor requested her to assess the wound on the resident's right outer ankle. Interview with the Director of Nursing (DON) on 10/08/19 at 4:55 PM revealed she did a skin assessment on Resident #5 on 10/03/19 and the resident had a scab on his/her right ankle. The DON stated she marked on the 10/03/19 skin assessment no observed new areas because the scab area had already been addressed on Resident #5's readmission note by the ADON. The DON stated that the ADON should have had Resident #5's physician to be more specific on 09/27/19, when he instructed the ADON to monitor the scabbed areas on the resident's lower extremities and ankle. She stated that according to how the physician answered the ADON, that would have decided if an order for [REDACTED].#5 to the 24-Hour Report/Change of Condition report. The DON verbalized that she had not looked to see if a nurse wrote an order for [REDACTED].#5 and LPN #5 stated she did assess Resident #5's ankle on 10/06/19; however, the DON could not remember if LPN #5 told her she applied a new dressing or left the old dressing on Resident #5's right ankle on 10/06/19. Further interview with the DON revealed she had not identified any concerns with staff not notifying the physician when a change in condition occurs, and staff are trained on notifying the physicians when a change in condition occurs with a resident. Interview with Resident #5's physician on 10/08/19 at 12:15 PM revealed his expectations were for staff to notify him on a daily basis concerning any residents with skin breakdown. The physician stated staff did not notify him until 10/07/19 about the open wound to Resident #5's right ankle. Further interview revealed staff notified him of the wound after the state surveyor left the faciity on [DATE].

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to revise the plan of care for one (1) of three (3) sampled residents (Resident #5). The facility developed a Comprehensive Care Plan with a revision date of 09/16/19 for Residents #5 that identified that the resident was at risk for pressure ulcers due to decreased bed mobility. Resident #5 was readmitted to the facility on [DATE] after staying eight (8) nights in the hospital. During the readmission assessment, staff identified that Resident #5 had a Stage 1 Pressure Ulcer on his/her left buttock, and scabbed areas on his/her bilateral lower extremities, and on a bony prominence, the resident's right outer ankle. However, the facility failed to revise the Comprehensive Care Plan after the readmission assessment on 09/27/19 and on 10/06/19 when the scab on Resident #5's right ankle became an open wound. Observation of a skin assessment on 10/07/19 with staff revealed a Stage 3 Pressure Ulcer on Resident #5's right outer ankle that had not been identified by nursing staff. The findings include: Interview with the Director of Nursing (DON) on 10/08/19 at 4:55 PM revealed the facility utilizes the Resident Assessment Instrument (RAI) Version 3.0 Manual, effective date 10/01/19, for their Care Plan Policy. Review of the RAI revealed the care plan should be revised on an ongoing basis to reflect changes in the resident and the care that the resident is receiving (see 42 CFR 483.21(b), Comprehensive Care Plans). The resident's care plan must be reviewed after each assessment, as required by §483.20, except discharge assessments, and revised based on changing goals, preferences, and needs of the resident and in response to current interventions. Review of the facility's Policy, Reducing Pressure Ulcers, not dated, revealed the nursing assistants should check the resident's skin each time they provide care to a resident and note/report redness, especially over a bony area. Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was severely cognitively impaired. Further review of the quarterly MDS revealed Resident #5 required extensive assistance from staff with bed mobility. Review of the Comprehensive Care Plan, with a revision date of 09/16/19 and a target date of 12/18/19, revealed staff needed to observe the resident's skin daily, while providing care, and notify Resident #5's physician with any skin changes. Further review of the Comprehensive Care Plan revealed Resident #5 was at risk for developing a PU and required staff to turn and reposition him/her at regular intervals. Review of the readmission assessment dated [DATE] revealed staff documented that Resident #5 had a potential problem for friction and shearing. Staff documented that the resident moves feebly or requires minimum assistance, during a move, and will slide to some extent against sheets, chair, restraints, or other devices. Further review of the documentation on the readmission assessment revealed Resident #5 maintains relatively good posture in a chair or bed most of the time but occasionally slides down. Review of the Nurse's Notes from 09/27/19 through 10/06/19 revealed there was no documentation in the nurse's notes concerning the care for Resident #5's scabbed area on his/her right outer ankle. Review of a nurse's note on 09/27/19 revealed the Assistant Director of Nursing (ADON) readmitted Resident #5 to the facility and documented that the resident's buttocks were red, non-blanchable, and scabbed areas were noted on the resident's bilateral lower extremities and right outer ankle. The ADON further documented that the resident's physician was notified. Further review of the nurse's notes revealed on 09/27/19 the Wound Care Nurse documented that Resident #5 returned from the hospital with a Stage 1 PU on his/her buttock, and the resident's physician was notified and new treatment was ordered. Interview with the ADON on 10/08/19 at 10:45 AM revealed on 09/27/19 after she readmitted Resident #5 to the facility, she notified the resident's physician concerning the scabbed area on the resident's right ankle and lower extremities. She stated that Resident #5's physician instructed her to leave the scabbed areas on the resident's right ankle and lower extremities open to air and to monitor them. The ADON verbalized that she did not write an order or document the physician's instructions on the 24-Hour Report/Change of Condition Report concerning Resident #5's scabbed areas. Further review of the Comprehensive Plan of Care revealed the facility failed to revise the plan of care to address the Stage 1 PU to the resident's buttock, the scabbed areas to the lower extremities, and the scabbed area to the right ankle. Review of the Wound Evaluation Forms dated 09/27/19 and 10/04/19 revealed staff documented that Resident #5 had a Stage 1 PU on his/her left buttock measuring 3.8 centimeters (cm) in length, and 4 cm in width. Further review of the Wound Evaluation Forms revealed there was no drainage, no odor, and the skin around the PU was pink. There was no documentation on the Wound Evaluation Forms concerning the scabbed area on Resident #5's right outer ankle. Review of the Skin Monitoring Comprehensive Shower Forms dated 09/28/19, 10/02/19, and 10/05/19 revealed there were no skin issues to report by the State Registered Nurse Aides (SRNAs). Review of the 24-Hour Report/Change of Condition Report dated 09/27/19 through 10/07/19 revealed there was no evidence of documentation on Resident #5 concerning a scabbed area on the resident's right ankle. Interview with SRNA #7 on 10/08/19 at 2:13 PM revealed on 10/06/19 at approximately 9:30 PM, the SRNA requested Kentucky Medication Aide (KMA) #1 to come to Resident #5's room and assess the resident's ankle. SRNA #7 stated he noticed blood on Resident #5's bed linens and a bloody bandage on the resident's right ankle. SRNA #7 revealed he and KMA #1 removed the bloody bandage from Resident #5's right ankle, cleansed the open area with wound cleanser, and applied a border foam dressing over the resident's right outer ankle. SRNA #7 informed Licensed Practical Nurse (LPN) #5 about Resident #5's open area on his/her right ankle and stated he gave report to the SRNA coming on shift at 10:30 PM. SRNA #7 verbalized that when KMA #1 went to obtain the wound care supplies, she also brought heel protectors to apply on Resident #5's heels. Further interview with SRNA #7 revealed there was a little bit of redness around the open area on Resident #5's right outer ankle. SRNA #7 stated he gave Resident #5 a shower on 10/05/19 and noticed the resident had a bandage on his/her right ankle. SRNA #7 revealed Resident #5 is turned and repositioned every two (2) hours when he does his rounds to check and change the residents. Interview with KMA #1 on 10/08/19 at 3:20 PM revealed on 10/06/19 SRNA #7 requested her to look at Resident #5's right ankle because the SRNA had noticed blood on the resident's bed linens. KMA #1 stated she reported the open area on Resident #5's right outer ankle to LPN #5, who instructed KMA #1 to remove the bandage, apply a border foam dressing over the open area, and apply air boots. She revealed there was blood on the resident's bed linens and a crumpled, bloody bandage was on the resident's right ankle. KMA #1 revealed she could not remember if she cleaned the open area on Resident #5's right outer ankle, but she did apply a border foam dressing over the open area. Interview with LPN #5 on 10/08/19 at 11:13 AM revealed she was Resident #5's nurse on 10/05/19 and 10/06/19. LPN #5 stated she did not notice anything unusual about the resident's ankles and the only thing that was reported to her was that on 10/06/19 a SRNA reported she was having a hard time keeping Resident #5's ankle boots on because the resident was crossing (his/her) legs a lot. LPN #5 verbalized that if she had seen an open area on Resident #5's ankle she would have assessed the ankle and notified the resident's physician. Further interview with LPN #5 on 10/08/19 at 11:25 AM revealed on 10/06/19 KMA #1 reported to her that Resident #5 had a little bit of bloody drainage and a little bit of redness around an open area on (his/her) ankle. LPN #5 stated she assessed the open area, notified Resident #5's physician on 10/06/19 at approximately 10:30 PM, and received a phone order to cleanse the open area on Resident #5's right ankle with wound cleanser every day for three (3) days and apply a border foam dressing. LPN #5 verbalized that she did the wound care treatment on Resident #5's right outer ankle and wrote the verbal order for wound care on 10/06/19. LPN #5 stated she reported to the on-coming shift nurse, LPN #2, on 10/07/19 that Resident #5 had an open area on his/her right outer ankle and the resident's physician had ordered treatment for [REDACTED].#5 revealed she forgot to fill out the Change in Condition Form and forgot to put the new treatment order for Resident #5 on the 24-Hour Report/Change of Condition Form. Interview with LPN #2 on 10/08/19 at 11:40 AM revealed she was notified about Resident #5's wound on his/her right outer ankle on 10/08/19 by LPN #3. LPN #2 stated that LPN #3 reported that she and a state surveyor found a wound on Resident #5's right outer ankle during a skin assessment the previous night, and the Wound Care Nurse was going to assess it and get treatment started on it. LPN #2 verbalized that she relieved LPN #5 on 10/07/19 at 6:30 AM and was not told anything by LPN #5 concerning Resident #5. Further interview with LPN #2 revealed if a new order had been written for wound care for three (3) days on Resident #5 for 10/06/19, the order would have shown up on the resident's TAR. LPN #2 stated there were no wound treatment orders on Resident #5's TAR for 10/07/19. Interview with LPN #3 on 10/08/19 at 4:00 PM revealed she was Resident #5's nurse on 09/29/19, 09/30/19, 10/04/19, and 10/07/19. The LPN stated she was not informed about anything concerning Resident #5's PU on his/her bottom or an area on the resident's right ankle, and the first time she saw the PU on the resident's ankle was on 10/07/19 during a skin assessment with the state surveyor. Observation during a skin assessment with Licensed Practical Nurse (LPN) #3 on 10/07/19 at 7:35 PM revealed Resident #5 had a bloody bandage on his/her right outer ankle, and after LPN #3 removed the bandage, an open area with a large amount of redness around the open area was identified by LPN #3. Further observation of Resident #5's buttocks revealed the resident's Stage 1 PU was healed. Observation with the Wound Care Nurse on 10/07/19 at 7:40 PM revealed she assessed the wound on Resident #5's right outer ankle, staged the wound as a Stage 3 PU, cleansed the PU with wound cleanser, and applied a border foam dressing. Interview with the Wound Care Nurse on 10/08/19 at 9:10 AM revealed when a new wound is identified the nurse fills out a Change of Condition Form, notifies the resident's physician, and receives new treatment orders for the wound. The Wound Care Nurse stated, The nurse then notifies the POA, ensures the wound treatment is in place, and then notifies me. She verbalized that she documents the measurements/describes the wounds weekly and if the wound does not show any progress or gets worse, she notifies the resident's physician. The Wound Care Nurse revealed she did not find out about Resident #5's Stage 3 PU until 10/07/19 when the state surveyor requested her to assess the wound on the resident's right outer ankle. Further interview with the Wound Care Nurse on 10/08/19 at 4:30 PM revealed when she notified Resident #5's physician on 09/27/19 concerning the resident's Stage 1 PU on his/her left buttock, she thought that if the facility was using a house ointment staff did not have to write an order for [REDACTED]. Interview with Resident #5's physician on 10/08/19 at 12:15 PM revealed he was first notified of the open area to Resident #5's ankle on 10/07/19. The physician stated staff called him on 10/07/19 after the state surveyor left the facility. The physician stated he instructed them to continue with the same wound care treatment that was done on Resident #5's ankle on 10/07/19. Further interview with the physician revealed he expected to be notified on a daily basis concerning any skin breakdown on his residents. Resident #5's physician stated that unless the resident was crossing his/her legs a lot, the area on Resident #5's ankle was probably a Stasis Ulcer. Interview with the MDS Coordinator on 10/07/19 at 4:50 PM revealed the staff nurses on the floor do not update the care plans. She stated that she receives a copy of all the physician orders, most of the time, and updates the care plans on a daily basis and as needed, according to the physician's orders [REDACTED]. She further revealed that the DON was responsible for updating the interventions on the care plans when the interventions are discussed in the morning meetings. Interview with the Director of Nursing (DON) on 10/08/19 at 4:55 PM revealed the MDS Coordinator develops/revises the residents' care plans. The DON verbalized that the MDS Coordinator could not revise a care plan without the resident's orders. She revealed that the ADON should have asked Resident #5's physician to be more specific on 09/27/19 when he instructed the ADON to monitor the scabbed areas on the resident's lower extremities and ankle, and depending on the physician's answer, that would determine if an order should have been written by the ADON on 09/27/19. The DON further stated the Wound Care Nurse should have written an order for [REDACTED].#5 and the LPN stated she did assess Resident #5's ankle on 10/06/19 but the DON could not remember if LPN #5 told her she applied a new dressing or left the old dressing on Resident #5's right ankle. Further interview with the DON revealed she had not identified any concerns with the residents' care plans being revised when staff writes a new order.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide necessary treatments, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (1) of three (3) sampled residents (Resident #5). Resident #5 was readmitted to the facility on [DATE]. Staff interviews revealed that Resident #5's physician was notified on 09/27/19 of the scabbed areas to the resident's lower extremities and right ankle, and instructed staff to leave the scabbed areas open to air and to monitor them. The facility had assessed the resident to be at risk for pressure ulcers and planned interventions for staff to observe the resident's skin daily, while providing care, and notify Resident #5's physician with any skin changes. However, review of the nurse's notes from 09/28/19 through 10/07/19, and staff interviews, revealed no evidence of monitoring of the scabbed areas on Resident #5's legs and ankle. Observation during a skin assessment on 10/07/19 with staff revealed a Stage 3 Pressure Ulcer (PU) on Resident #5's right outer ankle that was not previously identified by nursing staff. The facility failed to notify Resident #5's physician of the decline in the condition of the wound to the right ankle or of the development of the Stage 3 PU to the resident's right ankle in order to obtain orders for treatment. The findings include: Review of the facility's policy, Skin Integrity Management, not dated, revealed on admission and readmission and then every seven (7) to ten (10) days each resident will have a head-to-toe skin inspection and the findings will be documented in the resident's medical record. A Braden Scale (identifying residents at risk for skin breakdown) will be completed upon admission, readmission, quarterly, significant change, and as needed. Further review of the policy revealed each identified wound will have a Wound Evaluation completed weekly, and a Wound Tracking Log will be completed during the wound rounds weekly. Continued review of the Skin Integrity Management Policy revealed the Wound Coordinator would conduct weekly rounds to assure the required documentation was completed, and assure the skin integrity management was addressed in the care plans and reflects the current status. Review of the facility's Policy, Reducing Pressure Ulcers, not dated, revealed the nursing assistants should check the resident's skin each time they provide care to a resident and note/report redness, especially over a bony area. Review of the hospital records revealed Resident #5 was assessed by the Emergency Department (ED) on 09/19/19 related to a fall in the facility. Resident #5 was admitted to the hospital from the ED on 09/19/19 with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), indicating the resident was severely cognitively impaired. Further review of the quarterly MDS revealed Resident #5 required extensive assistance with bed mobility and was not at risk for developing a PU. Review of the Comprehensive Care Plan, with a revision date of 09/16/19, revealed Resident #5 was at risk for developing a PU and required staff to turn and reposition the resident at regular intervals. Further review of the Comprehensive Care Plan revealed staff needed to observe the resident's skin daily, while providing care, and notify Resident #5's physician with any skin changes. Review of the Nurse's Notes from 09/27/19 through 10/06/19 revealed on 09/27/19 the Assistant Director of Nursing (ADON) readmitted Resident #5 to the facility and documented that the resident's buttocks were red, non-blanchable, and scabbed areas were noted on the resident's bilateral lower extremities and right outer ankle. The ADON further documented that the resident's physician and Power of Attorney (POA) were notified. Further review of the nurse's notes revealed on 09/27/19 the Wound Care Nurse documented that Resident #5 returned from the hospital with a Stage 1 PU on his/her buttock, and the resident's physician was notified and new treatment was ordered. There was no other documentation in the nurse's notes from 09/27/19 through 10/06/19 concerning Resident #5's scabbed area on his/her right outer ankle. Interview with the ADON on 10/08/19 at 10:45 AM revealed on 09/27/19 after she readmitted Resident #5 to the facility, she notified the resident's physician concerning the scabbed area on the resident's right ankle and lower extremities. She stated Resident #5's physician instructed her to leave the scabbed areas on the resident's right ankle and lower extremities open to air and to monitor them. The ADON verbalized that she did not write an order or document the physician's instructions on the 24-Hour Report/Change of Condition Report concerning Resident #5's scabbed areas. Review of the active physician orders [REDACTED].#5's skin every seven (7) days; however, there was no wound treatment orders for Resident #5's right outer ankle. Review of Resident #5's Treatment Administration Record (TAR) dated 09/27/19 through 10/06/19 revealed there were no wound treatment orders for the resident's right outer ankle. Review of the Skin Inspection Form, dated 10/04/19 and signed on 10/07/19 by the Director of Nursing (DON), revealed the DON documented that Resident #5 had no new observed skin issues. Review of the Wound Evaluation Forms dated 09/27/19 and 10/04/19 revealed staff documented that Resident #5 had a Stage 1 PU on his/her left buttock measuring 3.8 centimeters (cm) in length, and 4 cm in width. Further review of the Wound Evaluation Forms revealed there was no drainage, no odor, and the skin around the PU was pink. There was no documentation on the Wound Evaluation Forms concerning the scabbed area on Resident #5's right outer ankle. Review of the Weekly Wound Tracking Form dated 10/03/19 revealed Resident #5 had a Stage 1 PU on his/her left buttock measuring 3.8 cm in length, and 4 cm in width. There was no documentation on the Wound Tracking Form concerning the scabbed area on Resident #5's right outer ankle. Review of the Skin Monitoring Comprehensive Shower Forms dated 09/28/19, 10/02/19, and 10/05/19 revealed there were no skin issues to report by the State Registered Nurse Aides (SRNAs). Review of the 24-Hour Report/Change of Condition Report dated 09/27/19 through 10/07/19 revealed there was no evidence of documentation on Resident #5 concerning a scabbed area on the resident's right ankle. Observation during a skin assessment with Licensed Practical Nurse (LPN) #3 on 10/07/19 at 7:35 PM revealed Resident #5 had a border foam dressing over his/her coccyx area, and the Stage 1 PU was healed. Further observation during the skin assessment revealed a bloody bandage was on Resident #5's right outer ankle, and after the LPN removed the bandage, a large open area was identified by LPN #3. Observation with the Wound Care Nurse on 10/07/19 at 7:40 PM revealed she assessed the large wound on Resident #5's right outer ankle, staged the wound as a Stage 3 PU, cleansed the PU with wound cleanser, and applied a border foam dressing. Interview with SRNA #7 on 10/08/19 at 2:13 PM revealed on 10/06/19 at approximately 9:30 PM, the SRNA noticed there was blood on Resident #5's bed linens and a bloody bandage on the resident's right ankle. SRNA #7 notified the Kentucky Medication Aide (KMA) on the unit and requested her to come to Resident #5's room and assess the resident's ankle. SRNA #7 revealed he and KMA #1 removed the bloody bandage from Resident #5's right ankle, cleansed the open area with wound cleanser, and applied a border foam dressing over the resident's right outer ankle. SRNA #7 verbalized that when KMA #1 went to obtain the wound care supplies, she also brought heel protectors to apply on Resident #5's heels. SRNA #7 informed Licensed Practical Nurse (LPN) #5 about Resident #5's open area on his/her right ankle and he stated he gave report to the SRNA coming on shift at 10:30 PM. Further interview with SRNA #7 revealed there was a little bit of redness around the open area on Resident #5's right outer ankle. SRNA #7 stated he gave Resident #5 a shower on 10/05/19 and noticed the resident had a bandage on his/her right ankle. Interview with KMA #1 on 10/08/19 at 3:20 PM revealed on 10/06/19 SRNA #7 requested her to look at Resident #5 in the resident's room. She revealed there was blood on the resident's bed linens and a crumpled, bloody bandage was on the resident's right ankle. KMA #1 stated she reported the open area on Resident #5's right outer ankle to LPN #5, who instructed KMA #1 to remove the bandage, apply a border foam dressing over the open area, and apply air boots. KMA #1 revealed she could not remember if she cleaned the open area on Resident #5's right outer ankle before she applied the border foam dressing or not. Interview with LPN #5 on 10/08/19 at 11:13 AM revealed she was Resident #5's nurse on 10/05/19 and 10/06/19. LPN #5 stated she did not notice anything unusual about the resident's ankles and the only thing that was reported to her was that on 10/06/19 a SRNA reported she was having a hard time keeping Resident #5's ankle boots on because the resident was crossing (his/her) legs a lot. LPN #5 verbalized that if she had seen an open area on Resident #5's ankle she would have assessed the ankle and notified the resident's physician. Further interview with LPN #5 on 10/08/19 at 11:25 AM revealed on 10/06/19 KMA #1 reported to her that Resident #5 had a little bit of bloody drainage and a little bit of redness around an open area on (his/her) ankle. LPN #5 stated she assessed the open area, notified Resident #5's physician on 10/06/19 at approximately 10:30 PM, and received a phone order to cleanse the open area on Resident #5's right ankle with wound cleanser every day for three (3) days and apply a border foam dressing. LPN #5 verbalized that she did the wound care treatment on Resident #5's right outer ankle and wrote the verbal order for wound care on 10/06/19. LPN #5 stated she reported to the on-coming shift nurse, LPN #2, on 10/07/19 that Resident #5 had an open area on his/her right outer ankle and the resident's physician had ordered treatment for [REDACTED].#5 revealed she forgot to fill out the Change in Condition Form and forgot to put the new treatment order for Resident #5 on the 24 Hour Report/Change of Condition Form. Interview with LPN #2 on 10/08/19 at 11:40 AM revealed she was notified about Resident #5's wound on his/her right outer ankle on 10/08/19 by LPN #3. LPN #2 stated LPN #3 reported that she and a state surveyor found a wound on Resident #5's right outer ankle during a skin assessment the previous night, and the Wound Care Nurse was going to assess it and get treatment started on it. LPN #2 verbalized that she relieved LPN #5 on 10/07/19 at 6:30 AM and was not told anything by LPN #5 concerning Resident #5. Further interview with LPN #2 revealed that if a new order had been written for wound care for three (3) days on Resident #5 for 10/06/19, the order would have shown up on the resident's TAR. LPN #2 stated there was no wound treatment orders on Resident #5's TAR for 10/07/19. Interview with LPN #3 on 10/08/19 at 4:00 PM revealed she was Resident #5's nurse on 09/29/19, 09/30/19, 10/04/19, and 10/07/19. The LPN stated she was not informed about anything concerning Resident #5's PU on his/her right ankle, and the first time she saw the PU was on 10/07/19 during a skin assessment with the state surveyor. Interview with the Wound Care Nurse on 10/08/19 at 9:10 AM revealed when a new wound is identified, the nurse fills out a Change of Condition Form, notifies the resident's physician, and receives new treatment orders for the wound. The Wound Care Nurse stated, The nurse then notifies the POA, ensures the wound treatment is in place, and then notifies me. She verbalized that she documents the measurements/describes the wounds weekly and if the wound does not show any progress or gets worse, she notifies the resident's physician. Further interview with the Wound Care Nurse revealed she did not find out about Resident #5's Stage 3 PU until 10/07/19 when the state surveyor requested her to assess the wound on the resident's right outer ankle. Interview with the Director of Nursing (DON) on 10/08/19 at 4:55 PM revealed the ADON should have had Resident #5's physician to be more specific on 09/27/19 when he instructed the ADON to monitor the scabbed areas on the resident's lower extremities and ankle. The DON stated it would have been helpful if the ADON and the Wound Care Nurse had added the issues concerning Resident #5 to the 24-Hour Report/Change of Condition report. The DON verbalized that she had not looked to see if a nurse wrote an order for [REDACTED].#5 and LPN #5 stated she did assess Resident #5's ankle on 10/06/19 but the DON could not remember if LPN #5 told her she applied a new dressing or left the old dressing on Resident #5's right ankle on 10/06/19. Further interview with the DON revealed she had not identified any concerns with staff not notifying the physician when a change in condition occurs with a resident, or writing orders when a new order is received by the physician. Interview with Resident #5's physician on 10/08/19 at 12:15 PM revealed he was not informed of the Stage 3 wound to Resident #5's ankle until 10/07/19. The physician stated staff called him on 10/07/19 after the state surveyor left the facility and informed him about the open area. The physician stated he instructed them to continue with the same wound care treatment that was done on Resident #5's ankle on 10/07/19.

Based on interview, record review, and review of facility policy it was determined the facility failed to ensure services were provided to one (1) of three (3) sampled residents (Resident #1) in accordance with their comprehensive plan of care. On 08/09/19, facility staff failed to transfer Resident #1 utilizing a sit-to-stand lift and two (2) staff members as directed by the resident's plan of care. Resident #1 immediately began to exhibit signs/symptoms of pain after the transfer and was subsequently diagnosed with [REDACTED]. The findings include: Review of the facility's policy, Using the Care Plan, dated (MONTH) 2006, revealed a resident's care plan would be used in developing the resident's daily care routines and would be available to staff who have the responsibility of providing care or services to the resident. A review of Resident #1's medical record revealed the facility admitted the resident on 08/09/16 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 six (6), and to require extensive assistance of two staff members for transfers. Review of Resident #1's plan of care revealed the facility initiated the interventions on 10/31/18, for two (2) staff members to transfer the resident utilizing a sit-to-stand lift. A review of nurse's notes for Resident #1 dated 08/09/19 at 12:18 PM revealed the resident began complaining of right upper arm pain after staff transferred the resident from the bed to a chair. Further review of the nurse's notes revealed the resident's physician was notified of the resident's complaints and an order was received to obtain an x-ray of the resident's right arm. Review of a nurse's note dated 08/09/19 revealed the x-ray of Resident #1's right arm revealed a [MEDICAL CONDITION] humerus, and the resident was transferred to the hospital on [DATE] at 5:50 PM and diagnosed with [REDACTED]. Interview with LPN #1 on 08/21/19 at 12:45 PM revealed she was called to Resident #1's room on 08/09/19 at approximately 12:18 PM, because the resident began voicing pain to the right arm after being transferred from the bed to the chair. LPN #1 stated that upon arrival to the resident's room it was obvious the resident was in pain. Further interview with LPN #1 revealed she was informed that SRNA #1 had transferred Resident #1 from the bed to the chair without utilizing a lift or assistance of another staff member. Continued interview with LPN #1 revealed she immediately informed the DON of the incident and called the resident's physician. Interview with State Registered Nurse Aide (SRNA) #1 on 08/21/19 at 2:50 PM revealed on 08/09/19 at approximately 12:18 PM, the SRNA transferred Resident #1 from the bed to the chair without utilizing the sit-to-stand lift or the assistance of another staff member as the facility had assessed the resident to require. The SRNA stated Resident #1 began complaining of arm pain after the transfer. Further interview with SRNA #1 revealed she had not provided care to Resident #1 prior to the incident. The SRNA stated she was not familiar with the resident or the resident's plan of care and did not know the resident required the use of a lift or two staff members for transfers. According to the SRNA, staff were provided a Kardex with the resident's care needs and according to the SRNA, she was not aware Resident #1 was care planned for two staff members to use a lift to transfer the resident. Interview with the Director of Nursing (DON) on 08/21/19 at 1:00 PM revealed she was informed that SRNA #1 had transferred Resident #1 by herself and without utilizing the sit-to-stand lift, and the resident immediately began complaining of pain to the right upper arm. The DON stated SRNA #1 was removed from direct care and the Administrator was contacted. According to the DON staff was expected to follow each resident's plan of care and SRNA #1 should have transferred the resident as directed by the resident's plan of care.

Based on interview, record review, and review of the facility policy it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistance devices to prevent accidents. On 08/09/19, SRNA #1 transferred Resident #1 from a bed to a chair without the assistance of another staff member and without using a lift, which the resident was assessed to require. During the transfer, Resident #1 yelled out, Oh, Oh and continued to complain of pain after the transfer was completed. Subsequently, Resident #1 was transferred to the hospital on [DATE], and diagnosed with [REDACTED]. The findings include: A review of the facility policy titled Safe Lifting and Movement of Residents, dated (MONTH) (YEAR), revealed in order to protect the safety/well-being of staff/residents, and to promote quality of care, the facility would use appropriate techniques and devices to lift and move residents. Further review of the policy revealed manual lifting of residents would be eliminated when feasible. A review of Resident #1's medical record revealed the facility admitted the resident on 08/09/16 with [DIAGNOSES REDACTED]. A 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 6, indicating the resident was cognitively impaired. The facility also assessed the resident to require the extensive assistance of two (2) staff members for transfers. A review of Resident #1's plan of care revealed the facility implemented an intervention on 10/31/18 for two (2) staff members to transfer Resident #1 utilizing a sit-to-stand lift. Interview with Nurse Aide (NA) #1 on 08/20/19 at 1:50 PM, revealed she was assigned to provide care to Resident #1 on 08/09/19; however, the NA stated she was not certified and was not allowed to transfer Resident #1. Therefore, NA #1 stated she asked SRNA #1, who was certified, to transfer the resident. According to NA #1, SRNA #1 transferred Resident #1 from the bed to a chair without using a lift or obtaining the assistance of another staff member. Further interview with NA #1 revealed she heard a pop while SRNA #1 was transferring Resident #1, and the resident immediately yelled out in pain and continued to yell in pain after the transfer was completed. Interview with NA #2 on 08/21/19 at 9:50 AM, revealed she was present in Resident #1's room with NA #1 on 08/09/19, when SRNA #1 transferred Resident #1 by herself without using a lift from the bed to a chair. NA #2 stated she heard a pop during the transfer and Resident #1 screamed Oh, Oh. NA #2 stated the resident appeared to be in pain and continued to yell out after the transfer was completed. Review of Resident #1's nurse's notes dated 08/09/19, at 12:18 PM, revealed LPN #1 assessed the resident to be experiencing obvious pain to the right upper arm after being transferred from the bed to a chair. LPN #1 contacted Resident #1's physician and an in-house x-ray of the resident's right arm was ordered, which revealed the resident had a fracture to the right arm. Resident #1 was subsequently transferred to the hospital on [DATE], at 5:50 PM, for further evaluation and treatment and was diagnosed with [REDACTED]. An interview with SRNA #1 on 08/21/19 at 2:50 PM revealed the SRNA transferred Resident #1 from the bed to the chair by herself and the resident complained of arm pain after the transfer. According to SRNA #1 she had not taken care of Resident #1 before, and was not familiar with the resident or the plan of care, and thought the resident's care plan indicated that the resident was a one-person transfer and that the lift was not required. Interview with LPN #1 on 08/21/19 at 12:45 PM revealed she was summoned to Resident #1's room on 08/09/19 at approximately 12:18 PM, because the resident was in pain and yelling out after being transferred from the bed to a chair. LPN #1 stated that when she arrived at the resident's room she observed the resident sitting in a chair beside the bed in obvious visible pain. Continued interview with LPN #1 revealed she assessed Resident #1 and the resident complained of right upper arm pain. Further interview with LPN #1 revealed NA #1 and NA #2 informed her that SRNA #1 had transferred the resident to the chair from the bed by herself without using the sit-to-stand lift. LPN #1 stated she immediately informed the DON of the incident and called the resident's physician, who ordered an x-ray of the resident's right arm. LPN #1 stated the x-ray results revealed Resident #1 had a fracture to the right arm, and the resident was transferred to the hospital for further evaluation and treatment, and subsequently diagnosed with [REDACTED]. An interview with the Director of Nursing (DON) on 08/21/19 at 1:00 PM revealed she was informed of the incident on 08/09/19 and contacted the Administrator and initiated an investigation. The DON stated the facility's investigation revealed SRNA #1 failed to follow the resident's plan of care, resulting in an injury to Resident #1. An interview with Resident #1's Physician on 08/21/19 at 12:35 PM revealed in his opinion the cause of Resident #1's fracture was from the impaction of the resident's elbow onto the arm of the recliner during the transfer. An interview with the Administrator on 08/21/19 at 1:45 PM revealed she was not at the facility at the time of the incident, but was informed by the DON of the occurrence on 08/09/19. The Administrator stated she directed the DON to start an investigation, which determined SRNA #1 failed to follow Resident #1's care plan. According to the Administrator SRNA #1 was suspended and was still off pending an investigation by Adult Protective Services.

Based on interview, record review, review of hospital and [MEDICAL TREATMENT] clinic records, review of the facility's policy, and review of the Lippincott Manual of Nursing Practice (Ninth Edition), it was determined the facility failed to provide services that met professional standards of quality for one (1) of twenty-four (24) sampled residents (Resident #22). On [DATE], it was suspected and reported to Nursing by facility staff that Resident #22 aspirated and required additional nursing monitoring and intervention. However, the facility failed to assess the resident and ensure that professional standards of practice were provided by appropriate qualified personnel. Subsequently, Resident #22 expired at the hospital on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and [MEDICAL CONDITION] (abnormally high levels of potassium in the blood). (Refer to F157, F282, F309, F490, F514, and F520.) The facility's failure to provide services that met professional standards has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Lippincott Manual of Nursing Practice (Ninth Edition) Standard of Care Guidelines for Emergency Assessment and Intervention revealed when a patient presented with a potentially life threatening condition, the patient's airway, breathing, and circulation, along with pupillary reaction and level of responsiveness, should be assessed. Nursing staff should assist the patient with appropriate transport and further assessment and care as indicated. Review of Aspiration guidelines revealed nurses should be on guard and monitor patients for airway obstruction, development of fever, congestion, and frothy sputum when aspiration was suspected. Review of the facility's Change in a Resident's Condition or Status policy, revised [DATE], revealed the nurse was required to make detailed observations and gather relevant and pertinent information for the provider. Review of Resident #22's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #22's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was four (4), which indicated the resident was cognitively impaired. Further review revealed the resident required a therapeutic diet and was assessed to hold food in the mouth/cheeks or retain residual food in the mouth after meals. According to the assessment, Resident #22 started speech therapy on [DATE]. Further review revealed the resident did not have a condition or chronic disease that resulted in a life expectancy of less than six months. Review of Resident #22's care plan dated [DATE] revealed the facility identified that the resident required monitoring for chewing and swallowing difficulty. Review of Resident #22's Speech Therapy Notes revealed on [DATE], at 2:22 PM, the resident was very lethargic during the lunch meal, only consuming ,[DATE] bites. The Speech Therapist (ST) documented that Resident #22 did not chew the food and held the food in the right side of his/her mouth. The ST further documented that she manually removed the food from the resident's mouth with her fingers. After providing Resident #22 with liquids, the resident exhibited a productive cough (a productive cough produces phlegm or mucus), and began have wet vocals (which could indicate a person has aspirated food/liquid into their lungs). Interview with the Speech-Language Pathologist on [DATE] at 8:54 AM, revealed on [DATE], Resident #22 required a sternal rub and she believed the resident had aspirated food/fluid into the lungs during treatment on [DATE]. She stated she notified Nursing. Continued review of the ST's documentation on [DATE] at 2:22 PM, revealed she notified nursing staff who stated they would monitor Resident #22 for distress as a result of aspiration. However, review of Resident #22's Nursing Progress Notes, dated [DATE], revealed no documentation of the ST's concerns or any evidence that nursing staff assessed the resident. Review of Occupational Therapy Notes revealed on [DATE] at 1:21 PM, the Certified Occupational Therapy Assistant (COTA) documented that the resident was lethargic and required sternal rubs; however, the resident was unresponsive to arousal techniques. The COTA documented that she spoke with nursing staff about the resident's condition. However, there was no documentation that nursing staff responded to the COTA's concerns and assessed Resident #22. Interview with the COTA on [DATE] at 1:17 PM, revealed she reported Resident #22's condition to the nurse on [DATE] at 1:17 PM. Interview with State Registered Nurse Aide #9 on [DATE] at 10:25 AM, revealed on [DATE], at approximately 2:00 PM, prior to sending Resident #22 to [MEDICAL TREATMENT], the resident was noted to be more lethargic than usual, was unable to sit up in a wheelchair, and the resident barely mumbled. SRNA #9 stated she reported the resident's condition to nursing staff. However, there was no evidence nursing staff assessed Resident #22. Interview with Registered Nurse (RN) #3 on [DATE] at 1:08 PM, revealed on [DATE], she observed Resident #22 in a wheelchair at the nurses' station. RN #3 stated the resident was unable to hold his/her head up, had pinpoint, non-reactive pupils, and appeared limp. RN #3 stated she told the resident's nurse that the resident needed to go to the hospital Emergency Department (ED) for evaluation; however, there was no evidence that RN #3 took any action to ensure Resident #22 received a nursing assessment and necessary treatment. Interview with LPN #2 on [DATE] at 10:30 AM, revealed she failed to assess Resident #22 and denied that staff reported any concerns to her on [DATE]. Further review of Nursing Progress Notes revealed Resident #22 was transported to [MEDICAL TREATMENT] at 2:30 PM on [DATE] with no evidence that an assessment of the resident's condition was conducted. Upon arrival to the [MEDICAL TREATMENT] clinic, the resident was in respiratory distress and immediately transported to the hospital. Review of the hospital Emergency Department (ED) record revealed Resident #22 was pronounced dead on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and [MEDICAL CONDITION]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the QA (Quality Assurance) Committee met to discuss the events set forth in the notice of Immediate Jeopardy and developed an action plan. 2. On [DATE] to [DATE], the Interdisciplinary Team (IDT) which consisted of the Director of Nursing (DON), Assistant Director Of Nursing (ADON), Transition Nurse, and Social Service (SS), reviewed all active residents to identify any change of condition not previously identified utilizing the following criteria: the Minimum Data Set (MDS) criteria, Brief Interview for Mental Status (BIMS), Chart Documentation, and assessment of each resident. No concerns were identified. 3. On [DATE], the DON assessed the two (2) residents receiving [MEDICAL TREATMENT] services and no concerns were identified. 4. On [DATE], the Regional Director of Operations educated the Administrator related to utilizing facility resources and addressing concerns in the facility including but not limited to the Immediate Jeopardy action plan and follow-up, changes in condition, care plans, conducting daily stand-down meetings, Quality Assurance (QA) tools, and QA meetings. 5. On [DATE], the Regional Director of Clinical Services educated the DON, ADON, MDS, and SS on the use of the Clinical Check Off sheet. 6. Beginning [DATE], the Clinical Check Off sheet will be utilized during the clinical morning meeting Monday through Friday to review resident information to ensure any change of condition was identified and addressed. The form consists of criteria to review the last twenty-four (24) to seventy-two (72) hours of Nurses' Notes, Physician Orders, physician notification, the 24-hour report, and to ensure care plans are being implemented. 7. On [DATE], the Staff Development Coordinator (SDC), DON, and Regional Consultant developed the Resident Transfer Quality Assurance (QA) Checklist which was implemented on [DATE]. The Transfer Quality Assurance (QA) Checklist will be utilized to ensure documentation accompanies the resident to the appointment. 8. On [DATE], the Regional Consultant educated the DON, SDC, and ADON. The DON then educated the Transitional Nurse, Social Services, and Activities Director. The DON, ADON, SDC, and/or Transitional Nurse then educated all licensed nursing staff. Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit 9. On [DATE], the DON, ADON, SDC, Activity Director, and Social Services educated State Registered Nurse Aides (SRNAs). Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments. 10. On [DATE], a QA Committee Meeting was held to review progress of education, and to review audit information and the progress of the plan. 11. Beginning [DATE], audits will be conducted by the Transition Nurse, ADON, DON, SDC, Restorative Nurse, or Social Services to ensure the Transfer QA Checklist was completed for residents leaving the facility for appointments. The audits will be conducted two (2) times per week for eight (8) weeks, then two (2) times per month for one (1) month, and then at a minimum of quarterly. The results of the audits will be reported by the DON to the QA Committee. 12. Beginning [DATE], five (5) care plans will be audited by the MDS/DON/Social Services Director per week to validate care plans are being followed. The audits will be completed weekly for eight (8) weeks, then two (2) times a month for one (1) month. Results of the audits will be reported to the QA Committee by the MDS Nurse. 13. Beginning [DATE], Nurses' Notes for five (5) random residents will be reviewed five (5) times a week to ensure physicians and families are notified of changes in condition. The audits will be completed by MDS, Social Services, ADON, or DON. The audits will continue five (5) times a week for eight (8) weeks, and then two (2) times a month for one (1) month. The audit results will be reported to the QA Committee by the DON. 14. Daily beginning [DATE], an Administrative Nurse (DON, ADON, and Transition Nurse) will make walking rounds and monitor residents for any change of condition not already addressed. Any concerns will be addressed immediately. 15. Beginning [DATE], the Administrator and/or DON will conduct a stand-down meeting Monday through Friday afternoon (DON, ADON, MDS, and Social Services to attend) to confirm any concerns that arose throughout the workday were addressed. 16. A QA meeting will be held weekly for eight (8) weeks, then monthly for one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, or Regional Reimbursement Director/Chief Operating Officer) will attend the weekly meetings for eight (8) weeks. Concerns will be addressed immediately and will be address through the facility's QA Committee. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1. Review of QA meeting minutes and a sign-in sheet dated [DATE], revealed the Administrator, DON, ADON, SS, Activity Director (AD), Therapy Manager, Transitional Nurse, Restorative Nurse, MDS Nurse, and Medical Director met and developed an action plan for the Immediate Jeopardy allegation. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended a QA meeting on [DATE], to discuss the IJ allegation and to develop a plan of action. 2. Review of a resident roster dated [DATE], revealed the DON, ADON, Transitional Nurse, and SS reviewed all residents' medical records. On [DATE], review of resident review/assessment forms revealed the DON and ADON assessed all residents in the facility to ensure any change in a resident's condition had been addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they assisted in reviewing resident medical records and completing assessments for all residents in the facility. 3. Review of Nurse's Notes for Resident A and Resident B who received [MEDICAL TREATMENT] services, revealed the DON assessed the residents on [DATE], and did not identify any concerns. Interview with the DON on [DATE] at 12:30 PM, revealed she assessed Residents A and B and no concerns were identified. 4. Interview with the Administrator on [DATE] at 1:00 PM, revealed on [DATE], the Regional Director of Operations educated her regarding utilizing facility resources, the Immediate Jeopardy action plan, changes in condition, care plans, conducting daily stand-down meetings and QA meetings. 5. Review of a facility in-service roster dated [DATE], revealed the Regional Director of Clinical Services provided education for the DON, ADON, MDS Nurse, and the SS on the use of Clinical Check Off sheet. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE] at 11:40 AM, revealed the Regional Director of Nursing educated them on [DATE], regarding completion of the Clinical Check Off sheet. 6. Review of Clinical Check Off sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the Clinical Check Off sheet was being utilized during the facility's morning clinical meeting to ensure any change of condition was addressed. Interviews conducted with the Administrator on [DATE], at 1:00 PM, DON on [DATE], at 12:30 PM, ADON on [DATE], at 11:20 AM, SS on [DATE], at 10:50 AM, AD on [DATE], at 12:25 PM, BOM on [DATE], at 10:42 AM, Therapy Manager on [DATE], at 11:15 AM, Transitional Nurse on [DATE], at 10:17 AM, Restorative Nurse on ,[DATE], at 10:44 AM, Scheduler on [DATE], at 11:10 AM, and the MDS Nurse on [DATE], at 11:40 AM, all revealed they attended morning clinical meetings and utilized the Clinical Check Off sheet and reviewed all residents' nurses notes, physician notification, new physician orders, care plans, and the twenty four (24) hour report. 7. Review of Transfer QA Checklists completed since [DATE], revealed no concerns with the completion of documentation prior to residents leaving the facility for appointments. Interviews conducted with LPN #5 on [DATE], at 9:50 AM, LPN #3 on [DATE], at 9:55 AM, LPN #9 on [DATE], at 10:10 AM, LPN #10 on [DATE], at 9:48 AM, and LPN #11 on [DATE], at 9:56 AM, revealed they had received education related to completing the Resident Transfer QA Checklist and were completing the form as required. 8. Review of in-service rosters dated [DATE], revealed the Regional Consultant provided a train the trainer in-service for the DON, SDC, and the ADON. Further review of an in-service roster dated [DATE], revealed the DON provided an in-service for the Transitional Nurse, SS, and the AD on the following. In addition, the licensed nursing staff was educated by the DON, ADON, SDC, and Transitional Nurse provided on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Transitional Nurse on [DATE] at 10:17 AM, SDC on [DATE] at 12:16 PM, LPN #5 on [DATE] at 9:50 AM, LPN #3 on [DATE] at 9:55 AM, LPN #9 on [DATE] at 10:10 AM, LPN #10 on [DATE] at 9:48 AM, and LPN #11 on [DATE] at 9:56 AM, revealed they had been educated regarding the facility's change in condition, implementing care plans, documentation regarding appointments and changes in a resident's condition, and utilizing the Resident Transfer Checklist QA audit. The DON stated the facility was not currently utilizing agency staff in the facility; however, if any agency staff was utilized in the future, they would be required to complete the in-services prior to working. Interview with the SDC revealed there were currently no new employees; however, the education was added to new employee orientation. 9. Review of a facility in-service roster dated [DATE], revealed the DON, ADON, SDC, AD, and SS provided an in-service to all CNAs on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments Interviews conducted with CNA #8 on [DATE] at 3:30 PM, CNA #10 on [DATE] at 3:35 PM, CNA #4 on [DATE] at 3:38 PM, CNA #11 on [DATE] at 3:40 PM, and CNA #12 on [DATE] at 3:45 PM, revealed they had attended in-services regarding what constituted a change in a resident's condition, the process for accompanying residents to appointments, and to ensure the nurse assessed the resident prior to leaving the facility for an appointment. 10. Review of QA meeting rosters revealed a QA meeting was held on [DATE], and audit information was reviewed. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended the QA meeting on [DATE], and reviewed audit tools and discussed the progress of the Allegation of Compliance. 11. Review of audit tools which began [DATE], revealed the DON, ADON, Transition Nurse, SDC, Restorative Nurse, and SS had audited residents' medical records twice weekly to ensure documentation and the Resident Transfer QA Checklist were completed prior to residents leaving the facility for appointments. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing residents' medical records to validate the Resident Transfer QA Checklist had been completed. 12. Review of audit tools which began [DATE], revealed the DON, MDS Nurse, and SS audited five (5) resident care plans weekly for the past two (2) weeks to ensure care plans were being followed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for conducting five (5) resident care plan audits twice a week to ensure care plans were being followed. 13. Review of audit tools implemented on [DATE], revealed the DON, ADON, MDS Nurse, and SS had audited five (5) residents to ensure physicians and families were notified of any change in condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing five (5) random residents' medical records to ensure families and physician notification was made for of any change in a resident's condition. 14. Review of Clinical Walking Rounds audit tool, revealed an administrative nurse had made walking rounds daily beginning [DATE], to monitor for any change in a resident's condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they conducted rounds in the facility daily to monitor for any change in resident condition. 15. Interviews conducted with the Administrator on [DATE], at 1:00 PM, revealed she conducted Stand Down meetings every day Monday through Friday, and ensured all concerns were addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], revealed they had attended daily Stand Down meetings that were conducted by the administrator. 16. Review of QA meeting rosters revealed meetings were held on [DATE], [DATE], and [DATE]. Interview with the Administrator on [DATE] at 1:00 PM, revealed continued meetings will be held weekly for eight (8) weeks, then monthly. The Administrator stated a member of the regional team was attending the QA meetings.

Based on interview, record review, review of hospital and [MEDICAL TREATMENT] clinic records, and review of the facility's policies, it was determined the facility failed to notify the physician of a change in condition and need to alter treatment for one (1) of twenty-four (24) sampled residents (Resident #22). On [DATE], the facility's Speech-Language Pathologist (Speech Therapist) documented that the resident exhibited signs of aspiration during lunch. Nursing staff was notified of the incident; however, there was no documented evidence the resident's physician was notified. After lunch, nursing staff was notified that Resident #22 was unresponsive, could not sit up, was limp, and the resident's eyes were big/non-reactive. However, the facility failed to notify the resident's physician or the resident's family of the resident's change in condition and need to alter treatment. The facility subsequently transferred Resident #22 to the [MEDICAL TREATMENT] clinic at 2:30 PM on [DATE], unresponsive. The [MEDICAL TREATMENT] clinic's staff immediately transferred the resident to the hospital where he/she expired on [DATE] at 10:16 PM, due to Pneumonia, Septic Shock, and [MEDICAL CONDITION] (abnormally high levels of potassium in the blood). (Refer to F281, F282, F309, F490, F514, and F520.) The facility's failure to ensure the resident's physician and family were notified when there was a change in condition and need to alter treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Change in a Resident's Condition or Status policy, revised [DATE], revealed the nurse supervisor/charge nurse would notify the resident's attending physician or on-call physician when there was a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, and the need to transfer the resident to a hospital/treatment center. The policy stated a significant change of condition was an improvement or a decline in the resident's status that would not normally resolve itself. The policy further stated the nurse supervisor/charge nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Review of Resident #22's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #22's Speech Therapy (ST) Notes dated [DATE] at 2:22 PM, revealed the resident was very lethargic during the lunch meal and the ST suspected that Resident #22 had aspirated due to the resident developing a wet, productive cough. The ST documented that the nursing staff was notified and informed her that they would monitor Resident #22 for distress as a result of aspiration. However, there was no documented evidence Resident #22's physician or the resident's family was notified that the resident continued to be very lethargic or that the resident had aspirated. Review of Certified Occupational Therapy Assistant (COTA) notes revealed on [DATE] at 1:21 PM, Resident #22 was lethargic and unresponsive to arousal techniques. The COTA documented that she spoke with nursing staff about the resident's condition. Interview with State Registered Nurse Aide (SRNA) #9 on [DATE] at 10:25 AM, and Registered Nurse (RN) #3 on [DATE] at 1:08 PM revealed on [DATE], prior to leaving the facility for [MEDICAL TREATMENT], Resident #22 was noted to be more lethargic, leaning/falling forward, and unable to sit up in a chair unassisted. RN #3 stated the resident's chin was on his/her chest, the resident's arms were limp, and the resident's pupils were pinpoint and non-reactive. RN #3 also voiced concerns to the resident's assigned nurse that the resident needed to go the Emergency Department instead of [MEDICAL TREATMENT]. However, according to the Nursing Progress Notes, the resident was transferred to the [MEDICAL TREATMENT] clinic at 2:30 PM on [DATE]. Further review of the Nursing Notes revealed there was no documented evidence facility staff assessed the resident or notified the resident's physician and family that the resident had a change in condition. Interview with Resident #22's family members on [DATE] at 11:30 AM, revealed staff notified the resident's spouse on [DATE] at approximately 2:00 AM that the resident was more lethargic than usual. Further interview revealed the resident's spouse never heard from the facility again regarding the resident's condition. The resident's family stated the next notification they received was on [DATE] at approximately 4:00 PM, when the hospital called to tell them the resident was at the hospital. The family stated they had no idea what had happened, until the hospital staff told them when the facility sent the resident to the [MEDICAL TREATMENT] clinic that the resident was unresponsive. An interview was attempted with Resident #22's Physician on [DATE] at 1:40 PM; however, the physician was no longer [MEDICATION NAME] medicine due to illness. Review of the [MEDICAL TREATMENT] clinic's Nursing Notes dated [DATE] at 4:09 PM, revealed upon arrival staff called Emergency Medical Services because the resident was unresponsive, slumped over, and in respiratory distress. Review of the hospital Emergency Department (ED) record revealed Resident #22 arrived at the ED on [DATE] at 3:41 PM. The ED Physician documented that Resident #22 was unresponsive with no respiratory effort, had copious secretions, and was comatose. Resident #22 was pronounced dead on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and [MEDICAL CONDITION]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the QA (Quality Assurance) Committee met to discuss the events set forth in the notice of Immediate Jeopardy and developed an action plan. 2. On [DATE] to [DATE], the Interdisciplinary Team (IDT) which consisted of the Director of Nursing (DON), Assistant Director Of Nursing (ADON), Transition Nurse, and Social Service (SS), reviewed all active residents to identify any change of condition not previously identified utilizing the following criteria: the Minimum Data Set (MDS) criteria, Brief Interview for Mental Status (BIMS), Chart Documentation, and assessment of each resident. No concerns were identified. 3. On [DATE], the DON assessed the two (2) residents receiving [MEDICAL TREATMENT] services and no concerns were identified. 4. On [DATE], the Regional Director of Operations educated the Administrator related to utilizing facility resources and addressing concerns in the facility including but not limited to the Immediate Jeopardy action plan and follow-up, changes in condition, care plans, conducting daily stand-down meetings, Quality Assurance (QA) tools, and QA meetings. 5. On [DATE], the Regional Director of Clinical Services educated the DON, ADON, MDS, and SS on the use of the Clinical Check Off sheet. 6. Beginning [DATE], the Clinical Check Off sheet will be utilized during the clinical morning meeting Monday through Friday to review resident information to ensure any change of condition was identified and addressed. The form consists of criteria to review the last twenty-four (24) to seventy-two (72) hours of Nurses' Notes, Physician Orders, physician notification, the 24-hour report, and to ensure care plans are being implemented. 7. On [DATE], the Staff Development Coordinator (SDC), DON, and Regional Consultant developed the Resident Transfer Quality Assurance (QA) Checklist which was implemented on [DATE]. The Transfer Quality Assurance (QA) Checklist will be utilized to ensure documentation accompanies the resident to the appointment. 8. On [DATE], the Regional Consultant educated the DON, SDC, and ADON. The DON then educated the Transitional Nurse, Social Services, and Activities Director. The DON, ADON, SDC, and/or Transitional Nurse then educated all licensed nursing staff. Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit 9. On [DATE], the DON, ADON, SDC, Activity Director, and Social Services educated State Registered Nurse Aides (SRNAs). Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments. 10. On [DATE], a QA Committee Meeting was held to review progress of education, and to review audit information and the progress of the plan. 11. Beginning [DATE], audits will be conducted by the Transition Nurse, ADON, DON, SDC, Restorative Nurse, or Social Services to ensure the Transfer QA Checklist was completed for residents leaving the facility for appointments. The audits will be conducted two (2) times per week for eight (8) weeks, then two (2) times per month for one (1) month, and then at a minimum of quarterly. The results of the audits will be reported by the DON to the QA Committee. 12. Beginning [DATE], five (5) care plans will be audited by the MDS/DON/Social Services Director per week to validate care plans are being followed. The audits will be completed weekly for eight (8) weeks, then two (2) times a month for one (1) month. Results of the audits will be reported to the QA Committee by the MDS Nurse. 13. Beginning [DATE], Nurses' Notes for five (5) random residents will be reviewed five (5) times a week to ensure physicians and families are notified of changes in condition. The audits will be completed by MDS, Social Services, ADON, or DON. The audits will continue five (5) times a week for eight (8) weeks, and then two (2) times a month for one (1) month. The audit results will be reported to the QA Committee by the DON. 14. Daily beginning [DATE], an Administrative Nurse (DON, ADON, and Transition Nurse) will make walking rounds and monitor residents for any change of condition not already addressed. Any concerns will be addressed immediately. 15. Beginning [DATE], the Administrator and/or DON will conduct a stand-down meeting Monday through Friday afternoon (DON, ADON, MDS, and Social Services to attend) to confirm any concerns that arose throughout the workday were addressed. 16. A QA meeting will be held weekly for eight (8) weeks, then monthly for one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, or Regional Reimbursement Director/Chief Operating Officer) will attend the weekly meetings for eight (8) weeks. Concerns will be addressed immediately and will be address through the facility's QA Committee. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1. Review of QA meeting minutes and a sign-in sheet dated [DATE], revealed the Administrator, DON, ADON, SS, Activity Director (AD), Therapy Manager, Transitional Nurse, Restorative Nurse, MDS Nurse, and Medical Director met and developed an action plan for the Immediate Jeopardy allegation. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended a QA meeting on [DATE], to discuss the IJ allegation and to develop a plan of action. 2. Review of a resident roster dated [DATE], revealed the DON, ADON, Transitional Nurse, and SS reviewed all residents' medical records. On [DATE], review of resident review/assessment forms revealed the DON and ADON assessed all residents in the facility to ensure any change in a resident's condition had been addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they assisted in reviewing resident medical records and completing assessments for all residents in the facility. 3. Review of Nurse's Notes for Resident A and Resident B who received [MEDICAL TREATMENT] services, revealed the DON assessed the residents on [DATE], and did not identify any concerns. Interview with the DON on [DATE] at 12:30 PM, revealed she assessed Residents A and B and no concerns were identified. 4. Interview with the Administrator on [DATE] at 1:00 PM, revealed on [DATE], the Regional Director of Operations educated her regarding utilizing facility resources, the Immediate Jeopardy action plan, changes in condition, care plans, conducting daily stand-down meetings and QA meetings. 5. Review of a facility in-service roster dated [DATE], revealed the Regional Director of Clinical Services provided education for the DON, ADON, MDS Nurse, and the SS on the use of Clinical Check Off sheet. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE] at 11:40 AM, revealed the Regional Director of Nursing educated them on [DATE], regarding completion of the Clinical Check Off sheet. 6. Review of Clinical Check Off sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the Clinical Check Off sheet was being utilized during the facility's morning clinical meeting to ensure any change of condition was addressed. Interviews conducted with the Administrator on [DATE], at 1:00 PM, DON on [DATE], at 12:30 PM, ADON on [DATE], at 11:20 AM, SS on [DATE], at 10:50 AM, AD on [DATE], at 12:25 PM, BOM on [DATE], at 10:42 AM, Therapy Manager on [DATE], at 11:15 AM, Transitional Nurse on [DATE], at 10:17 AM, Restorative Nurse on ,[DATE], at 10:44 AM, Scheduler on [DATE], at 11:10 AM, and the MDS Nurse on [DATE], at 11:40 AM, all revealed they attended morning clinical meetings and utilized the Clinical Check Off sheet and reviewed all residents' nurses notes, physician notification, new physician orders, care plans, and the twenty four (24) hour report. 7. Review of Transfer QA Checklists completed since [DATE], revealed no concerns with the completion of documentation prior to residents leaving the facility for appointments. Interviews conducted with LPN #5 on [DATE], at 9:50 AM, LPN #3 on [DATE], at 9:55 AM, LPN #9 on [DATE], at 10:10 AM, LPN #10 on [DATE], at 9:48 AM, and LPN #11 on [DATE], at 9:56 AM, revealed they had received education related to completing the Resident Transfer QA Checklist and were completing the form as required. 8. Review of in-service rosters dated [DATE], revealed the Regional Consultant provided a train the trainer in-service for the DON, SDC, and the ADON. Further review of an in-service roster dated [DATE], revealed the DON provided an in-service for the Transitional Nurse, SS, and the AD on the following. In addition, the licensed nursing staff was educated by the DON, ADON, SDC, and Transitional Nurse provided on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Transitional Nurse on [DATE] at 10:17 AM, SDC on [DATE] at 12:16 PM, LPN #5 on [DATE] at 9:50 AM, LPN #3 on [DATE] at 9:55 AM, LPN #9 on [DATE] at 10:10 AM, LPN #10 on [DATE] at 9:48 AM, and LPN #11 on [DATE] at 9:56 AM, revealed they had been educated regarding the facility's change in condition, implementing care plans, documentation regarding appointments and changes in a resident's condition, and utilizing the Resident Transfer Checklist QA audit. The DON stated the facility was not currently utilizing agency staff in the facility; however, if any agency staff was utilized in the future, they would be required to complete the in-services prior to working. Interview with the SDC revealed there were currently no new employees; however, the education was added to new employee orientation. 9. Review of a facility in-service roster dated [DATE], revealed the DON, ADON, SDC, AD, and SS provided an in-service to all CNAs on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments Interviews conducted with CNA #8 on [DATE] at 3:30 PM, CNA #10 on [DATE] at 3:35 PM, CNA #4 on [DATE] at 3:38 PM, CNA #11 on [DATE] at 3:40 PM, and CNA #12 on [DATE] at 3:45 PM, revealed they had attended in-services regarding what constituted a change in a resident's condition, the process for accompanying residents to appointments, and to ensure the nurse assessed the resident prior to leaving the facility for an appointment. 10. Review of QA meeting rosters revealed a QA meeting was held on [DATE], and audit information was reviewed. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended the QA meeting on [DATE], and reviewed audit tools and discussed the progress of the Allegation of Compliance. 11. Review of audit tools which began [DATE], revealed the DON, ADON, Transition Nurse, SDC, Restorative Nurse, and SS had audited residents' medical records twice weekly to ensure documentation and the Resident Transfer QA Checklist were completed prior to residents leaving the facility for appointments. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing residents' medical records to validate the Resident Transfer QA Checklist had been completed. 12. Review of audit tools which began [DATE], revealed the DON, MDS Nurse, and SS audited five (5) resident care plans weekly for the past two (2) weeks to ensure care plans were being followed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for conducting five (5) resident care plan audits twice a week to ensure care plans were being followed. 13. Review of audit tools implemented on [DATE], revealed the DON, ADON, MDS Nurse, and SS had audited five (5) residents to ensure physicians and families were notified of any change in condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing five (5) random residents' medical records to ensure families and physician notification was made for of any change in a resident's condition. 14. Review of Clinical Walking Rounds audit tool, revealed an administrative nurse had made walking rounds daily beginning [DATE], to monitor for any change in a resident's condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they conducted rounds in the facility daily to monitor for any change in resident condition. 15. Interviews conducted with the Administrator on [DATE], at 1:00 PM, revealed she conducted Stand Down meetings every day Monday through Friday, and ensured all concerns were addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], revealed they had attended daily Stand Down meetings that were conducted by the administrator. 16. Review of QA meeting rosters revealed meetings were held on [DATE], [DATE], and [DATE]. Interview with the Administrator on [DATE] at 1:00 PM, revealed continued meetings will be held weekly for eight (8) weeks, then monthly. The Administrator stated a member of the regional team was attending the QA meetings.

Based on interview, record review, review of hospital and [MEDICAL TREATMENT] clinic records, and review of the facility's policies, it was determined the facility failed to provide services in accordance with the plan of care for one (1) of twenty-four (24) sampled residents (Resident #22). Resident #22's care plan required staff to monitor for any chewing or swallowing problems and to monitor for physical decline and notify the resident's physician. However, on [DATE], the facility failed to assess/monitor Resident #22 and failed to notify the resident's physician when the Speech-Language Pathologist (Speech Therapist) notified nursing staff at lunchtime that the resident had signs of aspiration. After lunch, staff reported to the licensed staff that Resident #22 was unresponsive, could not sit up, was limp, and the resident's eyes were big/non-reactive. However, there was no documented evidence the licensed nursing staff notified the resident's physician as required by the resident's care plan. The facility sent the resident out for a [MEDICAL TREATMENT] clinic appointment, where the resident was immediately transferred to the hospital for treatment. Resident #22 expired on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and Hyperbole. (Refer to F157, F281, F309, F490, F514, and F520.) The facility's failure to implement resident care plans has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Administrator on [DATE] at 1:05 PM revealed the facility did not have a policy related to care plans that addressed ensuring residents' care plans were implemented. The Administrator stated they followed the Resident Assessment Instrument (RAI) Manual. Review of the RAI User Manual revealed, Individualized care plans should be based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident. Review of Resident #22's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #22's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was cognitively impaired. Further review revealed the resident was usually understood, usually understood others, and required extensive to total assistance from staff with ADLs (activities of daily living). Review of Resident #22's care plan dated [DATE], revealed the facility identified that long-term care was expected for the resident and the facility would provide quality care which met the resident's physical and mental needs. The facility developed interventions that included monitoring the resident for physical/mental improvement or decline and notifying the resident's physician as needed. The facility also identified that the resident had inadequate food intake due to the resident's [DIAGNOSES REDACTED]. Review of Resident #22's Speech Therapy (ST) Notes revealed on [DATE], Resident #22 aspirated food/fluids during the lunch meal. The ST notified nursing staff who stated they would monitor the resident for distress as a result of aspiration. However, interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:30 AM and with Registered Nurse (RN) #4 on [DATE] at 10:40 AM revealed they were the nurses working on the unit where Resident #22 resided on [DATE]. The nurses stated they did not recall any staff member reporting a change in Resident #22's condition, assessing/monitoring the resident when the resident aspirated, or notifying the resident's physician that the resident had aspirated. Review of Certified Occupational Therapy Assistant (COTA) notes dated [DATE], and interview with the COTA on [DATE] at 1:17 PM, revealed when the COTA attempted to treat Resident #22 on [DATE] at 1:21 PM, the resident was unresponsive to arousal techniques. Further interview revealed the COTA notified nursing staff of the resident's condition. Again, there was no documented evidence staff assessed/monitored Resident #22 or notified the resident's physician of the resident's decline in physical condition as required by the resident's plan of care. Interview with State Registered Nurse Aide (SRNA) #9 on [DATE] at 10:25 AM, revealed on [DATE], at approximately 2:00 PM, prior to sending Resident #22 to [MEDICAL TREATMENT], the SRNA notified the licensed nursing staff that the resident was lethargic. SRNA #9 stated the resident was very hard to arouse; the resident's eyes were big, and he/she could not sit up in a chair unassisted. Interview with Registered Nurse (RN) #3 on [DATE] at 1:08 PM, revealed she saw Resident #22 sitting in a wheelchair prior to leaving the facility for [MEDICAL TREATMENT] on [DATE], and the resident's head was down, the resident's arms were limp, and his/her pupils were pinpoint and non-reactive. RN #3 stated she told the resident's nurse that the resident needed to go to the Emergency Department (ED) for evaluation. However, further review of Resident #22's medical record and interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 10:30 AM and with Registered Nurse (RN) #4 on [DATE] at 10:40 AM revealed no documented evidence an assessment was conducted of the resident's condition or that the physician was notified of the resident's change in condition as required by the resident's care plan. According to a Nursing Note dated [DATE], Resident #22 was transferred to the [MEDICAL TREATMENT] clinic on [DATE] at 2:30 PM. Review of Resident #22's medical record from the [MEDICAL TREATMENT] clinic revealed on [DATE], the [MEDICAL TREATMENT] clinic's staff called Emergency Medical Services (EMS) because the resident was slumped over, had copious amounts of sputum and mucus from the mouth and nose, was diaphoretic (sweating heavily), and had periods of apnea. Resident #22 was transferred to the hospital Emergency Department. Review of Resident #22's medical record from the hospital Emergency Department (ED) record on [DATE], revealed the resident was unresponsive with no respiratory effort, copious secretions, and was comatose upon arrival to the hospital. Resident #22's condition continued to deteriorate and the resident was pronounced dead on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and [MEDICAL CONDITION]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the QA (Quality Assurance) Committee met to discuss the events set forth in the notice of Immediate Jeopardy and developed an action plan. 2. On [DATE] to [DATE], the Interdisciplinary Team (IDT) which consisted of the Director of Nursing (DON), Assistant Director Of Nursing (ADON), Transition Nurse, and Social Service (SS), reviewed all active residents to identify any change of condition not previously identified utilizing the following criteria: the Minimum Data Set (MDS) criteria, Brief Interview for Mental Status (BIMS), Chart Documentation, and assessment of each resident. No concerns were identified. 3. On [DATE], the DON assessed the two (2) residents receiving [MEDICAL TREATMENT] services and no concerns were identified. 4. On [DATE], the Regional Director of Operations educated the Administrator related to utilizing facility resources and addressing concerns in the facility including but not limited to the Immediate Jeopardy action plan and follow-up, changes in condition, care plans, conducting daily stand-down meetings, Quality Assurance (QA) tools, and QA meetings. 5. On [DATE], the Regional Director of Clinical Services educated the DON, ADON, MDS, and SS on the use of the Clinical Check Off sheet. 6. Beginning [DATE], the Clinical Check Off sheet will be utilized during the clinical morning meeting Monday through Friday to review resident information to ensure any change of condition was identified and addressed. The form consists of criteria to review the last twenty-four (24) to seventy-two (72) hours of Nurses' Notes, Physician Orders, physician notification, the 24-hour report, and to ensure care plans are being implemented. 7. On [DATE], the Staff Development Coordinator (SDC), DON, and Regional Consultant developed the Resident Transfer Quality Assurance (QA) Checklist which was implemented on [DATE]. The Transfer Quality Assurance (QA) Checklist will be utilized to ensure documentation accompanies the resident to the appointment. 8. On [DATE], the Regional Consultant educated the DON, SDC, and ADON. The DON then educated the Transitional Nurse, Social Services, and Activities Director. The DON, ADON, SDC, and/or Transitional Nurse then educated all licensed nursing staff. Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit 9. On [DATE], the DON, ADON, SDC, Activity Director, and Social Services educated State Registered Nurse Aides (SRNAs). Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments. 10. On [DATE], a QA Committee Meeting was held to review progress of education, and to review audit information and the progress of the plan. 11. Beginning [DATE], audits will be conducted by the Transition Nurse, ADON, DON, SDC, Restorative Nurse, or Social Services to ensure the Transfer QA Checklist was completed for residents leaving the facility for appointments. The audits will be conducted two (2) times per week for eight (8) weeks, then two (2) times per month for one (1) month, and then at a minimum of quarterly. The results of the audits will be reported by the DON to the QA Committee. 12. Beginning [DATE], five (5) care plans will be audited by the MDS/DON/Social Services Director per week to validate care plans are being followed. The audits will be completed weekly for eight (8) weeks, then two (2) times a month for one (1) month. Results of the audits will be reported to the QA Committee by the MDS Nurse. 13. Beginning [DATE], Nurses' Notes for five (5) random residents will be reviewed five (5) times a week to ensure physicians and families are notified of changes in condition. The audits will be completed by MDS, Social Services, ADON, or DON. The audits will continue five (5) times a week for eight (8) weeks, and then two (2) times a month for one (1) month. The audit results will be reported to the QA Committee by the DON. 14. Daily beginning [DATE], an Administrative Nurse (DON, ADON, and Transition Nurse) will make walking rounds and monitor residents for any change of condition not already addressed. Any concerns will be addressed immediately. 15. Beginning [DATE], the Administrator and/or DON will conduct a stand-down meeting Monday through Friday afternoon (DON, ADON, MDS, and Social Services to attend) to confirm any concerns that arose throughout the workday were addressed. 16. A QA meeting will be held weekly for eight (8) weeks, then monthly for one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, or Regional Reimbursement Director/Chief Operating Officer) will attend the weekly meetings for eight (8) weeks. Concerns will be addressed immediately and will be address through the facility's QA Committee. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1. Review of QA meeting minutes and a sign-in sheet dated [DATE], revealed the Administrator, DON, ADON, SS, Activity Director (AD), Therapy Manager, Transitional Nurse, Restorative Nurse, MDS Nurse, and Medical Director met and developed an action plan for the Immediate Jeopardy allegation. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended a QA meeting on [DATE], to discuss the IJ allegation and to develop a plan of action. 2. Review of a resident roster dated [DATE], revealed the DON, ADON, Transitional Nurse, and SS reviewed all residents' medical records. On [DATE], review of resident review/assessment forms revealed the DON and ADON assessed all residents in the facility to ensure any change in a resident's condition had been addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they assisted in reviewing resident medical records and completing assessments for all residents in the facility. 3. Review of Nurse's Notes for Resident A and Resident B who received [MEDICAL TREATMENT] services, revealed the DON assessed the residents on [DATE], and did not identify any concerns. Interview with the DON on [DATE] at 12:30 PM, revealed she assessed Residents A and B and no concerns were identified. 4. Interview with the Administrator on [DATE] at 1:00 PM, revealed on [DATE], the Regional Director of Operations educated her regarding utilizing facility resources, the Immediate Jeopardy action plan, changes in condition, care plans, conducting daily stand-down meetings and QA meetings. 5. Review of a facility in-service roster dated [DATE], revealed the Regional Director of Clinical Services provided education for the DON, ADON, MDS Nurse, and the SS on the use of Clinical Check Off sheet. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE] at 11:40 AM, revealed the Regional Director of Nursing educated them on [DATE], regarding completion of the Clinical Check Off sheet. 6. Review of Clinical Check Off sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the Clinical Check Off sheet was being utilized during the facility's morning clinical meeting to ensure any change of condition was addressed. Interviews conducted with the Administrator on [DATE], at 1:00 PM, DON on [DATE], at 12:30 PM, ADON on [DATE], at 11:20 AM, SS on [DATE], at 10:50 AM, AD on [DATE], at 12:25 PM, BOM on [DATE], at 10:42 AM, Therapy Manager on [DATE], at 11:15 AM, Transitional Nurse on [DATE], at 10:17 AM, Restorative Nurse on ,[DATE], at 10:44 AM, Scheduler on [DATE], at 11:10 AM, and the MDS Nurse on [DATE], at 11:40 AM, all revealed they attended morning clinical meetings and utilized the Clinical Check Off sheet and reviewed all residents' nurses notes, physician notification, new physician orders, care plans, and the twenty four (24) hour report. 7. Review of Transfer QA Checklists completed since [DATE], revealed no concerns with the completion of documentation prior to residents leaving the facility for appointments. Interviews conducted with LPN #5 on [DATE], at 9:50 AM, LPN #3 on [DATE], at 9:55 AM, LPN #9 on [DATE], at 10:10 AM, LPN #10 on [DATE], at 9:48 AM, and LPN #11 on [DATE], at 9:56 AM, revealed they had received education related to completing the Resident Transfer QA Checklist and were completing the form as required. 8. Review of in-service rosters dated [DATE], revealed the Regional Consultant provided a train the trainer in-service for the DON, SDC, and the ADON. Further review of an in-service roster dated [DATE], revealed the DON provided an in-service for the Transitional Nurse, SS, and the AD on the following. In addition, the licensed nursing staff was educated by the DON, ADON, SDC, and Transitional Nurse provided on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Transitional Nurse on [DATE] at 10:17 AM, SDC on [DATE] at 12:16 PM, LPN #5 on [DATE] at 9:50 AM, LPN #3 on [DATE] at 9:55 AM, LPN #9 on [DATE] at 10:10 AM, LPN #10 on [DATE] at 9:48 AM, and LPN #11 on [DATE] at 9:56 AM, revealed they had been educated regarding the facility's change in condition, implementing care plans, documentation regarding appointments and changes in a resident's condition, and utilizing the Resident Transfer Checklist QA audit. The DON stated the facility was not currently utilizing agency staff in the facility; however, if any agency staff was utilized in the future, they would be required to complete the in-services prior to working. Interview with the SDC revealed there were currently no new employees; however, the education was added to new employee orientation. 9. Review of a facility in-service roster dated [DATE], revealed the DON, ADON, SDC, AD, and SS provided an in-service to all CNAs on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments Interviews conducted with CNA #8 on [DATE] at 3:30 PM, CNA #10 on [DATE] at 3:35 PM, CNA #4 on [DATE] at 3:38 PM, CNA #11 on [DATE] at 3:40 PM, and CNA #12 on [DATE] at 3:45 PM, revealed they had attended in-services regarding what constituted a change in a resident's condition, the process for accompanying residents to appointments, and to ensure the nurse assessed the resident prior to leaving the facility for an appointment. 10. Review of QA meeting rosters revealed a QA meeting was held on [DATE], and audit information was reviewed. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended the QA meeting on [DATE], and reviewed audit tools and discussed the progress of the Allegation of Compliance. 11. Review of audit tools which began [DATE], revealed the DON, ADON, Transition Nurse, SDC, Restorative Nurse, and SS had audited residents' medical records twice weekly to ensure documentation and the Resident Transfer QA Checklist were completed prior to residents leaving the facility for appointments. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing residents' medical records to validate the Resident Transfer QA Checklist had been completed. 12. Review of audit tools which began [DATE], revealed the DON, MDS Nurse, and SS audited five (5) resident care plans weekly for the past two (2) weeks to ensure care plans were being followed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for conducting five (5) resident care plan audits twice a week to ensure care plans were being followed. 13. Review of audit tools implemented on [DATE], revealed the DON, ADON, MDS Nurse, and SS had audited five (5) residents to ensure physicians and families were notified of any change in condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing five (5) random residents' medical records to ensure families and physician notification was made for of any change in a resident's condition. 14. Review of Clinical Walking Rounds audit tool, revealed an administrative nurse had made walking rounds daily beginning [DATE], to monitor for any change in a resident's condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they conducted rounds in the facility daily to monitor for any change in resident condition. 15. Interviews conducted with the Administrator on [DATE], at 1:00 PM, revealed she conducted Stand Down meetings every day Monday through Friday, and ensured all concerns were addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], revealed they had attended daily Stand Down meetings that were conducted by the administrator. 16. Review of QA meeting rosters revealed meetings were held on [DATE], [DATE], and [DATE]. Interview with the Administrator on [DATE] at 1:00 PM, revealed continued meetings will be held weekly for eight (8) weeks, then monthly. The Administrator stated a member of the regional team was attending the QA meetings.

Based on interview, record review, review of hospital and [MEDICAL TREATMENT] clinic records, and review of the facility's policies, it was determined the facility failed to assess one (1) of twenty-four (24) sampled residents (Resident #22) when the resident experienced a change in condition. On [DATE], the facility's Speech-Language Pathologist (Speech Therapist) documented that nursing staff was notified and would monitor the resident for distress as a result of aspiration (when food/fluid is breathed into the lungs instead of the esophagus and stomach). Three (3) other staff members notified licensed nursing staff that Resident #22 was unresponsive, could not sit up, was limp, and/or that the resident's eyes were big/non-reactive. However, the facility failed to assess the resident; instead they sent Resident #22 to a routine [MEDICAL TREATMENT] treatment at 2:30 PM on [DATE]. When Resident #22 arrived at the [MEDICAL TREATMENT] clinic on [DATE] (time not documented), staff called Emergency Medical Services (EMS) because the resident was slumped over in a wheelchair and was diaphoretic (sweating) with periods of apnea (not breathing). Review of the EMS records revealed at 3:22 PM, Resident #22 was unresponsive, in respiratory distress with agonal breathing (gasping). EMS staff intubated the resident (put a breathing tube in the resident's airway) to facilitate the resident's breathing and transported the resident to the hospital Emergency Department (ED). Resident #22 expired at the hospital on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and [MEDICAL CONDITION] (abnormally high levels of potassium in the blood). (Refer to F157, F281, F282, F490, F514, and F520.) The facility's failure to assess residents who experienced a change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Change in a Resident's Condition or Status policy, revised [DATE], revealed prior to notifying the physician or healthcare provider, the nurse would make detailed observations and gather relevant and pertinent information for the provider. Review of Resident #22's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #22's Nursing Progress Notes dated [DATE] at 4:45 PM, revealed the facility admitted the resident after being discharged from the hospital where the resident was treated for [REDACTED]. Further review of Resident #22's medical record revealed the resident required Cardiopulmonary Resuscitation (CPR), if needed. According to an admission Nursing Note, Resident #22 was alert and oriented to person and place; had unclear speech; had decreased grasps (strength) to the left and right hands; and required total assistance with Activities of Daily Living (ADLs). Review of Resident #22's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was four (4), which indicated the resident was cognitively impaired. Further review revealed the resident was usually understood, usually understood others, and required extensive to total assistance from staff with ADLs. Review of Resident #22's care plan dated [DATE], revealed the facility identified the resident had the potential for altered mood/behaviors due to [DIAGNOSES REDACTED]. Review of Nursing Progress Notes dated [DATE] at 2:15 AM, revealed Licensed Practical Nurse (LPN) #7 documented that Resident #22 had increased lethargy and the resident's physician and family were notified. Further review of Resident #22's Nursing Notes revealed on [DATE] at 6:15 AM, that LPN #8 documented that the resident's blood pressure medication could not be administered because the resident would not wake enough. Review of Resident #22's Speech Therapy (ST) Notes dated [DATE], revealed the resident was evaluated for speech therapy and therapy was recommended to treat the resident's cognitive communication deficit. According to the notes, ST was held from [DATE] to [DATE], pending payer approval. Further review revealed on [DATE], the ST provided fifteen (15) minutes of speech therapy, and there was no documentation that the resident had any complications with treatment. Further review of Resident #22's ST Notes revealed on [DATE], at 2:22 PM, the ST documented that treatment was provided during the meal and the resident was very lethargic. The ST Note stated the ST washed the resident's face with a cold washcloth and provided a sternal rub (rubbing the knuckles over the patient's breast bone applying firm downward pressure) to facilitate alertness. The Note stated the resident did not open his/her eyes but conversed with the ST about eating lunch. The ST documented that after providing maximum verbal and tactile cues to interact with the State Registered Nurse Aide (SRNA) during the meal, the resident only ate ,[DATE] bites. Further review of the ST Note revealed that Nursing (licensed nursing staff) was notified. Review of ST Notes revealed on [DATE], at 8:56 AM, the ST Note for Resident #22 for [DATE] was revised and stated that during the meal on [DATE], Resident #22 chewed and swallowed the first bite of food, but did not chew the second bite of food. The ST documented that the resident did not chew the food and held the food in the right side of his/her mouth, and the ST had to remove the food from the resident's mouth with her fingers. After the food was removed, the resident took a drink from a straw, then exhibited a productive cough (a productive cough produces phlegm or mucus), and began to have wet vocals (developed a wet or gurgly sound, which could indicate a person has aspirated food/liquid into their lungs). The ST cued the patient to cough multiple times, which appeared to clear the food/liquid. The ST documented that she notified nursing staff who stated they would monitor Resident #22 for distress as a result of aspiration (food/fluid is breathed into the lungs instead of the esophagus and stomach). Review of Occupational Therapy (OT) Notes dated [DATE] revealed Resident #22 had generalized weakness and OT was initiated to improve muscle strength to the resident's upper extremities. Further review of the OT Notes revealed treatment was held on [DATE] and [DATE] awaiting payer approval for therapy. Review of the OT Notes revealed on [DATE], the resident received thirty (30) minutes of OT with no complications documented. Review of OT Notes revealed on [DATE] at 1:21 PM, the Certified Occupational Therapy Assistant (COTA) documented that the resident was lethargic. Further review of the Notes revealed the COTA washed the resident's face and facilitated sternal rubs; however, the resident was unresponsive to arousal techniques. The COTA documented that she spoke with nursing staff about the resident's condition. Interview with State Registered Nurse Aide #9 on [DATE] at 10:25 AM, revealed on [DATE], at approximately 2:00 PM, prior to sending Resident #22 to [MEDICAL TREATMENT], the resident was noted to be more lethargic than usual and very hard to arouse. The SRNA stated she rubbed the resident's chest and tried to talk to the resident, but the resident barely mumbled, and his/her eyes were big. SRNA #1 stated this was unusual behavior for the resident. SRNA #1 further stated she summoned the treatment nurse, RN #1, who attempted to wake the resident unsuccessfully. The SRNA stated she asked RN #1 if the resident was going to be transported to [MEDICAL TREATMENT] in that condition and RN #1 stated that the resident was like that all the time and had to go to [MEDICAL TREATMENT]. SRNA #1 stated she transferred the resident to a wheelchair and the resident was leaning over, and fell forward, and she had to hold the resident in the chair. SRNA #9 stated she was going to report the resident's condition to the assigned nurse. However, RN #1 assisted the resident into a medical transportation vehicle to be transported to [MEDICAL TREATMENT]. Interview with RN #1 on [DATE] at 4:14 PM, revealed he had never cared for Resident #22. RN #1 stated he did not assess Resident #22 on [DATE], prior to the resident leaving for [MEDICAL TREATMENT] or assist the resident's nurse with the resident's care. Interview with Registered Nurse (RN) #3 on [DATE] at 1:08 PM, revealed she was not assigned to care for Resident #22 on [DATE], but she saw the resident sitting in a wheelchair prior to leaving the facility for [MEDICAL TREATMENT]. RN #3 stated the resident's chin was on his/her chest, the resident's arms were limp, and the resident's pupils were pinpoint and non-reactive. She stated she told the resident's nurse that the resident needed to go to the hospital Emergency Department (ED) for evaluation. RN #3 stated she told the medical transportation driver that he should not take responsibility for the resident in that condition; however, RN #3 stated staff transferred the resident to the [MEDICAL TREATMENT] center. Review of Resident #22's medical record revealed there was no documented evidence the facility assessed the resident's condition, when the ST, COTA, SRNA #9, and RN #3 reported the change/deterioration in Resident #22's condition. Review of a [MEDICAL TREATMENT]/Observation Communication Form completed by the facility prior to transferring Resident #22 to [MEDICAL TREATMENT] on [DATE] (no time documented and not signed) revealed staff were required to assess the resident's mental status/level of consciousness, heart, lungs, skin, and acute problems since last appointment, including changes in the resident's medical condition. However, facility staff failed to complete the areas on the form. According to the Nursing Progress Notes, the resident left for [MEDICAL TREATMENT] at 2:30 PM on [DATE], with no evidence an assessment of the resident's condition was conducted. Interview the Speech-Language Pathologist on [DATE] at 8:54 AM, revealed on [DATE], Resident #22 required a sternal rub, which was not a normal procedure used to elicit a response from a resident. The ST stated she believed the resident had aspirated food/fluid into the lungs during treatment on [DATE]. Further interview revealed the ST stated she notified Nursing that the resident had aspirated; however, she did not recall to whom she spoke. Interview with the COTA on [DATE] at 1:17 PM, revealed she was required to report to Nursing any resident changes or concerns. The COTA stated she reported Resident #22's condition to the nurse on [DATE] at 1:17 PM. Interview with the Therapy Supervisor on [DATE] at 11:07 AM, revealed therapy staff had reported to her that Resident #22 was more lethargic than usual and they had reported the resident's condition to Nursing. The Therapy Supervisor stated it was unusual for residents to require a sternal rub. She stated this was indicative of a decline in the resident's condition. Interview with LPN #2 on [DATE] at 10:30 AM and with RN #4 on [DATE] at 10:40 AM revealed they did not recall any staff member reporting a change in Resident #22's condition on [DATE]. LPN #2, the nurse assigned to Resident #22, stated she was at lunch when Resident #22 was transferred to [MEDICAL TREATMENT] and she did not recall seeing or assessing the resident after approximately 10:45 AM. RN #4 stated she was the charge nurse on [DATE], and would have been covering for LPN #2 while the LPN was gone to lunch. However, she did not recall assessing the resident prior to the resident leaving for [MEDICAL TREATMENT]. Interview with SRNA #1 on [DATE] at 10:10 AM, revealed she was on the medical transportation vehicle with Resident #22 on [DATE], when the resident was transported to [MEDICAL TREATMENT]. SRNA #1 stated she was unable to wake the resident and the resident could not hold his/her head up, which was not normal for the resident. SRNA #1 stated when Resident #22 arrived at the [MEDICAL TREATMENT] clinic, the clinic staff immediately sent the resident to the hospital Emergency Department (ED). On [DATE] at 3:55 PM, and on [DATE] at 12:25 PM, an interview with the Registered Nurse who worked at the [MEDICAL TREATMENT] clinic revealed it was not unusual for Resident #22 to be slightly lethargic, but the resident was able to ride in a wheelchair without problems and normally conversed with staff. However, when Resident #22 arrived at the [MEDICAL TREATMENT] clinic on [DATE], the resident was non-responsive, slumped over with his/her head on his/her knees, and the resident had agonal breathing. The RN stated she took the resident's vital signs (blood pressure continued to be normal at ,[DATE]) and called EMS. Review of the [MEDICAL TREATMENT] documentation dated [DATE] at 4:09 PM, revealed the [MEDICAL TREATMENT] Nurse documented that Resident #22 was slumped over, had copious amounts of sputum and mucus from the mouth and nose, was diaphoretic (sweating heavily), and had periods of apnea. The Nursing Note stated staff notified the physician and Emergency Medical Services (EMS). Review of EMS documentation revealed when they assessed Resident #22 at 3:22 PM on [DATE], the resident was unresponsive, in respiratory distress with agonal breathing, and had an irregular heartbeat. EMS staff intubated the resident (put a breathing tube in the resident's airway) at 3:29 PM, to facilitate the resident's breathing. The resident was transported to the hospital. Interview with Resident #22's family members on [DATE] at 11:30 AM, revealed the resident would normally speak when spoken to and could hold himself/herself up in a wheelchair. The family stated that they were notified on [DATE] at approximately 2:00 AM, that the resident was more lethargic than usual. The resident's family member stated she asked the nurse to send the resident to the hospital if the resident's condition did not improve. The resident's family stated they were again contacted on [DATE] at approximately 4:00 PM, by the hospital to notify them the resident was at the hospital. The family stated hospital staff informed them the resident was unresponsive when the facility (nursing facility) transferred the resident to the [MEDICAL TREATMENT] clinic. Review of the hospital Emergency Department (ED) record revealed Resident #22 arrived at the ED on [DATE] at 3:41 PM. The ED Physician documented that Resident #22 was unresponsive with no respiratory effort, had copious secretions, and had a Glasgow Coma Scale score of four (4) (which indicated the resident was comatose). Resident #22 was transferred to the Intensive Care Unit (ICU) for [MEDICAL TREATMENT]; however, the resident's condition continued to deteriorate and Resident #22 was pronounced dead on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and [MEDICAL CONDITION]. An interview with the Director of Nursing (DON) on [DATE] at 10:53 AM, revealed the DON was not working at the facility in that capacity on [DATE]. The DON stated that prior to a resident going to [MEDICAL TREATMENT], staff was required to conduct vital signs and complete the [MEDICAL TREATMENT] Communication Form. The DON stated if a resident was bent over and could not sit up, the resident should have been assessed. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the QA (Quality Assurance) Committee met to discuss the events set forth in the notice of Immediate Jeopardy and developed an action plan. 2. On [DATE] to [DATE], the Interdisciplinary Team (IDT) which consisted of the Director of Nursing (DON), Assistant Director Of Nursing (ADON), Transition Nurse, and Social Service (SS), reviewed all active residents to identify any change of condition not previously identified utilizing the following criteria: the Minimum Data Set (MDS) criteria, Brief Interview for Mental Status (BIMS), Chart Documentation, and assessment of each resident. No concerns were identified. 3. On [DATE], the DON assessed the two (2) residents receiving [MEDICAL TREATMENT] services and no concerns were identified. 4. On [DATE], the Regional Director of Operations educated the Administrator related to utilizing facility resources and addressing concerns in the facility including but not limited to the Immediate Jeopardy action plan and follow-up, changes in condition, care plans, conducting daily stand-down meetings, Quality Assurance (QA) tools, and QA meetings. 5. On [DATE], the Regional Director of Clinical Services educated the DON, ADON, MDS, and SS on the use of the Clinical Check Off sheet. 6. Beginning [DATE], the Clinical Check Off sheet will be utilized during the clinical morning meeting Monday through Friday to review resident information to ensure any change of condition was identified and addressed. The form consists of criteria to review the last twenty-four (24) to seventy-two (72) hours of Nurses' Notes, Physician Orders, physician notification, the 24-hour report, and to ensure care plans are being implemented. 7. On [DATE], the Staff Development Coordinator (SDC), DON, and Regional Consultant developed the Resident Transfer Quality Assurance (QA) Checklist which was implemented on [DATE]. The Transfer Quality Assurance (QA) Checklist will be utilized to ensure documentation accompanies the resident to the appointment. 8. On [DATE], the Regional Consultant educated the DON, SDC, and ADON. The DON then educated the Transitional Nurse, Social Services, and Activities Director. The DON, ADON, SDC, and/or Transitional Nurse then educated all licensed nursing staff. Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit 9. On [DATE], the DON, ADON, SDC, Activity Director, and Social Services educated State Registered Nurse Aides (SRNAs). Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments. 10. On [DATE], a QA Committee Meeting was held to review progress of education, and to review audit information and the progress of the plan. 11. Beginning [DATE], audits will be conducted by the Transition Nurse, ADON, DON, SDC, Restorative Nurse, or Social Services to ensure the Transfer QA Checklist was completed for residents leaving the facility for appointments. The audits will be conducted two (2) times per week for eight (8) weeks, then two (2) times per month for one (1) month, and then at a minimum of quarterly. The results of the audits will be reported by the DON to the QA Committee. 12. Beginning [DATE], five (5) care plans will be audited by the MDS/DON/Social Services Director per week to validate care plans are being followed. The audits will be completed weekly for eight (8) weeks, then two (2) times a month for one (1) month. Results of the audits will be reported to the QA Committee by the MDS Nurse. 13. Beginning [DATE], Nurses' Notes for five (5) random residents will be reviewed five (5) times a week to ensure physicians and families are notified of changes in condition. The audits will be completed by MDS, Social Services, ADON, or DON. The audits will continue five (5) times a week for eight (8) weeks, and then two (2) times a month for one (1) month. The audit results will be reported to the QA Committee by the DON. 14. Daily beginning [DATE], an Administrative Nurse (DON, ADON, and Transition Nurse) will make walking rounds and monitor residents for any change of condition not already addressed. Any concerns will be addressed immediately. 15. Beginning [DATE], the Administrator and/or DON will conduct a stand-down meeting Monday through Friday afternoon (DON, ADON, MDS, and Social Services to attend) to confirm any concerns that arose throughout the workday were addressed. 16. A QA meeting will be held weekly for eight (8) weeks, then monthly for one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, or Regional Reimbursement Director/Chief Operating Officer) will attend the weekly meetings for eight (8) weeks. Concerns will be addressed immediately and will be address through the facility's QA Committee. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1. Review of QA meeting minutes and a sign-in sheet dated [DATE], revealed the Administrator, DON, ADON, SS, Activity Director (AD), Therapy Manager, Transitional Nurse, Restorative Nurse, MDS Nurse, and Medical Director met and developed an action plan for the Immediate Jeopardy allegation. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended a QA meeting on [DATE], to discuss the IJ allegation and to develop a plan of action. 2. Review of a resident roster dated [DATE], revealed the DON, ADON, Transitional Nurse, and SS reviewed all residents' medical records. On [DATE], review of resident review/assessment forms revealed the DON and ADON assessed all residents in the facility to ensure any change in a resident's condition had been addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they assisted in reviewing resident medical records and completing assessments for all residents in the facility. 3. Review of Nurse's Notes for Resident A and Resident B who received [MEDICAL TREATMENT] services, revealed the DON assessed the residents on [DATE], and did not identify any concerns. Interview with the DON on [DATE] at 12:30 PM, revealed she assessed Residents A and B and no concerns were identified. 4. Interview with the Administrator on [DATE] at 1:00 PM, revealed on [DATE], the Regional Director of Operations educated her regarding utilizing facility resources, the Immediate Jeopardy action plan, changes in condition, care plans, conducting daily stand-down meetings and QA meetings. 5. Review of a facility in-service roster dated [DATE], revealed the Regional Director of Clinical Services provided education for the DON, ADON, MDS Nurse, and the SS on the use of Clinical Check Off sheet. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE] at 11:40 AM, revealed the Regional Director of Nursing educated them on [DATE], regarding completion of the Clinical Check Off sheet. 6. Review of Clinical Check Off sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the Clinical Check Off sheet was being utilized during the facility's morning clinical meeting to ensure any change of condition was addressed. Interviews conducted with the Administrator on [DATE], at 1:00 PM, DON on [DATE], at 12:30 PM, ADON on [DATE], at 11:20 AM, SS on [DATE], at 10:50 AM, AD on [DATE], at 12:25 PM, BOM on [DATE], at 10:42 AM, Therapy Manager on [DATE], at 11:15 AM, Transitional Nurse on [DATE], at 10:17 AM, Restorative Nurse on ,[DATE], at 10:44 AM, Scheduler on [DATE], at 11:10 AM, and the MDS Nurse on [DATE], at 11:40 AM, all revealed they attended morning clinical meetings and utilized the Clinical Check Off sheet and reviewed all residents' nurses notes, physician notification, new physician orders, care plans, and the twenty four (24) hour report. 7. Review of Transfer QA Checklists completed since [DATE], revealed no concerns with the completion of documentation prior to residents leaving the facility for appointments. Interviews conducted with LPN #5 on [DATE], at 9:50 AM, LPN #3 on [DATE], at 9:55 AM, LPN #9 on [DATE], at 10:10 AM, LPN #10 on [DATE], at 9:48 AM, and LPN #11 on [DATE], at 9:56 AM, revealed they had received education related to completing the Resident Transfer QA Checklist and were completing the form as required. 8. Review of in-service rosters dated [DATE], revealed the Regional Consultant provided a train the trainer in-service for the DON, SDC, and the ADON. Further review of an in-service roster dated [DATE], revealed the DON provided an in-service for the Transitional Nurse, SS, and the AD on the following. In addition, the licensed nursing staff was educated by the DON, ADON, SDC, and Transitional Nurse provided on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Transitional Nurse on [DATE] at 10:17 AM, SDC on [DATE] at 12:16 PM, LPN #5 on [DATE] at 9:50 AM, LPN #3 on [DATE] at 9:55 AM, LPN #9 on [DATE] at 10:10 AM, LPN #10 on [DATE] at 9:48 AM, and LPN #11 on [DATE] at 9:56 AM, revealed they had been educated regarding the facility's change in condition, implementing care plans, documentation regarding appointments and changes in a resident's condition, and utilizing the Resident Transfer Checklist QA audit. The DON stated the facility was not currently utilizing agency staff in the facility; however, if any agency staff was utilized in the future, they would be required to complete the in-services prior to working. Interview with the SDC revealed there were currently no new employees; however, the education was added to new employee orientation. 9. Review of a facility in-service roster dated [DATE], revealed the DON, ADON, SDC, AD, and SS provided an in-service to all CNAs on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments Interviews conducted with CNA #8 on [DATE] at 3:30 PM, CNA #10 on [DATE] at 3:35 PM, CNA #4 on [DATE] at 3:38 PM, CNA #11 on [DATE] at 3:40 PM, and CNA #12 on [DATE] at 3:45 PM, revealed they had attended in-services regarding what constituted a change in a resident's condition, the process for accompanying residents to appointments, and to ensure the nurse assessed the resident prior to leaving the facility for an appointment. 10. Review of QA meeting rosters revealed a QA meeting was held on [DATE], and audit information was reviewed. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended the QA meeting on [DATE], and reviewed audit tools and discussed the progress of the Allegation of Compliance. 11. Review of audit tools which began [DATE], revealed the DON, ADON, Transition Nurse, SDC, Restorative Nurse, and SS had audited residents' medical records twice weekly to ensure documentation and the Resident Transfer QA Checklist were completed prior to residents leaving the facility for appointments. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing residents' medical records to validate the Resident Transfer QA Checklist had been completed. 12. Review of audit tools which began [DATE], revealed the DON, MDS Nurse, and SS audited five (5) resident care plans weekly for the past two (2) weeks to ensure care plans were being followed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for conducting five (5) resident care plan audits twice a week to ensure care plans were being followed. 13. Review of audit tools implemented on [DATE], revealed the DON, ADON, MDS Nurse, and SS had audited five (5) residents to ensure physicians and families were notified of any change in condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing five (5) random residents' medical records to ensure families and physician notification was made for of any change in a resident's condition. 14. Review of Clinical Walking Rounds audit tool, revealed an administrative nurse had made walking rounds daily beginning [DATE], to monitor for any change in a resident's condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they conducted rounds in the facility daily to monitor for any change in resident condition. 15. Interviews conducted with the Administrator on [DATE], at 1:00 PM, revealed she conducted Stand Down meetings every day Monday through Friday, and ensured all concerns were addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], revealed they had attended daily Stand Down meetings that were conducted by the

Based on record review, interview, and review of the Administrator's job description, it was determined the facility failed to ensure that resources were used effectively and efficiently to attain or maintain the highest practicable well-being of each resident. Review of the Administrator's job description revealed the Administrator's purpose was to ensure the highest degree of quality care was provided to residents at all times. The Administrator was also required to assure the facility's Quality Assurance Performance Improvement (QAPI) process was utilized to continually improve all aspects of the facility's performance. On [DATE], the facility failed to complete a thorough assessment of Resident #22's condition, failed to notify the resident's physician and family when the resident experienced a change in condition in accordance with the resident's plan of care, failed to ensure Resident #22's medical record was complete and accurate, and failed to identify the quality of care deficiencies related to Resident #22's death and implement actions to correct the deficiencies. On [DATE], Resident #22 was unresponsive when staff transferred the resident to the [MEDICAL TREATMENT] clinic. [MEDICAL TREATMENT] clinic staff facilitated the resident's transfer to a hospital, where Resident #22 expired at the hospital on [DATE], approximately seven (7) hours later (Refer to F157, F281, F282, F309, F514, and F520). The facility's failure to ensure the facility was effectively administered has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's job description dated [DATE], revealed the Administrator's purpose was to direct the day to day operation of the facility to ensure compliance with guidelines and regulations that govern nursing facilities to assure each resident receives the highest degree of quality care at all times. The job description stated it was also the Administrator's purpose to create an environment where staff members were providing the highest level of clinical care and [MEDICATION NAME] to residents and families. The Administrator was required to assure the QAPI process was understood and utilized by all members of the Leadership Team to continually improve all aspects of the facility's performance. Record review and staff interviews revealed the facility failed to ensure Resident #22 was assessed and failed to ensure the resident's physician and family were notified on [DATE], when staff observed the resident had aspirated food/fluid, was unresponsive, could not sit up in a chair, and the resident's eyes were big. The facility failed to ensure the resident's medical record was complete and accurate when the facility failed to complete the resident's [MEDICAL TREATMENT]/Observation Communication Form. The facility transferred the resident to a [MEDICAL TREATMENT] clinic at 2:30 PM on [DATE]. Upon arrival to the [MEDICAL TREATMENT] clinic, the resident was slumped over, had copious amounts of sputum and mucus from the mouth and nose, was diaphoretic (sweating heavily), and had periods of apnea. The resident was transferred to the hospital from the [MEDICAL TREATMENT] clinic. Resident #22 was pronounced dead on [DATE] at 10:16 PM due to Pneumonia, Septic Shock, and [MEDICAL CONDITION]. Interview with Resident #22's family members on [DATE] at 11:30 AM, revealed they requested that the facility conduct an investigation of the circumstances surrounding Resident #22's unexpected death on [DATE]. The family stated they were notified that the resident had aspirated and was unresponsive when the resident was transferred to the [MEDICAL TREATMENT] clinic. The family stated they were unaware of the resident's change in condition until they were notified by hospital staff. During an interview with the Administrator on [DATE] at 1:50 PM, and on [DATE] at 3:12 PM, the Administrator refused to answer questions regarding Resident #22's death. When questioned regarding concerns surrounding the events prior to the resident's death, the Administrator would only respond, I'm not a nurse. Interview with the Administrator revealed she refused to discuss whether the facility had conducted an investigation, identified any concerns, or taken any action as a result of Resident #22's death. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the QA (Quality Assurance) Committee met to discuss the events set forth in the notice of Immediate Jeopardy and developed an action plan. 2. On [DATE] to [DATE], the Interdisciplinary Team (IDT) which consisted of the Director of Nursing (DON), Assistant Director Of Nursing (ADON), Transition Nurse, and Social Service (SS), reviewed all active residents to identify any change of condition not previously identified utilizing the following criteria: the Minimum Data Set (MDS) criteria, Brief Interview for Mental Status (BIMS), Chart Documentation, and assessment of each resident. No concerns were identified. 3. On [DATE], the DON assessed the two (2) residents receiving [MEDICAL TREATMENT] services and no concerns were identified. 4. On [DATE], the Regional Director of Operations educated the Administrator related to utilizing facility resources and addressing concerns in the facility including but not limited to the Immediate Jeopardy action plan and follow-up, changes in condition, care plans, conducting daily stand-down meetings, Quality Assurance (QA) tools, and QA meetings. 5. On [DATE], the Regional Director of Clinical Services educated the DON, ADON, MDS, and SS on the use of the Clinical Check Off sheet. 6. Beginning [DATE], the Clinical Check Off sheet will be utilized during the clinical morning meeting Monday through Friday to review resident information to ensure any change of condition was identified and addressed. The form consists of criteria to review the last twenty-four (24) to seventy-two (72) hours of Nurses' Notes, Physician Orders, physician notification, the 24-hour report, and to ensure care plans are being implemented. 7. On [DATE], the Staff Development Coordinator (SDC), DON, and Regional Consultant developed the Resident Transfer Quality Assurance (QA) Checklist which was implemented on [DATE]. The Transfer Quality Assurance (QA) Checklist will be utilized to ensure documentation accompanies the resident to the appointment. 8. On [DATE], the Regional Consultant educated the DON, SDC, and ADON. The DON then educated the Transitional Nurse, Social Services, and Activities Director. The DON, ADON, SDC, and/or Transitional Nurse then educated all licensed nursing staff. Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit 9. On [DATE], the DON, ADON, SDC, Activity Director, and Social Services educated State Registered Nurse Aides (SRNAs). Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments. 10. On [DATE], a QA Committee Meeting was held to review progress of education, and to review audit information and the progress of the plan. 11. Beginning [DATE], audits will be conducted by the Transition Nurse, ADON, DON, SDC, Restorative Nurse, or Social Services to ensure the Transfer QA Checklist was completed for residents leaving the facility for appointments. The audits will be conducted two (2) times per week for eight (8) weeks, then two (2) times per month for one (1) month, and then at a minimum of quarterly. The results of the audits will be reported by the DON to the QA Committee. 12. Beginning [DATE], five (5) care plans will be audited by the MDS/DON/Social Services Director per week to validate care plans are being followed. The audits will be completed weekly for eight (8) weeks, then two (2) times a month for one (1) month. Results of the audits will be reported to the QA Committee by the MDS Nurse. 13. Beginning [DATE], Nurses' Notes for five (5) random residents will be reviewed five (5) times a week to ensure physicians and families are notified of changes in condition. The audits will be completed by MDS, Social Services, ADON, or DON. The audits will continue five (5) times a week for eight (8) weeks, and then two (2) times a month for one (1) month. The audit results will be reported to the QA Committee by the DON. 14. Daily beginning [DATE], an Administrative Nurse (DON, ADON, and Transition Nurse) will make walking rounds and monitor residents for any change of condition not already addressed. Any concerns will be addressed immediately. 15. Beginning [DATE], the Administrator and/or DON will conduct a stand-down meeting Monday through Friday afternoon (DON, ADON, MDS, and Social Services to attend) to confirm any concerns that arose throughout the workday were addressed. 16. A QA meeting will be held weekly for eight (8) weeks, then monthly for one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, or Regional Reimbursement Director/Chief Operating Officer) will attend the weekly meetings for eight (8) weeks. Concerns will be addressed immediately and will be address through the facility's QA Committee. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1. Review of QA meeting minutes and a sign-in sheet dated [DATE], revealed the Administrator, DON, ADON, SS, Activity Director (AD), Therapy Manager, Transitional Nurse, Restorative Nurse, MDS Nurse, and Medical Director met and developed an action plan for the Immediate Jeopardy allegation. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended a QA meeting on [DATE], to discuss the IJ allegation and to develop a plan of action. 2. Review of a resident roster dated [DATE], revealed the DON, ADON, Transitional Nurse, and SS reviewed all residents' medical records. On [DATE], review of resident review/assessment forms revealed the DON and ADON assessed all residents in the facility to ensure any change in a resident's condition had been addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they assisted in reviewing resident medical records and completing assessments for all residents in the facility. 3. Review of Nurse's Notes for Resident A and Resident B who received [MEDICAL TREATMENT] services, revealed the DON assessed the residents on [DATE], and did not identify any concerns. Interview with the DON on [DATE] at 12:30 PM, revealed she assessed Residents A and B and no concerns were identified. 4. Interview with the Administrator on [DATE] at 1:00 PM, revealed on [DATE], the Regional Director of Operations educated her regarding utilizing facility resources, the Immediate Jeopardy action plan, changes in condition, care plans, conducting daily stand-down meetings and QA meetings. 5. Review of a facility in-service roster dated [DATE], revealed the Regional Director of Clinical Services provided education for the DON, ADON, MDS Nurse, and the SS on the use of Clinical Check Off sheet. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE] at 11:40 AM, revealed the Regional Director of Nursing educated them on [DATE], regarding completion of the Clinical Check Off sheet. 6. Review of Clinical Check Off sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the Clinical Check Off sheet was being utilized during the facility's morning clinical meeting to ensure any change of condition was addressed. Interviews conducted with the Administrator on [DATE], at 1:00 PM, DON on [DATE], at 12:30 PM, ADON on [DATE], at 11:20 AM, SS on [DATE], at 10:50 AM, AD on [DATE], at 12:25 PM, BOM on [DATE], at 10:42 AM, Therapy Manager on [DATE], at 11:15 AM, Transitional Nurse on [DATE], at 10:17 AM, Restorative Nurse on ,[DATE], at 10:44 AM, Scheduler on [DATE], at 11:10 AM, and the MDS Nurse on [DATE], at 11:40 AM, all revealed they attended morning clinical meetings and utilized the Clinical Check Off sheet and reviewed all residents' nurses notes, physician notification, new physician orders, care plans, and the twenty four (24) hour report. 7. Review of Transfer QA Checklists completed since [DATE], revealed no concerns with the completion of documentation prior to residents leaving the facility for appointments. Interviews conducted with LPN #5 on [DATE], at 9:50 AM, LPN #3 on [DATE], at 9:55 AM, LPN #9 on [DATE], at 10:10 AM, LPN #10 on [DATE], at 9:48 AM, and LPN #11 on [DATE], at 9:56 AM, revealed they had received education related to completing the Resident Transfer QA Checklist and were completing the form as required. 8. Review of in-service rosters dated [DATE], revealed the Regional Consultant provided a train the trainer in-service for the DON, SDC, and the ADON. Further review of an in-service roster dated [DATE], revealed the DON provided an in-service for the Transitional Nurse, SS, and the AD on the following. In addition, the licensed nursing staff was educated by the DON, ADON, SDC, and Transitional Nurse provided on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Transitional Nurse on [DATE] at 10:17 AM, SDC on [DATE] at 12:16 PM, LPN #5 on [DATE] at 9:50 AM, LPN #3 on [DATE] at 9:55 AM, LPN #9 on [DATE] at 10:10 AM, LPN #10 on [DATE] at 9:48 AM, and LPN #11 on [DATE] at 9:56 AM, revealed they had been educated regarding the facility's change in condition, implementing care plans, documentation regarding appointments and changes in a resident's condition, and utilizing the Resident Transfer Checklist QA audit. The DON stated the facility was not currently utilizing agency staff in the facility; however, if any agency staff was utilized in the future, they would be required to complete the in-services prior to working. Interview with the SDC revealed there were currently no new employees; however, the education was added to new employee orientation. 9. Review of a facility in-service roster dated [DATE], revealed the DON, ADON, SDC, AD, and SS provided an in-service to all CNAs on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments Interviews conducted with CNA #8 on [DATE] at 3:30 PM, CNA #10 on [DATE] at 3:35 PM, CNA #4 on [DATE] at 3:38 PM, CNA #11 on [DATE] at 3:40 PM, and CNA #12 on [DATE] at 3:45 PM, revealed they had attended in-services regarding what constituted a change in a resident's condition, the process for accompanying residents to appointments, and to ensure the nurse assessed the resident prior to leaving the facility for an appointment. 10. Review of QA meeting rosters revealed a QA meeting was held on [DATE], and audit information was reviewed. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended the QA meeting on [DATE], and reviewed audit tools and discussed the progress of the Allegation of Compliance. 11. Review of audit tools which began [DATE], revealed the DON, ADON, Transition Nurse, SDC, Restorative Nurse, and SS had audited residents' medical records twice weekly to ensure documentation and the Resident Transfer QA Checklist were completed prior to residents leaving the facility for appointments. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing residents' medical records to validate the Resident Transfer QA Checklist had been completed. 12. Review of audit tools which began [DATE], revealed the DON, MDS Nurse, and SS audited five (5) resident care plans weekly for the past two (2) weeks to ensure care plans were being followed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for conducting five (5) resident care plan audits twice a week to ensure care plans were being followed. 13. Review of audit tools implemented on [DATE], revealed the DON, ADON, MDS Nurse, and SS had audited five (5) residents to ensure physicians and families were notified of any change in condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing five (5) random residents' medical records to ensure families and physician notification was made for of any change in a resident's condition. 14. Review of Clinical Walking Rounds audit tool, revealed an administrative nurse had made walking rounds daily beginning [DATE], to monitor for any change in a resident's condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they conducted rounds in the facility daily to monitor for any change in resident condition. 15. Interviews conducted with the Administrator on [DATE], at 1:00 PM, revealed she conducted Stand Down meetings every day Monday through Friday, and ensured all concerns were addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], revealed they had attended daily Stand Down meetings that were conducted by the administrator. 16. Review of QA meeting rosters revealed meetings were held on [DATE], [DATE], and [DATE]. Interview with the Administrator on [DATE] at 1:00 PM, revealed continued meetings will be held weekly for eight (8) weeks, then monthly. The Administrator stated a member of the regional team was attending the QA meetings.

Based on record review, interview, and review of the facility's policies, it was determined the facility failed to maintain a complete medical record for one (1) of twenty-four (24) sampled residents (Resident #22). On [DATE], at approximately 2:30 PM, the facility sent Resident #22 to a routine [MEDICAL TREATMENT] appointment despite numerous reports from staff that Resident #22 had experienced a change in condition. The facility failed to assess the resident and complete the facility's [MEDICAL TREATMENT]/Observation Communication forms, which required staff to assess and document the resident's condition prior to being transferred to [MEDICAL TREATMENT]. Once the resident arrived to the [MEDICAL TREATMENT] clinic, staff ([MEDICAL TREATMENT] clinic staff) called Emergency Medical Services and the resident was transferred to a hospital. Resident #22 expired at the hospital on [DATE] due to [DIAGNOSES REDACTED]. (Refer to F157, F281, F282, F309, F490, and F520.) The facility's failure to ensure a resident's medical record was complete has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Medical Record Storage and Maintenance Policy, revised [DATE], revealed the policy did not address maintaining a complete medical record. Review of Resident #22's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Resident #22 required [MEDICAL TREATMENT] three (3) days per week on Monday, Wednesday, and Friday. Interview with the Director of Nursing on [DATE] at 10:53 AM, revealed staff were required to complete a [MEDICAL TREATMENT]/Observation Communication Form prior to sending a resident to a [MEDICAL TREATMENT] clinic. The form is utilized as a communication tool between the facility and the [MEDICAL TREATMENT] clinic to ensure residents receive appropriate care and treatment. Interview with the Speech-Language Pathologist (Speech Therapist) on [DATE] at 8:54 AM, the Certified Occupational Therapy Assistant (COTA) on [DATE] at 1:17 PM, State Registered Nurse Aide (SRNA) #9 on [DATE] at 10:25 AM, and Registered Nurse (RN) #3 on [DATE] at 1:08 PM, revealed after lunch on [DATE], Resident #22 experienced a change in condition and the ST suspected the resident aspirated the lunch meal. However, review of a [MEDICAL TREATMENT]/Observation Communication Form dated [DATE] (no time documented and not signed) revealed no evidence staff assessed or documented the resident's change in condition on the form to ensure the resident received appropriate monitoring and treatment at the [MEDICAL TREATMENT] clinic. Further review revealed the form had an area to document an assessment of the resident's mental status/level of consciousness, heart, lungs, skin, or acute problems since last appointment, to include changes in the resident's medical condition. However, the areas on the form were not completed and were blank. In addition, review of the [MEDICAL TREATMENT]/Observation Communication Forms for Resident #22 dated [DATE] and [DATE] revealed the forms had been initiated, but had not been completed. Further review revealed the forms had not been completed by facility staff on [DATE], [DATE], or [DATE], prior to transferring the resident to the [MEDICAL TREATMENT] clinic. The facility transferred Resident #22 to the [MEDICAL TREATMENT] clinic on [DATE], and [MEDICAL TREATMENT] staff immediately contacted Emergency Medical Services because the resident was slumped over, had copious amounts of sputum and mucus from the mouth and nose, was diaphoretic (sweating heavily), and had periods of apnea (not breathing). Resident #22 expired on [DATE] at 10:16 PM due to pneumonia, septic shock, and [MEDICAL CONDITION] (high levels of potassium in the blood). Interview with LPN #2 on [DATE] at 10:30 AM, revealed she did not assess Resident #22 and complete the [MEDICAL TREATMENT] Communication Form on [DATE], prior to the resident going to [MEDICAL TREATMENT]. Interview with RN #4 on [DATE] at 10:40 AM, who was the charge nurse on [DATE], revealed she did not recall completing the form prior to the resident going to [MEDICAL TREATMENT] on [DATE]. RN #4 stated staff did not always complete the form if residents were in good condition prior to leaving the facility for [MEDICAL TREATMENT]. Interview with the Director of Nursing on [DATE] at 10:53 AM, revealed staff were required to complete a [MEDICAL TREATMENT]/Observation Communication Form prior to any resident going to [MEDICAL TREATMENT], and she was not aware staff were not completing the form. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the QA (Quality Assurance) Committee met to discuss the events set forth in the notice of Immediate Jeopardy and developed an action plan. 2. On [DATE] to [DATE], the Interdisciplinary Team (IDT) which consisted of the Director of Nursing (DON), Assistant Director Of Nursing (ADON), Transition Nurse, and Social Service (SS), reviewed all active residents to identify any change of condition not previously identified utilizing the following criteria: the Minimum Data Set (MDS) criteria, Brief Interview for Mental Status (BIMS), Chart Documentation, and assessment of each resident. No concerns were identified. 3. On [DATE], the DON assessed the two (2) residents receiving [MEDICAL TREATMENT] services and no concerns were identified. 4. On [DATE], the Regional Director of Operations educated the Administrator related to utilizing facility resources and addressing concerns in the facility including but not limited to the Immediate Jeopardy action plan and follow-up, changes in condition, care plans, conducting daily stand-down meetings, Quality Assurance (QA) tools, and QA meetings. 5. On [DATE], the Regional Director of Clinical Services educated the DON, ADON, MDS, and SS on the use of the Clinical Check Off sheet. 6. Beginning [DATE], the Clinical Check Off sheet will be utilized during the clinical morning meeting Monday through Friday to review resident information to ensure any change of condition was identified and addressed. The form consists of criteria to review the last twenty-four (24) to seventy-two (72) hours of Nurses' Notes, Physician Orders, physician notification, the 24-hour report, and to ensure care plans are being implemented. 7. On [DATE], the Staff Development Coordinator (SDC), DON, and Regional Consultant developed the Resident Transfer Quality Assurance (QA) Checklist which was implemented on [DATE]. The Transfer Quality Assurance (QA) Checklist will be utilized to ensure documentation accompanies the resident to the appointment. 8. On [DATE], the Regional Consultant educated the DON, SDC, and ADON. The DON then educated the Transitional Nurse, Social Services, and Activities Director. The DON, ADON, SDC, and/or Transitional Nurse then educated all licensed nursing staff. Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit 9. On [DATE], the DON, ADON, SDC, Activity Director, and Social Services educated State Registered Nurse Aides (SRNAs). Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments. 10. On [DATE], a QA Committee Meeting was held to review progress of education, and to review audit information and the progress of the plan. 11. Beginning [DATE], audits will be conducted by the Transition Nurse, ADON, DON, SDC, Restorative Nurse, or Social Services to ensure the Transfer QA Checklist was completed for residents leaving the facility for appointments. The audits will be conducted two (2) times per week for eight (8) weeks, then two (2) times per month for one (1) month, and then at a minimum of quarterly. The results of the audits will be reported by the DON to the QA Committee. 12. Beginning [DATE], five (5) care plans will be audited by the MDS/DON/Social Services Director per week to validate care plans are being followed. The audits will be completed weekly for eight (8) weeks, then two (2) times a month for one (1) month. Results of the audits will be reported to the QA Committee by the MDS Nurse. 13. Beginning [DATE], Nurses' Notes for five (5) random residents will be reviewed five (5) times a week to ensure physicians and families are notified of changes in condition. The audits will be completed by MDS, Social Services, ADON, or DON. The audits will continue five (5) times a week for eight (8) weeks, and then two (2) times a month for one (1) month. The audit results will be reported to the QA Committee by the DON. 14. Daily beginning [DATE], an Administrative Nurse (DON, ADON, and Transition Nurse) will make walking rounds and monitor residents for any change of condition not already addressed. Any concerns will be addressed immediately. 15. Beginning [DATE], the Administrator and/or DON will conduct a stand-down meeting Monday through Friday afternoon (DON, ADON, MDS, and Social Services to attend) to confirm any concerns that arose throughout the workday were addressed. 16. A QA meeting will be held weekly for eight (8) weeks, then monthly for one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, or Regional Reimbursement Director/Chief Operating Officer) will attend the weekly meetings for eight (8) weeks. Concerns will be addressed immediately and will be address through the facility's QA Committee. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1. Review of QA meeting minutes and a sign-in sheet dated [DATE], revealed the Administrator, DON, ADON, SS, Activity Director (AD), Therapy Manager, Transitional Nurse, Restorative Nurse, MDS Nurse, and Medical Director met and developed an action plan for the Immediate Jeopardy allegation. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended a QA meeting on [DATE], to discuss the IJ allegation and to develop a plan of action. 2. Review of a resident roster dated [DATE], revealed the DON, ADON, Transitional Nurse, and SS reviewed all residents' medical records. On [DATE], review of resident review/assessment forms revealed the DON and ADON assessed all residents in the facility to ensure any change in a resident's condition had been addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they assisted in reviewing resident medical records and completing assessments for all residents in the facility. 3. Review of Nurse's Notes for Resident A and Resident B who received [MEDICAL TREATMENT] services, revealed the DON assessed the residents on [DATE], and did not identify any concerns. Interview with the DON on [DATE] at 12:30 PM, revealed she assessed Residents A and B and no concerns were identified. 4. Interview with the Administrator on [DATE] at 1:00 PM, revealed on [DATE], the Regional Director of Operations educated her regarding utilizing facility resources, the Immediate Jeopardy action plan, changes in condition, care plans, conducting daily stand-down meetings and QA meetings. 5. Review of a facility in-service roster dated [DATE], revealed the Regional Director of Clinical Services provided education for the DON, ADON, MDS Nurse, and the SS on the use of Clinical Check Off sheet. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE] at 11:40 AM, revealed the Regional Director of Nursing educated them on [DATE], regarding completion of the Clinical Check Off sheet. 6. Review of Clinical Check Off sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the Clinical Check Off sheet was being utilized during the facility's morning clinical meeting to ensure any change of condition was addressed. Interviews conducted with the Administrator on [DATE], at 1:00 PM, DON on [DATE], at 12:30 PM, ADON on [DATE], at 11:20 AM, SS on [DATE], at 10:50 AM, AD on [DATE], at 12:25 PM, BOM on [DATE], at 10:42 AM, Therapy Manager on [DATE], at 11:15 AM, Transitional Nurse on [DATE], at 10:17 AM, Restorative Nurse on ,[DATE], at 10:44 AM, Scheduler on [DATE], at 11:10 AM, and the MDS Nurse on [DATE], at 11:40 AM, all revealed they attended morning clinical meetings and utilized the Clinical Check Off sheet and reviewed all residents' nurses notes, physician notification, new physician orders, care plans, and the twenty four (24) hour report. 7. Review of Transfer QA Checklists completed since [DATE], revealed no concerns with the completion of documentation prior to residents leaving the facility for appointments. Interviews conducted with LPN #5 on [DATE], at 9:50 AM, LPN #3 on [DATE], at 9:55 AM, LPN #9 on [DATE], at 10:10 AM, LPN #10 on [DATE], at 9:48 AM, and LPN #11 on [DATE], at 9:56 AM, revealed they had received education related to completing the Resident Transfer QA Checklist and were completing the form as required. 8. Review of in-service rosters dated [DATE], revealed the Regional Consultant provided a train the trainer in-service for the DON, SDC, and the ADON. Further review of an in-service roster dated [DATE], revealed the DON provided an in-service for the Transitional Nurse, SS, and the AD on the following. In addition, the licensed nursing staff was educated by the DON, ADON, SDC, and Transitional Nurse provided on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Transitional Nurse on [DATE] at 10:17 AM, SDC on [DATE] at 12:16 PM, LPN #5 on [DATE] at 9:50 AM, LPN #3 on [DATE] at 9:55 AM, LPN #9 on [DATE] at 10:10 AM, LPN #10 on [DATE] at 9:48 AM, and LPN #11 on [DATE] at 9:56 AM, revealed they had been educated regarding the facility's change in condition, implementing care plans, documentation regarding appointments and changes in a resident's condition, and utilizing the Resident Transfer Checklist QA audit. The DON stated the facility was not currently utilizing agency staff in the facility; however, if any agency staff was utilized in the future, they would be required to complete the in-services prior to working. Interview with the SDC revealed there were currently no new employees; however, the education was added to new employee orientation. 9. Review of a facility in-service roster dated [DATE], revealed the DON, ADON, SDC, AD, and SS provided an in-service to all CNAs on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments Interviews conducted with CNA #8 on [DATE] at 3:30 PM, CNA #10 on [DATE] at 3:35 PM, CNA #4 on [DATE] at 3:38 PM, CNA #11 on [DATE] at 3:40 PM, and CNA #12 on [DATE] at 3:45 PM, revealed they had attended in-services regarding what constituted a change in a resident's condition, the process for accompanying residents to appointments, and to ensure the nurse assessed the resident prior to leaving the facility for an appointment. 10. Review of QA meeting rosters revealed a QA meeting was held on [DATE], and audit information was reviewed. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended the QA meeting on [DATE], and reviewed audit tools and discussed the progress of the Allegation of Compliance. 11. Review of audit tools which began [DATE], revealed the DON, ADON, Transition Nurse, SDC, Restorative Nurse, and SS had audited residents' medical records twice weekly to ensure documentation and the Resident Transfer QA Checklist were completed prior to residents leaving the facility for appointments. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing residents' medical records to validate the Resident Transfer QA Checklist had been completed. 12. Review of audit tools which began [DATE], revealed the DON, MDS Nurse, and SS audited five (5) resident care plans weekly for the past two (2) weeks to ensure care plans were being followed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for conducting five (5) resident care plan audits twice a week to ensure care plans were being followed. 13. Review of audit tools implemented on [DATE], revealed the DON, ADON, MDS Nurse, and SS had audited five (5) residents to ensure physicians and families were notified of any change in condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing five (5) random residents' medical records to ensure families and physician notification was made for of any change in a resident's condition. 14. Review of Clinical Walking Rounds audit tool, revealed an administrative nurse had made walking rounds daily beginning [DATE], to monitor for any change in a resident's condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they conducted rounds in the facility daily to monitor for any change in resident condition. 15. Interviews conducted with the Administrator on [DATE], at 1:00 PM, revealed she conducted Stand Down meetings every day Monday through Friday, and ensured all concerns were addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], revealed they had attended daily Stand Down meetings that were conducted by the administrator. 16. Review of QA meeting rosters revealed meetings were held on [DATE], [DATE], and [DATE]. Interview with the Administrator on [DATE] at 1:00 PM, revealed continued meetings will be held weekly for eight (8) weeks, then monthly. The Administrator stated a member of the regional team was attending the QA meetings.

Based on record review, interview, and review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, it was determined the facility failed to have an effective program to identify and correct quality deficiencies. On [DATE], staff sent Resident #22 to a scheduled [MEDICAL TREATMENT] appointment despite the resident being unresponsive after a suspected incident of aspiration. When Resident #22 arrived at the [MEDICAL TREATMENT] clinic, he/she remained unresponsive, was in respiratory distress, and was immediately transferred to a hospital. Resident #22 expired at the hospital on [DATE]. Resident #22's family asked the facility to investigate why the resident was sent to the [MEDICAL TREATMENT] clinic unresponsive. However, the Administrator refused to confirm or deny if the medical record of Resident #22 had been reviewed. Although the facility's QAPI policy stated the program was designed to incorporate feedback from family and adverse events were tracked, monitored, and investigated as soon as they occurred, there was no documented evidence that the facility conducted an investigation related to Resident #22's death on [DATE]. (Refer to F157, F281, F282, F309, F490, and F514.) The facility's failure to ensure the facility had an effective QAPI program to identify and correct quality deficiencies has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE], at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed on [DATE], which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F281 and F282), 483.25 Quality of Care (F309), 42 CFR 483.70 Administration (F490 and F514), and 42 CFR 483.75 Quality Assurance and Performance Improvement (F520), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program, revised [DATE], revealed the facility was required to develop, implement, and maintain an ongoing facility-wide QAPI program that built on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. The primary purpose of the QAPI program was to establish data-driven, facility-wide processes that improved the quality of care, quality of life, and clinical outcomes of facility residents. The policy stated that systems were in place to monitor care and services; systems were designed to incorporate feedback from caregivers, residents, family, and staff as appropriate; care processes and outcomes were monitored using performance indicators; adverse events were tracked, monitored, and investigated as soon as they occurred; and action plans were implemented to prevent recurrences of adverse events. On [DATE] the facility failed to thoroughly assess and document Resident #22's condition and notify the resident's physician and family that the resident had experienced a change in condition. The facility subsequently transferred the resident to the [MEDICAL TREATMENT] clinic, unresponsive. The resident arrived at the [MEDICAL TREATMENT] clinic in respiratory distress and was transferred to the hospital and expired on [DATE] at 10:16 PM. Interview with Resident #22's family members on [DATE] at 11:30 AM, revealed staff notified them on [DATE], at approximately 2:00 AM that the resident had increased lethargy; however, the family stated they were not aware the resident was unresponsive until hospital staff notified them that the resident was unresponsive when the facility transferred the resident to the [MEDICAL TREATMENT] clinic. The family stated they contacted the facility's Director of Nursing (DON) on [DATE], and requested that the DON conduct an investigation into the resident's death; however, the family was never contacted by the facility regarding what happened to Resident #22. An interview was attempted with the former DON, who was responsible when this incident occurred on [DATE] at 3:20 PM; however, the former DON refused to speak with the State Survey Agency. Review of the former DON's personnel file revealed the facility terminated the former DON's employment on [DATE]. An interview with the Administrator and the current DON on [DATE] at 1:50 PM, and further interview with the Administrator on [DATE] at 3:12 PM, revealed the facility's QAPI Committee met monthly. Interview with the staff revealed after each death, the facility utilized a Medical Record Review Form to review medical records to ensure the closed record contained all the required forms and data, such as a face sheet, weight records, admission history, and discharge summary. However, the form did not capture potential concerns with care and services provided by the facility that could have potentially contributed to the resident's death. Continued interview with the Administrator on [DATE] revealed she would not confirm or deny whether the facility reviewed Resident #22's medical record after the resident's death. The Administrator declined to answer whether the facility identified any concerns or took any actions related to an investigation of Resident #22's death. The Administrator stated, I'm not at liberty to answer these questions. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the QA (Quality Assurance) Committee met to discuss the events set forth in the notice of Immediate Jeopardy and developed an action plan. 2. On [DATE] to [DATE], the Interdisciplinary Team (IDT) which consisted of the Director of Nursing (DON), Assistant Director Of Nursing (ADON), Transition Nurse, and Social Service (SS), reviewed all active residents to identify any change of condition not previously identified utilizing the following criteria: the Minimum Data Set (MDS) criteria, Brief Interview for Mental Status (BIMS), Chart Documentation, and assessment of each resident. No concerns were identified. 3. On [DATE], the DON assessed the two (2) residents receiving [MEDICAL TREATMENT] services and no concerns were identified. 4. On [DATE], the Regional Director of Operations educated the Administrator related to utilizing facility resources and addressing concerns in the facility including but not limited to the Immediate Jeopardy action plan and follow-up, changes in condition, care plans, conducting daily stand-down meetings, Quality Assurance (QA) tools, and QA meetings. 5. On [DATE], the Regional Director of Clinical Services educated the DON, ADON, MDS, and SS on the use of the Clinical Check Off sheet. 6. Beginning [DATE], the Clinical Check Off sheet will be utilized during the clinical morning meeting Monday through Friday to review resident information to ensure any change of condition was identified and addressed. The form consists of criteria to review the last twenty-four (24) to seventy-two (72) hours of Nurses' Notes, Physician Orders, physician notification, the 24-hour report, and to ensure care plans are being implemented. 7. On [DATE], the Staff Development Coordinator (SDC), DON, and Regional Consultant developed the Resident Transfer Quality Assurance (QA) Checklist which was implemented on [DATE]. The Transfer Quality Assurance (QA) Checklist will be utilized to ensure documentation accompanies the resident to the appointment. 8. On [DATE], the Regional Consultant educated the DON, SDC, and ADON. The DON then educated the Transitional Nurse, Social Services, and Activities Director. The DON, ADON, SDC, and/or Transitional Nurse then educated all licensed nursing staff. Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit 9. On [DATE], the DON, ADON, SDC, Activity Director, and Social Services educated State Registered Nurse Aides (SRNAs). Additionally, agency staff will be educated prior to working in the facility, new hires will be educated in orientation, and no staff will be permitted to work until education is completed on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments. 10. On [DATE], a QA Committee Meeting was held to review progress of education, and to review audit information and the progress of the plan. 11. Beginning [DATE], audits will be conducted by the Transition Nurse, ADON, DON, SDC, Restorative Nurse, or Social Services to ensure the Transfer QA Checklist was completed for residents leaving the facility for appointments. The audits will be conducted two (2) times per week for eight (8) weeks, then two (2) times per month for one (1) month, and then at a minimum of quarterly. The results of the audits will be reported by the DON to the QA Committee. 12. Beginning [DATE], five (5) care plans will be audited by the MDS/DON/Social Services Director per week to validate care plans are being followed. The audits will be completed weekly for eight (8) weeks, then two (2) times a month for one (1) month. Results of the audits will be reported to the QA Committee by the MDS Nurse. 13. Beginning [DATE], Nurses' Notes for five (5) random residents will be reviewed five (5) times a week to ensure physicians and families are notified of changes in condition. The audits will be completed by MDS, Social Services, ADON, or DON. The audits will continue five (5) times a week for eight (8) weeks, and then two (2) times a month for one (1) month. The audit results will be reported to the QA Committee by the DON. 14. Daily beginning [DATE], an Administrative Nurse (DON, ADON, and Transition Nurse) will make walking rounds and monitor residents for any change of condition not already addressed. Any concerns will be addressed immediately. 15. Beginning [DATE], the Administrator and/or DON will conduct a stand-down meeting Monday through Friday afternoon (DON, ADON, MDS, and Social Services to attend) to confirm any concerns that arose throughout the workday were addressed. 16. A QA meeting will be held weekly for eight (8) weeks, then monthly for one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, or Regional Reimbursement Director/Chief Operating Officer) will attend the weekly meetings for eight (8) weeks. Concerns will be addressed immediately and will be address through the facility's QA Committee. ***The SSA verified the following actions to remove the Immediate Jeopardy: 1. Review of QA meeting minutes and a sign-in sheet dated [DATE], revealed the Administrator, DON, ADON, SS, Activity Director (AD), Therapy Manager, Transitional Nurse, Restorative Nurse, MDS Nurse, and Medical Director met and developed an action plan for the Immediate Jeopardy allegation. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended a QA meeting on [DATE], to discuss the IJ allegation and to develop a plan of action. 2. Review of a resident roster dated [DATE], revealed the DON, ADON, Transitional Nurse, and SS reviewed all residents' medical records. On [DATE], review of resident review/assessment forms revealed the DON and ADON assessed all residents in the facility to ensure any change in a resident's condition had been addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they assisted in reviewing resident medical records and completing assessments for all residents in the facility. 3. Review of Nurse's Notes for Resident A and Resident B who received [MEDICAL TREATMENT] services, revealed the DON assessed the residents on [DATE], and did not identify any concerns. Interview with the DON on [DATE] at 12:30 PM, revealed she assessed Residents A and B and no concerns were identified. 4. Interview with the Administrator on [DATE] at 1:00 PM, revealed on [DATE], the Regional Director of Operations educated her regarding utilizing facility resources, the Immediate Jeopardy action plan, changes in condition, care plans, conducting daily stand-down meetings and QA meetings. 5. Review of a facility in-service roster dated [DATE], revealed the Regional Director of Clinical Services provided education for the DON, ADON, MDS Nurse, and the SS on the use of Clinical Check Off sheet. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE] at 11:40 AM, revealed the Regional Director of Nursing educated them on [DATE], regarding completion of the Clinical Check Off sheet. 6. Review of Clinical Check Off sheets dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], revealed the Clinical Check Off sheet was being utilized during the facility's morning clinical meeting to ensure any change of condition was addressed. Interviews conducted with the Administrator on [DATE], at 1:00 PM, DON on [DATE], at 12:30 PM, ADON on [DATE], at 11:20 AM, SS on [DATE], at 10:50 AM, AD on [DATE], at 12:25 PM, BOM on [DATE], at 10:42 AM, Therapy Manager on [DATE], at 11:15 AM, Transitional Nurse on [DATE], at 10:17 AM, Restorative Nurse on ,[DATE], at 10:44 AM, Scheduler on [DATE], at 11:10 AM, and the MDS Nurse on [DATE], at 11:40 AM, all revealed they attended morning clinical meetings and utilized the Clinical Check Off sheet and reviewed all residents' nurses notes, physician notification, new physician orders, care plans, and the twenty four (24) hour report. 7. Review of Transfer QA Checklists completed since [DATE], revealed no concerns with the completion of documentation prior to residents leaving the facility for appointments. Interviews conducted with LPN #5 on [DATE], at 9:50 AM, LPN #3 on [DATE], at 9:55 AM, LPN #9 on [DATE], at 10:10 AM, LPN #10 on [DATE], at 9:48 AM, and LPN #11 on [DATE], at 9:56 AM, revealed they had received education related to completing the Resident Transfer QA Checklist and were completing the form as required. 8. Review of in-service rosters dated [DATE], revealed the Regional Consultant provided a train the trainer in-service for the DON, SDC, and the ADON. Further review of an in-service roster dated [DATE], revealed the DON provided an in-service for the Transitional Nurse, SS, and the AD on the following. In addition, the licensed nursing staff was educated by the DON, ADON, SDC, and Transitional Nurse provided on the following: A. Change of Condition Policy, B. When to Notify Physician/Nurse Practitioner and the responsible Party; C. Following care plans; D. Documentation: E. What to send with resident transporting out of facility, F. Situation, Background, Assessment, Recommendation (SBAR) documentation as related to change of condition; G. Utilizing the Resident Transfer Checklist QA audit Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Transitional Nurse on [DATE] at 10:17 AM, SDC on [DATE] at 12:16 PM, LPN #5 on [DATE] at 9:50 AM, LPN #3 on [DATE] at 9:55 AM, LPN #9 on [DATE] at 10:10 AM, LPN #10 on [DATE] at 9:48 AM, and LPN #11 on [DATE] at 9:56 AM, revealed they had been educated regarding the facility's change in condition, implementing care plans, documentation regarding appointments and changes in a resident's condition, and utilizing the Resident Transfer Checklist QA audit. The DON stated the facility was not currently utilizing agency staff in the facility; however, if any agency staff was utilized in the future, they would be required to complete the in-services prior to working. Interview with the SDC revealed there were currently no new employees; however, the education was added to new employee orientation. 9. Review of a facility in-service roster dated [DATE], revealed the DON, ADON, SDC, AD, and SS provided an in-service to all CNAs on the following: A. What is a change of condition and what to report to nursing. B. The process for accompanying residents to appointments C. Ensuring a nurse assesses the resident prior to leaving for appointments Interviews conducted with CNA #8 on [DATE] at 3:30 PM, CNA #10 on [DATE] at 3:35 PM, CNA #4 on [DATE] at 3:38 PM, CNA #11 on [DATE] at 3:40 PM, and CNA #12 on [DATE] at 3:45 PM, revealed they had attended in-services regarding what constituted a change in a resident's condition, the process for accompanying residents to appointments, and to ensure the nurse assessed the resident prior to leaving the facility for an appointment. 10. Review of QA meeting rosters revealed a QA meeting was held on [DATE], and audit information was reviewed. Interviews conducted with the Administrator on [DATE] at 1:00 PM, DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, AD on [DATE] at 12:25 PM, Therapy Manager on [DATE] at 11:15 AM, Transitional Nurse on [DATE] at 10:17 AM, Restorative Nurse on [DATE] at 10:44 AM, MDS Nurse on [DATE] at 11:40 AM, and the Medical Director on [DATE] at 4:13 PM, revealed they attended the QA meeting on [DATE], and reviewed audit tools and discussed the progress of the Allegation of Compliance. 11. Review of audit tools which began [DATE], revealed the DON, ADON, Transition Nurse, SDC, Restorative Nurse, and SS had audited residents' medical records twice weekly to ensure documentation and the Resident Transfer QA Checklist were completed prior to residents leaving the facility for appointments. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing residents' medical records to validate the Resident Transfer QA Checklist had been completed. 12. Review of audit tools which began [DATE], revealed the DON, MDS Nurse, and SS audited five (5) resident care plans weekly for the past two (2) weeks to ensure care plans were being followed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for conducting five (5) resident care plan audits twice a week to ensure care plans were being followed. 13. Review of audit tools implemented on [DATE], revealed the DON, ADON, MDS Nurse, and SS had audited five (5) residents to ensure physicians and families were notified of any change in condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], were responsible for auditing five (5) random residents' medical records to ensure families and physician notification was made for of any change in a resident's condition. 14. Review of Clinical Walking Rounds audit tool, revealed an administrative nurse had made walking rounds daily beginning [DATE], to monitor for any change in a resident's condition. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, and the Transitional Nurse on [DATE] at 10:17 AM, revealed they conducted rounds in the facility daily to monitor for any change in resident condition. 15. Interviews conducted with the Administrator on [DATE], at 1:00 PM, revealed she conducted Stand Down meetings every day Monday through Friday, and ensured all concerns were addressed. Interviews conducted with the DON on [DATE] at 12:30 PM, ADON on [DATE] at 11:20 AM, SS on [DATE] at 10:50 AM, and the MDS Nurse on [DATE], revealed they had attended daily Stand Down meetings that were conducted by the administrator. 16. Review of QA meeting rosters revealed meetings were held on [DATE], [DATE], and [DATE]. Interview with the Administrator on [DATE] at 1:00 PM, revealed continued meetings will be held weekly for eight (8) weeks, then monthly. The Administrator stated a member of the regional team was attending the QA meetings.

Based on observation, interview, record review, facility investigation review, and review of the Resident Assessment Instrument (RAI) manual, it was determined that the facility failed to follow the comprehensive plan of care for one (1) of three (3) sampled residents (Resident #1). The facility developed a care plan that required staff to provide care in pairs and to assist Resident #1 with toileting, dressing, and bed mobility. Review of a facility investigation dated 07/16/17, revealed State Registered Nurse Aide (SRNA) # 1 provided incontinence care for Resident # 1 without the assistance of another staff member. Resident #1 rolled off the bed and sustained a humerus (upper arm bone) fracture. The findings include: Interview with the Director of Nursing (DON) on 08/01/17 at 1:00 PM revealed the facility did not have a specific policy related to care plans, but followed the Resident Assessment Instrument (RAI) manual. Review of the RAI user manual revealed Individualized care plans should be based on an accurate assessment of the resident's self-performance and the amount and type of support being provided to the resident. Observation of Resident #1 on 07/31/17 at 1:10 PM revealed the resident was lying in bed with a sling on the right arm. Review of Resident #1's medical record revealed the facility admitted the resident on 01/06/04 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/23/17, revealed the facility assessed Resident #1's Brief Interview for Mental Status (BIMS) score to be fifteen (15), indicating the resident was interviewable. Further review of the MDS assessment revealed the resident required extensive assistance of two or more people with bed mobility, toileting, dressing, and transfers. Review of Resident #1's comprehensive care plan and Kardex (nurse aide care plan), revised on 07/15/17, revealed the resident had an alteration in Activities of Daily Living (ADL) function related to a history of [MEDICAL CONDITION] left side [MEDICAL CONDITION] (weakness/paralysis affecting one side of the body). The facility developed interventions that required staff to assist with bed mobility, total assistance when pulling the resident up in bed, total assistance of two staff members when transferring the resident, and total assistance of two staff members when assisting with toileting. Further review of the care plan and Kardex revealed Resident #1 required care in pairs. Interview with the DON and Administrator on 08/01/17 at 1:20 PM revealed Resident #1 required care in pairs (two staff members to provide care for the resident at all times) related to the resident's behavioral and assistance needs. Review of a facility investigation dated 07/16/17, revealed SRNA #1 heard Resident #1 yelling out and needed to be changed on 07/16/17. The SRNA assisted the resident with incontinence care by rolling the resident to one side and the resident quickly propelled forward and fell out of bed. Further review of the investigation revealed the facility transferred Resident #1 to the Emergency Department (ED) for evaluation and was diagnosed with [REDACTED]. Interview with Resident #1 on 07/31/17 at 1:10 PM revealed only one nurse aide was providing care for the resident on 07/16/17 when the resident rolled out of bed. Resident #1 stated he/she was weak and had a hard time moving around in bed. The resident stated, It broke my arm, and Yes, my arm hurts! Interview with SRNA #1 on 07/31/17 at 7:14 PM, revealed resident care plans were provided to the nurse aides at the beginning of each shift and the care needs for each resident were provided on the Kardex. Further interview revealed the SRNA knew Resident #1 required two people for assistance with incontinence care but attempted to provide care alone on 07/16/17. Interview with the DON and Administrator on 08/01/17 at 1:20 PM revealed staff were expected to review resident care plans before each shift and were expected to follow the care plans.

Based on observation, interview, record review, and a review of a facility investigation, it was determined the facility failed to provide adequate supervision and assistance to ensure that one (1) of three (3) sampled residents was free from accidents that resulted in bodily injury (Resident #1). State Registered Nurse Aide (SRNA) #1 provided incontinence care for Resident #1 without the assistance of another staff member as required by the resident's care plan. When SRNA #1 assisted Resident #1 with rolling onto the resident's right side, the resident rolled out of bed and fell to the floor, which resulted in a fractured humerus (upper arm bone). The findings include: Interview with the Director of Nursing (DON) on 08/01/17 at 1:00 PM revealed the facility did not have a specific policy related to supervision, accidents, or assistance with activities of daily living (ADL). Observation of Resident #1 on 07/31/17 at 1:10 PM, revealed the resident was lying in bed with a sling on the right arm. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident's Brief Interview for Mental Status (BIMS) score to be fifteen (15), indicating the resident was cognitively intact and interviewable. Further review of the MDS assessment revealed the resident required extensive assistance of two or more persons with bed mobility, transfers, dressing, and toileting. Review of Resident #1's comprehensive care plan revised on 07/15/17, revealed the facility developed a care plan for the resident because the resident had an alteration in Activities of Daily Living (ADL) function due to a CVA with left side hemiparesis (weakness/paralysis affecting one side of the body) and weakness. The facility developed interventions that required staff to assist with bed mobility, total assistance when pulling the resident up in bed, total assistance of two staff members when transferring the resident, and total assistance of two staff members when assisting with toileting. Further review of the care plan and Kardex revealed Resident #1 required care in pairs. Interview with the DON and Administrator on 08/01/17 at 1:20 PM revealed care in pairs as required by the resident's care plan indicated two staff members should care for Resident #1 at all times. Review of a facility investigation dated 07/16/17, revealed on 07/16/17, at approximately 2:00 PM, Resident #1 required incontinence care. The investigation stated Resident #1 was yelling out that he/she was dirty and needed to be changed. Further review of the investigation revealed SRNA #1 assisted the resident with incontinence care. SRNA #1 turned the resident to the resident's left side, and then when turning to the right, the resident put right hand on the top edge of the mattress and quickly propelled forward and fell on to the floor. Further review revealed the facility transferred the resident to the Emergency Department (ED) for evaluation and the resident was diagnosed with [REDACTED].#1 did not follow the care plan. The investigation stated the nurse aide was trying to attend to a combative resident who was yelling out to be changed and the aide was trying to provide the resident with a clean and dry environment in a timely manner. Review of Resident #1's x-ray results dated 07/16/17, revealed the resident had an impacted fracture of the proximal humerus and a mildly displaced fracture fragment involving the greater tuberosity (prominent part of the bone at the top of the humerus in the shoulder area. Fractures of this part of the bone are usually the result of falling on the shoulder or falling on an outstretched arm). Review of Resident #1's Physician order [REDACTED]. However, review of the resident's physician's orders [REDACTED]. Further review of the physician's orders [REDACTED]. Review of Resident #1's Medication Administration Record (MAR), dated July 2017, revealed the resident required nineteen (19) doses of the Ultram from 07/21/17 through 07/31/17 related to pain. Interview with Resident #1 on 07/31/17 at 1:10 PM revealed, The girl was cleaning me up and I fell off the bed. The resident stated, I didn't know I was falling until I hit the ground, and it broke my arm. The resident stated, Yes, my arm hurts! Interview with SRNA #1 on 07/31/17 at 7:14 PM revealed on 07/16/17, Resident #1 was screaming and feces was visible when the nurse aide entered the resident's room. The SRNA stated she was assisting the resident to turn and the resident rolled off the bed. The SRNA stated she knew the resident required two people for assistance with incontinence care; however, SRNA #1 provided care for the resident without a second person. The SRNA stated she was just trying to get the resident cleaned up. Interview with the DON and Administrator on 08/01/17 at 1:20 PM revealed staff were expected to provide care for Resident #1 in pairs related to behaviors and assistance needs. Further interview revealed they would have expected SRNA #1 to get another staff member to assist with incontinence care for Resident #1.

Based on interview, record review, review of the facility's investigations, and review of the facility's policy it was determined the facility failed to ensure allegations of abuse/neglect were reported immediately to the Executive Director (ED) and investigated, and failed to ensure residents were protected from further abuse/neglect for twelve (12) of twenty-seven (27) sampled residents (Residents #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). Facility staff reported to an administrative staff member that a State Registered Nurse Aide (SRNA) was rude and hateful to residents. However, the allegations were not reported to the ED and were not investigated. Furthermore, staff stated the SRNA (SRNA #13) moved residents' belongings out of their reach and told the residents to go to bed. In addition, on [DATE], staff reported to the Manager on Duty (MOD) that the residents SRNA #13 had cared for were left double or triple briefed and saturated with urine. The MOD failed to report the allegation of possible neglect to the ED and failed to investigate and protect residents from further potential neglect. Furthermore, SRNA #13 was allowed to continue to work with residents of the facility and residents were not protected from further neglect. The facility's failure to ensure allegations of abuse/neglect were reported immediately to the Executive Director (ED) and investigated, and failure to ensure residents were protected from further abuse/neglect has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was not removed until [DATE], which lowered the Scope and Severity to D level at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, last reviewed [DATE], revealed the facility would take appropriate steps to prevent the occurrence of abuse and neglect and report the allegation to the facility's Executive Director (ED) immediately. The policy further stated the ED or Director of Nursing would engage in efforts to identify, intervene, and correct situations in which abuse or neglect were more than likely to occur. The policy stated it was the responsibility of the supervisor to immediately communicate any report of an alleged violation to the ED. The policy further stated the ED would report the allegation to the appropriate state agencies and an investigation would be conducted. Further review revealed the policy stated the investigation should include interviews with employees and residents who may have knowledge of the alleged incident. The policy stated if the suspected perpetrator was an employee of the facility, the ED shall place the employee on immediate suspension while completing the investigation. 1. Review of the medical record for Resident #2 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. However, review of Resident #2's initial Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact and interviewable. Interview on [DATE] at 2:16 PM with Social Worker #1 and Social Worker #2 revealed even though Resident #2 had a [DIAGNOSES REDACTED].#2 was reliable with information provided and did not have a history of making false accusations. Interview on [DATE] at 1:15 PM with Resident #2 revealed different staff members had been rude to him/her, but one staff member on the night shift took the resident's television remote control, was hateful, and told him/her that it was time to go to sleep. Resident #2 stated the staff member on the night shift also frequently put two (2) briefs on him/her at night, so she did not have to get him/her up at night; however, the resident was unsure if the staff member was SRNA #13. 2. Record review revealed the facility admitted Resident #4 on [DATE], with [DIAGNOSES REDACTED]. However, review of Resident #4's Annual MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fourteen (14), which indicated the resident was cognitively intact and interviewable. Interview on [DATE] at 1:30 PM with Resident #4 revealed SRNA #13 was hateful and moved his/her television remote control where he/she could not reach the remote. Resident #4 stated SRNA #13 turned the television volume down and told him/her that he/she should not be watching that. 3. Record review revealed the facility admitted Resident #12 on [DATE], with [DIAGNOSES REDACTED]. However, review of Resident #12's Significant Change MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fourteen (14), which indicated the resident was cognitively intact and interviewable. Interview on [DATE] at 2:16 PM with Social Worker #1 and Social Worker #2 revealed although Resident #12 had a [DIAGNOSES REDACTED]. Review of Resident #12's facility Grievance Form, dated [DATE], revealed the resident's family member contacted the facility and reported that the resident's television remote control and cellular telephone (cell phone) were placed out of the resident's reach at times. Continued review of the Grievance Form revealed the facility's action plan was to interview the resident and family member and to educate staff to ensure the resident was able to reach his/her remote and cellular telephone. Interview on [DATE] at 2:11 PM with Resident #12 revealed SRNA #13 often jerks his/her television remote out of his/her hand, turns the television off, and places the remote out of the resident's reach and tells him/her that it was time for bed. Resident #12 stated SRNA #13 often moved his/her cell phone out of his/her reach. He/she stated that he/she liked to keep his/her cell phone in his/her hand to know what time it was. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #2 at 3:32 PM and SRNA #3 at 3:50 PM; on [DATE] with SRNA #5 at 1:07 PM, SRNA #6 at 1:24 PM, and SRNA #7 at 1:46 PM; on [DATE] with SRNA #8 at 8:12 AM and SRNA #10 at 12:51 PM; and on [DATE] at 11:45 AM with SRNA #12 revealed residents from the 200 Unit had made reports to the staff that SRNA #13 would move the residents' personal belongings out of the residents' reach and was rude and hateful with the residents. The interviews further revealed that staff had reported the residents' complaints to administrative staff (an Assistant Director of Nursing). However, this administrative staff person no longer worked for the facility and had never addressed the residents' concerns. Interview on [DATE] at 3:02 PM and on [DATE] at 12:43 PM with LPN #1 (Unit Manager) revealed night shift staff had reported to her recently that SRNA #13 had taken a resident's (Resident #12) cell phone and television remote control and placed the items out of the resident's reach. She stated she completed an incident report and reported the incident to Social Services. LPN #1 stated at times staff complained about SRNA #13 being hateful and rude; however, that was the first complaint she had received about the SRNA taking the residents' items. Further interview with LPN #1 on [DATE] at 12:43 PM revealed she had overheard the staff talking about SRNA #13 being loud, rude, and hateful to the residents; however, she felt that was just (SRNA #13's) personality and she was loud. Interview on [DATE] at 12:34 PM with LPN #6 revealed no residents or staff had reported any instances involving SRNA #13 to him. However, the LPN stated he often overheard the staff talk about SRNA #13 being rude and hateful to the residents. The LPN stated he had heard staff talk about the SRNA placing residents' items out of their reach. However, the LPN stated he did not feel the actions were abusive so he did not report the instances. Interview on [DATE] at 1:17 PM with LPN #5 revealed the LPN had not had reports from residents about SRNA #13; however, the LPN had worked with SRNA #13 and felt the SRNA had a bad attitude, so she educated the SRNA on her approach with residents. The LPN further stated she felt SRNA #13 aggravated the residents with her choice of words. However, LPN #5 denied reporting the incidents to administrative staff because she felt providing the education to SRNA #13 was the appropriate action. SRNA #13 was allowed to continue to work with the facility's residents. 4. Review of the medical record for Resident #14 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. The resident passed away on [DATE]. Review of Resident #14's Significant Change MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Interviews on [DATE] at 1:07 PM with SRNA #5; and, on [DATE] at 8:12 AM with SRNA #8 revealed Resident #14 (now deceased ) had reported to them that SRNA #13 took his/her urinal out of his/her reach and instructed the resident to just go in his/her brief because the resident often spilled the urine. Further interview revealed the SRNAs had reported their concerns to administrative staff (including an Assistant Director of Nursing and Administrator who were no longer employed by the facility) on several occasions. Interview on [DATE] at 3:10 PM with the ED revealed the facility had no documented evidence that an allegation of abuse or neglect had been reported or investigated involving Resident #14. The ED stated all allegations of abuse and neglect should be reported to the ED and investigated. 5. Review of Resident #13's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #13's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS score of fourteen (14), which indicated the resident was cognitively intact and interviewable. Review of the facility's Combined Incident Report/Final Report investigation dated [DATE], related to Resident #13, revealed the resident alleged that on the morning of [DATE], someone came into his/her room and squirted something into his/her eyes. Further review of the investigation revealed the resident was unable to name or describe the alleged perpetrator. The resident was sent to the emergency room for an evaluation of his/her eyes. Continued review of the investigation revealed no staff member was readily identifiable. An investigation was initiated to determine a staff member, if possible, and if an in-service and disciplinary action procedures were warranted. Further review of the investigation revealed the conclusion was, Sent to ER and returned with no new orders. There was no documented evidence a thorough investigation was completed to include residents or staff interviews. There was no documented evidence residents were protected from further possible abuse, or of the facility's findings of the investigation. Review of the facility's investigation witness statement, dated [DATE], by Housekeeper #2 revealed on [DATE] at approximately 10:30 AM a SRNA had asked the Housekeeper for air freshener to spray in residents' rooms. The Housekeeper denied being aware of which rooms the SRNA used the air freshener. The interview further revealed around 2:30 PM, the Housekeeper overheard that Resident #13 had been sprayed in the eyes with something so she reported that the SRNA had used the air freshener spray from her cart that morning. Review of the facility's investigation witness statement, dated [DATE], by SRNA #4 revealed on [DATE] at approximately 10:30 AM Resident #13 reported to the SRNA that someone had sprayed perfume in his/her eyes that morning. SRNA #4 informed the nurse. The investigation further stated that SRNA #4 had used the housekeeper's spray in two (2) resident rooms (not Resident #13's room) and returned the spray to the housekeeper. Review of the facility's investigation witness statement, dated [DATE], by Licensed Practical Nurse (LPN) #3 revealed Resident #13's aides had reported to the nurse that the resident had reported to them that someone had sprayed perfume in his/her eyes. The statement stated the LPN went to assess the resident's eyes and did not notice anything different than usual, and the resident had been rubbing his/her eyes earlier causing the eyes to be red. Review of Resident #13's emergency room record, dated [DATE] at 4:35 PM, revealed the resident complained of burning in his/her eyes and someone was cleaning that morning and sprayed something in the resident's eyes. Further review of the record revealed the resident had bilateral redness to the eyes. Review of the physician's documentation revealed Resident #13 had mild [DIAGNOSES REDACTED] to the eyelids bilaterally and slight conjunctiva [MEDICAL CONDITION] bilaterally. Continued review of the record revealed the resident's eyes were irrigated with an eye wash irrigation solution and the resident was given the discharge instructions to use artificial tears every hour as needed for the next two (2) days. Interview on [DATE] at 2:15 PM with Resident #13 revealed when the staff was changing him/her they sprayed something that smelled like perfume in his/her eyes. Resident #13 stated his/her eyes burned all day and they finally sent him/her to the hospital to have his/her eyes washed out. Interview on [DATE] at 12:05 PM with Social Worker (SW) #1, SW #2, and the Executive Director (ED) revealed the allegation was investigated and unsubstantiated, and no staff member was suspended because there was no proof anyone had sprayed anything in the resident's eyes, even though the resident required treatment for [REDACTED]. 6. Review of an Education/In-Service Report, dated [DATE], revealed education was provided on the topic of excessive use of briefs/pads to the night shift staff (working on [DATE]) with the purpose to reduce the wastefulness of facility supplies. Continued review of the [DATE] Education/In-Service Report, revealed upon rounds on the 200 Unit, residents (Residents #5, #6, #7, #8, #9, #10, #11, and #13) were observed to be double and triple-briefed or padded. Interviews on [DATE] at 3:32 PM with SRNA #2, and on [DATE] at 11:45 AM with SRNA #12 revealed when the staff made their first incontinence round on [DATE] between 8:00 AM and 9:00 AM, they found residents that SRNA #13 had cared for during the previous shift to be double-briefed and saturated with urine. The SRNAs stated they felt SRNA #13 double-briefed the residents so she would not have to provide incontinence care and change the residents throughout the night. The SRNAs stated they reported the incident to the Manager on Duty (MOD). The interview further revealed over the past several months the staff had reported to administrative staff (an Assistant Director of Nursing that was no longer employed by the facility) prior to this incident that residents had been found to be double-briefed after SRNA #13 had worked night shift; however, but the practice had continued. Interview on [DATE] at 2:58 PM with the ED and the DON revealed no investigation had been conducted regarding residents being found double-briefed and the administrative staff were unaware of when the practice of double-briefing residents had been initiated by SRNA #13. Review of the medical record for Resident #5 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #5's Annual MDS assessment, dated [DATE], revealed the facility assessed the resident to be severely cognitively impaired and was not interviewable. The assessment further revealed the resident required extensive assistance of two (2) staff persons for toileting and was always incontinent of bowel and bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #5 was observed to be double-briefed. 7. Review of the medical record for Resident #6 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of three (3), indicating the resident had a severe cognitive impairment and was not interviewable. The assessment further revealed the resident was assessed to require extensive assistance of two (2) staff members for toileting and was always incontinent of bowel and bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #6 was observed to be double-briefed. 8. Review of the medical record for Resident #7 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's Annual MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of six (6), indicating a severe cognitive impairment and not interviewable. The assessment further revealed the resident was assessed to require extensive assistance of two (2) staff members for toileting and was always incontinent of bowel and frequently incontinent of bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #7 was observed to be double-briefed. 9. Review of the medical record for Resident #8 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of six (6), having a severe cognitive impairment and was not interviewable. The assessment further revealed the resident was assessed to require the extensive assistance of two (2) staff members for toileting and was always incontinent of bowel and bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #8 was observed to be double-briefed. 10. Review of the medical record for Resident #9 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #9's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to not be interviewable. The assessment further revealed the resident was assessed to require the extensive assistance of two (2) staff members for toileting and was always incontinent of bowel and bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #9 was observed to be double-briefed. 11. Review of the medical record for Resident #10 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS score of 99, having a severe cognitive impairment and was not interviewable. The assessment further revealed the resident was assessed to require the extensive assistance of two (2) staff members for toileting and was always incontinent of bowel and bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #10 was observed to be double-briefed. 12. Review of the medical record for Resident #11 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's Annual MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of six (6), having a severe cognitive impairment and was not interviewable. The assessment further revealed the resident was assessed to require extensive assistance of one staff member for toileting and was occasionally incontinent of bowel and frequently incontinent of bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #11 was observed to be double-briefed. 13. Review of the medical record for Resident #13 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #13's Quarterly MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fourteen (14), which indicated the resident was cognitively intact and interviewable. The assessment further revealed the resident was assessed to require extensive assistance of two (2) staff members for toileting and was always incontinent of bowel and frequently incontinent of bladder. Review of an Education/In-Service Report, dated [DATE], revealed on [DATE] Resident #13 was observed to be double-briefed. Interview on [DATE] at 2:15 PM with Resident #13 revealed the resident did not have any complaints about SRNA #13. When the resident was questioned about being double briefed the resident stated, Are they not supposed to do that? Interview on [DATE] at 8:23 AM with SRNA #13 revealed the SRNA was still employed by the facility and had not been suspended for an investigation. Interviews on [DATE] with Licensed Practical Nurse (LPN) #6 at 12:42 PM and Registered Nurse (RN) #2 at 8:21 AM revealed they had overheard other staff talking about issues residents had with SRNA #13 and about residents being double-briefed, but since the allegation was not reported to them directly they had not reported the allegations to the ED. Interview on [DATE] at 1:17 PM with LPN #5 revealed the nurse had observed a resident that SRNA #13 had provided care for in [DATE] to be double-briefed and educated the SRNA that double-briefing was inappropriate. However, LPN #5 denied reporting the incident to supervisory staff because she stated she assumed the practice would stop. LPN #5 stated SRNA #13 had a bad attitude, so she educated the SRNA on her approach with residents. The LPN further stated she felt SRNA #13 aggravated the residents with her choice of words. However, LPN #5 denied reporting the incidents to administrative staff because she felt providing the education to SRNA #13 was the appropriate action. Interview on [DATE] at 2:49 PM with LPN #7 revealed staff had reported to her that residents were being double-briefed but she did not believe that it was happening, so she did not report the incidents to supervisory staff. Interview on [DATE] at 3:02 PM and on [DATE] at 12:43 PM with LPN #1 (Unit Manager) revealed that several SRNAs had reported to her that they had found residents to be double-briefed at times. However, the LPN stated she did not report the incidents to Administration because she had not observed the residents to be double-briefed herself. Further interview with LPN #1 revealed that she could not report information that was hearsay and she had to see an incident before she could report it. Interview on [DATE] at 11:30 AM with the MOD (the Business Office Manager) revealed she was the MOD on [DATE] when the allegation that the residents were being double-briefed was reported. She stated she went to one of the resident's rooms and observed that the resident did have two briefs on. She asked the staff to give her a list of the other residents that were double-briefed. The MOD stated she came in on the night shift and did an in-service instructing the staff to not double-brief residents because it was wasteful of the facility's supplies. She stated she did not further investigate the allegation and SRNA #13 was allowed to continue to work with residents. Continued interview revealed the MOD did not report the allegation to the Assistant Director of Nursing (ADON) until the next day. The MOD denied she had notified the ED. She stated she had not initiated an investigation of the allegation because she did not consider the incident to be neglectful. The MOD denied staff had reported to her that SRNA #13 had ever been rude or hateful to a resident. Interview on [DATE] at 2:58 PM with the ED and the DON revealed the administrative staff was not aware of the allegations until the surveyor was in the facility on [DATE]. The Administrative staff denied being aware of any issues with SRNA #13. They stated the SRNA only had one verbal warning in her file related to the double-briefing incident regarding wasting facility supplies. The interview further revealed SRNA #13 was still employed by the facility and no disciplinary action had been taken at this time. The ED stated the facility was currently utilizing Corporate staff to fulfill the roles of the ED and DON as they did not have a full time ED. The ED stated she had been at the facility since [DATE] and the DON had been at the facility since [DATE]. The Administrative staff stated they were not made aware of every problem in the facility or of all problems with staff in the facility when they accepted their positions. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy. 1) State Registered Nurse Aide (SRNA) #13 who allegedly failed to provide quality care was suspended by the Interim Executive Director (IED), Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), and the Human Resource Generalist (HRG), pending an investigation which the facility initiated on [DATE]. The facility terminated SRNA #13 on [DATE]. 2) Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to (15) fifteen (Residents #1, #2, #3, #4, #7, #9, #12, and #13) were re-interviewed by the DNS, ADNS, and the Social Services Coordinators regarding any allegations of neglect/abuse and none of these residents reported an allegation. Resident #2 stated he/she had been double-briefed once, but did not remember when or by whom. 3) Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were all assessed by the DNS, ADNS, Restorative RN, and RN Unit Manager from head to toe for any issues related to potential abuse and/or neglect. No issues were identified. 4) All residents with a BIMS score of eight (8) or greater were interviewed by the Social Services Coordinators, IED, and DNS to determine if they had experienced abuse or neglect. Of the forty-six (46) residents with a BIMS' score of eight (8) or greater, forty-two (42) of those residents stated they did not have any reports of abuse or neglect. One (1) resident stated he/she was unsure; one (1) resident was unable to answer questions; and two (2) residents stated they had personal items removed from their reach. Resident #12 stated items had been removed from reach; and his/her cell phone was placed on a bedside table out of his/her reach. However he/she was unsure of the exact date and time this had occurred. Resident #12 gave the description of SRNA #13 as the staff person that moved his/her belongings. Resident #4 stated items had been placed out of reach. However he/she could not remember the staff member's name, but he/she did describe SRNA #13, and stated SRNA #13 had placed the items out of his/her reach. Resident #4 stated it happened at night and only occurred every once in a while. Both of the allegations for Residents #12 and #4 were reported to OIG (Office of Inspector General) and APS (Adult Protective Services) and investigated. SRNA #13 was identified and suspended for a previous allegation on [DATE]. SRNA #13 was terminated on [DATE]. 5) Skin assessments (with a focus on the perineal area) of residents who wear any incontinence product were conducted by the DNS, ADNS, Restorative RN, RN Unit Manager, and Registered Nurse Assessment Coordinators (RNAC) to determine the presence of any rashes, bruising or fungi. No issues were noted and no resident was observed to be double-briefed. 6) Full head to toe skin assessments were performed by the DNS, ADNS, Restorative RN, RN Unit Manager, Field Service Clinical Director (FSCD) and an RN, on all residents (both continent and incontinent) and any new skin issues were reported to the resident's respective Medical Doctor (MD), interested party. None were determined to be of an unknown origin or related to being double-briefed. 7) All residents with a BIMS' score less than eight (8) were observed by the Social Services Coordinators, Admissions Director, Accounts Payable Clerk, and the IED for signs and symptoms of abuse, neglect, exploitation, and misappropriation. No issues were noted. Additionally, the residents with a BIMS' score below eight (8) had their respective interested parties contacted to inquire if they had any concerns with the care provided to their resident. Any concerns expressed by the interested parties that alleged an allegation of abuse, neglect, exploitation, or misappropriation were reported to the Office of Inspector General (OIG) and Adult Protective Services (APS) within the allowed twenty-four (24) hour timeframe and were investigated and followed up on as required. 8) All facility staff was interviewed related to any knowledge of neglect or abuse by the Social Services Coordinators. Findings: One CNA admitted to witnessing a resident being double-briefed, but stated she did not inform anyone. She has been re-trained ([DATE]) in abuse/neglect prevention and reporting and now understands her role in informing her supervisor or other management staff. 9) All incontinent residents had (on [DATE]) their weight and height reviewed for proper sizing of their respective brief size by the DNS, ADNS, and Central Supply. All residents requiring a change in brief size had the change completed. 10) An audit of voiding patterns of incontinent residents to identify copious nocturnal voiding was conducted by the DNS, Central Supply Clerk, and night shift SRNAs. Twenty-two (22) residents were identified by the staff to have a copious nocturnal voiding pattern. This was determined by reviewing their brief usage, the need to change the resident's linens, and by interviewing night shift SRNAs. 11) The facility's Restorative RN and RNACs conducted a bowel and bladder assessment on all residents to ensure if they needed to use a brief that they have them. 12) All staff working at the facility were trained on [DATE] by the Social Services Coordinators and Human Resources Director regarding abuse, neglect, and misappropriation, (TRUNCATED)

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure policies and procedures that prohibited neglect, mistreatment, and abuse were implemented for twelve (12) of twenty-seven (27) sampled residents (Residents #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14). Facility staff reported that a State Registered Nurse Aide (SRNA) was rude and hateful to residents; however, the allegations were not reported to the Executive Director (ED) and were not investigated according to the facility's policy. Furthermore, staff stated the SRNA (SRNA #13) moved residents' belongings out of their reach and told the residents to go to bed. The Charge Nurse was made aware of the allegations; however, she failed to follow the facility's policy, as she did not take action to report the allegations according to the facility's policy. In addition, on [DATE], staff reported to the Manager on Duty (MOD) that the residents that SRNA #13 had cared for were left double or triple briefed and saturated with urine. The MOD failed to report the allegation of possible neglect to the ED and failed to investigate and protect residents from further potential neglect. The facility's failure to ensure policies and procedures that prohibited neglect, mistreatment, and abuse were implemented has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was not removed until [DATE], which lowered the Scope and Severity to D level at 42 CFR 483.13 Resident Behavior and Facility Practices (F225 and F226) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, last reviewed [DATE], revealed the facility would take appropriate steps to prevent the occurrence of abuse and neglect and report the allegation to the facility's Executive Director (ED) immediately. The policy stated the ED or Director of Nursing (DON) would engage in efforts to identify, intervene and correct situations in which abuse or neglect are more than likely to occur. The policy stated it was the responsibility of the supervisor to immediately communicate any report of an alleged violation to the ED. The ED would report the allegation to the appropriate state agencies and an investigation would be conducted. If the suspected perpetrator was an employee of the facility, the ED shall place the employee on immediate suspension while completing the investigation. 1. Review of the medical record for Resident #2 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. However, review of Resident #2's Initial Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Interview on [DATE] at 2:16 PM with Social Worker #1 and Social Worker #2 revealed although Resident #2 had a [DIAGNOSES REDACTED]. Interview on [DATE] at 1:15 PM with Resident #2 revealed different staff members were rude to him/her, but one staff member on the night shift took the resident's television remote control and was hateful and told the resident it was time to go to sleep. The interview further revealed the staff member on the night shift also frequently put two (2) briefs on the resident at night so the staff member did not have to get the resident up at night; however the resident was unsure if the staff member was SRNA #13. 2. Review of the medical record for Resident #4 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Annual MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fourteen (14), which indicated the resident was cognitively intact and interviewable. Interview on [DATE] at 1:30 PM with Resident #4 revealed SRNA #13 was hateful and moved the resident's television remote control where the resident could not reach the remote. The resident stated SRNA #13 turned the television volume down and told him/her that he/she should not be watching that. 3. Review of the medical record for Resident #12 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. However, review of Resident #12's Significant Change MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fourteen (14), which indicated the resident was cognitively intact and interviewable. Interview on [DATE] at 2:16 PM with Social Worker #1 and Social Worker #2 revealed although Resident #12 had a [DIAGNOSES REDACTED]. Review of Resident #12's Grievance Form, dated [DATE], revealed the resident's family member contacted the facility and reported that the resident's television remote control and cellular telephone (cell phone) were placed out of the resident's reach at times. Continued review of the Form revealed the action plan was to interview the resident and family member and to educate staff to ensure the resident was able to reach his/her remote and cell phone. Interview on [DATE] at 2:11 PM with Resident #12 revealed SRNA #13 often jerks the resident's television remote out of the resident's hand, turns the television off, and places the remote out of the resident's reach and tells the resident it was time for bed. The resident stated SRNA #13 often moved his/her cell phone out of his/her reach and he/she liked to keep his/her cell phone in his/her hand to know what time it was. Interviews on [DATE] with State Registered Nurse Aide (SRNA) #2 at 3:32 PM and SRNA #3 at 3:50 PM; on [DATE] with SRNA #5 at 1:07 PM, SRNA #6 at 1:24 PM, and SRNA #7 at 1:46 PM; on [DATE] with SRNA #8 at 8:12 AM and SRNA #10 at 12:51 PM; and on [DATE] at 11:45 AM with SRNA #12 revealed residents from the 200 Unit had made reports to the staff that SRNA #13 moved the residents' personal belongings out of the residents' reach and was rude and hateful with the residents. The interviews further revealed the staff had reported the residents' complaints to administrative staff (an Assistant Director of Nursing); however, the administrative staff person no longer worked for the facility and the administrative staff never addressed the residents' concerns. Interview on [DATE] at 3:02 PM, and on [DATE] at 12:43 PM with LPN #1 (Unit Manager) revealed the night shift had reported to her recently that SRNA #13 had taken a resident's (Resident #12) cell phone and television remote control and placed the items out of the resident's reach so she had completed an incident report and reported the incident to Social Services. LPN #1 stated at times staff complained about SRNA #13 being hateful and rude; however, that was the first complaint she had received about the SRNA taking the residents' items. Further interview with LPN #1 on [DATE] at 12:43 PM revealed she overheard the staff talking about SRNA #13 being loud, rude, and hateful to the residents; however, she felt that was just (SRNA #13's) personality and she (SRNA #13) was loud. Interview on [DATE] at 12:34 PM with LPN #6 revealed no residents or staff had reported any instances involving SRNA #13 to the LPN; however, he stated he often overheard the staff talk about SRNA #13 being rude and hateful to the residents. LPN #6 stated he had heard the staff talk about the SRNA placing residents' items out of their reach; however, LPN #6 stated he did not feel the actions were abusive so he did not report them. Interview on [DATE] at 1:17 PM with LPN #5 revealed she had not had reports from residents about SRNA #13; however, the LPN had worked with SRNA #13 and felt the SRNA had a bad attitude, so she educated the SRNA on her approach with residents. LPN #5 stated she felt SRNA #13 aggravated the residents with her choice of words. LPN #5 denied reporting the incidents to administrative staff because she felt providing the education to SRNA #13 was the appropriate action. 4. Review of the medical record for Resident #14 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. The resident passed away on [DATE]. Review of Resident #14's Significant Change MDS assessment, dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Interviews on [DATE] at 1:07 PM with SRNA #5 and on [DATE] at 8:12 AM with SRNA #8 revealed Resident #14 (now deceased ) had reported to them that SRNA #13 took the resident's urinal out of the resident's reach and instructed the resident to just go in his/her brief because the resident often spilled the urine. Further interview revealed the SRNAs had reported their concerns to administrative staff (including an Assistant Director of Nursing and Executive Director that were no longer employed by the facility) on several occasions. Interview on [DATE] at 3:10 PM with the ED revealed the facility had no documented evidence an allegation of abuse or neglect had been reported or investigated involving Resident #14. The interview further revealed all allegations of abuse and neglect should be reported to the ED and investigated. 5. Record reviews revealed the facility assessed Residents #5, #6, #7, #8, #9, #10, and #13 to require extensive assistance of two (2) staff persons for toileting and these residents were incontinent of bowel and bladder. Resident #11 required the assistance of one staff person. SRNA #13 provided care for these residents. Interview on [DATE] at 8:23 AM with SRNA #13 revealed the SRNA was still employed by the facility and had not been suspended related to an investigation. Interviews on [DATE] at 3:32 PM with SRNA #2 and, on [DATE] at 11:45 AM with SRNA #12 revealed when they made their first incontinence round on [DATE] between 8:00 AM and 9:00 AM, they found residents that SRNA #13 had cared for during the previous shift to be double-briefed and saturated with urine. The SRNAs stated they felt SRNA #13 double-briefed the residents so she would not have to provide incontinence care and change the residents throughout the night. The SRNAs stated they reported the incident to the Manager on Duty (MOD). They stated they had reported to administrative staff (an Assistant Director of Nursing that was no longer employed by the facility) prior to this incident that residents had been found to be double-briefed over the last several months, but the practice had continued. Interviews on [DATE] with Licensed Practical Nurse (LPN) #6 at 12:42 PM and Registered Nurse (RN) #2 at 8:21 AM revealed they had overheard other staff talking about issues residents had had with SRNA #13 and about residents being double-briefed, but since the allegation was not reported to them directly, they had not reported the allegations to the ED. LPN #6 failed to follow the facility's policy, as she did not report the issues related to SRNA #13. Interview on [DATE] at 1:17 PM with LPN #5 revealed the nurse had observed a resident that SRNA #13 was providing care for in [DATE] to be double-briefed; she educated the SRNA that double-briefing was inappropriate. However, LPN #5 denied reporting the incident to supervisory staff because she stated she assumed the practice would stop. LPN #5 stated SRNA #13 had a loud and abrasive personality. However, LPN #5 failed to follow the facility's policy. The policy stated the facility would take appropriate steps to prevent the occurrence of abuse and neglect and report the allegation to the facility Executive Director (ED) immediately. Interview on [DATE] at 2:49 PM with LPN #7 revealed staff had reported to her that residents were being double-briefed but she did not believe that it was happening so she did not report the incidents to supervisory staff. LPN #7 failed to follow facility policy. Interview on [DATE] at 3:02 PM and on [DATE] at 12:43 PM with LPN #1 (Unit Manager) revealed that several SRNAs had reported to her that they had found residents to be double-briefed at times. However, the LPN stated she did not report the incidents to Administration because she had not observed the residents to be double-briefed herself. Further interview with LPN #1 revealed she did not follow the facility's policy, as she stated that she could not report information that was hearsay and she had to see an incident before she could report it. Interview on [DATE] at 11:30 AM with the MOD (the Business Office Manager) revealed she was the MOD on [DATE] when the allegation that the residents were being double-briefed was reported. The interview further revealed the Manager went to one of the resident's rooms and observed that the resident was wearing two (2) briefs. She asked the staff to give her a list of the other residents that were double-briefed. The Manager (MOD) revealed she came in on the night shift and did an in-service instructing the staff to not double-brief residents because it was wasteful of the facility's supplies. Continued interview revealed the MOD did not report the allegation to the Assistant Director of Nursing (ADON) until the next day. The MOD denied she had notified the ED. She stated she had not initiated an investigation of the allegation because she did not consider the incident to be neglectful. The MOD denied staff had reported to her that SRNA #13 had ever been rude or hateful to a resident. The Manager on Duty failed to follow the facility's policy, as she failed to immediately report the incident and initiate an investigation. Review of an Education/In-Service Report, dated [DATE], revealed education was provided on the topic of excessive use of briefs/pads to the night shift staff (working on [DATE]) with the purpose to reduce the wastefulness of facility supplies. Continued review of the Education/In-Service Report dated [DATE], revealed upon rounds on the 200 Unit, Residents #5, #6, #7, #8, #9, #10, #11, and #13 were observed to be double and triple-briefed or padded. Interview on [DATE] at 2:58 PM with the ED and the DON revealed the administrative staff was not aware of the allegations until the State Survey Agency initiated the investigation on [DATE]. The Administrative staff denied being aware of any issues with SRNA #13 and the SRNA only had one verbal warning in her file related to the double-briefing incident on [DATE] that was about wasting facility supplies. The interview further revealed SRNA #13 was still employed by the facility and no disciplinary action had been taken at that time. The ED stated the facility was currently utilizing corporate staff to fulfill the roles of the ED and DON as they did not have a full time ED. The ED stated she had been at the facility since [DATE] and the DON had been at the facility since [DATE]. **The facility provided an acceptable Allegation of Compliance (AOC) on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy. 1) State Registered Nurse Aide (SRNA) #13 who allegedly failed to provide quality care was suspended by the Interim Executive Director (IED), Director of Nursing Services (DNS), Assistant Director of Nursing Services (ADNS), and the Human Resource Generalist (HRG), pending an investigation which the facility initiated on [DATE]. The facility terminated SRNA #13 on [DATE]. 2) Residents with a Brief Interview for Mental Status (BIMS) score of eight (8) to (15) fifteen (Residents #1, #2, #3, #4, #7, #9, #12, and #13) were re-interviewed by the DNS, ADNS, and the Social Services Coordinators regarding any allegations of neglect/abuse and none of these residents reported an allegation. Resident #2 stated he/she had been double-briefed once, but did not remember when or by whom. 3) Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 were all assessed by the DNS, ADNS, Restorative RN, and RN Unit Manager from head to toe for any issues related to potential abuse and/or neglect. No issues were identified. 4) All residents with a BIMS score of eight (8) or greater were interviewed by the Social Services Coordinators, IED, and DNS to determine if they had experienced abuse or neglect. Of the forty-six (46) residents with a BIMS' score of eight (8) or greater, forty-two (42) of those residents stated they did not have any reports of abuse or neglect. One (1) resident stated he/she was unsure; one (1) resident was unable to answer questions; and two (2) residents stated they had personal items removed from their reach. Resident #12 stated items had been removed from reach; and his/her cell phone was placed on a bedside table out of his/her reach. However he/she was unsure of the exact date and time this had occurred. Resident #12 gave the description of SRNA #13 as the staff person that moved his/her belongings. Resident #4 stated items had been placed out of reach. However he/she could not remember the staff member's name, but he/she did describe SRNA #13, and stated SRNA #13 had placed the items out of his/her reach. Resident #4 stated it happened at night and only occurred every once in a while. Both of the allegations for Residents #12 and #4 were reported to OIG (Office of Inspector General) and APS (Adult Protective Services) and investigated. SRNA #13 was identified and suspended for a previous allegation on [DATE]. SRNA #13 was terminated on [DATE]. 5) Skin assessments (with a focus on the perineal area) of residents who wear any incontinence product were conducted by the DNS, ADNS, Restorative RN, RN Unit Manager, and Registered Nurse Assessment Coordinators (RNAC) to determine the presence of any rashes, bruising or fungi. No issues were noted and no resident was observed to be double-briefed. 6) Full head to toe skin assessments were performed by the DNS, ADNS, Restorative RN, RN Unit Manager, Field Service Clinical Director (FSCD) and an RN, on all residents (both continent and incontinent) and any new skin issues were reported to the resident's respective Medical Doctor (MD), interested party. None were determined to be of an unknown origin or related to being double-briefed. 7) All residents with a BIMS' score less than eight (8) were observed by the Social Services Coordinators, Admissions Director, Accounts Payable Clerk, and the IED for signs and symptoms of abuse, neglect, exploitation, and misappropriation. No issues were noted. Additionally, the residents with a BIMS' score below eight (8) had their respective interested parties contacted to inquire if they had any concerns with the care provided to their resident. Any concerns expressed by the interested parties that alleged an allegation of abuse, neglect, exploitation, or misappropriation were reported to the Office of Inspector General (OIG) and Adult Protective Services (APS) within the allowed twenty-four (24) hour timeframe and were investigated and followed up on as required. 8) All facility staff was interviewed related to any knowledge of neglect or abuse by the Social Services Coordinators. Findings: One CNA admitted to witnessing a resident being double-briefed, but stated she did not inform anyone. She has been re-trained ([DATE]) in abuse/neglect prevention and reporting and now understands her role in informing her supervisor or other management staff. 9) All incontinent residents had (on [DATE]) their weight and height reviewed for proper sizing of their respective brief size by the DNS, ADNS, and Central Supply. All residents requiring a change in brief size had the change completed. 10) An audit of voiding patterns of incontinent residents to identify copious nocturnal voiding was conducted by the DNS, Central Supply Clerk, and night shift SRNAs. Twenty-two (22) residents were identified by the staff to have a copious nocturnal voiding pattern. This was determined by reviewing their brief usage, the need to change the resident's linens, and by interviewing night shift SRNAs. 11) The facility's Restorative RN and RNACs conducted a bowel and bladder assessment on all residents to ensure if they needed to use a brief that they have them. 12) All staff working at the facility were trained on [DATE] by the Social Services Coordinators and Human Resources Director regarding abuse, neglect, and misappropriation, in accordance with company policy. New employees, those on leave and/or vacation, as well as any temporary agency staff that were not trained on [DATE], will be trained prior to their first shift back in the facility. 13) The Area Vice President (AVP) in-serviced the Interim Executive Director (IED) and Director of Nursing Services (DNS) on Abuse, Neglect, Exploitation, and the requirement to report and investigate allegations. The policy and procedure of Golden Living Centers on the prevention of Abuse, Neglect, Exploitation, and Misappropriation as well as the Federal and Kentucky regulations requiring the reporting of allegation was used to conduct this in-service. The IED is the Administrator of record for the facility and has been since [DATE], the SSA was notified of this on [DATE] via Certified Return Receipt mail. The IED is an RN, MSN, and LNHA and has been in the long term care business since 1978; she has been a Licensed Nursing Home Administrator since 1996. The IJ cited on [DATE] was based upon an issue identified by OIG to have allegedly occurred on [DATE]. All future Interim Executive Directors or hired full-time Executive Directors and DNS will receive training by the AVP or FSCD prior to beginning their work. The training will include the policy and procedure of the Living Centers on the prevention of Abuse, Neglect, Exploitation, and Misappropriation as well as the federal and state regulations requiring the reporting of allegations. 14) The personal cell phone number of the IED, DNS, and AVP were posted on the walls of public areas by Medical Records to inform residents and family members of whom to call with a concern. 15) All residents were given a copy of the IED, DNS, FSCD, and AVP personal cell phone numbers to contact the Social Services Coordinators and Activities Assistant with any concerns or allegations of Abuse, Neglect, Exploitation, or Misappropriation. 16) A special meeting was called for the Resident Council. This meeting was held by the Activity Director and the IED to ensure residents were aware of the allegation made regarding neglect and to assure them of their safety and non-reprisal policy should any of them ever have a concern to report. Further, the avenues for reporting any concerns were addressed. None voiced a care concern or fear of any similar reporting. 17) The facility is conducting rounds on each shift/2 times per day to check for neglectful care to ensure all abuse and neglect is investigated properly and reported timely. The Manager on Duty (MOD), ADNS, DNS, Unit Managers, and Department Heads were trained by the IED who received training from the AVP on how to conduct these rounds. The examples of situations where abuse and neglect may be reviewed include, but are not limited to the following: a. Resident Grooming-- Hair clean and combed; Eyes and ears clean; Face clean before and after meals; Oral care mouth and tongue clean; Fingernails and toenails cut and clean; Skin lubricated (no dry, flaky skin); Hand rolls and other restorative devices in place as indicated by care plan. b. Resident in Bed-- Body free of odor; Skin clean and dry with attention to creases; Skin lubricated; Bed linen clean and dry; Positioning and supportive devices in place per care plan; Turning and repositioning resident; Catheter tubing and bag properly positioned, leg bands present; Urinals empty, clean and within reach; Call light accessible and answered promptly; Water pitcher with lid and in reach; No excessive padding on bed; Privacy observed; Clothing clean and dry; Lab robe or cover - no exposure; No more than one brief in use. c. Room Condition-- Over the bed table clean and free of clutter and spills; Bathroom area clean - No bedpan, urinal, basin on back of toilet; Personal items labeled and stored; No safety issues noted. As well as any other area that might be considered as neglect or abuse. The rounds from [DATE] through [DATE] did not result in an allegation of abuse or neglect. 18) The Quality Assurance Performance Improvement (QAPI) meeting was held on [DATE] with the following members in attendance: IED, DNS, ADNS, Activity Director, Social Workers, Unit Managers, Director of Resident Assessment, HRG, Maintenance Director via phone, Medical Director via telephone, and the Director of Rehabilitation. 19) The AVP or Field Service Clinical Director (FSCD) or IED or DNS or ADNS or Manager on Duty (MOD) will be in the center seven (7) days per week for the next four (4) weeks to monitor care, interview residents and staff; all concerns will be reviewed by the QAPI Committee weekly for the next four (4) weeks. All facility rounds being conducted twice a day will be reviewed in the weekly QAPI meeting for the next four (4) weeks. Rounds from [DATE] through [DATE] did not result in an allegation of abuse or neglect. 20) The FSCD or the AVP will monitor (read and ensure all steps are followed up with the resident concern and sign off on the grievance report) all family and resident concerns weekly for the next six (6) months to ensure all allegations are reported timely, investigated completely, and reported to the proper agencies (i.e., OIG, APS, etc.). 21) All grievances over the past 60 days were reviewed by the AVP to ensure all allegations were reported timely, investigated completely, and reported to the proper agencies. There were no grievances from the past 60 days that were not followed up with properly, with the exception of the concern raised by staff on the double-briefing of residents which led to the initial complaint of double-briefing. 22) The IED and the DNS were again in-serviced by the AVP on abuse, neglect, exploitation, and misappropriation, as well as how to and who to report any occurrence. The AVP also in-serviced in detail about reporting, investigating, and concluding an investigation. 23) The IED in-serviced all Department Heads on abuse, neglect, exploitation, and misappropriation, as well as how to and who to report any occurrence. The IED also in-serviced in detail about reporting, investigating, and concluding an investigation. The IED involved the Department Heads in going back and reviewing and summarizing the findings for four (4) investigations. 24) All Staff at the facility were trained on [DATE] and [DATE] including contract staff (rehabilitation, housekeeping, and agency) by the Social Services Coordinators, the RN Unit Manager, the Activity Director, and the IED in accordance with the facility's policy on abuse, neglect, and misappropriation, as well as how to and who to report any occurrence. 25) All newly hired staff including contract staff (rehabilitation, housekeeping, and agency) will be in-serviced by the HRG or the DNS or the IED on abuse, neglect, exploitation, and misappropriation, as well as on how to and who to report any occurrence. ****The State Survey Agency verified the removal of Immediate Jeopardy as follows: 1) Review of facility documentation, 3 Step Employee Memorandum, dated [DATE], revealed SRNA #13 was suspended due to an investigation of abuse and neglect related to double-briefing and removal of personal items such as cell phone and television remotes. Interview on [DATE] at 4:38 PM with the ED revealed SRNA #13 had been suspended on [DATE] and terminated from employment on [DATE]. 2) Review of facility documentation revealed all interviewable residents were interviewed by facility staff regarding allegations of abuse/neglect and no further allegations were reported. Interviews on [DATE] with Social Worker (SW) #1 at 2:11 PM and SW #2 at 2:31 PM revealed all residents in the facility have been interviewed at least three (3) times about abuse/neglect. 3) Review of facility documentation revealed residents that were not interviewable (Residents #5, #6, #8, #9, #10, and #11) were assessed from head to toe by facility staff. Interviews with RN #1 (Unit Manager) at 2:59 PM and RN #4 (Restorative Nurse) at 3:16 PM revealed Residents #5, #6, #8, #9, #10, and #11 were assessed from head to toe for signs and symptoms of abuse and neglect and no new issues were identified. 4) Review of the facility's documentation revealed that all interviewable residents were interviewed regarding abuse and neglect. Further review of the investigations revealed the allegations involving Resident #4 and Resident #12 were investigated appropriately. SRNA #13 was suspended and then terminated as a result of the facility's investigations. Interviews on [DATE] with SW #1 at 2:11 PM, SW #2 at 2:51 PM, and the ED at 4:38 PM revealed all interviewable residents were interviewed and any allegations of abuse identified as a result of the interviews were investigated. 5) Review of the facility's documentation revealed all residents that wear an incontinence product had their skin assessed and no issues were identified related to skin impairment or double-briefing. Interviews on [DATE] with RN #1 (Unit Manager) at 2:59 PM, RN #4 (Restorative Nurse) at 3:16 PM, Registered Nurse Assessment Coordinator (RNAC) #1 at 3:34 PM, and RNAC #2 at 3:38 PM revealed all residents that used incontinence products, such as briefs, were assessed and no new issues were identified. 6) Review of the facility's documentation revealed full head to toe assessments were performed on all residents and any new skin issues identified were reported to the resident's MD and RP, and none were determined to be of unknown origin. Interviews on [DATE] with RN #1 (Unit Manager) at 2:59 PM and RN #4 (Restorative Nurse) at 3:16 PM, revealed head to toe assessments were completed on all residents and any skin issues identified were reported to the resident's MD and RP and there were no issues that were determined to be of unknown origin. 7) Review of the facility's documentation revealed facility staff observed all non-interviewable residents for abuse and neglect. Continued review of the documentation revealed the facility staff also contacted the residents' interested parties and inquired if they had any concerns related to the care that was provided to the residents and any concerns that alleged abuse or neglect were reported and investigated. Interviews on [DATE] with SW #1 at 2:11 PM, SW #2 at 2:31 PM, and the ED at 4:38 PM revealed all non-interviewable residents were obs(TRUNCATED)

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 ensure services were provided in accordance with each resident's written plan of care for one (1) of six (6) sampled residents (Resident #1). Review of Resident #1's Comprehensive Care Plan effective 01/21/15, revealed the facility had assessed Resident #1 as being at risk for wandering and elopement and had initiated interventions including 15-minute visual checks and providing redirection as needed. However, on 01/21/15, staff failed to perform the visual checks as required and although at least three (3) staff members were aware Resident #1 was wandering around the facility and off his/her unit, staff failed to provide the resident with the required redirection. (Refer to F323.) On 01/21/15, Resident #1 exited the facility without staff knowledge. Resident #1 was discovered by a staff member, who was exiting the facility to go on break, at approximately 3:24 AM. Resident #1 was outside the facility in a wheelchair unattended in the parking lot adjacent to the facility's breezeway. Review of archived weather records revealed on 01/21/15, at 3:15 AM, the temperature in the vicinity of the facility was 41 degrees Fahrenheit with a wind chill index of 35 degrees Fahrenheit. The resident was wearing a polyester dress with tall socks and loafer-style shoes and a jersey cardigan with a sweatshirt-type lining. Staff assisted Resident #1 back into the facility and determined the resident had not sustained any injury. The facility's failure to have an effective system in place to ensure interventions on the care plan were provided as required 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 01/21/15 at 42 CFR 483.20 Resident Assessment (F282) and 483.25 Quality of Care (F323) with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/28/15. An acceptable Allegation of Compliance was received on 02/04/15 which alleged removal of the Immediate Jeopardy on 02/04/15. A partial extended survey was conducted on 02/05-06/15. The State Survey Agency determined the Immediate Jeopardy was removed on 02/04/15 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F282) and 42 CFR 483.25 Quality of Care (F323) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Director of Nursing Services on 02/05/15 at 12:16 PM revealed the facility did not have a policy and procedure related to the development of Comprehensive Care Plans; the facility utilized the Resident Assessment Instrument for guidance in completing resident care plans. Review of the facility's policy, "Elopement Guideline," revised 2013, revealed residents assessed to be at risk for elopement would be reassessed quarterly and as needed. The policy also stated the facility would implement a care plan that addressed the resident's potential to wander or exit the facility, and the measures which would be taken to prevent wandering/elopement. Review of the facility's investigation initiated on 01/21/15 revealed at approximately 3:15 AM, staff observed an emergency exit door to be alarming and ajar. Approximately nine minutes later, a staff member exited the facility for a routine break and discovered Resident #1 outside the facility unattended in the parking lot adjacent to the facility's breezeway. The facility's investigation determined the resident had exited the building from an emergency exit door located at the end of the Unit 100 second hallway, and traveled in the wheelchair approximately 155 feet to the area where the resident was found. Review of the medical record for Resident #1 revealed the facility admitted the resident on 11/30/12. The facility assessed the resident to be an elopement risk on 12/07/12, and placed the resident on visual checks every 30 minutes to ensure the resident's safety and whereabouts. Review of Resident #1's Comprehensive Care Plan dated 01/15/15, revealed the facility had identified that Resident #1 was exhibiting increased restlessness, wandering about the facility, going to exit doors and pushing on the handle, trying to open the doors, and making statements about leaving. As a result of the behavioral changes exhibited by Resident #1, the Care Plan directed staff to increase Resident #1's visual checks to every 15 minutes. The Care Plan also stated staff should provide redirection to Resident #1 as needed. Review of Resident #1's Minimum Data Set (MDS) assessment completed on 01/21/15 revealed the facility assessed the resident to have moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8. Observation with Resident #1 on 01/27/15, at 3:05 PM revealed the resident was independently mobile in a wheelchair. Review of the facility's investigation and a written statement dated 01/21/15, signed by Certified Nursing Assistant (CNA) #1, revealed the CNA, who was assigned to care for Resident #1 on 01/21/15 during third shift, "followed" Resident #1 while the resident self-propelled in a wheelchair off Unit 200, where the resident resided. CNA #1 wrote in the statement, "I suspected (he/she) might try to leave the facility." However, CNA #1 failed to provide Resident #1 with redirection as required by the resident's plan of care, leaving the resident unattended on Unit 100. The statement stated that CNA #1 returned to Unit 200 and informed Licensed Practical Nurse (LPN) #1 that Resident #1 was on Unit 100. The State Survey Agency was unable to contact CNA #1 for an interview. Interviews with LPN #1 on 01/27/15, at 2:20 PM and on 01/28/15, at 6:50 AM revealed she last observed Resident #1 on Unit 200 at approximately 3:00 AM; and at approximately 3:10 AM she recognized the resident was no longer on the unit or within sight. LPN #1 stated she instructed CNA #1 at that time to find Resident #1 and return the resident to the unit before the CNA left for her lunch break. LPN #1 stated CNA #1 never reported to her that she had observed Resident #1 on Unit 100, or that she suspected the resident would try to leave the facility. Interview with Registered Nurse (RN) #3 on 01/27/15, at 6:15 PM, revealed she was assigned to Unit 300 for third shift on 01/21/15. RN #3 stated she observed Resident #1 self-propelling in a wheelchair on Unit 100 attempting to enter a resident's room at approximately 3:00 AM on 01/21/15. RN #3 stated she redirected Resident #1 out of the room, and then alerted the Unit 100 Nurse that the resident was on the unit and "to keep an eye on (him/her)." However, according to RN #3 she provided no further redirection or supervision for Resident #3. An interview was conducted on 01/27/15, at 11:48 AM with LPN #2, who was the third shift nurse for Unit 100 on 01/21/15. LPN #2 stated that RN #3 had informed her that Resident #1 was on the unit and had been redirected out of another resident's room. However, LPN #2 stated she provided no further redirection or supervision for Resident #1 to ensure the resident's safety and she did not notify the Unit 200 staff that Resident #1 was on Unit 100. LPN #2 stated she was aware that Resident #1 was at risk for elopement, but it was not unusual to observe Resident #1 to be independently mobile in the wheelchair throughout the facility. Review of the "Visual Checks" documentation for Resident #1 dated 01/21/15, revealed the visual check required for Resident #1 at 3:15 AM had not been conducted. Interviews with LPN #1 on 01/27/15, at 2:20 PM and on 01/28/15, at 6:50 AM revealed she had conducted the visual checks for Resident #1 throughout the shift because the resident had been with her. LPN #1 stated when she realized Resident #1 was no longer visible at approximately 3:10 AM, she instructed CNA #1 to "find" the resident, but CNA #1 failed to locate the resident as LPN #1 had instructed her to do. LPN #1 stated she last visualized Resident #1 at approximately 3:00 AM, and did not observe the resident again until she was discovered outside the facility unattended at approximately 3:24 AM. Interview with the Executive Director and Director of Nursing Services on 01/28/15, at 10:55 AM, revealed the facility's investigation had identified that facility staff did not provide Resident #1 with the supervision and redirection required in accordance with the resident's plan of care on 01/21/15. **The facility provided an acceptable Allegation of Compliance (AOC) on 02/04/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 was found outside of the facility at approximately 3:24 AM on 01/21/15. Resident #1 was assisted back into the facility safely. The Charge Nurse completed an assessment to rule out injury, including obtaining vital signs. 2) A head count was completed on 01/21/15 for all residents on all three units by the Charge Nurses. All residents were accounted for at that time. 3) The Executive Director and Director of Nursing Services immediately initiated an investigation of Resident #1's elopement. 4) The Accutech Bracelet worn by Resident #1 was checked by the Charge Nurse and was found to be working properly when the resident was returned inside the facility on 01/21/15. 5) On 01/21/15, the Interdisciplinary Team reviewed Resident #1's Care Plan which was updated to reflect the resident's elopement on 01/21/15. 6) The Maintenance Director checked all door alarms and the Accutech system on 01/21/15. All doors and equipment were found to be operating correctly. 7) Resident #1's family and physician were notified of Resident #1's elopement on 01/21/15. 8) The attending Physician Assistant visited Resident #1 on 01/21/15 and wrote orders for Resident #1 to have an echocardiogram performed, a chest x-ray, and laboratory tests completed. 9) A medication review was conducted for Resident #1 on 01/21/15 by the facility's consulting pharmacist and new medications were ordered by the physician. 10) Resident #1 was on visual checks every 15 minutes at the time the resident eloped from the facility. Resident #1's visual checks were increased to every 10 minutes on 01/30/15. 11) Resident #1's Comprehensive Care Plan and Certified Nursing Assistant Care Sheets were updated to reflect the 10-minute visual checks implemented on 01/30/15 for Resident #1. 12) Certified Nursing Assistants were assigned to complete the 10-minute visual checks for Resident #1. If a Certified Nursing Assistant was unable to complete the 10-minute visual checks, the Charge Nurse would then complete the visual checks for Resident #1. Nurses and CNAs were educated on the changes to the care plan/care sheets on 01/30/15 by the Interdisciplinary Team and Director of Nursing Services. 13) Resident #1 was transferred to a behavioral unit on 02/02/15. 14) All residents residing in the facility on 01/21/15 were reassessed for elopement risk by the Interdisciplinary Team and Social Services. 15) Facility Elopement Binders were reviewed and updated as indicated on 01/21/15 by Social Services staff. One additional resident was identified as an elopement risk and added to the Elopement Binders. The Director of Nursing Services and the Assistant Director of Nursing Services verified the Elopement Binders were current and up to date on 01/21/15. 16) On 01/21/15, the Interdisciplinary Team and the Assistant Director of Nursing Services audited all residents at Risk for Elopement and completed the following resident reviews: Care Plans, Care Sheets, and Certified Nursing Assistant Documentation of Accutech Bracelets, and ensured all Accutech bracelets were functioning properly. 17) The Interdisciplinary Team will continue to monitor and revise care sheets, care plans, and Accutech Bracelets daily during Clinical Start Up Meetings to ensure revisions are made as needed. The Director of Nursing Services and the Assistant Director of Nursing Services or House Supervisor will conduct the monitoring on weekends. 18) The Executive Director, Director of Nursing Services, Assistant Director of Nursing Services, and Interdisciplinary Team initiated education related to elopement guidelines to all employees, including contracted services, on 01/21/15. The training was completed on 01/23/15. Employees who have not received the training will not be permitted to work until they have received the training. 19) The Activity Director conducted assessments on 01/21/15 for all residents at risk for elopement. 20) An "Applied Audio Visual" contractor was in the facility on 01/21/15 to assess all doors in the facility. A visual and operational check was conducted for each door; all doors were found to be working properly. 21) Beginning 01/22/15, Charge Nurses will document that Accutech bracelets are in place and functioning for each resident who utilizes the device. The documentation will be done on the electronic Medication Administration Record [REDACTED] 22) Charge Nurses will check and document weekly on the electronic Medication Administration Record [REDACTED]. 23) The Director of Nursing Services and/or Assistant Director of Nursing Services will audit the Medication Administration Records daily, and the House Supervisor will conduct the audits on weekends to ensure the Charge Nurses are monitoring the functioning of the Accutech Bracelets daily and battery function weekly. 24) The Interdisciplinary Team, Assistant Director of Nursing Services, and Department Managers initiated education related to Care Sheets and Care Plans on 01/28/15 and completed the trainings on 01/29/15. Certified Nursing Assistants will review care sheets every shift to identify any resident for elopement. The training was to ensure that Certified Nursing Assistants and Nurses were aware of residents' care needs. Post tests were completed. 25) When Resident #1 is readmitted to the facility the Unit Manager will conduct a thorough assessment, including elopement risk, and the Director of Nursing Services and/or Assistant Director of Nursing Services will review the assessment. 26) Beginning 02/03/15, Charge Nurses will document visual checks every 30 minutes on residents that are at risk for elopement. If the Charge Nurse is unable to document the visual checks, the House Supervisor will be responsible for the visual checks and documentation. 27) Unit Managers will audit the Charge Nurse 30-minute Visual Check Logs every three hours per shift to ensure the visual checks are being conducted. 28) On 02/03/15, all Charge Nurses were educated by the Director of Nursing Services and/or Assistant Director of Nursing Services on the importance of conducting and documenting the 30-minute visual checks. 29) Education by the Director of Nursing Services and/or the Assistant Director of Nursing Services with the Unit Managers related to reviewing the Charge Nurse 30-minute Visual Check Log every three hours was completed on 02/03/15. If Unit Managers see concerns with documentation, corrective action will take place immediately, including re-education. 30) Reviews conducted by the Unit Managers of the Charge Nurse 30-minute Visual Check Logs will be monitored and audited by the Director of Nursing Services and/or House Supervisor daily during the Clinical Start Up meeting. On weekends the House Supervisor will review the Logs. 31) Identified concerns related to the Charge Nurse 30-minute Visual Check Logs will be reported to the Director of Nursing Services and/or the Assistant Director of Nursing Services. The Executive Director and/or the Director of Nursing Services will take corrective actions which will include re-education. 32) On 01/27/15, an "Applied Audio Visual" contractor returned to the facility and provided recommendations and presented a monetary bid to add additional Accutech equipment. The monetary bid made by "Applied Audio Visual" was approved by the facility and equipment has been ordered which will be installed on all exit doors in the facility that currently utilize the delayed emergency egress function, lead to the outside perimeter, and give residents access to off-grounds property. 33) The current alarm system includes magnetic Locks and secondary alarms. This dual alarm system is in place on the door at the end of the Unit 200 Wing, the smoking exit door, the first hall Unit 100 door, the second hall Unit 100 door, the door at the end of the hall on Unit 300, and the Therapy door in the new building addition. 34) The secondary alarms were installed on 01/29/15 and produce a loud distinctive sound when an exit door is opened. The secondary alarms can be heard at all nursing stations and rooms on each unit. This was tested by posting staff members on each unit and by the Nurses' Stations and sounding the alarms. These alarms will be in place until the new Accutech equipment is installed. The new Accutech system will sound alarms at the Nurses' Stations as well as at the door. 35) On 01/29/15, staff was educated on Elopement Guidelines and how to react to sounding alarms and potential elopements. Any staff not attending the training must receive education before returning to work. 36) Education on responding to alarms, which included activation/deactivation of secondary alarms, was conducted on 01/30/15. All staff is required to receive the training and will not be permitted to work in the facility until they have been trained on the procedures as follow: A. All staff will respond immediately to any sounding alarms. B. The door alarm should remain sounding and not turned off so additional staff can render help. C. Go to the door that is alarming and conduct an outside perimeter check. D. If no resident is noted to be outside, go back inside the door. E. Deactivate the alarm and page "golden alert"; this alerts the units to conduct a head count for all residents. F. If all residents are accounted for then page "all clear." G. If a resident is "missing" immediately page "golden alert" and announce the room number. This alerts all staff there is a "missing resident." H. If a resident is "missing" then follow the facility's elopement guideline located in the elopement book. 37) Door alarm drills were initiated on 01/21/15 and were conducted every shift by the Maintenance Director. The door alarm drills included how to react to a sounding door alarm. The drills consist of placing staff members on each unit and at each Nurses' Station. The Maintenance Director activates an alarm at a specific door. Employees answering the alarm are timed as to how long it takes them to respond to the alarming door. Employees that do not answer the alarm are immediately re-educated on the correct procedure when a door alarm is activated. 38) On 01/23/15, door alarm checks and drills were conducted and documented hourly from 8:00 AM through 11:00 PM. The Logs were audited by the Executive Director to ensure they had been completed. 39) Beginning 01/24/15 door alarm drills and door checks will be conducted every shift Monday through Friday by the Maintenance Director and/or Executive Director. The Manager on duty and/or House Supervisor will complete the door checks and alarm drills on the weekend. 40) Logs to ensure the daily door drills and door alarm checks were conducted will be audited by the Executive Director daily Monday through Friday and by the House Supervisor on weekends. 41) The Maintenance Director provided training to all staff on 01/29/15 related to activating/deactivating secondary alarms and performing door checks on the magnetic locking doors and the Accutech doors. 42) All reviews and audits will be taken to the weekly Quality Assurance Committee meetings for four weeks, then monthly, to be analyzed for trends. If concerns are identified appropriate action will be taken including system revision and education as deemed necessary. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of Nursing documentation dated 01/21/15, revealed Resident #1 required no treatment after the elopement and was assessed to have sustained no injury when returned inside the facility. Vital signs were obtained and documented; they were within normal limits. 2) Review of the facility's documentation, dated 01/21/15 and interview with Licensed Practical Nurse (LPN) #1 on 01/27/15, at 2:20 PM, LPN #2 on 01/27/15 at 11:48 AM, and RN #3 on 01/27/15 at 6:15 PM, revealed head counts were conducted on all three units and each resident was accounted for at that time. 3) Review of the facility's investigation and interview with the Executive Director (ED) on 02/06/15 at 11:50 AM and the Director of Nursing Services (DNS) on 02/06/15, revealed the investigation was initiated on 01/21/15. 4) Review of documentation, dated 01/21/15, revealed Resident #1's Accutech bracelet was in place and functioning appropriately when the resident was returned inside the facility on 01/21/15. 5) Review of Resident #1's Comprehensive Care Plan dated 01/21/15, revealed the Care plan had been updated to reflect the resident's elopement on 01/21/15. 6) Review of a Door Audit dated 01/21/15, and signed by the Maintenance Director revealed all locking mechanisms on each door in the facility were examined with no concerns noted. 7) Review of the facility's documentation revealed Resident #1's Physician and Responsible Party were notified that Resident #1 had eloped from the facility on 01/21/15. 8) Review of documentation made by the Physician Assistant (PA) revealed the PA examined Resident #1 on 01/21/15, and ordered an electrocardiogram, chest x-ray, and laboratory tests for the resident. Review of Resident #1's medical record on 01/28/15 revealed the tests had been conducted with no significant abnormalities noted. 9) Review of a Clinical Pharmacist Medication Regimen Review Summary dated 01/21/15, revealed a medication review was conducted on 01/21/15 for Resident #1, with recommendations made and approved by Resident #1's Physician. 10) Review of Visual Checks documentation revealed the facility had been conducting 15-minute visual checks on Resident #1 since 01/15/15. Documentation of Visual Checks revealed the 15-minute visual checks were increased to every 10 minutes on 01/30/15. 11) Review of Resident #1's Comprehensive Care Plan revealed it was updated on 01/30/15, to reflect the increase in visual checks to every 10 minutes for Resident #1. Review of a Certified Nursing Assistant (CNA) Care Sheet dated 01/30/15 also revealed staff was to perform visual checks for Resident #1 every 10 minutes. 12) Review of Visual Checks documented by staff for Resident #1 from 01/30/15 through 02/01/15, revealed the visual checks were documented as conducted every 10 minutes. Interviews on 02/06/15 at 10:18 AM with CNA #7, 10:42 AM with CNA #10, and 11:19 AM with RN #8 and the Unit 200 Manager, revealed they had conducted visual checks for Resident #1 from 01/30/15 through 02/01/15 every 10 minutes, and were aware of the procedures for performing the visual checks. Interview on 02/06/15 at 12:00 PM with the Director of Nursing Services revealed she had performed staff training related to conducting visual checks for Resident #1 on 01/30/15. 13) Review of nursing documentation dated 02/02/15, revealed Resident #1 was transferred to a behavioral unit on 02/02/15. Resident #1 remained out of the facility on 02/06/15. 14) Review of Risk Elopement assessments, dated 01/21/15 revealed all residents in the facility had been re-evaluated for elopement risks. Interviews on 01/28/15, at 3:23 PM with MDS (Minimum Data Set) Coordinators #1 and #2; and at 4:25 PM with the Social Services Director revealed reassessments of all residents in the facility were conducted on 01/21/15. 15) Review of the Elopement Binders located on each Nursing Unit, in the Dietary Department, Business Office, Housekeeping Area, and Therapy Department revealed the binders contained information on all residents identified to be at risk for elopement and the Elopement Guidelines and procedures. 16) Review of Clinical Audits dated 01/21/15 and interviews on 01/28/15, at 3:23 PM with MDS Coordinators #1 and #2; at 4:25 PM with the Social Services Director; and on 02/06/15, at 11:45 AM with the Assistant Director of Nursing Services revealed audits of all residents at Risk for Elopement had been completed and they had also conducted reviews of Comprehensive Care Plans, Care Sheets, Certified Nursing Assistant documentation of Accutech Bracelets, and ensured all Accutech bracelets were functioning properly on 01/21/15. 17) Review of Clinical Start Up Meeting documentation dated 02/05/15 and interviews on 02/06/15 at 12:00 PM with the Director of Nursing Services, at 11:45 AM with the Assistant Director of Nursing Services, and at 10:12 AM with RN #4, the Weekend Supervisor, revealed the Care Sheets, Care Plans, and Accutech bracelets were monitored daily during the Clinical Start Up meeting and as needed, and would also be performed on weekends by the House Supervisor. 18) Review of In-service Training "Elopement Guidelines" dated 01/21/15-01/23/15, revealed the training had been conducted by staff including the Executive Director and Director of Nursing Services. Interviews on 02/06/15 at 11:19 AM with RN #8, 10:56 AM with RN #5, 10:36 AM with LPN #5, 11:06 AM with LPN #7, 10:50 AM with LPN #6, 10:18 AM with CNA #7, 10:24 AM with CNA #8, 10:30 AM with CNA #9, 10:42 AM with CNA #10, and at 11:35 AM with CNA #11, and on 02/05/15, at 4:15 PM with LPN #7, at 4:06 PM with CNA #12, at 4:30 PM with CNA #13, at 4:58 PM with the Business Office Manager, at 4:26 PM with PTA (Physical Therapy Assistant) #1, at 4:28 PM with the Rehabilitation Manager, at 4:40 PM with the Dietary Manager, and at 4:10 PM with Housekeeping Staff #1 revealed all the staff interviewed had attended the training and were knowledgeable related to the locations of the Elopement Binders and the Elopement Guidelines. Staff interviewed was able to verbally state the steps to take if an exit door was found alarming and/or a resident had eloped from the facility. 19) Review of Activity assessments for residents identified to be at risk for elopement revealed assessments were conducted on 01/21/15. 20) Review of documentation revealed "Applied Audio Visual" was in the facility on 01/21/15, and found no concerns with exit doors. 21) Interviews on 02/06/15, at 10:36 AM with LPN #5, 11:06 AM with LPN #7, and 10:50 AM with LPN #6, and review of Medication Administration Records for Residents #1, #2, #3, #5, #6, and #7 revealed documentation by nurses that the Accutech bracelets were in place and functioning every shift was contained on the Medication Administration Records. 22) Interviews on 02/06/15, at 10:36 AM with LPN #5, 11:06 AM with LPN #7, and 10:50 AM with LPN #6, and review of Medication Administration Records for Residents #1, #2, #3, #5, #6 and #7 revealed documentation by nurses that the Accutech bracelet batteries worn by the residents were checked weekly for functioning utilizing the activation/deactivation boxes. Interview with Resident #6 on 02/05/15, at 3:08 PM revealed staff had brought a device to the resident's room and checked the bracelet's functioning. 23) Review of the Accutech Bracelets Medication Administration Record [REDACTED]#4, the Weekend Supervisor, revealed they had conducted audits of the Medication Administration Records for residents at risk for elopement to ensure the bracelet functioning and battery functioning had been conducted by the nurses as required. 24) Review of in-service training "Care Sheets and Care Plans" dated 01/28-29/15, and Post Tests also dated 01/28/15 and 01/29/15, revealed the training had been conducted and staff had been administered the test. Interviews on 02/05/15 at 4:06 PM with CNA #12, at 4:30 PM with CNA #13, and on 02/06/15 at 10:18 AM with CNA #7, at 10:24 AM with CNA #8, at 10:30 AM with CNA #9, at 10:42 AM with CNA #10, and at 11:35 AM with CNA #11 revealed the staff had received the training and taken the post test. Staff interviewed was knowledgeable on how to obtain the care sheets, what information was contained on the care sheets, and their responsibility to review the care sheets to ascertain each resident's care needs. 25) Resident #1 remained out of the facility on 02/06/15. 26) Review of Visual Checks dated 02/03/15 through 02/05/15 for Residents #2, #3, #5, #6 and #7 revealed nurses had documented they had visualized the residents every thirty (30)minutes. Interviews on 02/06/15 at 10:36 AM with LPN #5, at 11:06 AM with LPN #7, and at 10:50 AM with LPN #6 revealed they were knowledgeable regarding the visual checks and had conducted the checks as required. Interview on 02/06/15, at 10:12 AM with RN #4, the Weekend Supervisor, revealed she was knowledgeable regarding that if the Charge Nurses were unable to perform and document the visual checks for residents identified to be at risk for elopement it would be the House Supervisor's responsibility to conduct and document the visual checks. 27) Review of the Unit Manager Visual Check Audits dated 02/03-05/15, and interviews on 02/06/15 at 11:19 AM with RN #8, the Unit 200 Manager; and at 10:56 AM with RN #5, the Unit 300 Manager, revealed the Unit Managers had been conducting audits every three (3) hours to ensure Charge Nurses were completing the visual checks as required. 28) Review of documentation revealed in-service training was conducted on 02/03/15 by the Director of Nursing Services and Assistant Director of Nursing Services related to Charge Nurses conducting the visual checks for residents identified to be at risk for elopement. Interviews on 02/05/15 at 4:15 PM with LPN #7; and on 02/06/15 at 10:36 AM with LPN #5, at 11:06 AM with LPN #7; and at 10:50 AM with LPN #6, revealed the Charge Nurses received the training and were knowledgeable regarding the process for conducting and documenting visual checks for residents identified to be at risk for elopement. 29) Review of documentation revealed in-service training was conducted on 02/03/15 by the Director of Nursing Services and Assistant Director of Nursing Services for Unit Managers related to Charge Nurses conducting the visual checks for residents identified to be at risk for elopement. Interviews on 02/06/15 at 11:19 AM with RN #8, the Unit 200 Manager and at 10:56 AM with RN #5, the Unit 300 Manager, revealed they had attended the training and were knowledgeable regarding auditing the Charge Nurse's visual check and if concerns were identified to take immediate corrective action including re-education. 30) Review of Audits performed by the Director of Nursing Services and House Supervisors and interview on 02/06/15 at 12:00 PM with the Director of Nursing Services, and at 10:12 AM with RN #4, the Weekend House Supervisor, revealed they had conducted daily reviews to ensure visual checks were being performed as required for residents in the facility identified to be at risk for elopement. 31) Interviews on 02/06/15 at 12:00 PM with the Director of Nursing Services, at 11:45 AM with the Assistant Director of Nursing Services; and at 11:50 AM with the Executive Director revealed no identified concerns had been identified with staff performing the visual checks as required for residents identified to be at risk for elopement. 32) Review of documentation dated 01/27/15 revealed an "Applied Audio Visual" contractor submitted a bid to the facility for installation of equipment to doors in the facility. Interview on 02/06/15 at 11:50 AM with the Executive Director of the facility revealed all exit doors in the facility currently utilizing a delayed emergency egress function and leading to the outside perimeter which gives residents access to off-grounds property will be equipped to fun

Based on observation, interview, record review, review of the facility's investigation and review of the facility's policy and procedures, it was determined the facility failed to have an effective system in place to ensure that one (1) of six (6) 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 the resident on elopement precautions including "30 minute visual checks" which required staff to visually observe Resident #1 to ensure the resident was safe and that staff was aware of the resident's whereabouts. The precautions also included providing Resident #1 with an Accutech 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). On 01/15/15, the facility identified Resident #1 to be exhibiting an increase in exit-seeking behaviors; and at that time the facility increased the resident's visual checks to every 15 minutes. However, the facility failed to ensure the visual checks were performed as required, and Resident #1 exited the facility on 01/21/15 at approximately 3:15 AM, without staff knowledge, and was discovered outside the facility unattended at approximately 3:24 AM when a staff member exited the facility while on a break. Resident #1 was escorted back into the facility by staff and assessed to have sustained no injuries. Additionally, the facility failed to ensure that the exit doors in the facility were maintained and functioning appropriately to effectively minimize the risk of residents exiting the facility without staff knowledge. 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 01/21/15 at 42 CFR 483.20 Resident Assessment (F282) and 483.25 Quality of Care (F323) with Substandard Quality of Care at 42 CFR 483.25 Quality of Care (F323). The facility was notified of the Immediate Jeopardy on 01/28/15. An acceptable Allegation of Compliance was received on 02/04/15 which alleged removal of the Immediate Jeopardy on 02/04/15. A partial extended survey was conducted on 02/05-06/15. The State Survey Agency determined the Immediate Jeopardy was removed on 02/04/15 as alleged, which lowered the scope and severity to "D" at 42 CFR 483.20 Resident Assessment (F282) and 42 CFR 483.25 Quality of Care (F323) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, "Elopement Guidelines," revised 2013, revealed the facility would assess each resident upon admission, quarterly, and as needed to establish elopement risks. The guidelines directed staff to perform eight specific steps to locate a missing resident; however, the guidelines did not address specific steps for staff to follow when an exit door was found alarming and/or open and it was unknown if, or specifically which, if any, resident had exited the facility. The policy also indicated the facility would identify environmental hazards such as entrances/exits "that pose a foreseeable danger to residents who wander or have an exit seeking behavior," and implement interventions to minimize the risks as appropriate. Record review revealed the facility admitted Resident #1 on 11/30/12, with [DIAGNOSES REDACTED]. The facility assessed Resident #1 to be at risk for elopement on 12/07/12. Elopement precautions initiated for Resident #1 on 12/07/12, included placing the resident on "30 minute visual checks" which required staff to visually observe Resident #1 to ensure the resident was safe and that staff was aware of the resident's whereabouts. Review of a "Risk for Elopement" assessment for Resident #1 dated 01/04/15, revealed the facility assessed Resident #1 to continue to be a risk for elopement. Review of Behavior Charting for Resident #1 and the resident's Comprehensive Care Plan both dated 01/15/15 revealed staff had identified that Resident #1 was exhibiting increased restlessness and exit-seeking behaviors. The facility increased the resident's visual checks to every 15 minutes on 01/15/15. Review of Resident #1's Minimum Data Set (MDS) assessment completed 01/21/15 revealed the facility assessed the resident to have moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8. Review of the facility's investigation initiated on 01/21/15 revealed at approximately 3:15 AM on 01/21/15, Registered Nurse (RN) #3, who was working on Unit 300 heard an alarm and discovered the Unit 100 second hall emergency exit door was alarming and open. RN #3 looked outside the door without exiting the facility, and observed no resident. However, when CNA #1 exited the facility during her lunch break on 01/21/15, at approximately 3:24 AM she discovered Resident #1 outside the facility in a wheelchair, unattended, in the parking lot adjacent to the facility's breezeway. Facility staff assisted Resident #1 back into the facility and assessed the resident to have sustained no injury. Observation of Resident #1 on 01/27/15, at 10:50 AM, revealed the resident to be independently mobile in a wheelchair. Review of a written statement dated 01/21/15, provided by Certified Nursing Assistant (CNA) #1, who was caring for Resident #1 on 01/21/15, revealed at approximately 2:50 AM she observed Resident #1 self-propelling in a wheelchair on Unit 200 where the resident resided. CNA #1 stated she "suspected (Resident #1) might try to leave the facility" so she "followed" Resident #1 to Unit 100, then returned to Unit 200 to inform Licensed Practical Nurse (LPN) #1 that Resident #1 was on Unit 100. She did not redirect the resident and left the resident unattended. Interviews with LPN #1 on 01/27/15, at 2:20 PM and on 01/28/15, at 6:50 AM revealed she was caring for Resident #1 on 01/21/15. LPN #1 stated Resident #1 had been awake and self-propelling in a wheelchair, following her as she performed her duties, since the beginning of the shift on 01/20/15 at 10:30 PM. LPN #1 stated she last visualized Resident #1 at approximately 3:00 AM, prior to her leaving Unit 200. LPN #1 stated upon returning to Unit 200 at approximately 3:10 AM she noticed Resident #1 was not on the unit or within sight. LPN #1 stated at that time she instructed CNA #1 to locate Resident #1 before she (CNA #1) went to lunch and return the resident to Unit 200. LPN #1 stated at no time did CNA #1 inform her that Resident #1 was on Unit 100 or that CNA #1 suspected Resident #1 would attempt to leave the facility. Review of the "Visual Checks" documentation dated 01/21/15, revealed staff failed to perform the 3:15 AM visual check to identify the resident's whereabouts and ensure the resident's safety. Interviews with RN #3 on 01/27/15, at 6:15 PM, and on 01/28/15, at 10:34 AM, 2:38 PM and 4:43 PM revealed she was the third shift nurse assigned to Unit 300 on 01/21/15. RN #3 stated at approximately 3:00 AM she observed Resident #1 self-propelling on Unit 100, attempting to enter another resident's room. RN #3 stated at that time she redirected Resident #1 out of the other resident's room, and alerted the Unit 100 nurse that Resident #1 was on the unit and to "keep an eye on (him/her)." RN #3 stated she went back to Unit 300 to count medications with Pharmacy staff that had arrived at the facility. RN #3 stated as she was signing the last pharmacy receipt dated 01/21/15 and timed 3:15 AM, she heard a "faint" alarm sounding and discovered it was the Unit 100 second hall emergency exit door alarming and that the door was "ajar." RN #3 stated she looked through the glass of the door and "opened it (the door) just a little," but did not step out, and did not see anyone in the vicinity. RN #3 stated she then silenced the alarm, shut the door, and proceeded to attempt to locate other facility staff to notify them she had discovered the door ajar and the alarm sounding. However, according to RN #3, by the time she located staff Resident #1 had already been located outside of the facility, nine minutes after she first heard the door alarming. RN #3 stated she had planned to search the perimeter of the facility once she had located other staff and notified them of what had transpired. However, RN #3 stated she was not aware of the facility's specific sequential steps for staff to follow when an exit door was found to be alarming and/or open to make a timely determination if or which resident had exited the facility. Interview on 01/27/15 at 11:48 AM, with LPN #2, who was the Unit 100 Nurse on 01/21/15 for third shift, revealed she did recall RN #3 stating to her that Resident #1 was on Unit 100, but it was not uncommon for the resident to self-propel in the facility, and she took no action to redirect the resident or notify Unit 200 staff of the resident's whereabouts. Review of a written statement dated 01/21/15 and signed by CNA #1, and review of the facility's "time punch" records, revealed CNA #1 clocked out for lunch break at 3:24 AM, and upon exiting the facility discovered Resident #1 outside in a wheelchair unattended in the parking lot adjacent to the facility's breezeway. According to the facility's investigation and CNA #1's statement, she went back into the facility to notify LPN #1 that she had found the resident outside the facility, again leaving the resident outside unattended without supervision. Review of archived weather records revealed the temperature in the facility's area at 3:15 AM on 01/21/15, was 41 degrees Fahrenheit with a wind chill index of 35 degrees Fahrenheit. The resident was wearing a polyester dress with tall socks and loafer-style shoes and a jersey cardigan with a sweatshirt-type lining. Facility staff assisted Resident #1 back into the facility and assessed the resident to have sustained no injuries. Further review of the "Risk for Elopement" assessment dated [DATE], for Resident #1 revealed staff assessed the resident to continue to be an elopement risk, indicating the resident self-propels in a wheelchair "but does wear wrist alarm which triggers outside doors." Observation of exit doors in the facility conducted with the Executive Director on 01/27/15, at 3:05 PM revealed seven exit doors in the facility were accessible to residents, including the Unit 100 second hall emergency exit door, and were not equipped to operate with the facility's Accutech system. Observations revealed the exit doors that were not equipped with the Accutech system would emit an audible alarm three seconds after the push bar was engaged when attempting to open the door. The alarm continued to sound when the magnetic locks released the door after fifteen seconds of continued pressure being applied, and could not be silenced until a numerical sequence was entered into a keypad adjacent to the door which reset the door alarm. Observation of the Unit 100 second hall emergency exit door also revealed a small device secured to the upper part of the door along the inside hinge. According to the Executive Director, the device had been in place on the door prior to his employment at the facility. However, the Executive Director explained the device functioned as a "secondary" alarm which also emitted an audible alarm when the door was open, and operated independently of the magnetic door lock alarm utilized to alert staff when the door was open. A "key" device used to silence the secondary alarm was located on the medication cart keys for staff to utilize if the alarm sounded. The facility was not utilizing the "secondary" alarm and it was inoperable at the time of the door observation on 01/27/15. Demonstration of the audible alarm emitted by the Unit 100 second hall emergency exit door on 01/27/15, at 3:10 PM revealed the sound of the alarm became very faint at the end of the Unit 100 hallway and was undetectable at the Unit 100 Nurses' Station located approximately 159 feet from the exit door and at the 300 Unit Nurses' Station located approximately 150 feet from the exit door. Interview with RN #3 on 01/27/15, at 6:15 PM, and on 01/28/15, at 10:34 AM, 2:38 PM, and 4:43 PM revealed when she first detected the sounding alarm on 01/27/15, the sound was faint and she first perceived it to be an intravenous (IV) medication pump alarming. RN #3 stated the alarm was "not very loud" and was "hard to hear," indicating the alarm could have been sounding prior to 3:15 AM, but she failed to hear it. RN #3 stated it was the first time she had heard the door alarm and "thought it would have been louder." RN #3 stated that she silenced the alarm by entering the numerical sequence into the keypad, but did not have to use the "key" for the secondary alarm, because "it was not alarming." Interviews conducted on 01/27/15 at 11:48 AM with LPN #2, at 2:00 PM with CNA #4, at 2:20 PM with LPN #1, at 2:50 PM with CNA #2, at 5:00 PM with CNA #3, on 01/28/15 at 7:08 AM with CNA #5, and on 01/29/15 at 2:21 PM with CNA #6, and review of a written statement dated 01/21/15 by CNA #1, who were all working in the facility during third shift on 01/21/15, and interview on 01/28/15 at 2:45 PM with Pharmacy staff delivering medications in the facility on 01/21/15 from approximately 3:00 AM until 3:30 AM revealed none of the staff interviewed, including the Pharmacy staff, heard an exit door alarm sound on 01/21/15. Interview with the Maintenance Director on 01/28/15, at 3:45 PM, revealed he conducted daily door audits which included the Unit 100 second hall emergency exit door. Review of the Door Audit documentation for January 2015 revealed the magnetic locks, keypad, and alarm on all the doors were all included in the daily door audits; however, the documentation did not indicate how each of the three identified components were "audited." The Maintenance Director stated that he checked the magnetic locks to ensure the door was locked by applying pressure to the push bar, and the alarm was checked by visually observing a light which flashed within the three seconds prior to the audible alarm sounding which indicated the system was working, and therefore the audible alarm was not always engaged during the daily door audit. The Maintenance Director stated he visually observed the keypad to ensure the lights indicated it was functioning properly and that no keys were "stuck" on the keypad. The Maintenance Director stated the daily door audits had been conducted primarily on first shift and he had never conducted any testing related to how far from the door the alarm was audible or how easily detectable the alarms were for staff to hear at various times and in various locations in the facility. The Maintenance Director stated that staff had voiced to him "things like it (the door alarm) is not very loud," but he could not recall if they had made the statements before or after 01/27/15. The Maintenance Director stated the secondary alarm was not required to be on the door and thought "it was working" on 01/27/15, but he "can't be sure" because he did not check the "secondary" alarm at regular intervals for functioning. Continued interview with the Maintenance Director revealed he was also required to perform Monthly Door Alarm Drills on all doors equipped with a security system. Review of the Monthly Door Alarm Drill form revealed ten steps were required to be followed which included activating the door alarm, timing staff response to the alarm, and questioning staff on proper procedures. However, the Maintenance Director stated that although he had been conducting the monthly audits, he was not performing the audits in any sequential manner to ensure each door was tested within a certain timeframe. The Maintenance Director further stated he was not recording the monthly audits, and therefore was unable to state if or when the Unit 100 second hall emergency exit door had undergone a monthly door alarm audit. Interview with the Executive Director on 01/28/15 at 5:00 PM revealed he was unaware of any problems related to the functioning of the facility door alarms, and conducted no oversight related to the door audits performed by the Maintenance Director prior to 01/21/15. The Executive Director stated since he had been employed at the facility there had not been a resident elopement, and he had identified no areas of concern related to the elopement policies or procedures utilized by the facility. **The facility provided an acceptable Allegation of Compliance (AOC) on 02/04/15. The facility implemented the following actions to remove the Immediate Jeopardy: 1) Resident #1 was found outside of the facility at approximately 3:24 AM on 01/21/15. Resident #1 was assisted back into the facility safely. The Charge Nurse completed an assessment to rule out injury, including obtaining vital signs. 2) A head count was completed on 01/21/15 for all residents on all three units by the Charge Nurses. All residents were accounted for at that time. 3) The Executive Director and Director of Nursing Services immediately initiated an investigation of Resident #1's elopement. 4) The Accutech Bracelet worn by Resident #1 was checked by the Charge Nurse and was found to be working properly when the resident was returned inside the facility on 01/21/15. 5) On 01/21/15, the Interdisciplinary Team reviewed Resident #1's Care Plan which was updated to reflect the resident's elopement on 01/21/15. 6) The Maintenance Director checked all door alarms and the Accutech system on 01/21/15. All doors and equipment were found to be operating correctly. 7) Resident #1's family and physician were notified of Resident #1's elopement on 01/21/15. 8) The attending Physician Assistant visited Resident #1 on 01/21/15 and wrote orders for Resident #1 to have an echocardiogram performed, a chest x-ray, and laboratory tests completed. 9) A medication review was conducted for Resident #1 on 01/21/15 by the facility's consulting pharmacist and new medications were ordered by the physician. 10) Resident #1 was on visual checks every 15 minutes at the time the resident eloped from the facility. Resident #1's visual checks were increased to every 10 minutes on 01/30/15. 11) Resident #1's Comprehensive Care Plan and Certified Nursing Assistant Care Sheets were updated to reflect the 10-minute visual checks implemented on 01/30/15 for Resident #1. 12) Certified Nursing Assistants were assigned to complete the 10-minute visual checks for Resident #1. If a Certified Nursing Assistant was unable to complete the 10-minute visual checks, the Charge Nurse would then complete the visual checks for Resident #1. Nurses and CNAs were educated on the changes to the care plan/care sheets on 01/30/15 by the Interdisciplinary Team and Director of Nursing Services. 13) Resident #1 was transferred to a behavioral unit on 02/02/15. 14) All residents residing in the facility on 01/21/15 were reassessed for elopement risk by the Interdisciplinary Team and Social Services. 15) Facility Elopement Binders were reviewed and updated as indicated on 01/21/15 by Social Services staff. One additional resident was identified as an elopement risk and added to the Elopement Binders. The Director of Nursing Services and the Assistant Director of Nursing Services verified the Elopement Binders were current and up to date on 01/21/15. 16) On 01/21/15, the Interdisciplinary Team and the Assistant Director of Nursing Services audited all residents at Risk for Elopement and completed the following resident reviews: Care Plans, Care Sheets, and Certified Nursing Assistant Documentation of Accutech Bracelets, and ensured all Accutech bracelets were functioning properly. 17) The Interdisciplinary Team will continue to monitor and revise care sheets, care plans, and Accutech Bracelets daily during Clinical Start Up Meetings to ensure revisions are made as needed. The Director of Nursing Services and the Assistant Director of Nursing Services or House Supervisor will conduct the monitoring on weekends. 18) The Executive Director, Director of Nursing Services, Assistant Director of Nursing Services, and Interdisciplinary Team initiated education related to elopement guidelines to all employees, including contracted services, on 01/21/15. The training was completed on 01/23/15. Employees who have not received the training will not be permitted to work until they have received the training. 19) The Activity Director conducted assessments on 01/21/15 for all residents at risk for elopement. 20) An "Applied Audio Visual" contractor was in the facility on 01/21/15 to assess all doors in the facility. A visual and operational check was conducted for each door; all doors were found to be working properly. 21) Beginning 01/22/15, Charge Nurses will document that Accutech bracelets are in place and functioning for each resident who utilizes the device. The documentation will be done on the electronic Medication Administration Record every shift. 22) Charge Nurses will check and document weekly on the electronic Medication Administration Record that the Accutech batteries are functioning properly utilizing activation/deactivation boxes. 23) The Director of Nursing Services and/or Assistant Director of Nursing Services will audit the Medication Administration Records daily, and the House Supervisor will conduct the audits on weekends to ensure the Charge Nurses are monitoring the functioning of the Accutech Bracelets daily and battery function weekly. 24) The Interdisciplinary Team, Assistant Director of Nursing Services, and Department Managers initiated education related to Care Sheets and Care Plans on 01/28/15 and completed the trainings on 01/29/15. Certified Nursing Assistants will review care sheets every shift to identify any resident for elopement. The training was to ensure that Certified Nursing Assistants and Nurses were aware of residents' care needs. Post tests were completed. 25) When Resident #1 is readmitted to the facility the Unit Manager will conduct a thorough assessment, including elopement risk, and the Director of Nursing Services and/or Assistant Director of Nursing Services will review the assessment. 26) Beginning 02/03/15, Charge Nurses will document visual checks every 30 minutes on residents that are at risk for elopement. If the Charge Nurse is unable to document the visual checks, the House Supervisor will be responsible for the visual checks and documentation. 27) Unit Managers will audit the Charge Nurse 30-minute Visual Check Logs every three hours per shift to ensure the visual checks are being conducted. 28) On 02/03/15, all Charge Nurses were educated by the Director of Nursing Services and/or Assistant Director of Nursing Services on the importance of conducting and documenting the 30-minute visual checks. 29) Education by the Director of Nursing Services and/or the Assistant Director of Nursing Services with the Unit Managers related to reviewing the Charge Nurse 30-minute Visual Check Log every three hours was completed on 02/03/15. If Unit Managers see concerns with documentation, corrective action will take place immediately, including re-education. 30) Reviews conducted by the Unit Managers of the Charge Nurse 30-minute Visual Check Logs will be monitored and audited by the Director of Nursing Services and/or House Supervisor daily during the Clinical Start Up meeting. On weekends the House Supervisor will review the Logs. 31) Identified concerns related to the Charge Nurse 30-minute Visual Check Logs will be reported to the Director of Nursing Services and/or the Assistant Director of Nursing Services. The Executive Director and/or the Director of Nursing Services will take corrective actions which will include re-education. 32) On 01/27/15, an "Applied Audio Visual" contractor returned to the facility and provided recommendations and presented a monetary bid to add additional Accutech equipment. The monetary bid made by "Applied Audio Visual" was approved by the facility and equipment has been ordered which will be installed on all exit doors in the facility that currently utilize the delayed emergency egress function, lead to the outside perimeter, and give residents access to off-grounds property. 33) The current alarm system includes magnetic Locks and secondary alarms. This dual alarm system is in place on the door at the end of the Unit 200 Wing, the smoking exit door, the first hall Unit 100 door, the second hall Unit 100 door, the door at the end of the hall on Unit 300, and the Therapy door in the new building addition. 34) The secondary alarms were installed on 01/29/15 and produce a loud distinctive sound when an exit door is opened. The secondary alarms can be heard at all nursing stations and rooms on each unit. This was tested by posting staff members on each unit and by the Nurses' Stations and sounding the alarms. These alarms will be in place until the new Accutech equipment is installed. The new Accutech system will sound alarms at the Nurses' Stations as well as at the door. 35) On 01/29/15, staff was educated on Elopement Guidelines and how to react to sounding alarms and potential elopements. Any staff not attending the training must receive education before returning to work. 36) Education on responding to alarms, which included activation/deactivation of secondary alarms, was conducted on 01/30/15. All staff is required to receive the training and will not be permitted to work in the facility until they have been trained on the procedures as follow: A. All staff will respond immediately to any sounding alarms. B. The door alarm should remain sounding and not turned off so additional staff can render help. C. Go to the door that is alarming and conduct an outside perimeter check. D. If no resident is noted to be outside, go back inside the door. E. Deactivate the alarm and page "golden alert"; this alerts the units to conduct a head count for all residents. F. If all residents are accounted for then page "all clear." G. If a resident is "missing" immediately page "golden alert" and announce the room number. This alerts all staff there is a "missing resident." H. If a resident is "missing" then follow the facility's elopement guideline located in the elopement book. 37) Door alarm drills were initiated on 01/21/15 and were conducted every shift by the Maintenance Director. The door alarm drills included how to react to a sounding door alarm. The drills consist of placing staff members on each unit and at each Nurses' Station. The Maintenance Director activates an alarm at a specific door. Employees answering the alarm are timed as to how long it takes them to respond to the alarming door. Employees that do not answer the alarm are immediately re-educated on the correct procedure when a door alarm is activated. 38) On 01/23/15, door alarm checks and drills were conducted and documented hourly from 8:00 AM through 11:00 PM. The Logs were audited by the Executive Director to ensure they had been completed. 39) Beginning 01/24/15 door alarm drills and door checks will be conducted every shift Monday through Friday by the Maintenance Director and/or Executive Director. The Manager on duty and/or House Supervisor will complete the door checks and alarm drills on the weekend. 40) Logs to ensure the daily door drills and door alarm checks were conducted will be audited by the Executive Director daily Monday through Friday and by the House Supervisor on weekends. 41) The Maintenance Director provided training to all staff on 01/29/15 related to activating/deactivating secondary alarms and performing door checks on the magnetic locking doors and the Accutech doors. 42) All reviews and audits will be taken to the weekly Quality Assurance Committee meetings for four weeks, then monthly, to be analyzed for trends. If concerns are identified appropriate action will be taken including system revision and education as deemed necessary. ***The SSA validated the Immediate Jeopardy was removed as follows: 1) Review of Nursing documentation dated 01/21/15, revealed Resident #1 required no treatment after the elopement and was assessed to have sustained no injury when returned inside the facility. Vital signs were obtained and documented; they were within normal limits. 2) Review of the facility's documentation, dated 01/21/15 and interview with Licensed Practical Nurse (LPN) #1 on 01/27/15, at 2:20 PM, LPN #2 on 01/27/15 at 11:48 AM, and RN #3 on 01/27/15 at 6:15 PM, revealed head counts were conducted on all three units and each resident was accounted for at that time. 3) Review of the facility's investigation and interview with the Executive Director (ED) on 02/06/15 at 11:50 AM and the Director of Nursing Services (DNS) on 02/06/15, revealed the investigation was initiated on 01/21/15. 4) Review of documentation, dated 01/21/15, revealed Resident #1's Accutech bracelet was in place and functioning appropriately when the resident was returned inside the facility on 01/21/15. 5) Review of Resident #1's Comprehensive Care Plan dated 01/21/15, revealed the Care plan had been updated to reflect the resident's elopement on 01/21/15. 6) Review of a Door Audit dated 01/21/15, and signed by the Maintenance Director revealed all locking mechanisms on each door in the facility were examined with no concerns noted. 7) Review of the facility's documentation revealed Resident #1's Physician and Responsible Party were notified that Resident #1 had eloped from the facility on 01/21/15. 8) Review of documentation made by the Physician Assistant (PA) revealed the PA examined Resident #1 on 01/21/15, and ordered an electrocardiogram, chest x-ray, and laboratory tests for the resident. Review of Resident #1's medical record on 01/28/15 revealed the tests had been conducted with no significant abnormalities noted. 9) Review of a Clinical Pharmacist Medication Regimen Review Summary dated 01/21/15, revealed a medication review was conducted on 01/21/15 for Resident #1, with recommendations made and approved by Resident #1's Physician. 10) Review of Visual Checks documentation revealed the facility had been conducting 15-minute visual checks on Resident #1 since 01/15/15. Documentation of Visual Checks revealed the 15-minute visual checks were increased to every 10 minutes on 01/30/15. 11) Review of Resident #1's Comprehensive Care Plan revealed it was updated on 01/30/15, to reflect the increase in visual checks to every 10 minutes for Resident #1. Review of a Certified Nursing Assistant (CNA) Care Sheet dated 01/30/15 also revealed staff was to perform visual checks for Resident #1 every 10 minutes. 12) Review of Visual Checks documented by staff for Resident #1 from 01/30/15 through 02/01/15, revealed the visual checks were documented as conducted every 10 minutes. Interviews on 02/06/15 at 10:18 AM with CNA #7, 10:42 AM with CNA #10, and 11:19 AM with RN #8 and the Unit 200 Manager, revealed they had conducted visual checks for Resident #1 from 01/30/15 through 02/01/15 every 10 minutes, and were aware of the procedures for performing the visual checks. Interview on 02/06/15 at 12:00 PM with the Director of Nursing Services revealed she had performed staff training related to conducting visual checks for Resident #1 on 01/30/15. 13) Review of nursing documentation dated 02/02/15, revealed Resident #1 was transferred to a behavioral unit on 02/02/15. Resident #1 remained out of the facility on 02/06/15. 14) Review of Risk Elopement assessments, dated 01/21/15 revealed all residents in the facility had been re-evaluated for elopement risks. Interviews on 01/28/15, at 3:23 PM with MDS (Minimum Data Set) Coordinators #1 and #2; and at 4:25 PM with the Social Services Director revealed reassessments of all residents in the facility were conducted on 01/21/15. 15) Review of the Elopement Binders located on each Nursing Unit, in the Dietary Department, Business Office, Housekeeping Area, and Therapy Department revealed the binders contained information on all residents identified to be at risk for elopeme