Every finding on record at Stonecreek Health and Rehabilitation

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the admission Minimum Data Set (MDS) Assessment accurately reflected the resident's current status for 1 of 4 residents sampled for MDS Assessments out of the total sample of 26, (Resident (R)91). The findings include: Review of the facility policy titled, Resident assessment dated [DATE], revealed the purpose of the policy was to assure all residents received an accurate assessment and/or reassessment. Per review, the purpose also include the accurate assessment and/or reassessment was to be reflective of the resident's status at the time of assessment by the staff qualified to assess relevant care areas. Review of the facility's admission Observation assessment dated [DATE], signed by Licensed Practical Nurse (LPN) 3 revealed documentation under the integumentary system section noted R91 to have normal skin color, warm temperature, and skin moisture was dry. Further review revealed under alterations in skin, documentation noting, none in regards to wounds. Review of the medical record for R91 revealed the facility admitted the resident on 10/13/2025, with diagnoses of paroxysmal atrial fibrillation, chronic fatigue, and adult failure to thrive. Review of the admission MDS Assessment, with an Assessment Reference Date (ARD) of 10/17/2025, revealed the facility assessed R91 as having a Brief Interview for Mental Status (BIMS) score of 13 out of15, indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed R91 to have a stage 2 pressure ulcer and an unstageable deep tissue injury present on admission, although the admission Observation Assessment noted none. In interview with the MDS Nurse on 12/06/2025 at 2:18 PM, she stated she had coded R91's pressure ulcers as present on admission as the ulcers had developed and were assessed before the MDS ARD. She said however, there had been no documentation indicating R91 had pressure ulcers upon admission to the facility in the hospital discharge information or in the facility's admission Observation Assessment. She reported having reviewed R91's hospital discharge summary and not having seen documentation noting R91 had wounds while in the hospital or at discharge. The MDS Nurse further stated she would have expected there to have been treatment orders on R91's admission if the resident had pressure ulcers. In interview with the Director of Nursing (DON) on 12/04/2025 at 3:56 PM, she stated she expected the facility's MDS Assessments to be coded accurately to reflect a resident's status. She further stated R91's wound information should have been verified before it was coded on the admission MDS Assessment. In interview on 12/06/2025 at 4:45 PM, the Administrator stated she expected the resident MDS Assessments to be coded accurately to reflect the resident's status. She further stated the admission assessment, and the hospital discharge summary should have been reviewed before coding the resident as having wounds on admission.

Based on observation, interview, record review and review of facility policy, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 26 sampled residents (Resident (R)91). The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised on 03/03/2025, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, physical, mental, and psychosocial needs. Per review, the comprehensive care plan was to describe, at a minimum, the following services that were to be furnished to attain or maintain the resident's highest practical, physical, mental, and psychosocial well-being. Continued review revealed resident-specific interventions that reflected the resident's needs and preferences and aligned with the resident's cultural identity were to be provided, as indicated. Further review revealed the comprehensive care plan was to be reviewed and revised by the interdisciplinary team (IDT) after each comprehensive and quarterly assessment. Review of the Resident Face Sheet for R91 revealed the facility admitted the resident on 10/13/2025, with diagnoses of paroxysmal atrial fibrillation, chronic fatigue, and adult failure to thrive. Continued review revealed on 10/23/2025, a diagnosis of pressure ulcer of unspecified buttock, stage 3, had been added, and on 12/03/2025, a diagnosis of pressure ulcer to right buttock, unstageable, had been added to the diagnosis list. Review of the admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 10/17/2025, revealed the facility assessed R91 as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Review of the facility's Wound Management Detail Report dated 10/16/2025 at 4:02 PM, revealed documentation noting R91 had a stage 2 pressure ulcer to the left buttock that measured 1.5 centimeters (cm) x 1.5 cm. Continued review revealed the facility additionally noted R91 had a stage 3 pressure ulcer to the right buttock that measured 3.5 cm x 5 cm x 0.1 cm. Review of the Wound Management Detail Report dated 10/30/2025, revealed the facility noted R91 had a new unstageable pressure ulcer to the left heel that measured 3 cm x 7 cm, which had been documented as a blood-filled blister. Review of the facility's Comprehensive Care Plan for R91 dated 10/14/2025, revealed a problem for integumentary, noting the resident was at risk for skin impairment related to hypertension, malnutrition, impaired mobility, and pain. Per review, the interventions dated 10/14/2025, revealed staff were to assist R91 with turning and repositioning as needed during routine rounds; conduct a systematic skin inspection weekly on shower days, paying attention to boney prominences; and a pressure reduction mattress. In addition, review revealed the facility's goal for R91 was the resident would not have skin complications related to risk of skin impairment through 01/23/2026, which had been updated with no changes on 11/05/2025. Continued review revealed the facility developed an integumentary care plan dated 10/17/2025 and revised on 12/03/2025, related to a pressure ulcer to the right and left side of the buttocks. Per review, the interventions for that care plan included encouraging the resident to shift positions while in bed and to turn from side to side, dated 10/17/2025, and pressure-relieving boots to both heels as resident would allow, dated 10/30/2025. However, further care plan review revealed no plan of care for the current pressure ulcers on both of R91's heels. In interview with Certified Nursing Assistant (CNA) 4 on 12/04/2025 at 2:45 PM, she stated she was not familiar with R91, as staff rotated halls every other week or so and it was hard to get to know the residents. CNA 4 said she was aware R91 wore heel boots and had an air mattress which were part of the resident's plan of care. She further stated she sometimes reviewed the care plan in the residents' electronic health record (EHR); however, mainly relied on reports from the other CNAs as to the care the residents required. In interview with CNA 12 on 12/05/2025 at 10:24 AM, he stated today was only the second time he had not provided care for R91, and was not very familiar with him. He stated staff switched halls every other week or so, and it was hard to get to know the residents. CNA 12 reported he knew R91 had wounds on his heels, but had not known the resident had a wound on his buttock until he (CNA 12) assisted the nurse today. He stated R91 could reposition self when in bed. He stated he did not have to do much for R91. CNA 12 further stated the care plan was available on the computer and he tried to look at it when he worked. He additionally stated he received a shift to shift report from the other CNAs and sometimes from the nurse regarding the care the residents needed. In interview with the Assistant Director of Nursing (ADON) on 12/06/2025 at 2:49 PM, she stated she thought R91's coccyx wounds had been present on admission; however, would have to check the chart to verify that. She stated a care plan was to be developed on a resident's admission and was to include interventions to prevent pressure ulcers if necessary. The ADON said she expected the nurses to follow the physician's orders and complete the treatment as ordered. She further stated she expected the residents' care plans to be followed and the interventions implemented. The ADON additionally stated If a resident developed a new wound the care plan was to be updated to reflect that information with necessary interventions. In interview with the Director of Nursing (DON) on 12/06/2025 at 3:33 PM, she stated she expected staff to initiate and implement interventions for residents who were at risk for pressure ulcers. She stated she expected staff to follow the residents' care plans and ensure the interventions were being used. In interview with the Administrator on 12/06/2025 at 4:45 PM, she stated that care plan interventions were communicated to the staff. She said she expected the care plan interventions to be implemented when developed and put in place. The Administrator further stated staff were made aware of residents' care plan interventions during morning huddles and shift to shift report.

Based on interview, record review, and review of facility policy, the facility failed to ensure the comprehensive person-centered care plan was reviewed and revised for 1 of 26 sampled residents, (Resident (R)21). The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised on 03/03/2025, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, physical, mental, and psychosocial needs. Per review, the comprehensive care plan was to describe services to be furnished to attain or maintain the resident's highest practical, physical, mental, and psychosocial well-being. Continued review revealed the comprehensive care plan was to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessments. Further review revealed the comprehensive care plan was to also include measurable objectives and time frames to meet the residents' needs as identified in the residence comprehensive assessment. In addition, the objectives were to be utilized to monitor the resident's progress and alternative interventions documented as needed. Review of Resident Face Sheet for R21 revealed the facility admitted the resident on 10/17/2024, with diagnoses which included chronic systolic (congestive) heart failure, unspecified dementia, and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/17/2025, revealed the facility assessed R21 to have a Brief Interview for Mental Status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. Further review of the MDS revealed the facility coded R21 to have experienced no behavioral symptoms, rejection of care, or wandering. Review of the facility's Event Report dated11/07/2025, revealed R21 had sustained a fall, and the root cause of the fall was noted as, resident states that he was leaning over trying to get his cup. Continued review revealed the immediate interventions put in place were fall mat to both sides of bed .Therapy notified. Further review revealed the facility noted the outcome of the intervention as intervention effective. Observation on 12/03/2025 at 4:55 PM; 12/05/2025 at 12:35 PM; and 12/06/2025 at 2:15 PM, revealed a fall mat on the right side of R21's bed between the resident's bed and his roommate's (R75) bed. However, further observation revealed no fall mat located to the left of R21's bed during any of the observations. In interview on 12/06/2025 at 12:43 PM with the MDS Nurse, she stated revisions were made to the residents' care plans when the Interdisciplinary Team (IDT) came together to figure out what the best solution was for the resident. She additionally stated a nurse could make revisions to a resident's care plan; however, the IDT team went over those changes. The MDS Nurse further stated the IDT went over the residents' full care plan to ensure all issues were resolved. In interview on 12/06/2025 at 3:31 PM, the Director of Nursing (DON), stated any intervention listed on an investigation was to be on the resident's care plan and implemented by staff. The DON, after reviewing the documentation from the Event Report dated 11/07/2025 involving R21, stated the intervention for fall mats to both sides of R21's bed should have been on the resident's care plan and put in place. In interview on 12/06/2025 at 4:20 PM, the Administrator stated an intervention for a resident listed on an event report was to be added to their care plan immediately upon the decision to make it an intervention. She said a lack of communication could be the cause an intervention was not added to a resident's care plan. The Administrator reported if a necessary intervention had not been placed on the resident's care plan, no one would know it should be followed. She further stated her expectation was for staff to ensure care plans were revised as necessary and followed.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide a safe, clean homelike environment for 1 of 26 sampled residents, (Resident (R)21).The findings include: Review of the facility policy titled, Accidents and Supervision, last reviewed/revised 06/01/2025, revealed the resident environment was to remain as free of accident hazards as was possible. Per review, Environment referred to any environment or area in the facility that was frequented by or accessible to residents, including (but not limited to) the residents' rooms and bathrooms. Continued policy review revealed Hazards referred to elements of the resident environment that had the potential to cause injury or illness. Further review revealed Risk referred to any external factor, facility characteristic (e.g., staffing or physical environment) or characteristic of an individual resident that influenced the likelihood of an accident. In interview on 12/03/2025 at 3:02 PM, R21 stated his commode needed repairing. Observation of R21's commode (in room [ROOM NUMBER]) on 12/03/2025 at 3:10 PM, revealed the base of the resident's commode was not secured to the floor and therefore, caused it to rotate side to side. Further observation revealed the commode also rocked front to back. Observation of R21's commode on 12/04/2025 at 4:20 PM, revealed the commode to be in the same unstable condition as the previous day. Further observation revealed there were multiple brown paper towels stuffed between the base of the commode and the floor in attempts to stabilize or level the commode. In interview on 12/05/2025 at 12:35 PM, the Maintenance Assistant stated he thought it was just a few days ago that he and his boss pulled the old commode in R21's bathroom and installed the current one. He said the commode had been installed incorrectly; however, stated, what was I supposed to do, he was my boss? The Maintenance Assistant reported in his opinion, R21's commode was unstable and unsafe, and that needed to be corrected. He explained he would get with the Administrator about the commode. The Maintenance Assistant stated it was his guess the brown paper towels had been shoved between the commode and floor by the nurse aides trying to help. Observation of the commode, with the Maintenance Assistant, during the interview, revealed the commode was in the same condition as the previous observations. In interview on 12/06/2025 at 4:20 PM, the Administrator stated she had been made aware of R21's commode condition on the previous day by the Maintenance Assistant. She further stated a plan was to be developed to make the needed repairs to the commode. The Administrator additionally stated in her opinion the commode was a potential safety hazard.

Based on observation, the facility failed to ensure a medication error rate less than 5 percent (%), which affected 1 of 8 residents sampled during medication observation, (Resident (R)50). The findings include: Review of the facility policy titled, Medication Administration, last reviewed on 06/01/2025, revealed medications were to be administered as ordered by the physician. Further review revealed the Medication Administration Record (MAR) was to be reviewed to identify the medication to be administered. Review of the facility's MAR for R50, dated 12/04/2025, for revealed one hydrocodone-acetaminophen 5 - 325 milligram (mg) tablet (a narcotic medication used to treat moderate to severe pain) ordered for administration at 4:00 PM. Continued review revealed saccharomyces boulardiii 250 mg (a probiotic yeast used to support gut health), one capsule ordered for administration between 7:00 PM and 11:00 PM. Observation on 12/04/2025 at 8:30 PM, revealed Licensed Practical Nurse (LPN) 3 noting the 4:00 PM dose of R50's hydrocodone-acetaminophen had not been administered while the LPN was reviewing the resident's MAR during the bedtime medication preparation. Continued observation revealed no documented reason for why the dose of R50's hydrocodone-acetaminophen had been omitted. Additionally, observation of LPN 3, while preparing the scheduled medications, revealed the LPN discovered no saccharomyces boulardiii was available for administration. During interview with LPN 3 on 12/04/2024 at 8:50 PM, she stated she added the documentation of Not Administered: Other onto R50's MAR regarding the 4:00 PM omitted dose of hydrocodone-acetaminophen. She said the missed dose of that medication would not be made-up because it had not been noticed until several hours after it was due to be administered. The LPN explained at that time (8:50 PM) it had been too close to the next scheduled dose (at 12:00 AM) for the narcotic medication to be safely administered. She reported the ordering physician/Medical Director would be notified of the 4:00 PM dose having been missed. LPN 3 further stated if R50 requested something for pain before the 12:00 AM dose of hydrocodone-acetaminophen could be administered; Tylenol would be given to the resident. Review of the MAR revealed, Not Administered: Drug/Item Unavailable was documented by LPN 3 for the missing saccharomyces boulardiii dose. In continued interview on 12/04/2024 at 8:50 PM, LPN 3 stated the ordered saccharomyces boulardiii bedtime dose was not available in the medication cart to administer to R50. She said she checked the facility's pyxis (medication storage cabinet) and there had been no saccharomyces boulardiii available. LPN 3 reported she did not know why there was none of the medication available for administration or why it had not previously been ordered by someone else. The LPN said she ordered the replacement medication. She further stated the ordering physician/medical director would also be notified of the missed dose of R50's saccharomyces boulardiii. During interview on 12/06/2025 at 3:31 PM, the Director of Nursing (DON) stated if the medication cart had none of an ordered medication, the nurse was to check the facility's omnicell (another name for a medication cabinet) to see if there was an extra supply of the missing medication. The DON said there was a button on the electronic medical record (EMR) to reorder medications when they were running low. She reported whoever was passing medication when a medication reached the designated reorder level was responsible for re-ordering the medication to ensure the supply remained available. The DON additionally stated she expected staff to follow the physician orders and expected residents receive their medications as ordered. During interview on 12/0/2025 at 4:20 PM, the Administrator stated she was not aware of the exact process for reordering medications; however, did know there was a button on the EMR to re-order medications. The Administrator further stated her expectation was for all residents to get their medications as ordered.

Based on observation, interview, record review, and facility policy review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 residents sampled for infection control out of the total sample of 26 residents, (Residents (R)4, R91, R93, and R95). The findings include: Review of the facility policy titled, Transmission-Based Precautions revised 05/21/2025, revealed it was the facility's policy to take appropriate action to prevent the transmission of infectious agents, based on the agents' modes of transmission. Per policy review, healthcare personnel caring for residents on Contact Precautions were to wear a gown and gloves for all interactions that might involve contact with the resident or potentially contaminated areas in the resident's environment. Continued review revealed staff must don personal protective equipment (PPE) upon entry and discard the PPE before exiting the resident's room for residents in Contact Precautions. Further review revealed donning PPE upon room entry and discarding it before exiting the room was done to contain pathogens, especially those that had been implicated in transmission through environmental contamination. 1). Review of the Face Sheet for R95 revealed the facility admitted him on 11/28/2025, with diagnosis which included enterocolitis due to Clostridium difficile, type 2 diabetes mellitus with foot ulcer, and arteriovenous fistula, acquired-left upper arm. Further record review revealed the facility had not yet completed the admission Minimum Data Set (MDS) Assessment for R95; therefore, the Brief Interview for Mental Status (BIMS) score had been assessed for the resident. Review of the General Orders for R95 revealed an order received and started on 12/03/2025, for the resident to be in Isolation Type: Contact related to a diagnosis of Clostridium Difficile (C-Diff - a highly contagious bacterium that causes diarrhea and colitis). In interview with Certified Nurse Aide (CNA) 2 on 12/04/2025 at 11:55 AM, she stated she was familiar with R95; however, did not know why the resident was on contact precautions. She added that he may have fell or something, she was not sure. Observation on 12/05/2025 at 12:45 PM, revealed Certified Occupational Therapy Assistant (COTA) 2 pushing R95 in his wheelchair out of his room and through the hallway to the therapy room. Per observation, neither COTA 2, nor R95 were wearing any PPE. In interview with COTA 2 on 12/05/2025 at 12:47 PM, in R95's presence, he confirmed the resident was on contact precautions. He stated contact precautions meant, you have to put on a gown when you go in the room. COTA 2 said he had a gown on when he was in R95's room, but had taken it off before he exited the room with the resident. When the State Survey Agency (SSA) Surveyor asked if a resident should leave his room when contact precautions were ordered, COTA 2 did not respond and answer the question; however, R95 stated, I've been leaving my room. 2). Review of the Resident Face Sheet for R91 revealed the facility admitted the resident on 10/13/2025, with diagnoses of paroxysmal atrial fibrillation, chronic fatigue, and adult failure to thrive. Per continued review, a diagnosis of pressure ulcer of unspecified buttock, stage 3, was added on 10/23/2025. Further review revealed on 12/03/2025, a diagnosis of pressure ulcer to right buttock, unstageable, was added to the diagnosis list. Review of R91s physician orders dated 12/04/2025, revealed an order that read isolation type, contact related to Methicillin Resistant Staph Aureus (MRSA). Review of the admission MDS Assessment, with an Assessment Reference Date of 10/17/2025, revealed the facility assessed R91 to have a BIMS score of 13 out of 15, indicating intact cognition. Review of the physician orders dated 12/03/2025 for R91 revealed an order for isolation, type, contact, related to coccyx wound infection, pseudomonas/staph (Staphylococcus aureus and Pseudomonas aeruginosa most common bacteria co-isolated from chronic infected wounds). Review of R91's Comprehensive Care Plan dated 10/14/2025, the facility care planned the resident as being under EBP for an indwelling urinary catheter. Per review, the interventions dated 10/14/2025, included encouraging R91 to participate in activities of choice, as tolerated to ensure psychosocial well-being, isolation per the physician's order, and promoting the resident's psychosocial well-being while in isolation. Continued review revealed all interventions on the care plan for EBP were dated 10/14/2025. The goal was that R91 would not have complications related to being in isolation. Further review revealed on 12/03/2025, the care plan had been edited and changed to read: contact precautions for Pseudomonas and Staph in the wound. Observation on 12/03/2025 at 2:11 PM, revealed Certified Nursing Assistant (CNA) 8 entering R91's room without donning PPE, even though there was signage on the door frame that read Contact Precautions. In interview with CNA 8, at the time of observation, she stated she had just been putting a blanket on R91, and thought she only had to put PPE on when she was performing direct care for the resident. CNA 8 reviewed the signage on R91's door, and stated she should have put on a gown and gloves prior to entering the resident's room. 3). Review of the Resident Face Sheet for R93 revealed the facility admitted the resident on 12/02/2025, with diagnosis of adult failure to thrive, acute kidney failure, sepsis, and Methicillin-resistant Staphylococcus Aureus (MRSA). Review of Resident 93's Entry MDS Assessment with an ARD of 12/02/2025, revealed the facility assessed the resident to have a BIMS score of 99, which indicated the interview was not completed. In interview with R93 on 12/03/2025 at 12:23 PM, he stated he just got to the facility last night. R93 further stated he was at the facility, just for rehabilitation and doesn't know anything about any precaution status. Observation on 12/03/2025 at 4:32 PM, revealed R93 was had signage outside the room indicating the resident was on isolation precautions. Continued observation revealed CNA 1 walked out of R93's room with no PPE in place. Further observation revealed CNA 1 walked to the linen cart located in the hallway, obtained a washcloth and returned to the R93's room without donning PPE. In interview with CNA 1 on 12/03/2025 at 4:51 PM, she stated she had been under the impression she did not have to don PPE if she was taking care of R93's roommate and would get clarification on that. She further stated she had been informed by her superior that as long as she was not providing care for the affected resident she did not have to don PPE. Observation on 12/03/2025 at 4:53 PM, revealed Housekeeper (HK) 1 entering R93's room without donning PPE and removing trash bags with her bare hands. Continued observation revealed after leaving R93's room, HK 1 continued to enter another resident's room to empty the trash receptacle. In interview with HK 1 on 12/03/2025 at 4:57 PM, she stated she had been employed at the facility for about eight months. She said she did not wear gloves when she was removing the trash because she did not want to change gloves so frequently. HK 1 said so she just picked up the trash with her bare hands and used hand sanitizer after each room. She reported she had not been told anything about contact isolation rooms. HK 1 further stated she had not donned PPE when she went to remove the trash from R93's room because she just doesn't do that. Observation on 12/04/2025 at 12:36 PM, revealed that CNA 6, CNA 7, and COTA 1 were in R93's room with no PPE in place, even though there was signage indicating the resident was on contact precautions. In interview with COTA 1, during the observation, she stated it was her first day working with R93. The COTA said she had not seen the contact precaution sign posted on the resident's door frame. In interview with CNA 6 on 12/04/2025 at 12:40 PM, he stated he had been following what he had been told to do by the facility's Infection Control (IC) nurse. He further stated he had not had to don PPE before prior to entering a resident room who was in contact precautions, unless he was providing direct care to the resident. In interview with CNA 7 on 12/04/2025 at 12:45 PM, she stated she had not seen the sign posted on the door frame indicating R93 was in contact precautions. The CNA reviewed the sign outside R93's door, and said she should have paid attention to it and donned PPE prior to entering the room. 4). Review of the Resident Face Sheet for R4 revealed the facility admitted the resident on 03/27/2024, with diagnoses of congestive heart failure, chronic kidney disease and diabetes mellitus. Review of the Quarterly MDS Assessment, with an ARD of 09/18/2025, revealed the facility assessed R4 as having a BIMS score of 13 out of 15, indicating intact cognition. Observation on 12/04/2025 at 2:33 PM, revealed CNA 4 and CNA 5 were providing direct care to R4. Per observation, R4 who had signage in place outside the room for Enhanced Barrier Precaution (EBP). Further observation revealed neither of the CNAs were wearing PPE as required. In interview with CNA 4, during the observation, she stated she had forgotten to put on PPE as required. In interview with CNA 5 on 12/04/2025 at 2:33 PM, she stated she had just run into the room to help CNA 4 and had forgotten to put PPE on. CNA 4 stated she had received education provided by the Staff Development Coordinator that morning on PPE. Interview with CNA 5 on 12/04/2025 at 2:33 PM, during observation, she stated she had just run into the room to help CNA 4 and forgot to put PPE on. CNA 5 stated she was provided education by the Staff Development Coordinator this morning. (12/04/2025) on PPE. In interview with Licensed Practical Nurse (LPN) 1 on 12/03/2025 at 4:47 PM, she stated if you have a resident in contact precautions in a room you would still dress out in PPE even if you were not doing anything for the resident that was on the precautions. In interview with the Environmental Services Manager (ESM) on 12/06/2025 at 10:31 AM, she stated isolation contact rooms required staff to don full PPE. She stated she had always informed staff they should suit up for everything because you just don't know. The ESM reported if a resident had a yellow caddy hanging on their door regardless if signage was present or not. She stated staff should just don PPE to be safe. The ESM further stated the potential negative outcome of not donning PPE was possible cross contamination, disease transfer or you could become contaminated yourself with the organism. In interview on 12/06/2025 at 2:49 PM, the Assistant Director of Nursing (ADON) stated there had been no concerns before that week related to contact precautions. She stated staff had been made aware during huddle that a resident had been placed on precautions and the nurse would let the aides know more after report. The ADON said signage was placed beside the resident's door when TBP were ordered. She reported before staff went in the room of a resident on contact precautions, they need don PPE. The ADON explained there had been some confusion on whether or not staff needed to don PPE if they were going in the room to care for the affected resident or if they were going into the room in general. She further stated the correct approach was to don PPE if you were going into the room period. In interview with the Staff Development Coordinator/Infection Prevention Nurse (SDC/IP) on12/06/2025 at 10:50 AM, she stated when a resident had contact precautions ordered staff were to put on PPE when they went into the resident's room and remove the PPE when they came out of the room. She said she thought staff were getting confused on the precautions and had since been reeducated on the facility's contact isolation precautions. The SDC/IP Nurse reported staff were to pay attention to signage which directed them on which transmission-based precaution (TBP) was applicable to the resident. She stated for a resident who had contact precautions ordered, their therapy was to be performed in the their room. The IP Nurse further stated possible outcomes from not doing proper hand hygiene and donning/doffing PPE, was the potential for staff to pass the bacteria/infection to another resident. In interview with the Assistant Director of Nursing (ADON) on 12/06/2025 at 2:49 PM, she stated staff were made aware during huddle that a resident had been placed on precautions, and when the nurse got report on a resident, she would let all other staff on the unit know about the precautions that day. The ADON said signage was placed outside the resident's room door to indicate the precautions. She further stated before staff went in the contact isolation resident's room they needed to put on PPE regardless. In interview with the Director of Nursing (DON) on 12/06/2025 at 3:31 PM, she stated she thought the confusion on for staff regarding PPE and not adhering to contact precautions was because they were not doing it at all. She stated staff had been educated on TBPs and not long ago the facility had a skills fair that included contact precautions and staff had to demonstrate donning and doffing gowns and gloves, which they were found to be proficient in. The DON said, to be honest what is hindering them from following policy and procedures is just them doing it. The DON said they did audits on precautions/PPE use; however, she was not sure how often the audits were done. She reported she had done the audits a few times when she first started working at the facility, but then the unit managers did them (audits). The DON further stated they had everybody demonstrate when to don and doff PPE in the facility's skills fair held a few months ago. She also stated her expectations was for the staff to use PPE for their own protection as well as for the protection of the residents. During interview with the Administrator on 12/06/2025 at 4:20 PM and 4:29 PM, she stated she was unaware of the problem with PPE regarding residents in contact and enhanced barrier precautions and that contact precautions were such a big problem until that week. She said the facility had started educating staff since the State Survey Agency (SSA) survey process started. The Administrator stated the facility had processes and policies always in place; however, it was not normal to have contact precaution residents in the facility. She explained all four residents currently in precautions had just been admitted within the last week or so. The Administrator reported there were signs on the door of a resident in precaution for a reason and staff should read those signs if they any questions, as they are there for a reason. She explained those signs told staff what to do for those precautions, and staff should read the signs so they would know what to do. The Administrator stated they went through life safety and infection control processes during orientation with contract employees as well and every department was involved in the education process. She further stated she expected staff to follow the physicians orders and care plans, and ensure precautions were implemented as required.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers for 1 of 4 residents sampled for pressure ulcers out of the total sample of 26 residents (Resident (R)91).The findings include: Review of the facility policy titled, Pressure Injury Prevention and Management dated 06/04/2025, revealed the facility was committed to the prevention of avoidable pressure injuries unless clinically unavoidable. Per review, the facility was also committed to providing treatment and services to heal pressure ulcers, prevent infection, and prevent the development of additional pressure ulcers. Continued review revealed a licensed nurse was to conduct a full body skin assessment on all residents upon admission, readmission, weekly, and after any newly identified pressure injury. Policy review revealed the findings of those assessments were to be documented in the residents' medical record. Further review revealed the staging of pressure injuries was to be clearly identified to ensure the correct coding on the Minimum Data Set (MDS) Assessment. Review of the hospital discharge summary for R91 dated 10/13/2025, revealed no documented evidence the resident had pressure ulcers at the time of discharge. Continued review of the hospital discharge summary, of the discharge medication list revealed no documented physician orders for treatments or wound care for R91. Review of the Resident Face Sheet for R91 revealed the facility admitted the resident on 10/13/2025, with diagnoses of paroxysmal atrial fibrillation, chronic fatigue, and adult failure to thrive. Review of the admission MDS Assessment, with an Assessment Reference Date (ARD) of 10/17/2025, revealed the facility assessed R91 to have a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating the resident was cognitively intact. Further MDS review revealed the facility assessed R91 to have a stage 2 pressure ulcer on the right buttock and an unstageable deep tissue injury (DTI) on the left buttock present on admission. Review of the admission Observation assessment dated [DATE], signed by Licensed Practical Nurse (LPN) 3, revealed under the integumentary system section R91 had normal skin color, warm temperature, and the skin moisture was dry. Further review of the admission Observation Assessment, under alterations in skin, the nurse noted none. Review of the facility's initial Skin and Wound Progress Note dated 10/22/2025, completed by an outside provider, revealed the provider noted R91 presented to the nursing home after a recent discharge from the hospital. Continued review revealed the provider also noted R91's hospital discharge summary had no injuries documented. Further review revealed the provider had seen R91 today for follow-up for a deep tissue injury to the right buttock and a stage 2 pressure injury to the left buttock which had been present upon the resident's admission. Review of the Physician Orders dated 10/13/2025 revealed no orders present for wound care for R91. Review of the physician order dated 10/14/2025, revealed an order for Calmoseptine (a barrier cream) to be applied to R91's buttock area every shift, which was discontinued on 10/22/2025. Review of the physician's order dated 10/16/2025, revealed an order for Triad cream (a dressing paste used to treat wounds) to R91's left and right buttocks twice a day, which was discontinued on 10/24/2025. Review of the physician's order dated 10/22/2025, revealed to cleanse R91's right and left buttocks with in-house wound cleanser; apply collagen to the base of the wound; secure with bordered gauze; and change daily. Review of the physician's order dated 10/24/2025, revealed an order for R91 to have low air loss mattress to the bed. Review of physician's order dated 10/29/2025, revealed an order for pressure-relieving boots to be applied to R91's feet when in bed. Review of the physician's order dated 10/29/2025, revealed an order for skin prep (a barrier wipe used to form a film to protect the skin) twice a day to R91's bilateral heels. Review of the physician's order dated 12/03/2025, revealed an order for treatment to R91's right heel, which was to cleanse with normal saline, and apply calcium alginate with silver (calcium alginate absorbs wound exudate, and silver helps reduce infection). Review of the Comprehensive Care Plan for R91 dated 10/14/2025, revealed the resident was care planned as at risk for skin impairment related to hypertension, malnutrition, impaired mobility and pain. Continued review revealed the Interventions dated 10/14/2025 included a pressure relieving cushion for pressure reduction when R91 was up in the chair; using a moisture barrier product to the resident's perineal area as needed; and providing incontinent care after each incontinent episode. Per review, the interventions also included a pressure reduction mattress to the bed; keeping bony prominences from direct contact with one another; and conducting a systemic skin inspection weekly on shower days paying attention to the bony prominences. Further review revealed the interventions additionally included avoiding shearing during positioning, transferring, and turning; assisting R91 with turning and repositioning as needed during routine rounds. In addition, review revealed the facility's goal for R91 was for the resident not to have skin complications related to his risk of skin impairments, with the goal date of 01/23/2026. Review of the Comprehensive Care Plan for R91 dated 10/17/2025, revealed the resident had pressure ulcers to the right and left sides of his buttock. Per review, the interventions dated 10/17/2025, included encouraging R91 to shift positions while in bed and turn from side to side. Review of the intervention dated 10/30/2025, revealed therapy was to evaluate R91 for a leg rest; pressure-relieving boots to bilateral heels as he would allow. Further review revealed an intervention added on 12/03/2025, for a low air loss mattress to R91's bed. (a). Review of the Wound Management Detail Report dated 10/16/2025 at 4:02 PM, revealed R91 was noted to have a stage 2 pressure ulcer to the left buttock that measured 1.5 centimeters (cm) x 1.5 cm. Review of the Wound Management Detail Report dated 11/19/2025, revealed the stage 2 to the left buttock was noted as healed. (b). Review of the Wound Management Detail Report dated 10/16/2025 at 4:02 PM, revealed R91 was noted to have a stage 3 pressure ulcer to the right buttock that measured 3.5 cm x 5 cm x 0.1 cm. Review of the Wound Management Detail Report dated 10/29/2025 revealed the right buttock wound area measured 5 cm x 5 cm x 0.2 cm and had moderate exudate. Per continued review of the 10/29/2025 Report revealed the right buttock area was declining, and the physician was made aware. Review of the Wound Management Detail Report dated 11/12/2025, revealed R91's right buttock wound continued to decline, noted as unstageable, measuring 6 cm x 4 cm x 0.3 cm, with necrotic tissue (dead tissue), fifty percent (50%) eschar (devitalized tissue found in a wound bed), and 40% slough (a yellowish, soft, and often stringy material). Continued review of the Wound Management Detail Report revealed one dated 11/19/2025, noting R91's right buttock pressure ulcer was unstageable and measured 9.5 cm x 4.5 cm x 0.3 cm was 50% slough and 40% eschar. Review of the Wound Management Detail Report dated 11/26/2025, revealed the right buttock was an unstageable pressure ulcer measuring 8.5 cm x 4.5 cm with moderate drainage, which was noted as 50% sloth 50% eschar, and documented as stable. Review of the Wound Management Detail Report dated 12/03/2025, revealed the right buttock unstageable wound was improving with delayed closure, 6.5 cm by 4.5 cm by 1.2 cm with 100% slough. (c). Review of the Wound Management Detail Report dated 10/30/2025 revealed R91 had a new unstageable pressure ulcer to the left heel that measured 3 cm x 7 cm and was documented as a blood-filled blister. Review of the Wound Management Detail Report dated 11/12/2025 revealed a pressure ulcer to left heel. The wound was stable, measuring 4.5 cm x 7 centimeters. This area was a blister that had ruptured, and there was 100% intact epithelium with evidence of deeper tissue injury. Review of the Wound Management Detail Report dated 11/26/2025 revealed necrotic tissue to the left heel, 4.5cm x 7 cm. 100% eschar. The wound was improving without complications. Review of the Wound Management Detail Report dated 12/03/2025 revealed left heel pressure ulcer measuring 2 by 2.5cm and was 100% necrotic tissue. (d). Review of the Wound Management Detail Report dated 10/30/2025 revealed R91 had a new unstageable pressure ulcer to the right heel that measured 3 cm x 7 cm and was documented as a blood-filled blister. Review of the Wound Management Detail Report dated 11/12/2025, revealed R91 had a stage 3 pressure ulcer to the right heel, which was improving, measuring 3 cm by 4 cm. Review of the Wound Management Detail Report dated 11/26/2025, revealed R91 continued to have a stage 3 to the right heel, which measured 2 cm x 3.5 cm, with 100% eschar, improving without complications. Review of the Wound Management Detail Report dated 12/03/2025, revealed there continued to be a stage 3 pressure ulcer to R91's right heel that measured 2.5 by 3.0 cm and was 100% necrotic. Observation of R91 on 12/03/2025 at 2:28 PM, and on 12/04/2025 at 8:20 PM, revealed the resident lying on the bed with a low air loss mattress on his bed and pressure-relieving boots on both feet. Observation on 12/04/2025 at 8:20 PM, revealed R91's right heel had no dressing in place, and the wound was observed to be actively bleeding. In interview with R91, at the time of observation, he stated he had been at the facility for over a month, and had sores on both of his feet and his backside (coccyx). R91 stated no when the State Survey Agency (SSA) Surveyor asked if he had the wounds when he was admitted to the facility. The SSA Surveyor asked R91 how he got the wounds, and the resident stated he did not know how they happened. Observation on 12/05/2025 at 12:10 PM, during R91s wound care performed by Registered Nurse (RN) 2 and Certified Nursing Assistant (CNA) 12, and with the Unit Manager present in the resident's room, revealed RN 2 and CNA 12 positioned the resident on his left side. Continued observation revealed RN 2 proceeded to perform wound care to an unstageable pressure ulcer on the resident's right buttock, a stage 3 pressure ulcer to his right heel, and an unstageable pressure ulcer to his left heel. In interview with CNA 4 on 12/04/2025 at 2:45 PM, she stated she was not familiar with R91 or the residents on that hall. CNA 4 reported staff rotated halls every other week or so and it was hard to get to know the residents. She said she was aware R91 wore heel boots and had an air mattress. The CNA further stated she sometimes reviewed the care plan in the electronic health record (EHR) but relied on reports from the other CNAs as to residents' care needs. In interview with CNA 12 on 12/05/2025 at 10:24 AM, he stated today had been only the second time he had provided care for R91, so he was not very familiar with him. CNA 12 said staff switched halls every other week or so, and it was hard to get to know the residents. He reported he knew R91 had wounds on his heels; however, had not known the resident had a wound on his buttock until he assisted the nurse that day. CNA 12 further stated R91 could reposition himself when in bed. In interview with Licensed Practical Nurse (LPN) 3 on 12/06/2025 at 9:45 AM, she stated she was the nurse who had completed the admission assessment for R91. The LPN said R91 had not had wounds on admission, he only had redness to his buttocks. She reported when residents were admitted with wounds they usually had physician's orders in place, and if they did not, she notified the provider for orders. LPN 3 stated when a resident developed a new wound, the nurse created an event for a change in condition. She further stated when events were created, that triggered a care plan for the resident. In interview with the Director of Nursing (DON) on 12/06/2025 at 3:33 PM, she stated she expected staff to initiate interventions for residents who were at risk for pressure ulcers. She said R91 had not had wounds present on his admission. The DON reported R91 refused to eat, was depressed and had a diagnosis of adult failure to thrive. She stated all residents had a pressure reducing mattress to their bed when admitted and R91 now had a low air loss mattress. The DON further stated R91 sometimes refused to turn and preferred to lie on his back. She additionally stated the wound care provider came to the facility weekly to assess residents and measure all wounds. In interview with the Administrator on 12/06/2025 at 4:45 PM, she stated she expected wound care and treatments to be completed as ordered by the physician or wound Nurse Practitioner (NP). She reported If a resident's dressing was not in place as ordered, she expected the aides to report that to the nurse so the dressing could be replaced. The Administrator further stated R91 had adult failure to thrive, and had poor meal intake which attributed to poor healing.

Based on observation, interview, review of facility policy, and review of the FDA Food Code 2022 the facility failed to thaw, store, label and date food in accordance with professional standards for food service safety. Observation revealed meat thawing in sinks, meat on a tray out at room temperature (temp). Additionally, observation revealed expired and/or outdated food in the walk in cooler. The findings include: 1. A policy on thawing of frozen foods was requested from the Dietary Manager on [DATE]; however, such policy was not received. Review of the FDA Food Code 2022 Chapter 3. Food, Chapter [DATE].13 Thawing, revealed the time/temperature control for safety was that food should be thawed (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less Pf; or (B) Completely submerged under running water . Observation on [DATE] at 11:14 AM, during the initial kitchen tour, revealed in one of the sinks of the three compartment sinks were three thawing packaged whole pork loins. Continued observation revealed in another sink area a large roll of ground beef was lying on a tray. In an interview with the [NAME] on [DATE] at 3:18 PM, she stated she had been employed at the facility for six months. She stated meat was to be thawed in the cooler on the lowest shelf and on a tray for food safety. The [NAME] further stated frozen meat was not to be thawed at room temperature. During an interview with the Dietary Manager (DM) on [DATE] at 11:25 AM, she stated the pork loin and ground beef should have been placed on a tray and thawed in the cooler for food safety. She stated meats were not to be thawed in the sink or at room temperature. In an interview with the Administrator on [DATE] at 7:29 PM, she stated kitchen staff were expected to follow policy and procedure when thawing meats; however, she did not know what the facility policy was. In an interview with the Regional Director of Operations (RDO) on [DATE] at 8:01 PM, she stated all staff had been educated on thawing meats on the bottom shelf in the walk-in (cooler) or under cool running water. 2. Review of the facility policy titled, Food storage, Cold, undated, revealed it was policy to ensure all time/temperature control for safety, frozen and refrigerated food items be appropriately stored in accordance with guidelines of the FDA Food Code. Continued review revealed the dining service director or cook were to ensure all food items were stored properly in covered containers labeled and dated and arranged in a manner to prevent cross contamination. Observation of walk in cooler on [DATE] at 11:14 AM, revealed the following items were expired/outdated: a large plastic container ,d+[DATE] full of sliced peaches dated [DATE]; a small container ,d+[DATE] full of pears with white green substance undated; a jar with 4 whole boiled eggs that were brown in color, dated [DATE]; a large container ,d+[DATE] full of Parmesan cheese dated [DATE]; a plastic container of banana pudding dated [DATE]; a bag ,d+[DATE] full of shredded cheese dated [DATE]; and a small container of bacon grease dated [DATE]. During continued interview with the DM on [DATE] at 11:25 AM, she stated she had been on vacation last week and the cooks had been responsible for checking the coolers (for expired/outdated food) while she was off. The DM stated all staff had been educated on food storage and signs were all over the kitchen to remind staff to label and date all items. She further stated staff had also been educated on checking the coolers on a daily basis. In an interview with the [NAME] on [DATE] at 3:18 PM, she stated she had been employed at the facility for 6 months. The [NAME] stated all items were to be labeled and dated before storing in the coolers. She stated items stored were good for three days once opened. She stated the morning cook was supposed to check the cooler daily for items that were out of date. She further stated the evening cook was to check at the end of the shift. In an interview with the Regional Director of Operations (RDO) on [DATE] at 8:01 PM, she stated she expected staff to label and date all items prior to putting them in the walk-in cooler. She stated all staff had been educated on doing that. She stated the managers and cooks were to check the coolers in the morning when opening the kitchen and in the evening when closing the kitchen. In an interview with the Administrator on [DATE] at 7:29 PM, she stated the kitchen staff were expected to follow policy and procedures on labeling and dating food items before placing them in the walk-in cooler. She further stated she expected staff to check for expired food items and dispose of them if not within the appropriate date.

Based on observation and interview the facility failed to ensure garbage was stored appropriately and covered, away from food preparation (prep) areas in the kitchen. Observation revealed a large, uncovered trash receptacle almost full of trash, which was stored approximately four steps away from the food prep area. The findings include: During an interview with the Dietary Manager on 07/30/2024 at 11:25 AM, she stated she expected the staff to keep the trash bins covered and away from the food prep area. Observation on 07/30/2024 at 11:14 AM, revealed a large, uncovered trash receptacle 3/4 full of trash stored approximately four steps away from the food prep area in the kitchen. In an interview with the [NAME] on 08/01/2024 at 3:18 PM, she stated trash bins should always be covered. She further stated the trash bins should not have been stored that close to the food prep area. In an interview with the Dietary Manager (DM) on 07/30/2024 at 11:25 AM, she stated the trash bins should have been stored in a corner area of the kitchen and away from the food prep area. She further stated the bins should have been covered at all times. In an interview with the Regional Director of Operations (RDO) on 08/01/2024 at 8:01 PM, she stated she expected staff to ensure the trash bins were moved away from the food prep areas. In addition, she stated she expected staff to always keep the trash bins covered. In an interview with the Administrator on 08/01/2024 at 7:29 PM, she stated her expectation was that the trash containers be covered and moved away from any area where food was being served or prepared.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure drugs and biologicals were stored in accordance with the manufacturer's specifications and accepted professional nursing principles and practices for one (1) of two (2) medication rooms audited. Observation on [DATE] at 10:40 AM, of the medication room that serviced rooms on the facility's 100 and 200 halls revealed one (1) open and undated multidose vial of medication and sixty-two (62) wound care products that were beyond the expiration date printed on the label. The findings include: Review of the facility's policy titled, Medication Administration with a revision date of [DATE], revealed medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state .and in accordance with professional standards of practice in order to prevent contamination or infection. Further review revealed the person administering the medication was to, Identify the expiration date. If expired, notify nurse manager. Observation on [DATE] at 10:40 AM, of the medication room that served the 100 and 200 halls, revealed one (1) opened and undated bottle of Tubersol (an injectable solution used for testing for tuberculosis) available for use in the refrigerator. Continued observation revealed nine calcium alginate 12 rope dressing material (utilized for wounds) with an expiration date of [DATE]; ,d+[DATE] x 2 calcium alginate with silver dressing materials with an expiration date of [DATE]; nine 4 x 8 calcium alginate with silver sheets with an expiration date of [DATE]; and one (1) package of Promogran collagen matrix (also utilized for wounds) with a printed expiration date of [DATE], all available for use beyond the printed expiration date on the packaging. During an interview on [DATE] at 6:04 PM, with Licensed Practical Nurse (LPN) 10 and LPN 4, stated it was important to date all medications when opened, and not use them or other products beyond the expiration date, to avoid a potential inaccurate result, loss of potency, allergic or skin reactions. In an interview on [DATE] at 6:22 PM, the DON stated when opening a multidose medication, the vial was to be dated with the opened date and placed in to the refrigerator and tossed after 30 days. In an interview with the Administrator on [DATE] at 6:22 PM, she stated it was her expectation for staff to follow the facility's policies.

Based on interview, record review and review of the facility policy, the facility failed to develop a comprehensive person-centered care plan which included timeframes and measurable results to meet each resident's medical, nursing, mental and psychological needs as identified in the comprehensive assessment for three residents, (R)7, R48 and R14 out of 25 total of sampled residents. The findings include: Review of the facility policy titled, Comprehensive Care Plans dated 08/30/2022 and reviewed/revised on 02/2024, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, physical, mental, and psychosocial needs. Continued review revealed the comprehensive care plan was to include measurable objectives and timeframe's to meet the resident's needs as identified in the resident's comprehensive assessment. Further review revealed the objectives were to be utilized to monitor the resident's progress, and alternative interventions were to be documented, as needed. In addition, policy review revealed qualified staff responsible for carrying out (residents') interventions specified in the care plan were to be notified of their roles and responsibilities regarding the interventions, initially and when changes were made. 1(a). Review of the face sheet for R7 revealed the facility admitted the resident on 12/19/2022, with diagnoses of atherosclerotic heart disease, chest pain, diabetes mellitus, chronic kidney disease, and contractures of left hip, right knee, and left knee. Review of the Quarterly Minimum Data Set (MDS) Assessment for R7 dated 07/27/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, meaning R7 had intact cognition. Review of the Comprehensive Care Plan for R7 dated 12/22/2022, revealed the facility developed a problem for Respiratory/Pulmonary related to nicotine dependence with cigarettes. Continued review revealed on 05/29/2023, the facility noted R7 was to be free from injuries related to unsafe smoking practices with approaches (interventions) that included educating the resident about smoking risks and hazards. Further review revealed additional approaches included educating the resident and/or responsible party of the facility's policy on smoking locations, times, and safety rules. During observations on 07/30/2024 at 3:20 PM; 07/31/2024 at 10:55 AM; and 08/01/2024 at 9:22 AM, R7 was observed in his room with an opened pack of cigarettes and a lighter either lying on his overbed table or on his bed. Continued observation revealed a lock box sitting on the bedside table. In interview, on 08/01/2024 at 9:22 AM, R7 stated, when asked about the lock box, it was for his cigarettes and lighter to be stored in. In addition, R7 further stated he was about to go out and smoke and he had just taken the cigarettes and lighter out of the lockbox. However, the State Survey Agency (SSA) Surveyor had observed R7 in the smoking area prior to the interview. 1(b). Review of the face sheet for R48 revealed the facility admitted him on 05/06/2022, with diagnoses of chronic obstructive pulmonary disease (COPD), acquired absence of right and left legs below knees and personality disorder. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed R48 to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. Review of the Comprehensive Care Plan for R48 dated 06/12/2022, revealed the facility noted under the category of Activities of Daily Living (ADLs) Functional Status/Rehabilitation Potential the resident was an independent smoker dated 06/12/2022. Continued review revealed a goal target date of 08/29/2024 revealed a goal for R48 to not suffer injury from unsafe smoking practices through the next review date. Further review revealed approaches included on 06/12/2022 to instruct R48 on the facility policy regarding smoking locations, times, and safety. Additional review revealed an approach start date of 06/12/2022, noting R48 might smoke unsupervised, with a last reviewed/revised date of 07/18/2024. During observations of R48 on 07/30/2024 at 3:04 PM; 07/31/2024 at 10:40 AM; and 08/01/2024 at 1:33 PM, the resident was observed sitting on his bed with cigarettes and lighter lying either at the end of the bed or on his overbed table. In interview at 07/30/2024 at 3:04 PM and 08/01/2024 at 1:33 PM, R48 stated he was going out to smoke soon or had just returned from smoking were the reasons given for him not having the lighter and cigarettes stored in the locked box. During an interview with the Activities Director (AD) on 08/01/2024 at 9:57 AM, regarding the smoking policy and residents keeping a lock box with cigarettes and lighters in their rooms, she stated the lock boxes had been in residents' rooms for a few years. She stated it was her responsibility to ensure the residents had cigarettes to smoke during their smoke breaks. The AD stated R7 and R48 were independent smokers and were able to smoke whenever they wanted; however, they had also been observed to smoke in restricted areas like the front of the building and in the vending machine area. She further stated she also developed residents' comprehensive care plans related to smoking and should have included the lock boxes for their smoking paraphernalia on their care plans. In an interview conducted with the MDS Coordinator on 08/01/2024 at 3:45 PM, she stated the Activities Director usual responsibility was to develop the residents' smoking care plans. She also stated however, it was my responsibility to ensure it (smoking) was on the residents' care plans. The MDS Coordinator further stated she was unaware of the locked boxes in the residents' rooms used for storage of their cigarettes and lighters. In an interview on 08/01/2024 at 5:32 PM, the Administrator and DON stated they were unaware the residents' care plans did not reflect the lock boxes being used as an approach for safety. 2. Review of R14's Face Sheet, revealed the facility admitted the resident on 11/04/2022, with diagnoses to include; hereditary spastic paraplegia, Parkinson's Disease with dyskinesia, and multiple sclerosis. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed R14 to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed the facility also assessed R14 as dependent on staff for transfers. Review of R14's Comprehensive Care Plan dated 11/11/2022, revealed the facility had developed a focus problem related to Activities of Daily Living (ADL's), self-care performance deficit related to impaired mobility. Continued review revealed an intervention dated 11/11/2022, for R14's transfers with assist of two staff and use of a mechanical lift. Observation on 07/29/2024 at 6:50 PM, State Surveyor Agency (SSA) Surveyor observed Certified Nursing Assistant (CNA) 17 enter R14's room with a mechanical lift. The SSA Surveyor waited 4-5 minutes and entered R14's room and observed R14 lying on the bed and CNA 17 was moving the lift away from the bed. Further observation revealed no other staff present in R14's room therefore, CNA 17 had utilized the mechanical lift alone when transferring R 14 to bed. Review of the Resident Profile (the facility's CNA Care Guide) dated 11/11/2022, revealed R14 required assistance of two staff members and use of a mechanical lift for transfers. In an interview with R14 on 07/29/2024 at 7:00 PM, he stated that had not been the first time only one staff member had transferred him with the lift onto his bed. He stated he was unsure how many staff were to transfer him. R14 further stated sometimes it was two people and sometimes it was only one person. In an interview with CNA 17 on 07/29/2024 at 6:55 PM, she stated R14 required assist of two staff and the mechanical lift for transfers. She stated she had not been able to find anyone to help her put R14 to bed. CNA 17 stated there had been another aide on the floor, but she was assisting residents on another hall. She stated there was a nurse on the unit; however, she had not asked the nurse for help. CNA 17 further stated it was important to follow R14's care plan as the mechanical lift could tilt and the resident could sustain a fall. In an interview with the DON on 08/01/2024 at 2:24 PM, she stated she expected staff to follow the residents' care plans and ensure residents' safety. She further stated by not following the care plan CNA 17 had not ensured R14's safety. In an interview with the Administrator on 08/01/2024 at 7:29 PM, she stated she was not clinical; however, she expected nursing staff to follow the facility's policies and follow residents' care plans. She stated the care plan directed staff on how to care for the residents. The Administrator stated nurses were to ensure residents' care plans were followed and that outcomes would be different for each resident. She stated R14's safety was why two staff were used. The Administrator stated CNAs had access to the residents' care guides Matrix (charting system) and were educated to review and chart on residents on a daily basis. She further stated overall she expected staff to follow the care plan. 44370

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to enter wound treatment orders upon receipt of the orders for two of 25 sampled residents (R)237 and R99. The findings include: Review of the facility policy titled, Clean Dressing Change dated 03/12/2024, revealed It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Further review revealed Physician's orders were to specify the type of dressing and frequency of changes. 1. Review of R237's record revealed the facility admitted the resident on 07/25/2024, from an acute hospital setting, with diagnosis that included a Stage 4 pressure ulcer of the sacrum; other pulmonary embolism (blood clot blocking artery in the lung) with acute cor pulmonale (type of acute right side heart failure), and unspecified severe protein calorie malnutrition. Review of the Brief Interview for Mental Status (BIMS) assessment revealed the resident was severely cognitively impaired as evidenced by a score of five out of 15. Review R237's acute Continue Care Hospital document titled, Patient Discharge Instructions and Treatment Form dated 07/25/2024, for R237 revealed Wound Care instructions for the sacrum wound and left heel. Continued review revealed the sacral wound care instructions included a wound vac (vacuum) to be changed three times a week and wound care instructions for the left heel and wound prevention for the bilateral heels. Review of the Admission Observation information for R237 dated 07/25/2024 at 5:50 PM, revealed it noted the presence of a Stage 4 ulcer of the resident's coccyx/sacrum and redness of the left heel. Review of the Wound Management Detail Report for R237 completed 07/26/2024 at 12:31 PM, revealed the resident had a pressure ulcer on sacrum. Per review, a Corrected Wound Edit History on 07/30/2024 at 9:38 AM, for R237 noted the wound to be a Stage 4 with measurements documented. Review of the Date of Service Progress Note for R237 dated 07/29/2024, the documented by the Advanced Practice Registered Nurse (APRN) revealed in the Assessment / Plan for staff to Continue wound vac from hospital. Review of the 07/25/2024 Progress Note at 18:53 for R237, revealed it read, Has a large open area on coccyx to have wound vac applied. Review of the Progress Notes dated 07/26/2024 at 6:42 AM, and 07/27/2024 at 6:32 AM revealed no documented evidence of a wound treatment in the notes. Review of the Progress Note entered on 07/27/2024 at 3:20 PM, revealed dressing changed to coccyx/sacrum and remains excoriated along peri wound. Silicone sacral dressing applied. Review of the Progress Note documented on 07/28/2024 at 2:26 PM, revealed the dressing to R237's coccyx/sacrum C/D/I (clean, dry, and intact) at that time. Additional review of the Progress Notes revealed no documented evidence of the wound vac being applied. Review of the Daily Skilled Service nursing note for R237 dated 07/25/2024 at 6:11 PM, revealed documentation for Skin and Wound Management noted as Wound Vac to Coccyx. Review of the Daily Skilled Service Observation documentation on 07/27/2024 at 3:32 PM for R237 revealed wound care treatment with no documented details of what treatment was performed. Review of an additional Daily Skilled Service Observation note entered on 07/28/2024 at 2:30 PM, revealed Skin and Wound Management Interventions were in place with no details of the treatment services provided. Further review of the Daily Skilled Service Observation notes revealed no documented evidence of the wound vac having been applied as per Physician's orders. Review APRN 20's Healing Partners Visit note dated 07/30/2024, revealed an assessment of the resident's wound characteristics was completed, the wound debrided (the process of removing dead skin and foreign material from a wound). Further review revealed a new recommendation and order for Dakin's (an antimicrobial solution) gauze and cover with bordered gauze to be completed twice a day. Review of R237's Medication Administration Summary for 07/01/2024 through 07/30/2024, revealed no documentation noting treatment orders addressing the resident's wound on the sacrum or heel, nor of treatment having been performed to the wound. Review of all orders for R237, both active and inactive, for the time period of 07/01/2024 through 07/30/2024, revealed no wound care orders for the resident's sacral wound until 07/30/2024 (five days after the resident's admission) at 5:35 PM, when an order was entered for Dakin's solution 0.125% gauze with bordered gauze to be completed twice a day as ordered. In an interview with Licensed Practical Nurse (LPN) 5 on 07/31/2024 at 3:32 PM, she stated she was not aware of the treatment orders from the referring facility (acute hospital) for R237. She stated she did not recall seeing anything in R237's paperwork about his wounds. The LPN stated she had measured the wound the day after his admission and a wet to dry dressing was in place at that time with a border gauze over it. LPN 5 said she did not recall if that dressing had been dated or not. She stated she had observed redness around the wound and stated she recalled there was tunneling (when a wound extends deeper into the tissue than its surface, creating a channel or tunnel) of the wound, but was not sure if there had been undermining (when significant erosion occurs underneath the visible wound margins resulting in more extensive damage beneath the skin surface). Per LPN 5's interview, she was told from the nurse who had been assigned to care for R237 to apply a normal saline wet to dry dressing to the wound. She stated she did not recall if she documented the dressing change though in R237's electronic medical record (EMR) or not. The LPN stated she had not seen R 237's wound since she assessed the wound the day after his admission. She further stated she did not know if there was a facility protocol for wounds and verbalized if a resident did not have an order, the nurse should call the Medical Doctor or the Nurse Practitioner for orders. In an interview with the admitting nurse, LPN 6 on 07/31/2024 at 3:56 PM, she stated she received report from the referring facility (acute care hospital), but had written her notes on regular paper. LPN 6 stated she had not seen a paper from the referring facility with wound care instructions on it. She stated there was another nurse assisting with putting in the orders for R237's admission, and she had not known the ancillary orders were not entered. The LPN stated she asked the medical APRN about a dressing order, but the APRN did not feel comfortable giving her an order. Per LPN 6's interview, she did not know who first put a normal saline wet to dry dressing on R237's wound, and she did not return to work again until the following Thursday. She further stated the wound vac had been available in R237's room at the time of his admission and she asked the nurse who relieved her to apply the wound vac. LPN 6 additionally stated she did not know why the wound vac was not placed. In an interview with LPN 9 on 07/31/2024 at 4:20 PM, she stated she made rounds with the wound APRN as well as worked as a floor nurse. LPN 9 stated she was not there the day R237 came in, but worked on the floor the weekend after his admission. She stated she recalled placing a wet to dry dressing on R237's wound during her shifts as she had been assigned the resident. The LPN said she had received the instruction in report and stated she was asked to talk to the wound APRN on Tuesday when the APRN made rounds at the facility. LPN 9 stated she just charted in the nurse's notes or observation documentation that the wound care was done. She went on to say that Medical Director 19 delegated the wound care to the wound APRN. LPN 9 further stated R237's wound looked about the same on Tuesday as it had when she cared for the resident as the assigned nurse the previous weekend. In an interview on 08/01/2024 at 9:45 AM, with Medical Doctor 19, he stated he was the Physician for R237. He stated he was aware R237 had been admitted with a Stage 4 wound to the coccyx. The Medical Director stated he recalled a nurse contacted him regarding the peri wound status and the wound vac not having been placed as ordered. He stated he recalled giving the order to apply a saline wet to dry dressing until the wound APRN saw R237 on Tuesday; however, did not recall who contacted him. He further stated the wound APRN recommendations were to be implemented as orders and he expected nursing staff to contact him if there was a question or concern. In an interview with the Regional Resource Nurse (RRN) on 08/01/2024 at 8:25 AM, the RRN produced a timeline validating wound care was provided for R237. The RRN verified the order had not been entered. During the interview, RRN also provided documentation of education initiated on 07/31/2024, addressing the necessity of entering an order into the facility's Matrix Electronic Medical Record (EMR) MATRIX. Per the RRN's interview, the educational inservice titled, MD Order was initiated on 07/31/2024 for all licensed staff related to the person receiving treatment orders, as well as verifying the treatment on the TAR in MATRIX prior to performing the treatment. 2. Review of R99's medical record revealed the facility admitted the resident on 02/17/2024, with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD); aspiration pneumonitis; Chronic Kidney Disease, Stage 4 (severe); and chronic systolic (congestive) heart failure. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed R99 to have a BIMS score of 12 out of 15 indicating the resident was cognitively intact. Review of the 02/17/2024 Admission Assessment information revealed the presence of a wound on R99's coccyx and foot; however, with no orders entered for treating those skin areas. Per record review, R99 had been by the Wound Care APRN on 02/22/2024 with treatment orders given. Review of R99's February and March 2024 Physician orders and Treatment Administration Record (TAR) revealed no orders noted for wound care until mid-March. Review of the weekly Wound APRN Notes dated 03/07/2024 through 03/28/2024, revealed R99's wounds were improving week - to - week. In interview on 08/01/2024 at 6:08 PM, the former Unit Manager/LPN 4 (UM/LPN 4) stated she personally completed the treatments for R99 every day, including on the weekend because she had been on-call. She stated she also completed the treatments because she took special interest in R99 due to knowing the resident's daughter. Former UM / LPN4 further stated she used to be the wound care nurse and had a great memory for treatment orders and had been very active and involved in the care of the residents on her unit. In an interview with the Director of Nursing (DON) on 08/01/2024 at 03:10 PM, DON stated it was her expectation that orders would be entered on the same day they are received. In an interview with the Administrator on 08/01/2024 at 06:30 PM, the Administrator stated it was her expectation that orders were entered into the EMR and expected nurses to follow the orders.

Based on observation, interview, record review, and review of the facility policy, the facility failed to have an effective system in place to ensure residents' safety and adequate supervision was provided to prevent accidents related to smoking in prohibited areas and smoking paraphernalia not being kept in secured locations for three residents (R) 7 and R48) out of twenty-five total sampled residents. R48 was observed smoking in a prohibited area, and R7, R14, and R48 were all observed with smoking paraphernalia lying on their beds and bedside tables and not secured in the bedside lockbox provided as required. In addition, the facility failed to ensure staff utilized a mechanical lift (as required) during transfer of R14. The findings include: Review of the facility policy titled, Accidents and Supervision dated 01/02/2020, with a revision date of 02/21/2024, revealed the resident environment was to remain as free of accident hazards as was possible, and they were to receive adequate supervision and assistive devices to prevent accidents. Continued review revealed ensuring adequate supervision and assistive device to prevent accidents included: identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks and monitoring effectiveness; and modifying interventions when necessary. Review of the facility policy titled, Resident Smoking dated 03/2020, revised 05/20/2024, revealed, it was the policy of the facility to provide a safe and healthy environment for residents including safety as related to smoking. Per policy review, smoking was prohibited in all areas except the designated smoking area. Continued review revealed a Designated Smoking Area sign was to be prominently posted. Further review revealed the safety measures to be provided included a designated smoking area to be located away from exits and a common space to be utilized to protect non-smoking residents from second-hand smoke. In addition, review revealed all smoking materials were to be maintained in a secure location either with the resident or with facility staff. 1(a). Review of the face sheet for R7 revealed the facility admitted the resident on 12/19/2022, with diagnoses of atherosclerotic heart disease, chest pain, diabetes mellitus, chronic kidney disease, and contractures of left hip, right knee, and left knee. Review of the 07/27/2024 Quarterly Minimum Data Set (MDS) Assessment for R7 revealed the facility assessed him to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating he was cognitively intact. Observation of R7 on 07/30/2024 at 3:20 PM, revealed him in his room with an opened pack of cigarettes and a lighter lying on the overbed table. Per observation, a lock box was sitting on the resident's bedside table. When questioned regarding the lock box at the time of observation, R7 stated it was for storage of his cigarettes and lighter. He further stated he was about to go out and smoke and had just taken the cigarettes and lighter out of the lockbox. R7 said he was aware his cigarettes and lighter were to be locked in the lock box when not in use. However, during an earlier observation of the resident by the State Survey Agency (SSA) Surveyor, R7 was observed in the smoking area. In an observation and interview on 07/31/2024 at 10:55 AM of R7, the resident was in his room with his cigarettes and lighter again sitting on the overbed table. He stated he had just returned from smoking and had not locked his cigarettes and lighter away yet. In additional observation on 08/01/2024 at 9:22 AM of R7, the resident was in his room with his cigarettes and lighter lying on the overbed table. R7 was watching television (TV), but stated he would be going out to smoke soon. 1(b). Review of the face sheet for R48 revealed the facility admitted him on 05/06/2022, with diagnoses that included chronic obstructive pulmonary disease (COPD), personality disorder, and acquired absence of right and left legs below knees. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed him to have a BIMS score of 14 out of 15, which indicated he was intact cognitively. Observation on 07/30/2024 at 3:04 PM, of R48 revealed he was in his room with cigarettes and a lighter lying on his bed, with a lock box sitting on the bedside table. He stated he was going out to smoke soon and that was why the cigarettes were out. R48 further stated he had been smoking most of his life and had smoked here since his admission, and knew the cigarettes and lighter were to be locked up. Observation on 07/31/2024 at 10:40 AM, of R48 revealed he outside on the smoking porch smoking. Continued observation at 10:55 AM, revealed R48 was back in his room with the cigarettes lying on the overbed table. The resident stated he had not had time to return the cigarettes to the lock box. Observation on 08/01/2024 at 1:33 PM, of R48 revealed him sitting on bed with his cigarettes and lighter at the end of the bed. R48 stated he would be going out to smoke soon. In interview on 08/01/24 at 9:57 AM, the Activities Director (AD) stated residents who were independent smokers, had a lock box to store their cigarettes and lighters in located in their rooms. She stated she knew there was a form the nurses filled out to assess residents in order for residents to independently smoke. In interview on 08/01/24 05:32 PM, the Director of Nursing (DON) and Administrator stated they were not aware of R48 smoking in a restricted smoking area. They stated if the residents doing that did not follow the policy, their smoking privileges would be revoked. In additional interview on 08/01/2024 at 5:40 PM, the Administrator stated she expected the residents to follow the facility's policy regarding smoking. In additional interview on 08/01/2024 at 5:55 PM, the DON she expected all residents to follow the facility's policies. She further stated those particular residents (R7 and R48) were difficult to manage regarding their smoking. 2. Review of the facility policy titled, Safe Handling/Transfers, dated 02/2024, revealed it was the facility's policy to ensure residents were handled and transferred safely to prevent or minimize risks for injury. Continued review revealed the facility's policy to provide and promote a safe, secure and comfortable experience for the resident in accordance with current standards and guidelines. Further review revealed all residents required safe handling when transferred to prevent or minimize the risk for injury to themselves and employees assisting them. Review of the Face Sheet for R14 revealed the facility admitted him on 11/04/2022, with diagnoses that included: multiple sclerosis, hereditary spastic paraplegia, and Parkinson's Disease with dyskinesia. Review of the Annual MDS assessment dated [DATE], revealed the facility assessed R14 to have a BIMS score of 15 out of 15 indicating he was intact cognitively. Additional MDS review revealed the facility also assessed the resident as dependent on staff for transfers. Review of the Comprehensive Care Plan for R14 dated 11/11/2022, revealed the facility had developed a focus problem for Activities of Daily Living (ADL's) due to self-care performance deficit related to impaired mobility. Review of the care plan further revealed intervention dated 11/11/2022, for R14 to be transferred with a mechanical lift and assist of two staff. Review of the 11/11/2022, Resident Profile (the Certified Nursing Assistant [CNA] Care Guide) revealed the facility noted R14 required assistance of two staff members and use of mechanical lift for transfers. Observation on 07/29/2024 at 6:50 PM, revealed CNA 17 enter R14's room with a mechanical lift with no other staff member present. Continued observation, after four to five minutes later, when the State Survey Agency (SSA) Surveyor entered R14's room, revealed the resident was lying on his bed and CNA 17 was moving the mechanical lift away from the bed. Further observation revealed no other staff present to have assisted with R14's transfer, therefore, CNA 17 had utilized the mechanical lift alone when transferring the resident. In interview on 07/29/2024 at 7:00 PM, R14 stated CNA 17's transfer of him alone, had not been the first time only one staff member had transferred him to bed. R14 further stated he was not sure how many staff were to transfer him, and sometimes it was two people and sometimes it was one person. In interview on 07/29/2024 at 6:55 PM, CNA 17 stated R14 required a lift and assist of two staff for transfers. CNA 17 stated she had not been able find anyone to help her transfer R14 to bed. CNA 17 said there had been another CNA, but that aide had been assisting on another hall. She stated a nurse had been on the unit, but she had not asked the nurse for help. The CNA also stated it was important to follow R17's care plan as the lift could tilt and the resident could fall. In an interview on 08/01/2024 at 2:24 PM, the DON stated CNA 17 had been sent home after being made aware R14 transferred R14 without using two staff (as required). The DON stated all staff were to ensure residents' safety and CNA 17, by not following R14's care plan and using two staff had not ensured the resident's safety. In an interview on 08/01/2024 at 7:29 PM, the Administrator stated she expected staff to follow the facility's policies and residents' care plans. The Administrator said residents' care plan directed staff on how to care for the resident. She stated R14's safety was why two staff were used and CNA's had access to residents' care guides in Matrix (charting system). The Administrator additionally stated she expected staff to follow the (residents') care plan. 44370

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to maintain safe and sanitary infection control precautions during wound care for 1 of 3 residents sampled for wound care out of 25 totaled sampled residents, (R)237. The finding include: Review of the facility's policy, Infection Prevention and Control Program with a revision date of 02/01/2024, revealed the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. Per review, the facility's infection prevention program was also to help prevent the development and transmission of communicable diseases and infections. Continued review revealed All staff were to assume all residents were potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Review of the facility's policy titled, Clean Dressing Change with a revised date of 03/12/2024, revealed it was the policy of the facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Record review revealed the facility admitted R237 on 07/25/2024, with a chronic Stage 4 wound to the sacrum. Review of R237's current Physician's orders revealed the wound care and dressing change orders were for Dakin's solution 0.125% (a topical antiseptic used to treat and prevent infections in wounds, burns, and other areas) wet to dry dressing and cover with a bordered gauze twice daily. Observation on 08/01/2024 at 11:20 AM, of wound care for R237, revealed Licensed Practical Nurse (LPN) 6 cleaned the overbed table, laid a clean barrier on the table, and placed the wound care supplies onto the clean barrier. Continued observation revealed the wound care supplies included an unopened package of non-sterile 4 x 4's dressings, wound cleanser spray, the Dakin's solution, a bordered gauze dressing and a non-sterile cup. Per observation, LPN 6 washed her hands and donned a gown and gloves. Observation revealed LPN 6 proceeded with the wound care procedure and cleansed the wound with the wound cleansing spray and patted the wound bed with a non-sterile gauze she had laid onto the clean barrier. LPN 6 was then observed to discard the used 4x4 into a waste bag; however, without changing gloves, the LPN removed additional non-sterile 4x4's dressings from the non-sterile 4 x 4 package. Further observation revealed LPN 6 then applied the secondary bordered gauze dressing and removed her gloves and performed hand hygiene. In interview on 08/01/2024 at 11:55 AM, LPN 6 stated she was not aware she had reached into the 4x4 package with a used glove. LPN 6 was then observed to remove the 4x4 dressing package from the treatment cart. In interview on 08/01/2024 at 3:59 PM, Staff Development Coordinator (SDC) 2 revealed staff were educated annually through the competency skills fair regarding infection control and wound care. SDC 2 stated competency skills were completed through observation of staff performing the task utilizing a mannequin. The SDC stated staff were evaluated and educated during the observation. SDC 2 further stated the competency skills fair would be completed in the near future. In interview on 08/01/2024 at 6:30 PM, the Administrator stated it was her expectation staff followed the facility's policies.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure residents were able to exercise their right to view the results of the facility's State Survey Agency's (SSA's) results and the facility's Plan of Correction. Additionally, the facility failed to post signage related to reviewing the survey results and failed to ensure residents and/or family members were aware of the location of the survey results. Observations on 07/28/2024 through 8/01/2024, revealed the survey results were not readily accessible to residents, family members, and legal representatives of the residents. Further observation revealed no signage posted informing residents and visitors where survey results were available for viewing. The findings include: Review of the facility's policy titled, Resident Rights dated 03/18/2024, revealed residents had the right to exercise their rights to be free of interference, coercion, discrimination, and reprisal from the facility in exercising their rights and to be supported by the facility in the exercise of those rights. Observation on 07/28/2024 at 11:45 AM, in the entry way and lobby area, revealed no signage posted indicating where the facility's survey results were available to view. Further observation revealed the SSA Surveyor was unable to locate the survey results in the facility until 08/01/2024, when the Surveyor asked asked to the results. The receptionist phoned the Administrator and provided the survey results that she removed from a drawer at the front desk. During the Resident Group interview on 07/30/2024 at 3:06 PM, with nine facility residents, Resident (R) 2 stated the Activity Director (AD) talked about the survey results; however, R2 did not know where the results were located in the facility. Additionally, R18 and R63 stated they were unaware of where the survey results were located in the facility. Review of the Minimum Data Set (MDS) Assessment for Resident (R)2, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Review of the Quarterly MDS Assessment for R18 dated 05/30/2024, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, indicating intact cognition. In an interview with R18 on 07/30/2024 at 3:32 PM, she stated she was not sure where the (facility's) survey (results) book was located and had never examined the survey book. Review of the Quarterly MDS assessment dated [DATE] for R63 revealed the facility assessed the resident as having a BIMS score of 15 out of 15, indicating intact cognition. In an interview with R63 on 07/30/2024 at 3:32 PM, she stated she was not sure where the survey book was located and had never examined the survey book Review of the Quarterly MDS Assessment for R10 dated 06/20/2024, revealed the facility assessed the resident as having a BIMS score of 15 out of 15, indicating intact cognition. In an interview with R10 on 07/30/2024 at 3:32 PM, she stated they had discussed the survey results in meetings, but she was not sure where the survey book was located and had never examined the survey book. Review of Resident Council meeting minutes for May, June and July 2024, revealed the Activity Director had discussed the location of the survey results binder with residents during the council meetings. In an interview with the Activity Director on 08/01/2024 at 9:35 AM, she stated she discussed the survey results with the residents during resident council meetings. She stated the survey results binder should be located in the lobby area; however, did not know why it was not there. In an interview with the Administrator on 08/01/2024 at 7:29 PM, she stated she was aware the survey results were to be available for residents, staff, family and visitors. The Administrator stated she did not know signage had be be posted regarding the survey results. She stated the facility had experienced a large turnover in staffing and the receptionist did not know the results had to be out and visible to the public. The Administrator stated it was her responsibility to ensure the survey results were out for residents and visitors.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain clinical records in accordance with accepted professional standards for one of three (3) sampled residents (Residents #6). Review of Resident #6's Medication Administration Record (MAR) revealed staff failed to document that the resident received seventeen doses of Norco (Hydrocodone 5, Acteaminophen 325), from 09/27/2023 through 10/28/2023 on the MAR. However, only two doses of the medication were signed out on the Medication Administration Record (MAR). The findings include: Review of the facility's policy, Medication Administration, dated 11/01/2023, revealed that medications were administered by licensed nurses or other staff who were legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Continued review revealed that staff would sign the medication administration record (MAR) after the medication was administered Closed record review revealed the facility admitted Resident #6 to the facility on [DATE] with diagnoses which included Unspecified Convulsions, Dysphasia and Aphasia. Further review of the record revealed Resident #6 was discharged on [DATE]. Review of Resident #6's Quarterly Minimum Data Set (MDS) Assessment, dated 10/26/2023, revealed the facility assessed to resident to have a Brief Interview for Mental Status (BIMS) score of zero (0) indicating the resident was rarely understood. Review of Resident #6's Narcotic Control Record, revealed from 9/27/2023 through 10/28/2023, Resident #6 had seventeen (17) doses of Norco (Hydrocodone 5 Acetaminophen 325) signed out. However, review of the Medication Administration Record (MAR) dated 09/27/2023 through 09/30/2023 and [DATE]/01/2023 through 10/28/2023, revealed that only two (2) doses of Norco had been signed out on the medication administration record (MAR). Interview with Licensed Practical Nurse # 1 on 11/22/2023 at 6:38 AM, she stated the MAR and the narcotic control logs are supposed to match. She stated she should have signed out Resident #6's medication on the MAR when it was administered. In an interview with the Director of Nursing (DON), on 11/21/2023 at 3:45 PM, she stated on 11/08/2023 staff caught Resident #6's spouse trying to get access to the medication cart to review the narcotic book. She stated Resident #6's spouse told her the MAR was blank and she knew Resident #6 had received pain medication. The DON stated she audited Resident #6's MAR/Narcotic record and discovered licensed staff were only signing the narcotic book and not documenting on the MAR. During an interview with the Administrator on 11/22/2023 at 12:00 PM, she stated the DON had made her aware that Resident #6's spouse had seen a copy of the MAR and it was blank. She stated they immediately started an investigation and discovered some of the nurses were not signing the MAR when administering PRN medication. She stated on 11/08/2023, she, the DON and the Medical Director held an ad hoc telephone call to discuss staff not signing the MAR after medication administration. *The facility implemented the following actions to correct the deficient practice: 1. On 11/08/2023 the Director of Nursing was made aware that licensed nurses and medication aides were not documenting the administration of as needed controlled drugs in the electronic health record. 2. On 11/08/2023, current residents that received PRN medications were reviewed by the DON and/or Assistant Director of Nursing (ADON). 3. On 11/08/2023 licensed staff and medication aides were educated by the DON that all controlled medications must be signed out on the narcotic sheet and in the electronic medical record (EMR) on the medication administration record (MAR). 4. On 11/09/2023 the facility initiated random audits on 100, 200, 300 and 400 halls, one resident daily from each hall, that were ongoing and would continue for twelve (12) weeks and the results would be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for review and documentation recommendation. The next QAPI meeting was scheduled for the week of 11/27/2023. 5. On 11/08/2023, an Ad HOC Quality Assurance (QA) with the Medical Director, Administrator, and DON was held. The purpose of the Ad HOC meeting was to discuss the outcomes of the medication administration audit conducted on 11/8/2023 by the DON and to ensure staff were educated on signing out controlled drugs in the HER (electronic health record). **The State Survey Agency Validated the corrective action by the facility as follows: 1. In an interview with the Director of Nursing (DON), on 11/21/2023 at 3:45 PM, she stated Resident #6's spouse told her on 11/08/2023, that the MAR was blank, and she knew Resident #6 had received pain medication. She stated she audited Resident #6's MAR/Narcotic record and discovered licensed staff were not signing the MAR, only the narcotic book. 2. Interview with the DON on 11/21/2023 at 3:45 PM, she stated on 11/08/2023, she and the Unit Manager completed MAR audits on all current residents receiving PRN pain medication. 3.Interviews with Kentucky Medication Aide (KMA) #1 on 11/21/2013 at 4:02 PM, the Staff Development Coordinator (SDC) on 11/21/2023 at 4:15 PM, Licensed Practical Nurse (LPN) #1 on 11/22/2023 at 6:38 AM, KMA #2 on 11/22/2023 at 11:00 AM, and LPN #2 on 11/22/2023 at 11:25 AM, revealed they had been educated recently by either the DON/Unit Manager on signing out PRN medication in the EMAR (Electronic Medication Record) and on the narcotic control logs. 4. Review of the Audit for MAR Documentation, revealed the Unit Manager conducted audits of the Medication Records. Audits were initiated on 11/09/2023 and were ongoing as of 11/22/2023. Audits would continue for 12 weeks and results forwarded to the QAPI committee for review. 5. Review of Attendance Rosters, dated 11/08/2023, revealed the facility had an Ad HOC meeting with the Medical Director, Administrator, and DON on 11/08/2023. During an interview with the Administrator on 11/22/2023 at 12:00 PM, she stated she and the DON notified the Medical Director and had a telephone meeting to discuss the licensed staff signing the MAR after administering medications. In an interview with the Medical Director on 11/22/2023 at 12:40 PM, he stated he received a call from the Administrator and as Ad HOC QAPI meeting was held via telephone on 11/08/2023, to discuss the nurses not signing out medications in the EMR.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately. However, not later than two (2) hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for one (1) out of five (5) sampled residents, Resident #3. On [DATE], Resident #3 was noted to have bruising and increased pain to his/her right knee. An X-ray of the right knee was performed on [DATE], and review of the X-ray report dated [DATE] at 5:40 AM, revealed Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility reported the injury incident as an injury of unknown origin. The findings include: Review of the facility policy, Abuse, Neglect, and Exploitation, dated [DATE] and revised on [DATE], revealed it was the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. Continued review revealed on reporting and response the facility was to have written procedures that included reporting all alleged violations to the Administrator, State Agency, Adult Protective Services (APS) and to all other required agencies within the specified time frames immediately, but not later than two (2) hours after the allegation was made if the events that caused the allegation involved abuse or resulted in serious bodily injury. Further review revealed reporting should not be later than twenty-four (24) hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury. Review of the closed medical record for Resident #3 revealed the facility admitted the resident on [DATE], with diagnoses that included: Dementia, Unspecified; Unilateral Primary Osteoarthritis, Unspecified Knee; Osteomyelitis Unspecified; and Difficulty in Walking. Continued review revealed Resident #3 was admitted to Hospice Care on [DATE] and expired in the facility on [DATE]. Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of one (1) indicating the resident had severe cognitive impairment. Continued review of the MDS Assessment, section G, Activities of Daily Living (ADL) revealed the facility assessed Resident #3 to require limited assist of one (1) staff for transfers; supervision of one (1) staff member for walking in his/her room; and as independent with no supervision required when walking in the corridor. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of two (2) indicating he/she continued to have severe cognitive impairment. Continued review of MDS Assessment, section G, ADL, revealed the facility assessed Resident #3 to require extensive assist of two (2) staff for transfers; and walking in the room and corridor, coded as an eight (8) which indicated the activity did not occur. Review of the Progress Note dated [DATE] at 9:52 AM, signed by Licensed Practical Nurse (LPN) #1 revealed Resident #3 complained of pain to his/her right knee, ankle and foot area. Further review revealed LPN #1 also noted Resident #3's right knee was bruised. Review of the Progress Note dated [DATE] at 3:16 PM, signed by LPN #1 revealed a new order was received from Hospice to obtain an X-ray of Resident #3's right knee due to increased pain and swelling with bruising. Review of the X-ray imaging report dated [DATE], revealed the X-ray resulted at 5:40 AM, noted the results were fracture of the distal femoral shaft with malalignment joint space narrowing and mild soft tissue swelling. Further review revealed the conclusion was an acute appearing femoral fracture. Review of the Progress Note dated [DATE] at 8:55 PM, but created on [DATE], by the former Director of Nursing (DON) revealed she spoke with Resident #3's Power of Attorney (POA) regarding the X-ray results which noted the fracture to the resident's right femur. Continued review revealed the POA agreed the cause was from Resident #3 self-transferring or his/her spouse attempting to transfer the resident. Per review, Resident #3's right leg had a history of issues and integrity was compromised due to the multiple infections of the right knee and multiple surgeries. Further review revealed Resident #3 had a history of Osteoarthritis, Osteomyelitis, and Osteopenia. Further review revealed the POA voiced appreciation for the follow up and expressed that she did not want any surgical intervention, and the facility should focus on keeping the resident comfortable. Review of the History and Physical (H&P) dated [DATE], completed by the attending Physician revealed Resident #3 was under Hospice care; had a right femur fracture, pathological due to long term Prednisone use; and painful movement. Continued review of the H&P revealed the Physician noted Resident #3 had chronic pain syndrome for which he/she received Morphine and Norco (both narcotic pain medications). Per review, Resident 33 had Vascular Dementia worsening with sundowners (confusion, restlessness, agitation, and disorientation occurring in the late afternoon and lasting into the night). Further review revealed Resident #3 had Remeron (antidepressant medication) for depression and anxiety. Review further revealed due to Resident #3's femur he/she was bedridden, and was to continued to receive Hospice care and pain control. In addition, the Physician noted Resident #3's condition poor and prognosis were poor. In an interview on [DATE] at 5:33 PM, the former DON stated the Progress Note she documented as [DATE] was not documented by her until [DATE]; however, she did not enter the Note as a late entry. She stated the facility did not perform an investigation of Resident #3's injury of unknown origin, nor report the femur fracture as such. The DON further stated the Physician said the fracture was pathological in nature and therefore she did not document or report the fracture. During an interview on [DATE] at 1:28 PM, the current DON stated she had been the DON at the facility for approximately thirty (30) days. She stated her expectation was that any injury of unknown origin be investigated and reported as required. The DON stated she was not here at the time and could not speak to whether or not an investigation happened in regard's to Resident #3's femur fracture. During an interview on [DATE] at 1:45 PM, the Administrator stated she had been at the facility since [DATE], and had been a Licensed Nursing Home Administrator (LNHA) for a year. She stated she was unsure about the facility's policy; however, she would seek counsel from the facility's corporate staff related to injuries of unknown origin being reported to the State Agency. The Administrator stated if an incident was truthfully an injury of unknown origin, then it should have been investigated and reported as such. She further stated the facility was required to investigate and report all alleged violations of abuse/neglect within two (2) hours.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure medical records were accurately documented for one (1) of five (5) sampled residents, Resident #3. On [DATE] Resident #3 was noted with bruising to the right knee and increased pain. An X-ray of the right knee was performed on [DATE] and the results obtained on [DATE] at 5:40 AM, revealed Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility notified the attending Physician until [DATE], nor that Hospice Services was notified. The findings include: Review of the facility policy, Charting and Documentation, revised ,d+[DATE], revealed all services provided to the resident, progress towards the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition was to be documented in the resident's medical record. Review revealed medical records was to facilitate communication between the interdisciplinary team (IDT) regarding the resident's condition and response to care. Continued review revealed the following information was to be documented in the residents' medical records: treatments or services performed; changes in the resident's condition; any events, incidents, or accidents, involving the resident and any treatment services performed. Review further revealed the documentation of procedures and treatments was to include care specific details such as: the assessment data and any unusual findings obtained during the procedure or treatment; and notification of the Physician, family, or other staff, if indicated. Review of the closed medical record for Resident #3 revealed the facility admitted the resident on [DATE], with diagnoses which included: Unilateral Primary Osteoarthritis, Unspecified Knee; Dementia, Unspecified; Osteomyelitis Unspecified and Difficulty in Walking. Review further revealed the resident was admitted to Hospice Care on [DATE], and he/she expired in the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) Assessment for Resident #3 dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2) indicating he/she was severely cognitively impaired. Review of Resident #3's Progress Note dated [DATE] at 9:52 AM, documented by Licensed Practical Nurse (LPN) #1 revealed the resident complained of pain in his/her right knee, ankle and foot area. Per review, Resident #3's right knee was bruised. Review revealed the Hospice Nurse/Registered Nurse (RN) #4, was at the facility on that date, and questioned Resident #3 about falling. Continued review revealed Resident #3 told Hospice Nurse/RN #4 he/she had not fallen. Further review revealed Hospice Nurse/RN #4 asked if the facility Nurse Practitioner (NP) could assess Resident #3, and she (Hospice Nurse/RN #4) stated she told facility staff she would return later to do the resident's Hospice Recertification. In addition, Hospice Nurse/RN #4 and the facility NP were both aware of Resident #3's bruised right knee area, and pain in the resident's knee, ankle, and foot area and assessed. Review of the Hospice Recertification visit documentation dated [DATE] at 2:05 PM, by Hospice Nurse/RN #4, revealed Resident #3 had complained of increased pain to his/her right knee, ankle, and foot area. Per review, the facility reported Resident #3 had not fallen and that he/she would be unable to get himself/her self up off the floor if he/she had fallen. Continued review revealed Resident #3 had chronic right knee pain; however, stated the pain was unbearable today. Further review revealed Hospice Nurse/RN #4 spoke with the Hospice Supervisor and an order for an X-ray was received. In addition, review further revealed Resident #3 did have chronic history of right knee being swollen due to a recent surgery; however, the swelling was increased. Review of the Progress Note dated [DATE] at 3:16 PM, documented by LPN #1 revealed a new order had been received from Hospice to obtain an X-ray of Resident #3's right knee due to increased pain and swelling with bruising. Review of the X-ray imaging report dated [DATE] at 5:40 AM, revealed the results were fracture of the resident's distal femoral shaft with malalignment; joint space narrowing; and mild soft tissue swelling. Further review revealed the conclusion was noted as an acute appearing femoral fracture. Review of Resident #3's Progress Note dated [DATE] at 8:55 PM; however created on [DATE], by the former Director of Nursing (DON) revealed she spoke with Resident #3's Power of Attorney (POA) regarding the resident's X-ray results which noted a fracture to the right femur. Per review of the Note, the POA agreed that the cause of the fracture was from Resident #3 self-transferring or his/her spouse attempting to transfer the resident. Continued review revealed Resident #3's right leg had a history of issues and of the integrity being compromised due to the multiple infections of the right knee and multiple surgeries. Further review revealed a history of Osteoarthritis, Osteomyelitis, and Osteopenia noted and the POA voiced appreciation for the follow up. In addition, the POA expressed she did not want any surgical intervention for Resident #3, and said the facility should focus on keeping the resident comfortable. Review of the Progress Note for Resident #3 dated [DATE], revealed there was no documented evidence indicating the X-ray results had been received. Continued review revealed no documented evidence the Physician or Hospice had been notified of the results. Review of Resident #3's history and physical, completed by the attending Physician and dated [DATE], revealed the resident had been receiving Hospice care and had a right femur fracture which was pathological, due to long term steroid use. Continued review revealed Resident #3 had painful movement, chronic pain syndrome, vascular Dementia worsening with sundowners; Depression; and Anxiety. Further review revealed Resident #3 had Osteoarthritis of the right knee; previous surgeries; Osteomyelitis of the right tibia; and history of patellar fracture which was non-operable; incontinence of both bowel and bladder; weakened condition, with a poor prognosis. In addition, it was noted Resident #3 had Morphine and Norco, ordered for pain. During an interview on [DATE] at 1:08 PM, the facility's Nurse Practitioner (NP) stated LPN #1 made her aware of Resident #3's bruised knee. She stated Resident #3 started receiving Hospice a few months ago and she did not see the resident other than seeing him/her in the common area. The NP further stated Hospice took care of all Resident #3's needs. She further stated she had not notified the Physician about the resident's bruised right knee, nor of the X-ray results. In an interview on [DATE] at 8:18 PM, LPN #1 stated she made the facility's NP aware of Resident #3's right knee bruising. She stated she did not make the Physician aware; however, she thought the NP had notified the Physician. LPN #1 stated she had not been working when the X-ray results returned to the facility on [DATE]. In an interview on [DATE] at 9:40 AM, Hospice Nurse/RN #4 stated she saw Resident #3 on [DATE], and noted increased pain and bruising to the resident's right knee. She stated Resident #3 had a history of right knee pain. The RN stated she asked LPN #1 if the facility NP could assess Resident #3. She stated the NP ordered an X-ray and she spoke with her Hospice Supervisor and received an order to proceed. Hospice Nurse/RN #4 stated Hospice was not notified of the X-ray results until she visited Resident #3 on [DATE]. In an interview on [DATE] at 11:28 AM, the Physician stated he had been notified of Resident #3's right femur fracture when the X-ray results were received. He stated the former DON, or the floor nurse made him aware. The Physician stated Resident #3 had multiple issues with his/her right knee and received steroids. He further stated Resident #3's femur fracture was a pathological fracture. During an interview on [DATE] at 5:33 PM, the former Director of Nursing (DON) stated she could not recall reporting Resident #3's X-ray results to the attending Physician. She stated she did recall calling the POA and it was decided at that time that no surgical intervention would be done. In continued interview the former DON, stated she could not speak to Resident #3's injury and an injury of unknown origin as the Physician stated it was a pathological fracture. The former DON stated she could not recall if that was documented prior to [DATE] or not. During an interview on [DATE] at 1:45 PM, the Administrator stated she had been a Licensed Nursing Home Administrator for a year, and had been at the facility since [DATE]. She stated she expected all staff to follow policies and procedures of the facility. The Administrator stated she expected the nurses to notify the Physician when a change in condition occurred to a resident, and to document the notification in the medical record as per the policy.

Based on interview, record review, Centers for Medicare and Medicaid Services (CMS)Resident Assessment Instrument (RAI) Manual, and review of facility policy, it was determined the facility failed to review and revise a comprehensive person-centered care plan for two (2) of fourteen (14) sampled residents reviewed for care plans, Residents #2 and #3. Record review revealed Resident #2's care plan was not revised after he/she exhibited refusal and noncompliance with care. On [DATE] Resident #3 was noted with bruising to the right knee and increased pain. An X-ray of the right knee was performed on [DATE] and resulted on [DATE] at 5:40 AM and indicated Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence that the facility revised the comprehensive care plan when the fracture occurred. Record review revealed Resident #3's care plan was not revised after he/she sustained a right distal femur fracture on [DATE]. Review of the CMS RAI Manual, Section 4.7 The RAI and Care Planning, dated ,d+[DATE], revealed the care plan was to be revised on an ongoing basis to reflect changes in the resident and the care that the resident required. The findings include: Review of the facility policy, Comprehensive Care Plans, dated [DATE], revealed it was the policy of the facility to develop and implement a comprehensive person centered care plan for each resident consistent with resident rights. Continued policy review revealed the comprehensive person centered care plan was also to include measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that had been identified in the resident's comprehensive assessment. Further review revealed the comprehensive care plan was to be reviewed and revised by the interdisciplinary team (IDT)after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Review of the facility policy, Care Plan Revisions Upon Status Change, dated [DATE], revealed the purpose of the procedure was to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Review further revealed the comprehensive care plan was to be reviewed and revised as necessary when a resident experienced a status change. 1. Review of the closed record for Resident #3 revealed the facility admitted him/her on [DATE] with diagnoses that included: Difficulty Walking; Dementia, Unspecified; Unilateral Primary Osteoarthritis, Unspecified Knee; Osteomyelitis Unspecified. Review further revealed Resident #3 was admitted to Hospice Care on [DATE], and expired at the facility on [DATE]. Review of the Significant Change in Status MDS assessment dated [DATE] revealed the facility assessed Resident #3 to have a Brief Interview for Mental Status (BIMS) score of one (1) indicating he/she had severe cognitive impairment. Review of Resident #3's Comprehensive Care Plan dated [DATE], revealed the facility had developed a focus problem for pain, chronic, related to Osteoarthritis (OA). Per review, the care plan was reviewed by MDS Coordinator #1 on [DATE]. Continued review revealed the care plan contained the following interventions: administer medications as ordered; administer opioid reversal agent as ordered; observe and report changes in usual routine, sleep patterns; decrease in functional abilities. Review revealed the interventions also included: observing for decreased range of motion; withdrawal or resistance to care; observe, record, report to nurse any signs or symptoms of nonverbal pain, changes in breathing, vocalizations, mood or behavior, face or body changes. Further review revealed no documented evidence Resident #3's care plan was revised on or after [DATE], when Resident #3 sustained the right distal femur fracture. Review of the Progress Note dated [DATE], revealed Resident #3 complained of pain in his/her right knee, ankle and foot area. Review revealed Resident #3's right knee was bruised. Continued review revealed the Hospice Nurse/Registered Nurse (RN) #4, was at the facility on that date, and questioned Resident #3 about falling. Further review revealed Resident #3 told Hospice Nurse/RN #4 he/she had not fallen. During an interview on [DATE] at 11:44 AM, Licensed Practical Nurse (LPN) #2 stated she had received in report that Resident #3 had a right femur fracture. She stated she was not told how the fracture happened. The LPN stated Resident #3 often had pain and received routine and as needed pain medications. She further stated she would think Resident #3's new fracture would have been documented on his/her care plan. During an interview on [DATE] at 11:13 AM, the Unit Manager stated that she was told by the nurse on [DATE] that Resident #3 had fallen the night before. She stated on [DATE] the X-ray results revealed Resident #3 had a right femur fracture. The Unit Manager stated the femur fracture should have been added to Resident #3's care plan and the care plan should have been updated and revised if needed. She further stated all nurses could update residents' care plans. Interview on [DATE] at 9:00 AM, the MDS Coordinator stated Resident #3's pain and activity of daily living (ADL's) care plan should have been updated and revised when the facility learned of the femur fracture. She stated the fracture should have been discussed in the facility's daily clinical meeting and the resident's care plan revised at that time. In an interview on [DATE] at 9:30 AM, MDS #2 stated she was aware Resident #3 sustained a right femur fracture. She stated certainly, Resident #3's care plan should have been updated and revised when the fracture occurred. She stated she expected the nurse or the Unit Manager who received the X-ray report to update Resident #3's care plan. 2. Review of the closed record for Resident #2 revealed the facility admitted the resident on [DATE], with diagnoses to include: Quadriplegia, Incomplete; Pressure Ulcer of Sacral Region, Stage four (4); Psychotic Disturbance; and Mood and Anxiety Disturbance. Further review revealed Resident #2 was discharged from the facility on [DATE]. Review of the Quarterly MDS Assessment for Resident #2 dated [DATE], revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating he/she was cognitively intact. Review of the Progress Note dated [DATE] at 11:35 AM, signed by the Unit Manager revealed Resident #2 refused to be seen by the wound care NP and refused to have his/her wound vac changed. Continued review revealed Resident #2 said he/she would wait for the night nurse to provide his/her wound care. Review of Resident #2's Comprehensive Care Plan dated [DATE], revealed there was no documented evidence the facility developed the resident's care plan with focus problems related to his/her mood, anxiety, behaviors, or non-compliance and refusal of care. During an interview on [DATE] at 11:13 AM, the Unit Manager stated stated Resident #2 was noncompliant and often refused care. She stated she thought Resident #2 was care planned for those behaviors. In interview on [DATE] at 9:00 AM, the MDS Coordinator stated Resident #2 often made choices that were not right for his/her care. The MDS Coordinator further stated refusal of care as well as non-compliance with care should have been addressed on Resident #2's care plan. In further interview on [DATE] at 9:00 AM, the MDS Coordinator stated the purpose of the care plan was that it drove resident care and allowed staff to know what care a resident needed. She stated the admissions nurse initiated a new resident's baseline care plan and the IDT met to formulate the resident's comprehensive care plan. The MDS Coordinator stated charts were reviewed daily in clinical meeting and they discussed any new orders and falls during those meetings. She stated the nurses on the floor had been trained on care plans and could update and revise the care plans and initiate any new problems for a resident. In an interview on [DATE] at 9:30 AM, MDS #2 stated she had been the MDS Nurse at the facility for five (5) years. She stated care plans were updated by the nurses on the floor. MDS #2 stated the purpose of the care plan was that it drove resident care and allowed staff to know what was required for the resident's care. During an interview on [DATE] at 1:28 PM, the Director of Nursing (DON) stated she had been the DON at the facility for approximately thirty (30) days. She stated her expectation of her staff would be that they updated residents' care plans and revised them as needed when a resident had a change in condition, had orders that affected his/her care, and/or with changes in the resident's ADL's. The DON stated the nurses had been trained on care plans. She further stated she was not employed when Resident #2 and Resident #3's were in the facility and so, she could not speak directly to that. During an interview on [DATE] at 1:45 PM, the Administrator stated she had been Administrator at the facility since [DATE]. She stated her expectation of staff was for residents' care plans to be updated and revised when a resident had a change in condition that required different care. The Administrator further stated the outcome of a resident's care plan not being revised would be that staff would not know what care to provide.

Based on interview, record review and review of the facility's Abuse policy, it was determined the facility failed to conduct a thorough investigation concerning an injury of unknown origin which was diagnosed as a right distal femur fracture for one (1) of five (5) sampled residents reviewed for potential abuse, neglect and mistreatment, Resident #3. On [DATE], Resident #3 was noted to have bruising to his/her right knee and increased pain in the knee. An X-ray of the right knee was obtained on [DATE] and on [DATE] at 5:40 AM, the X-ray results noted Resident #3 had an acute distal femur fracture with malalignment. However, there was no documented evidence the facility investigated the incident as an injury of unknown origin. The findings include: Review of the facility policy, Abuse, Neglect, and Exploitation, dated [DATE] and revised on [DATE], revealed it was the facility's policy to provide protection for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. Continued review revealed an Alleged Violation, was a situation or occurrence that had been observed or reported by staff, residents, relatives, visitor, or others; however, had not yet been investigated. Per review, if the situation or occurrence was verified it could be indication of noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Review revealed the Investigation of Alleged Abuse, Neglect and Exploitation, an immediate investigation was warranted if suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation, occurred. Per policy review, the written procedures for investigations included: investigating different types of alleged violations, identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, and witnesses and others who might have knowledge of the allegation. Further review revealed the policy was noted as focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment had occurred, and providing complete and thorough documentation of the investigation. Review of the closed medical record for Resident #3 revealed the facility admitted him/her on [DATE], with diagnoses which included: Primary Unilateral Osteoarthritis, Unspecified Knee; Osteomyelitis, Unspecified; Difficulty in Walking; and Dementia, Unspecified. Continued review revealed Resident #3 was admitted to Hospice Care on [DATE] and was noted as deceased in the facility on [DATE]. Review of the Significant Change of Status Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #3 as having a Brief Interview for Mental Status (BIMS) score of one (1), indicating the resident was severely cognitively impaired. Continued review of the MDS Assessment, section G, Activities of Daily Living (ADLs) revealed the facility assessed the resident as requiring limited assistance of one (1) staff for transfers. Further review of section G revealed the facility also assessed Resident #3 to require supervision of one (1) staff person for walking in his/her room and as independent with no supervision required when walking in the corridor. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #3 as having a BIMS score of two (2), which indicated the resident as severely cognitively impaired. Continued review of section G, ADLs revealed the facility assessed the resident as requiring extensive assist of two (2) staff for transfers. Further review of section G, ADLs revealed the facility assessed Resident #3 as the activity of walking in his/her room and corridor as not occurring. Review of Resident #3's Progress Note dated [DATE] at 9:52 AM, signed by Licensed Practical Nurse (LPN) #1 revealed the resident complained of pain in his/her right knee, ankle and foot area, and his/her right knee was observed as bruised. Per review of the Note, Hospice Nurse/Registered Nurse (RN) #4, was at the facility and questioned Resident #3 about falling. Continued review revealed Resident #3 told Hospice Nurse/RN #4 he/she had not fallen. Further review revealed Hospice Nurse/RN #4 then asked if the facility Nurse Practitioner (NP) could assess Resident #3. Hospice Nurse/RN #4 and the facility's NP were both aware of the injured areas and assessed Resident #3. Review of the Progress Note dated [DATE] at 2:26 PM, documented by LPN #1 revealed Hospice Nurse/RN #4 was at the facility to see Resident #3 and had been made aware that the NP had ordered an X-ray of the resident's right foot and ankle due to pain in that area. Continued review revealed Hospice Nurse/RN #4 notified the Hospice Physician's nurse to request the next step to take regarding Resident #3's foot and ankle. Further review revealed the facility's NP had been made aware that Hospice would follow up with Resident #3's injury in the morning, and the facility's Director of Nursing (DON) was aware. Review of the Progress Note dated [DATE] at 3:16 PM, noted by LPN #1 revealed a new order had been received from Hospice to obtain an X-ray of Resident #3's right knee due to increased pain and swelling with bruising. Review of the X-ray imaging report dated [DATE] at 5:30 AM, revealed the X-ray results noted Resident #3 had a fracture of the distal femoral shaft with malalignment, joint space narrowing, and mild soft tissue swelling. Further review of the Report revealed the conclusion was noted as an acute appearing femoral fracture. Review of the facility's History and Physical (H&P) dated [DATE], completed by Resident #3's attending Physician revealed the resident was receiving Hospice care and had a right femur pathological due to long term steroid use. Continued review revealed the right leg was painful with movement, and Resident #3 had Chronic Pain Syndrome, which he/she had Morphine and Norco (narcotic pain medications) ordered for. Per review, the Physician noted Resident #3 had Vascular Dementia with worsening due to sundowners (agitation, confusion, restlessness, and disorientation occurring in late afternoon and lasting into the night). Further review revealed Resident #3 had Remeron (antidepressant medication) for diagnoses of depression and anxiety. Review further revealed the Physician noted Resident #3's Chronic Obstructive Pulmonary Disease (COPD) was stable with use of inhalers and medications. In addition, review of the H&P revealed Resident #3 had Osteoarthritis of the right knee, previous surgeries, old Osteomyelitis in right tibia, and history of patellar fracture non-operable, the resident's condition and prognosis were poor. In an interview with the former Director of Nursing (DON) on [DATE] at 5:33 PM, revealed she stated she could not speak to Resident #3's femur fracture as an injury of unknown origin as the Physician stated it was a pathological fracture. The DON stated the facility had not performed an investigation of the femur fracture as an injury of unknown origin. She further stated the Physician made rounds twice weekly in the facility; however, she was unable to say why there had been no documentation of the injury until [DATE], two (2) weeks following the fracture diagnosis. In an interview with the Administrator on [DATE] at 1:45 PM, she stated she had been a Licensed Nursing Home Administrator (LNHA) for a year, and had been at the facility since [DATE]. The Administrator stated she was unsure about the facility's abuse policy; however, would seek counsel from the facility's corporate personnel regarding if injuries of unknown origin were to be reported to the State. She stated if an incident was truthfully an injury of unknown origin, it should have been investigated. The Administrator additionally stated the facility was required to investigate all alleged violations of abuse or neglect within a two (2) hour timeframe.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents received adequate supervision to prevent accidents for one (1) of five (5) sampled residents (Resident #1). On admission to the facility on [DATE], the facility assessed Resident #1 as at risk for falls and the Comprehensive Care Plan (CCP) dated [DATE], revealed an intervention for the assistance of two (2) staff with bed mobility and incontinence care. However, on [DATE], Certified Nursing Assistant (CNA) #6 provided Resident #1's incontinence care while the resident was in bed without the assistance of another staff member as per the CCP, and the resident fell off the bed onto the floor. Interview with CNA #6 revealed she had turned the resident toward the left side of the bed, and the resident began to kick his/her legs and slid off the bed hitting his/her head on a nearby chair, and then falling onto the floor. Resident #1 was immediately transferred to the local hospital Emergency Department (ED) for evaluation and treatment and arrived unresponsive with bag mask being performed. Per the hospital ED Note, dated [DATE], the resident was ventilated and oxygenated through endotracheal tube after intubation, and after multiple rounds of Cardiopulmonary Resuscitation (CPR) and epinephrine, the resuscitation was discontinued and the patient was pronounced deceased . The facility's failure to ensure each resident received adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656) at the highest Scope and Severity (S/S) of a J, and 42 CFR 483.25 Quality of Care (F689) at the highest S/S of a J. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], alleging removal of the Immediate Jeopardy on ,d+[DATE]//2022. The State Survey Agency (SSA) determined the IJ had been removed on [DATE], as alleged, prior to exit on [DATE], with remaining noncompliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656 at a S/S of a D and 42 CFR 483.25 Quality of Care, F689 at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F656 The findings include: Review of facility's policy titled, Accidents and Supervision Policy, revised [DATE], revealed the resident environment would remain as free of accident hazards as possible. Each resident would receive adequate supervision and assistive devices to prevent accidents, which would include identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Closed medical record review revealed the facility admitted Resident #1, on [DATE], with diagnoses which included Peripheral Vascular Disease, Anemia, and Need for Assistance With Personal Care. Review of Resident #1's Admit/Readmit Nursing Assessment, under the Section titled: Fall Risk-MORSE, dated [DATE], revealed the facility assessed the resident as high risk for falls with a score of fifty (50). Per the Morse Fall Scoring, a score of forty-five (45) or greater indicated the resident would be a high risk for falls. Review of Resident #1's Comprehensive Care Plan (CCP), dated [DATE], revealed the resident was at risk for falls. The goal stated the resident would be free of falls through the review target date of [DATE]. Interventions included: Anticipate and meet the resident's needs, initiated [DATE]; and be sure the call light was within reach and encourage the resident to use it for assistance as needed, initiated [DATE]. Further review of Resident #1's CCP, dated [DATE], revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit due to immobility and weakness. The goal stated the resident would improve current level of function in all ADLs through the review target date of [DATE]. Interventions included: Assistance of two (2) staff with bed mobility and incontinence care, initiated [DATE]. Review of Resident #1'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 twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Continued review of the MDS Assessment, Section G, Activities of Daily Living, revealed the facility assessed Resident #1 to require extensive assistance of two (2) staff for bed mobility and total assist of two (2) staff for toileting and transfers. Further review of the MDS Assessment, Section H, Bladder and Bowel, revealed Resident #1 was frequently incontinent of both bowel and bladder. Review of Section J, Health Conditions, revealed the facility assessed the resident as having no falls within the last month, prior to his/her facility admission. Review of the facility provided Kardex (untitled reference guide for CNAs to utilize in providing care to residents), undated, revealed Resident #1 required the assistance of two (2) staff with bed mobility and incontinence care. Review of Resident #1's Progress Note, dated [DATE] at 1:20 AM, completed by Licensed Practical Nurse (LPN) #3, revealed, Called in resident's room, resident was on feet with nurse aide holding resident around chest. Resident slid to floor and landed on bilateral knees. As this nurse went forward to catch resident, resident fell forward on face. This nurse asked resident his/her name and resident was able to verbalize. Per the Note, the nurse left resident with nurse aide to call Emergency Medical Services (EMS). EMS arrived. Resident assisted to stretcher x four (4) and escorted out of facility per this nurse. Medical Doctor and daughter notified. Review of the facility's Post Fall Review, dated [DATE] at 1:20 AM, completed by LPN #3, revealed Resident #1 fell from the bed while CNA #6 was providing incontinence care. Further review revealed while CNA #6 was providing care, she was unable to hold the resident up on the bed and the resident fell off the bed onto the floor. Resident #1 was sent to the hospital Emergency Department (ED) for evaluation and treatment. Further review of Resident #1's Post Fall Review Section III, Interdisciplinary Team (IDT) Review, signed by the Director of Nursing (DON) on [DATE], revealed based on review of conditions/factors, Resident being provided care, slid from bed, staff assisted slowed the resident but was unable to hold the resident up and on the bed. Review of the hospital Emergency Department (ED) Note, dated [DATE] at 3:35 AM, revealed Resident #1 arrived unresponsive with bag mask being performed. Per the Note, Emergency Medical Services (EMS) stated they were called to the nursing home for a patient who fell on the floor and became unresponsive. Further review of the ED Note, revealed the patient was ventilated and oxygenated through endotracheal tube after intubation. After multiple rounds of Cardiopulmonary Resuscitation (CPR) and epinephrine, the resuscitation was discontinued and the patient was pronounced deceased . Interview with CNA #6, on [DATE] at 8:30 PM, revealed on [DATE], while providing incontinence care to Resident #1 by herself, she had turned the resident toward the left side of the bed, and the resident began to kick his/her legs and began sliding off the bed. CNA #6 stated she was holding the resident up around the chest area, but couldn't keep the resident from sliding. She stated she slowed the resident's fall, but the resident fell hitting his/her head on a nearby chair, and then hit the floor. Per interview, she called for help and the resident was talking and responsive during LPN #3's assessment. However, CNA #6, stated once the ambulance staff arrived the resident had stopped talking. Further interview with CNA #6, revealed Resident #1 required two (2) staff to assist the resident out of bed because he/she required the use of a mechanical lift for transfers. However, she stated she was unaware Resident #1 required the assist of two (2) staff with incontinent care and bed mobility because she had done it alone many times with no issues. She further stated she knew where to locate resident care plans and the Kardex which was a care guide for CNAs on the amount of assistance required to care for residents. Continued interview revealed if she had been aware of the need for two (2) staff while providing incontinence care, she would have asked for help. Interview with LPN #3, on [DATE] at 9:00 AM, revealed she was the nurse working on [DATE], when Resident #1 fell from the bed while staff was providing incontinence care. She stated the resident was talking during her immediate assessment and was shaken up, but had no complaints of pain. LPN #3 further stated she called the doctor and obtained an order to transfer the resident to the hospital ED for evaluation. Continued interview with LPN #3, revealed she was not aware that only one (1) CNA had been providing care at the time of Resident #1's fall on [DATE]. She stated it was her expectation the CNAs followed the Kardex which was a guide generated from the CCP used for the CNAs in providing resident care. Interview with the Director of Nursing (DON), on [DATE] at 4:30 PM, revealed she expected staff to review resident care plans and the Kardex daily prior to providing care. She further stated it was important for staff to be knowledgeable of the assistance each resident required. Further interview with the DON, on [DATE] at 11:10 AM, revealed she was unaware Resident #1 required two (2) staff assist with bed mobility and incontinence care until she was reviewing the [DATE] fall. She stated after Resident #1 sustained the fall on [DATE], she identified the need for staff education related to resident Care Plans and Kardex, and on the importance of checking them daily and prior to care for any updates. The DON stated she was not going to comment further on what outcomes could occur if staff did not follow the care plan because each situation could be different and have different results. She further stated she would no longer discuss the situation in regards to Resident #1's fall because staff had been recently educated on care plans and she expected staff to follow instructions. Interview with the Administrator, on [DATE] at 11:25 AM, revealed he expected staff to meet the resident's needs to ensure the safety of staff and residents. He further stated staff had been educated recently on how staff was to utilize the care plans to identify how much assistance residents required. 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. On [DATE], the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) provided one on one (1:1) re-education with the Certified Nursing Assistants (CNA) that were directly involved in Resident #1's bed mobility and incontinence care. An emphasis was placed on ensuring residents received care based on their individually identified needs, as it pertains to required supervision while positioning in bed and providing incontinence care. 2. On [DATE], the DON, Assistant Director of Nursing (ADON), and Regional Director of Clinical services (RDCS), reviewed all current in-house residents' Morse Fall Risk Assessment Tools to ensure fall and safety risk accuracy. 3. On [DATE], the RDCS and Regional Director of Clinical Reimbursement (RDCR) reviewed the care plan of current in-house residents identified as at risk for falls or requiring two (2) staff for bed mobility and incontinence care. This was to ensure resident-specific safety interventions for incontinence care and bed mobility; and to ensure those safety measures and resident specific interventions were added to the care plans and were also reflected on the Kardex, so the CNA's had access to this information. 4. On [DATE], the DON, and ADON, re-educated full time, part time and PRN (as needed) Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and State Registered Nursing Assistants (SRNAs) to review the updated Kardex prior to their next shift. No nursing staff will be allowed to work until re-education has been provided. The facility does not utilize agency for staffing. 5. On [DATE], an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held via telephone with the Medical Director, LNHA, DON, RDCS, and Regional Director of Operations (RDO) to discuss plan for removal of Jeopardy and plan of correction moving forward. 6. On [DATE], the RDCS re-educated the DON on the facility Fall Prevention Program; all facility fall-related policies; how to conduct a Root Cause Analysis (RCA), and how to ensure incident investigations were timely and complete. Education also included following resident care plan/Kardex interventions as it pertained to required supervision for bed mobility and incontinence care. 7. On [DATE], the DON initiated re-education for full time, part time and PRN Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants. The facility does not utilize agency for staffing. Education consisted of, but was not limited to, facility Fall Prevention Program guidelines and following care plan/Kardex interventions as it pertains to required supervision for bed mobility and incontinence care. Certified letters were mailed on [DATE] to Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants the facility was unable to contact informing them there was mandatory re-education. No nursing staff will be allowed to work until receiving re-education. 8. On [DATE], the DON added education to the facility orientation program on following the plan of care plan, with an emphasis on ensuring residents received care based on their individually identified needs, as it pertained to required supervision while positioning in bed and providing incontinence care. Newly hired Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants will not be allowed to work on the floor without receiving the education. 9. Beginning [DATE], the Interdisciplinary Team (IDT), consisting of the DON, ADON, Social Service Director (SSD), and Minimum Data Set Coordinator (MDSC) will audit new admissions and re-admissions daily to ensure the Fall Risk Assessment Tool has been completed and safety measures, and resident specific interventions for bed mobility and incontinence care are reflected on the care plan as well as updated on the Kardex. 10. Beginning [DATE], the RDCS will review all falls within one (1) working day for three (3) months to ensure a RCA has been conducted and resident specific safety interventions are reflected in the fall care plan, the bed mobility and incontinence care plan, as well as updated on the Kardex. 11. Beginning [DATE], the IDT will audit falls at the Daily Clinical Meeting. Audit will include ensuring appropriate fall and safety interventions are implemented, the resident's care plan has been reviewed, revised and the Kardex has been updated with any safety interventions. Any identified non-compliance will result in one on one (1:1) re-education with progressive discipline for further non-compliance. 12. Beginning [DATE], the DON or ADON will observe Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants providing incontinence care and assisting residents with bed mobility to ensure resident's Kardex safety interventions are followed. Observations will be conducted on three (3) residents, five (5) times weekly for four (4) weeks; then three (3) residents, three (3) times weekly for four (4) weeks; then one (1) resident weekly for four (4) weeks; then one (1) resident monthly for three (3) months. Observational audits will be conducted across all shifts and including weekends. 13. Beginning [DATE], results of audits will be forwarded to the QAPI Committee by the DON for a period of six (6) months for further review and recommendations as deemed appropriate by the QAPI Committee. The QAPI Committee consists of the Licensed Nursing Home Administrator (LNHA) DON, ADON, Social Services Director (SSD), MDSC, and Medical Director. 14. On [DATE], another Ad-hoc QAPI meeting was conducted with the Medical Director, LNHA, DON, ADON, RDCS and RDO regarding immediate jeopardy and removal plan. Fall audits were reviewed to ensure falls, bed mobility, and incontinence interventions were followed per the plan of care with no concerns. Audits were compared with residents' current medical records with no findings or concerns noted. Beginning [DATE], QAPI Meetings will increase to weekly meetings for four (4) weeks, with monthly meetings resuming after. 15. Observational audits are conducted by the DON, and ADON. The audits of the fall care plans are conducted when there is admission/readmission. The Admission/Readmission fall care plan audits have taken place on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] to ensure that interventions for falls, bed mobility, and incontinence have been placed on the plan of care and have been implemented. Any falls are audited in the clinical IDT meeting on a daily basis, with a follow up audit on any falls by the RDCS. 16. Residents within the facility have had falls on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Fall audits were completed on the following day to ensure that fall, bed mobility and incontinence care interventions were in place per the plan of care. There no concerns noted. 17. Observations of staff providing incontinence care and bed mobility have been conducted on three (3) residents, five (5) times weekly by the DON and ADON on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Care plan interventions were followed with no concerns noted. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of training records revealed the LNHA and DON provided re-education for SRNAs directly involved in Resident #1's bed mobility and incontinence care. Per the content, an emphasis was placed on ensuring residents received care based on their individually identified needs, as it pertained to required supervision while positioning in bed and providing incontinence care. Attendance was documented as education taking place on [DATE]. Interviews with the LNHA on [DATE] at 2:37 PM, and with the DON on [DATE] at 3:31 PM, revealed they provided this training. Interviews on [DATE] with CNA # 3 at 2:48 PM; CNA #15 at 3:21 PM; CNA #16 at 3:44 PM; CNA #13 at 4:03 PM; CNA #17 at 4:33 PM; and CNA #14 at 5:09 PM, revealed they received the education and were able to state the content of the education. 2. Review of the audits revealed Morse Fall Risk Assessments were reviewed by the DON, ADON and RDCS for all current in-house residents on [DATE]. Interviews on [DATE] with the DON at 3:31 PM; the ADON at 3:04 PM; and the RDCS at 3:59 PM, revealed they had reviewed Morse Fall Risk Assessments for all in house residents on [DATE]. 3. Review of the audits/documentation revealed on [DATE], the RDCS and RDCR, reviewed all in-house residents identified as at risk for falls or the need for two staff for bed mobility and incontinence care, ensuring safety measures and resident specific interventions were added and also reflected in Kardex. An Audit of the Electronic Medical Records revealed notes demonstrating review of assessments and updates. Interview with the RDCS on [DATE] at 03:59 PM revealed she and the RDCR reviewed all records of in house residents identified at risk for falls or identified as needing two staff for bed mobility and incontinence care, ensuring safety measures and specific interventions were in place as well as reflected in the Kardex. Interviews with CNA #3 on [DATE] at 2:48 PM; CNA #15 on [DATE] at 3:21 PM; CNA #16 on [DATE] at 3:44 PM; CNA #13 on [DATE] at 4:03 PM; CNA #17 on [DATE] at 4:33 PM and CNA #14 on [DATE] at 5:09 PM, revealed they knew how to access a resident's Kardex to obtain care needs. 4. Review of re-education documentation, confirmed the DON and ADON had conducted training beginning [DATE], with full time, part time and PRN (as needed) RNs, LPNs and CNAs related to the need to review Kardex prior to shift. Per the documentation, no nursing staff will be allowed to work until re-education has been provided. Interviews with CNA #3 on [DATE] at 2:48 PM; CNA #15 on [DATE] at 3:21 PM; CNA #16 on [DATE] at 3:44 PM; CNA #13 on [DATE] at 4:03 PM; CNA #17 on [DATE] at 4:33 PM and CNA #14 on [DATE] at 5:09 PM revealed they had all received education to review Kardex prior to shifts. Interviews with LPN #8 on [DATE] at 5:00 PM; LPN #9 on [DATE] at 5:29 PM; RN #2 on [DATE] at 6:00 PM; RN #3 on [DATE] at 6:39 PM. and LPN #4 on [DATE] at 7:09 PM, revealed all had received re-education on reviewing care plans prior to shifts. Interviews on [DATE] with DON at 03:31 PM and the ADON at 03:04 PM revealed they conducted training for full time, part time and PRN RNs, LPNs and CNAs regarding the expectation to review resident Kardex prior to each shift, beginning [DATE]. 5. Review of documentation from the AdHoc QAPI meeting, held on [DATE], revealed content reflecting plan for Jeopardy removal and plan of correction. Per the documentation, attendance was held via telephone with the Medical Director, LNHA, DON, RDCS, and Regional Director of Operations (RDO). Interviews on [DATE] with the LNHA at 4:23 PM; DON at 3:31 PM; and RDCS at 3:59 PM, revealed they took part in the AdHoc QAPI meeting regarding plan for jeopardy removal and plan of correction on [DATE]. 6. Review of education documentation revealed the RDCS provided education to the DON on the facility Fall Prevention Program; facility fall related policies; how to conduct a Root Cause Analysis and how to ensure incident investigations were completed and in a timely manner, as well as following resident care plan/Kardex intervetions as it pertains to required supervision for bed mobility and incontinence care on [DATE]. Interview with the DON, on [DATE] at 3:31 PM, revealed she did receive education on [DATE] from the RDCS related to the facility Fall Prevention Program; all facility fall-related policies; how to conduct a Root Cause Analysis (RCA), and how to ensure incident investigations were timely and complete. Per interview, education also included following resident care plan/Kardex interventions as it pertained to required supervision for bed mobility and incontinence care. 7. Review of education documentation revealed the DON provided education beginning [DATE] for nursing staff, including RNs, LPNs and CNAs consisting of facility Fall Prevention Program guidelines and following care plan/Kardex interventions as it pertains to required supervision for bed mobility and incontinence care. Review of copies of certified letters mailed on [DATE] to RNs, LPNs and CNA staff whom the facility was unable to contact, revealed they were informed they must complete the mandatory re-education before being allowed to work again. Interviews with CNA #3 on [DATE] at 2:48 PM; CNA #15 on [DATE] at 3:21 PM; CNA #16 on [DATE] at 3:44 PM; CNA #13 on [DATE] at 4:03 PM; CNA #17 on [DATE] at 4:33 PM and CNA #14 on [DATE] at 5:09 PM, revealed they had all received education on fall prevention as well as following the Kardex for bed mobility and incontinence care. Interviews with LPN #8 on [DATE] at 5:20 PM; LPN #9 on [DATE] at 5:29 PM; RN #3 on [DATE] at 6:39 PM; LPN #4 on [DATE] at 7:09 PM; and RN #2 on [DATE] at 7:30 PM, revealed all had received education on Fall Prevention Program Guidelines and following care plan/Kardex interventions as it pertains to required supervision for bed mobility and incontinence care. 8. Review of the facility orientation program confirmed the DON had added education, as of [DATE], related to the need to follow the plan of care and ensuring residents received care based on their individually identified needs, as it pertained to required supervision while positioning in bed and providing incontinence care. Further review revealed newly hired RN, LPN and SRNA staff would not be allowed to work without receiving the education. Interview with DON on [DATE] at 3:31 PM revealed she had added education to the orientation program pertaining to following the plan of care and ensuring residents received care based on their own plans. 9. Reviewed audits of new admissions and re-admissions and confirmed the IDT had started auditing on [DATE] to ensure Fall Risk Assessments had been completed and safety measures, and resident specific interventions for bed mobility and incontinence care were reflected on the care plan as well as updated on the Kardex. Interviews on [DATE] with the LNHA at 04:23 PM; the DON at 03:31 PM; and the ADON at 03:04 PM, revealed IDT begain auditing as of [DATE] to ensure Fall Risk Assessments had been completed with resident specific interventions reflected on care plans. 10. Reviewed documentation confirming on [DATE], the RDCS began conducting reviews of falls within one (1) working day of the fall to ensure a RCA has been conducted and resident specific safety interventions were reflected in the fall care plan, the bed mobility and incontinence care plan, as well as updated on the Kardex. Interview with RDCS on [DATE] at 03:59 PM revealed on [DATE], she began conducting fall reviews within one working day to ensure a RCA had been conducted and interventions were in place in the fall care plan. 11. Reviewed documentation demonstrating IDT began auditing falls at Daily Clinical Meeting as of [DATE], ensuring appropriate fall and safety interventions were implemented, the resident's care plan has been reviewed, revised and the Kardex has been updated with any safety interventions. No non-compliance was noted at time of review. Interviews on [DATE] with the RDCS at 03:59 PM; the LNHA at 04:23 PM; and the DON at 03:31 PM, revealed IDT began auditing falls at the daily clinical meetings as of [DATE]. 12. Reviewed documentation demonstrating the DON and ADON were making observations starting on [DATE] of RNs, LPNs and CNAs providing incontinence care and assisting residents with bed mobility to ensure resident's Kardex safety interventions were followed. These observations were being conducted during different shifts and days of the week as per the schedule outlined. Interviews on [DATE] with the DON at 03:31 PM; and the ADON at 03:04 PM, revealed they observed RNs, LPNs and CNAs providing incontinence care and bed mobility assistance to ensure staff were following residents' safety interventions. 13. Reviewed documentation demonstrating results of audits were forwarded to the QAPI Committee by the DON beginning [DATE] and were being further reviewed by the QAPI Committee. Interview with DON on [DATE] at 03:31 PM revealed she began making audit documentation available to the QAPI Committee as of [DATE]. 14. Reviewed the [DATE] QAPI meeting which was conducted with the Medical Director, LNHA, DON, ADON, RDCS and RDO in attendance. The content included the immediate jeopardy and removal plan. Additionally, fall audits were reviewed to ensure falls, bed mobility, and incontinence interventions were followed per the plan of care with no concerns. Further review revealed the increased meeting frequency had commenced. Interviews on [DATE] with the RDCS at 03:59 PM; the LNHA at 04:23 PM; the DON at 03:31 PM; and the ADON at 03:04 PM, revealed the content of the [DATE] QAPI meeting included the immediate jeopardy and removal plan as well as review of fall audits to ensure the interventions were followed to the plan of care. 15. Review revealed observational audits were conducted by the DON, and ADON. This included audits of the fall care plans conducted when there was an admission/readmission on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] to ensure that interventions for falls, bed mobility, and incontinence have been placed on the plan of care and have been implemented. Additionally, review of audits revealed falls were reviewed in the clinical IDT meeting on a daily basis, with a follow up audit on any falls by the RDCS. Interviews on [DATE] with the DON at 03:31 PM and the ADON at 03:04 PM revealed they conducted fall care plan audits with admissions and readmissions as of [DATE]. 16. Reviewed documentation that demonstrated audits were completed the day following falls that occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], ensuring that fall, bed mobility and incontinence care interventions were in place per the plan of care. Surveyor audits confirmed the same, with no concerns noted. 17. Reviewed documentation of observations of staff providing incontinence care and bed mobility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Per the documentation, Care plan interventions were followed with no concerns noted. Interviews on [DATE] with DON at 03:31 PM and ADON at 03:04 PM revealed they observed staff providing incontinence care and bed mobility assistance on the dates noted.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Care Plan was implemented for one (1) of five (5) sampled residents (Resident #1). The facility assessed and care planned Resident #1 to require the assistance of two (2) staff members for bed mobility and incontinence care. However, on [DATE], Certified Nursing Assistant (CNA) #6 attempted to provide incontinence care without the assistance of another staff member as per the Comprehensive Care Plan (CCP). As a result, the resident sustained a fall from the bed, to the floor, hitting his/her head on a chair during the fall. Resident #1 was immediately transferred to the local hospital Emergency Department (ED). Per the hospital ED Note, dated [DATE], the resident arrived unresponsive and was ventilated and oxygenated through endotracheal tube after intubation. After multiple rounds of Cardiopulmonary Resuscitation (CPR) and epinephrine, the resuscitation was discontinued and the resident expired. The facility's failure to ensure the Comprehensive Care Plan was implemented to ensure adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656) at the highest Scope and Severity (S/S) of a J, and 42 CFR 483.25 Quality of Care (F689) at the highest S/S of a J. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy (IJ) on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency (SSA) determined the IJ had been removed on [DATE], as alleged, prior to exit on [DATE], with remaining noncompliance in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656 at a S/S of a D and 42 CFR 483.25 Quality of Care, F689 at a S/S of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F689 The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised [DATE], revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, including measurable objectives and timeframe's to meet a resident's medical, nursing, mental, and psychosocial needs that would be identified in the resident's comprehensive assessment. Closed clinical record review revealed the facility admitted Resident #1 on [DATE], with diagnoses which included Peripheral Vascular Disease, Anemia and Need for Assistance With Personal Care. Review of the facility provided Kardex (untitled reference guide for CNAs to utilize in providing care to residents), undated, revealed Resident #1 required the assistance of two (2) staff with bed mobility and incontinence care. Review of Resident #1's Comprehensive Care Plan (CCP), dated [DATE], revealed the resident was at risk for falls. The goal stated the resident would be free of falls through the next review date. Continued review revealed interventions which included: anticipate and meet resident needs, initiated [DATE]; and be sure the call light was within reach and encourage the resident to use it for assistance as needed, initiated [DATE]. Further review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed the resident had an Activities of Daily Living (ADL) self-care performance deficit related to immobility and weakness. The goal stated the resident would improve current level of function in all ADLs through the next review date. Interventions included: Resident required the assistance of two (2) staff with bed mobility and incontinence care, date initiated [DATE]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of twelve (12) out of fifteen (15), indicating moderate cognitive impairment. Additional review of the MDS Assessment, Section G, Activities of Daily Living, revealed the facility assessed Resident #1 to require extensive assistance of two (2) staff for bed mobility and total assist of two (2) staff for toileting and transfers. Additional review of the MDS Assessment, Section H, Bladder and Bowel, revealed Resident #1 was frequently incontinent of both bowel and bladder. Review of Section J, Health Conditions, revealed the resident had no falls within the last month, prior to his/her facility admission. Review of the facility's Post Fall Review, dated [DATE] at 1:20 AM, signed by Licensed Practical Nurse (LPN) #3, revealed Resident #1 fell from the bed while CNA #6 was providing incontinence care. Continued review revealed while CNA #6 was providing care, the CNA was unable to hold the resident up on the bed and he/she fell off the bed onto to the floor. Further, Resident #1 was sent to the Emergency Department for evaluation and treatment. Additional review of the facility's Post Fall Review Section III, Interdisciplinary Team (IDT) Review, signed by the Director of Nursing (DON) on [DATE], revealed based on review of conditions/factors, Resident being provided care, slid from bed, staff assisted slowed resident but unable to hold resident up and on bed. Review of Resident #1's hospital Emergency Department (ED) Note, dated [DATE] at 3:35 AM, revealed the patient arrived unresponsive with bag mask being performed. Additional review of the ED Note, revealed the patient was ventilated and oxygenated through endotracheal tube after intubation. According to the ED Note, after multiple rounds of Cardiopulmonary Resuscitation (CPR) and epinephrine, the resuscitation was discontinued and the patient was pronounced deceased . Interview with Certified Nurse Aide (CNA) #6, on [DATE] at 8:30 PM, revealed on [DATE], while providing incontinent care to Resident #1, she turned the resident toward the left side of the bed, and the resident began to kick his/her legs and began sliding off the bed. CNA #6 stated she was holding the resident up around the chest area, but couldn't keep the resident from sliding. Per interview, she slowed the resident's fall, but could not keep him/her up on the bed. CNA #6 stated when the resident fell he/she hit his/her head on a nearby chair, and then hit the floor and she called for help. She stated Licensed Practical Nurse (LPN) #3 came to assess the resident and during the assessment the resident was talking and responsive, but once the Emergency Medical Technicians (EMTs) arrived, the resident stopped talking. Additional interview revealed she had always provided incontinence care to Resident #1 by herself without any issues. She stated she was unaware the resident was care planned for two (2) staff for bed mobility and incontinence care and if she had been aware of this she would have asked for assistance with the resident. She stated she could not recall when she last viewed Resident #1's Kardex, prior to the resident sustaining the fall on [DATE]. Interview with LPN #3, on [DATE] at 9:00 AM, revealed she was the nurse working on [DATE], when Resident #1 sustained the fall from the bed while staff was providing incontinence care. Per interview, the resident was talking during her immediate assessment and was shaken up, but had no complaints of pain. LPN #3 stated she called the Physician and received an order to transfer the resident to the hospital ED for evaluation. Additional interview revealed she was unaware that only one (1) staff member had been providing care at the time of Resident #1's fall, as the resident was care planned for two (2) staff for bed mobility and incontinence care. Per interview the CNAs were expected to follow the Kardex which was a reference used in providing care for the residents. Interview with LPN #2, on [DATE] at 9:15 AM, revealed when he provided wound care to Resident #1, he would have at least one (1) CNA in the room to assist because the resident required two (2) staff assist while providing wound care as it was safer for all involved. Interview with the Director of Nursing (DON), on [DATE] at 4:30 PM, revealed it was her expectation for staff to review resident care plans and Kardexes daily prior to providing resident care as these were guides as to how much assistance each resident required. Additional interview with the DON, on [DATE] at 11:10 AM, revealed she was unaware Resident #1 required two (2) staff to assist with bed mobility and incontinence care, until she reviewed the fall the resident sustained on [DATE]. Further interview revealed after Resident #1 sustained the fall on [DATE], she identified the need for staff education to include the importance of checking the CCP, Kardexes daily and prior to resident care for any updates. Continnued interview revealed she was not going to comment further on what outcomes could occur if staff did not follow the care plan because each situation could be different and have different results. Further, she would no longer discuss the situation in regards to Resident #1's fall because staff had been educated on care plans and she expected staff to follow instructions. Interview with the Administrator, on [DATE] at 11:25 AM, revealed it was his expectation staff implement resident care plans when providing care in order to meet the resident's needs. He further stated the facility had recently identified the need for staff education and staff had been educated on resident care plans, and where they could be located. Further, if staff was to have questions related to a resident's care or concerns they could follow up with the nurse on shift. 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. On [DATE], the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) provided one on one (1:1) re-education with the Certified Nursing Assistants (CNA) that were directly involved in Resident #1's bed mobility and incontinence care. An emphasis was placed on ensuring residents received care based on their individually identified needs, as it pertains to required supervision while positioning in bed and providing incontinence care. 2. On [DATE], the DON, Assistant Director of Nursing (ADON), and Regional Director of Clinical services (RDCS), reviewed all current in-house residents' Morse Fall Risk Assessment Tools to ensure fall and safety risk accuracy. 3. On [DATE], the RDCS and Regional Director of Clinical Reimbursement (RDCR) reviewed the care plan of current in-house residents identified as at risk for falls or requiring two (2) staff for bed mobility and incontinence care. This was to ensure resident-specific safety interventions for incontinence care and bed mobility; and to ensure those safety measures and resident specific interventions were added to the care plans and were also reflected on the Kardex, so the CNA's had access to this information. 4. On [DATE], the DON, and ADON, re-educated full time, part time and PRN (as needed) Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and State Registered Nursing Assistants (SRNAs) to review the updated Kardex prior to their next shift. No nursing staff will be allowed to work until re-education has been provided. The facility does not utilize agency for staffing. 5. On [DATE], an AdHoc Quality Assurance Performance Improvement (QAPI) meeting was held via telephone with the Medical Director, LNHA, DON, RDCS, and Regional Director of Operations (RDO) to discuss plan for removal of Jeopardy and plan of correction moving forward. 6. On [DATE], the RDCS re-educated the DON on the facility Fall Prevention Program; all facility fall-related policies; how to conduct a Root Cause Analysis (RCA), and how to ensure incident investigations were timely and complete. Education also included following resident care plan/Kardex interventions as it pertained to required supervision for bed mobility and incontinence care. 7. On [DATE], the DON initiated re-education for full time, part time and PRN Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants. The facility does not utilize agency for staffing. Education consisted of, but was not limited to, facility Fall Prevention Program guidelines and following care plan/Kardex interventions as it pertains to required supervision for bed mobility and incontinence care. Certified letters were mailed on [DATE] to Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants the facility was unable to contact informing them there was mandatory re-education. No nursing staff will be allowed to work until receiving re-education. 8. On [DATE], the DON added education to the facility orientation program on following the plan of care plan, with an emphasis on ensuring residents received care based on their individually identified needs, as it pertained to required supervision while positioning in bed and providing incontinence care. Newly hired Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants will not be allowed to work on the floor without receiving the education. 9. Beginning [DATE], the Interdisciplinary Team (IDT), consisting of the DON, ADON, Social Service Director (SSD), and Minimum Data Set Coordinator (MDSC) will audit new admissions and re-admissions daily to ensure the Fall Risk Assessment Tool has been completed and safety measures, and resident specific interventions for bed mobility and incontinence care are reflected on the care plan as well as updated on the Kardex. 10. Beginning [DATE], the RDCS will review all falls within one (1) working day for three (3) months to ensure a RCA has been conducted and resident specific safety interventions are reflected in the fall care plan, the bed mobility and incontinence care plan, as well as updated on the Kardex. 11. Beginning [DATE], the IDT will audit falls at the Daily Clinical Meeting. Audit will include ensuring appropriate fall and safety interventions are implemented, the resident's care plan has been reviewed, revised and the Kardex has been updated with any safety interventions. Any identified non-compliance will result in one on one (1:1) re-education with progressive discipline for further non-compliance. 12. Beginning [DATE], the DON or ADON will observe Registered Nurses, Licensed Practical Nurses and State Registered Nursing Assistants providing incontinence care and assisting residents with bed mobility to ensure resident's Kardex safety interventions are followed. Observations will be conducted on three (3) residents, five (5) times weekly for four (4) weeks; then three (3) residents, three (3) times weekly for four (4) weeks; then one (1) resident weekly for four (4) weeks; then one (1) resident monthly for three (3) months. Observational audits will be conducted across all shifts and including weekends. 13. Beginning [DATE], results of audits will be forwarded to the QAPI Committee by the DON for a period of six (6) months for further review and recommendations as deemed appropriate by the QAPI Committee. The QAPI Committee consists of the Licensed Nursing Home Administrator (LNHA) DON, ADON, Social Services Director (SSD), MDSC, and Medical Director. 14. On [DATE], another Ad-hoc QAPI meeting was conducted with the Medical Director, LNHA, DON, ADON, RDCS and RDO regarding immediate jeopardy and removal plan. Fall audits were reviewed to ensure falls, bed mobility, and incontinence interventions were followed per the plan of care with no concerns. Audits were compared with residents' current medical records with no findings or concerns noted. Beginning [DATE], QAPI Meetings will increase to weekly meetings for four (4) weeks, with monthly meetings resuming after. 15. Observational audits are conducted by the DON, and ADON. The audits of the fall care plans are conducted when there is admission/readmission. The Admission/Readmission fall care plan audits have taken place on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] to ensure that interventions for falls, bed mobility, and incontinence have been placed on the plan of care and have been implemented. Any falls are audited in the clinical IDT meeting on a daily basis, with a follow up audit on any falls by the RDCS. 16. Residents within the facility have had falls on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Fall audits were completed on the following day to ensure that fall, bed mobility and incontinence care interventions were in place per the plan of care. There no concerns noted. 17. Observations of staff providing incontinence care and bed mobility have been conducted on three (3) residents, five (5) times weekly by the DON and ADON on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Care plan interventions were followed with no concerns noted. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Review of training records revealed the LNHA and DON provided re-education for SRNAs directly involved in Resident #1's bed mobility and incontinence care. Per the content, an emphasis was placed on ensuring residents received care based on their individually identified needs, as it pertained to required supervision while positioning in bed and providing incontinence care. Attendance was documented as education taking place on [DATE]. Interviews with the LNHA on [DATE] at 2:37 PM, and with the DON on [DATE] at 3:31 PM, revealed they provided this training. Interviews on [DATE] with CNA # 3 at 2:48 PM; CNA #15 at 3:21 PM; CNA #16 at 3:44 PM; CNA #13 at 4:03 PM; CNA #17 at 4:33 PM; and CNA #14 at 5:09 PM, revealed they received the education and were able to state the content of the education. 2. Review of the audits revealed Morse Fall Risk Assessments were reviewed by the DON, ADON and RDCS for all current in-house residents on [DATE]. Interviews on [DATE] with the DON at 3:31 PM; the ADON at 3:04 PM; and the RDCS at 3:59 PM, revealed they had reviewed Morse Fall Risk Assessments for all in house residents on [DATE]. 3. Review of the audits/documentation revealed on [DATE], the RDCS and RDCR, reviewed all in-house residents identified as at risk for falls or the need for two staff for bed mobility and incontinence care, ensuring safety measures and resident specific interventions were added and also reflected in Kardex. An Audit of the Electronic Medical Records revealed notes demonstrating review of assessments and updates. Interview with the RDCS on [DATE] at 03:59 PM revealed she and the RDCR reviewed all records of in house residents identified at risk for falls or identified as needing two staff for bed mobility and incontinence care, ensuring safety measures and specific interventions were in place as well as reflected in the Kardex. Interviews with CNA #3 on [DATE] at 2:48 PM; CNA #15 on [DATE] at 3:21 PM; CNA #16 on [DATE] at 3:44 PM; CNA #13 on [DATE] at 4:03 PM; CNA #17 on [DATE] at 4:33 PM and CNA #14 on [DATE] at 5:09 PM, revealed they knew how to access a resident's Kardex to obtain care needs. 4. Review of re-education documentation, confirmed the DON and ADON had conducted training beginning [DATE], with full time, part time and PRN (as needed) RNs, LPNs and CNAs related to the need to review Kardex prior to shift. Per the documentation, no nursing staff will be allowed to work until re-education has been provided. Interviews with CNA #3 on [DATE] at 2:48 PM; CNA #15 on [DATE] at 3:21 PM; CNA #16 on [DATE] at 3:44 PM; CNA #13 on [DATE] at 4:03 PM; CNA #17 on [DATE] at 4:33 PM and CNA #14 on [DATE] at 5:09 PM revealed they had all received education to review Kardex prior to shifts. Interviews with LPN #8 on [DATE] at 5:00 PM; LPN #9 on [DATE] at 5:29 PM; RN #2 on [DATE] at 6:00 PM; RN #3 on [DATE] at 6:39 PM. and LPN #4 on [DATE] at 7:09 PM, revealed all had received re-education on reviewing care plans prior to shifts. Interviews on [DATE] with DON at 03:31 PM and the ADON at 03:04 PM revealed they conducted training for full time, part time and PRN RNs, LPNs and CNAs regarding the expectation to review resident Kardex prior to each shift, beginning [DATE]. 5. Review of documentation from the AdHoc QAPI meeting, held on [DATE], revealed content reflecting plan for Jeopardy removal and plan of correction. Per the documentation, attendance was held via telephone with the Medical Director, LNHA, DON, RDCS, and Regional Director of Operations (RDO). Interviews on [DATE] with the LNHA at 4:23 PM; DON at 3:31 PM; and RDCS at 3:59 PM, revealed they took part in the AdHoc QAPI meeting regarding plan for jeopardy removal and plan of correction on [DATE]. 6. Review of education documentation revealed the RDCS provided education to the DON on the facility Fall Prevention Program; facility fall related policies; how to conduct a Root Cause Analysis and how to ensure incident investigations were completed and in a timely manner, as well as following resident care plan/Kardex intervetions as it pertains to required supervision for bed mobility and incontinence care on [DATE]. Interview with the DON, on [DATE] at 3:31 PM, revealed she did receive education on [DATE] from the RDCS related to the facility Fall Prevention Program; all facility fall-related policies; how to conduct a Root Cause Analysis (RCA), and how to ensure incident investigations were timely and complete. Per interview, education also included following resident care plan/Kardex interventions as it pertained to required supervision for bed mobility and incontinence care. 7. Review of education documentation revealed the DON provided education beginning [DATE] for nursing staff, including RNs, LPNs and CNAs consisting of facility Fall Prevention Program guidelines and following care plan/Kardex interventions as it pertains to required supervision for bed mobility and incontinence care. Review of copies of certified letters mailed on [DATE] to RNs, LPNs and CNA staff whom the facility was unable to contact, revealed they were informed they must complete the mandatory re-education before being allowed to work again. Interviews with CNA #3 on [DATE] at 2:48 PM; CNA #15 on [DATE] at 3:21 PM; CNA #16 on [DATE] at 3:44 PM; CNA #13 on [DATE] at 4:03 PM; CNA #17 on [DATE] at 4:33 PM and CNA #14 on [DATE] at 5:09 PM, revealed they had all received education on fall prevention as well as following the Kardex for bed mobility and incontinence care. Interviews with LPN #8 on [DATE] at 5:20 PM; LPN #9 on [DATE] at 5:29 PM; RN #3 on [DATE] at 6:39 PM; LPN #4 on [DATE] at 7:09 PM; and RN #2 on [DATE] at 7:30 PM, revealed all had received education on Fall Prevention Program Guidelines and following care plan/Kardex interventions as it pertains to required supervision for bed mobility and incontinence care. 8. Review of the facility orientation program confirmed the DON had added education, as of [DATE], related to the need to follow the plan of care and ensuring residents received care based on their individually identified needs, as it pertained to required supervision while positioning in bed and providing incontinence care. Further review revealed newly hired RN, LPN and SRNA staff would not be allowed to work without receiving the education. Interview with DON on [DATE] at 3:31 PM revealed she had added education to the orientation program pertaining to following the plan of care and ensuring residents received care based on their own plans. 9. Reviewed audits of new admissions and re-admissions and confirmed the IDT had started auditing on [DATE] to ensure Fall Risk Assessments had been completed and safety measures, and resident specific interventions for bed mobility and incontinence care were reflected on the care plan as well as updated on the Kardex. Interviews on [DATE] with the LNHA at 04:23 PM; the DON at 03:31 PM; and the ADON at 03:04 PM, revealed IDT begain auditing as of [DATE] to ensure Fall Risk Assessments had been completed with resident specific interventions reflected on care plans. 10. Reviewed documentation confirming on [DATE], the RDCS began conducting reviews of falls within one (1) working day of the fall to ensure a RCA has been conducted and resident specific safety interventions were reflected in the fall care plan, the bed mobility and incontinence care plan, as well as updated on the Kardex. Interview with RDCS on [DATE] at 03:59 PM revealed on [DATE], she began conducting fall reviews within one working day to ensure a RCA had been conducted and interventions were in place in the fall care plan. 11. Reviewed documentation demonstrating IDT began auditing falls at Daily Clinical Meeting as of [DATE], ensuring appropriate fall and safety interventions were implemented, the resident's care plan has been reviewed, revised and the Kardex has been updated with any safety interventions. No non-compliance was noted at time of review. Interviews on [DATE] with the RDCS at 03:59 PM; the LNHA at 04:23 PM; and the DON at 03:31 PM, revealed IDT began auditing falls at the daily clinical meetings as of [DATE]. 12. Reviewed documentation demonstrating the DON and ADON were making observations starting on [DATE] of RNs, LPNs and CNAs providing incontinence care and assisting residents with bed mobility to ensure resident's Kardex safety interventions were followed. These observations were being conducted during different shifts and days of the week as per the schedule outlined. Interviews on [DATE] with the DON at 03:31 PM; and the ADON at 03:04 PM, revealed they observed RNs, LPNs and CNAs providing incontinence care and bed mobility assistance to ensure staff were following residents' safety interventions. 13. Reviewed documentation demonstrating results of audits were forwarded to the QAPI Committee by the DON beginning [DATE] and were being further reviewed by the QAPI Committee. Interview with DON on [DATE] at 03:31 PM revealed she began making audit documentation available to the QAPI Committee as of [DATE]. 14. Reviewed the [DATE] QAPI meeting which was conducted with the Medical Director, LNHA, DON, ADON, RDCS and RDO in attendance. The content included the immediate jeopardy and removal plan. Additionally, fall audits were reviewed to ensure falls, bed mobility, and incontinence interventions were followed per the plan of care with no concerns. Further review revealed the increased meeting frequency had commenced. Interviews on [DATE] with the RDCS at 03:59 PM; the LNHA at 04:23 PM; the DON at 03:31 PM; and the ADON at 03:04 PM, revealed the content of the [DATE] QAPI meeting included the immediate jeopardy and removal plan as well as review of fall audits to ensure the interventions were followed to the plan of care. 15. Review revealed observational audits were conducted by the DON, and ADON. This included audits of the fall care plans conducted when there was an admission/readmission on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] to ensure that interventions for falls, bed mobility, and incontinence have been placed on the plan of care and have been implemented. Additionally, review of audits revealed falls were reviewed in the clinical IDT meeting on a daily basis, with a follow up audit on any falls by the RDCS. Interviews on [DATE] with the DON at 03:31 PM and the ADON at 03:04 PM revealed they conducted fall care plan audits with admissions and readmissions as of [DATE]. 16. Reviewed documentation that demonstrated audits were completed the day following falls that occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE], ensuring that fall, bed mobility and incontinence care interventions were in place per the plan of care. Surveyor audits confirmed the same, with no concerns noted. 17. Reviewed documentation of observations of staff providing incontinence care and bed mobility on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Per the documentation, Care plan interventions were followed with no concerns noted. Interviews on [DATE] with DON at 03:31 PM and ADON at 03:04 PM revealed they observed staff providing incontinence care and bed mobility assistance on the dates noted.

Based on observation, interview, record review, and review of facility's policy, it was determined the facility failed to provide care and services consistent with professional standards of practice to promote the prevention of pressure ulcer/injury development and the healing of existing pressure ulcers/injuries for two (2) of four (4) sampled residents (Residents #1 and #5). On 12/02/2020, the facility readmitted Resident #5 from the hospital with a Stage II pressure ulcer to his/her right buttock. The facility failed to document the description of wound characteristics (skin type and exudate), obtain a physician order to treat the pressure ulcer, complete a weekly skin assessment until 12/16/2020; and complete a weekly wound assessment until 12/19/2020. On 12/19/2020, (seventeen {17} days later), the pressure ulcer on the right buttock had worsened (larger) and two (2) additional Stage II pressure ulcers to his/her left buttock were identified. In addition, the facility assessed Resident #1 to have pressure wounds and require the extensive assistance of two (2) or more staff with bed mobility. Observations revealed the facility failed to turn and reposition Resident #1, from side to side, for more than 2 hours (from 12:00 PM-2:40 PM) in order to prevent further skin breakdown and promote healing. The findings include: Review of the facility's policy titled, Prevention of Pressure Ulcer/Injury, not dated, revealed the purpose of this procedure was to provide guidelines for the structured assessment and identification of residents at risk of developing pressure injuries. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission for existing pressure ulcer/injury risk factors. Inspect the skin on a daily basis when performing or assisting with personal care or ADL's (Activities of Daily Living). At least every 2 hours, reposition residents who were reclining and dependent on staff for repositioning. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort. Evaluate, report, and document potential changes in the skin. Review of the facility's policy titled, Wound Treatment Management dated 09/03/2020, revealed to promote wound healing of various types of wounds, it was the policy of this facility to provide evidence-based treatments in accordance with the current standards and physician orders. Wound treatments were to be provided in accordance with the physician orders, including the cleansing method, type of dressing, and frequency of dressing change. In the absence of treatment orders, the licensed nurse was to notify the physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. Treatment decisions were to be based on characteristics of the wound, location of the wound, goals and preferences of the resident/representative. The facility was to follow specific physician orders for providing wound care. Treatments were to be documented on the Treatment Administration Record (TAR). The effectiveness of treatments was to be monitored through ongoing assessment of the wound. 1. Closed record review revealed the facility readmitted Resident #5 on 12/02/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Admission Nursing Assessment, dated 12/02/2020, revealed a Stage II pressure ulcer to the right buttock which measured 2.0 centimeters (cm) by 1.0 cm.; however, there was no documentation of the wound characteristics (type of tissue and exudate). Review of Resident #5's Admission Minimum Data Set (MDS) assessment, dated 12/08/2020, revealed the facility assessed Resident #5's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was interviewable. Further review of the MDS, Section M: Skin Conditions, revealed the facility assessed Resident #5 at risk for pressure ulcers and identified the resident had an unhealed Stage II pressure ulcer. Review of Resident #5's Comprehensive Care Plan titled, Stage ll Pressure Ulcer to Right Buttock, dated 12/02/2020, revealed goals to have intact skin, free of redness, blisters, or discoloration and Pressure Ulcer would show signs of healing and remain free from infection. Further review of the care plan revealed interventions for treatment as ordered, check for effect and effectiveness, check dressing every shift to ensure it was intact and adhering, report loose dressing to treatment nurse, and weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, type of tissue and exudate. Review of the Admitting Physician Orders, dated 12/02/2020, revealed there was no order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Weekly Skin Assessments revealed the next weekly skin assessment was not completed until 12/16/2020 (seventeen days later) with no new skin issues identified. Further review of the resident's Electronic Healthcare Record (EHR) revealed the facility failed to initiate a Weekly Pressure/Non-Pressure Wound Observation Tool when his/her Stage II pressure ulcer was identified on readmission. Review of the Resident #5's Physician Orders and Progress Notes, dated 12/02/2020 until 12/19/2020, revealed there was no Physician Orders for treatment or any evidence of further assessments of the Stage II pressure ulcer identified on readmission until 12/19/2021 (seventeen{17}days later). Review of a Progress Note, dated 12/19/2020, revealed Resident #5's Stage II pressure ulcer to the right buttock had increased in size and measured 4.0 cm length by 1.0 cm width by 0.2 cm depth. The pressure ulcer wound base was pink and red with irregular borders, and positioned next to the gluteal fold of the right buttock. Further review of the note revealed the resident had developed two (2) additional Stage II pressure ulcers on the left buttock. A pressure ulcer to left buttock next to the gluteal fold measured 1.0 cm length by 0.3 cm width with red and pink wound bed, and irregular borders; and, one on the left buttock that measured 5.0 cm. by 5.0 cm in length, 3.0 cm in width; and 0.2 cm depth with wound bed pink and red, with irregular borders. Review of Resident #5's Physician Order, dated 12/21/2020 (nineteen {19} days after Stage II on right buttock identified and two {2} days after two {2} Stage II pressure ulcers identified on left buttock), revealed an order to cleanse with wound cleanser and apply silicone dressing daily, to pressure ulcers on each buttock. Review of Resident #5's Progress Notes, dated 12/21/2020, revealed Resident #5 was transferred to another long term care facility on 12/21/2020 due to his/her family request. Interview with Resident #5's Sister, on 02/10/2021 at 6:30 PM, revealed Resident #5 was readmitted to facility on 12/02/2020 due to COVID-19. She stated she was aware the resident had a small pressure ulcer on the right buttock upon return to the facility. Continued interview revealed the facility failed to provide care to the pressure ulcer on the resident's right buttock and it worsened. She stated in addition to my (resident) wound getting worse, they let (him/her) acquire two (2) major open wounds on (his/her} buttocks; which was the reason for the transfer to the other facility. Interview with State Registered Nurse Aide (SRNA) #3, on 02/17/2021 at 1:35 PM, revealed Resident #5 had a small area on the right buttock on readmission to the facility and barrier cream was applied to the area. Continued interview revealed the resident was readmitted to the COVID unit where he/she remained for several days (unsure how many days) before transferring to general population. SRNA #3 stated I do not recall if the resident still had the wound when transferred from COVID unit. Interview with SRNA #4, on 02/17/2021 at 3:10 PM, revealed she worked the unit that Resident #5 was transferred to from the COVID unit. SRNA #4 stated the resident's bottom was red and was treated with barrier cream; however, she stated I do not recall if the skin was opened. She revealed Resident #5 complained of burning sensation to buttocks at times and the burning was relieved when barrier cream applied. Interview with Registered Nurse (RN) #3, on 02/22/2021 at 3:15 PM, revealed she was the nurse that identified Resident #5's Stage II pressure ulcer to his/her right buttock, on 12/02/2020 at approximately 6:00 PM, when readmitted to the facility. RN #3 stated the resident did not have a treatment ordered for the pressure ulcer, so she sent a text to the resident's doctor for an order. Continued interview revealed RN #3 stated, I had not received a reply for a treatment order before my shift ended, so I made the oncoming nurse aware. Unfortunately, an order was never received and barrier cream was used as a treatment to the pressure ulcer. RN #3 also revealed she was the nurse working on 12/09/2020 when Resident #5's weekly skin/wound assessment was due; however, there was no documentation the skin assessment was done. She stated, If I did not document the assessment, I did not do it. I should have documented the assessment was not done, although I did report it to the oncoming nurse. Continued interview revealed her failure to perform the resident's weekly skin assessment could have delayed identifying any changes of skin conditions and treatment in a timely manner. Interview with RN #2, on 02/22/2021 at 2:35 PM, revealed she performed Resident #5's Weekly Skin Assessment on 12/16/2020. RN #2 stated the resident's buttocks were red and were treated with barrier cream. She revealed, There were no further skin issues identified, the buttocks was red and being treated with barrier cream. I do not recall noticing a Stage II pressure wound. Interview with Licensed Practical Nurse (LPN) #3, on 02/22/2021 at 3:00 PM, revealed on 12/19/2020 she was assigned to work the 100 unit and while assisting with Resident #5's care, the resident complained of his/her bottom burning. LPN #3 stated she assessed the resident's bottom and identified three (3) Stage II pressure ulcers. Further interview revealed LPN #3 provided care to Resident #5 when he/she was on the COVID unit and stated, he had a small area to his right buttock which was treated with barrier cream and healed before transferring off COVID unit on 12/08/2020. She stated she measured the pressure ulcers then notified Resident #5's doctor, sister, and the former Director of Nursing (DON) of the pressure ulcers. Interview with the Director of Nursing (DON), on 12/23/2021 at 8:50 AM, revealed she worked in the role as MDS Coordinator when Resident #5 was in facility. The DON stated she participated in Interdisciplinary Team meetings and remembered the discussion that Resident #5's was thought to have Moisture Associated Skin Damage (MASD) instead of a Stage II pressure ulcer. The DON stated, It was questionable if the resident's wound was pressure ulcer or MASD. The former DON was to assess the wound and contact the resident's doctor for a treatment order; however, she failed to do so. The expectation was to notify the resident's doctor to obtain a treatment order and family when the wound was identified on admission . Further interview revealed the facility's policy was for weekly skin assessments to be done when populated in the User Defined Assessments (UDA) Board seven (7) days from admission and nurses are expected to do skin assessments when they are due. Further interview (Post Survey) with the DON, on 03/05/2021 at 1:40 PM, revealed Wound Assessments were performed by the facility's contracted Wound Care Advanced Practice Registered Nurse (APRN) weekly and were documented in the residents' Electronic Health Record (EHR) under Weekly Pressure or Weekly Non-Pressure Wound Observation, based on the type of wound. She stated if assessments were not conducted and documented, there would be no way to identify and track progress of a wound. Interview with the Administrator, on 02/23/2021 at 9:10 AM, revealed weekly skin assessments for Resident #5 were not done as expected. He stated when a nurse identified a resident had any area of concern, he expected the nurse to assess the identified concern daily and implement a plan of care. 2. Record review revealed the facility admitted Resident #1 on 02/21/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 11/12/2021 revealed the facility assessed Resident #1's cognition as severely impaired with a BIMS score of ninety-nine (99), which indicated the resident was not interviewable. Review of Section G: Functional Status Activities of Daily Living (ADL) Assistance revealed the facility assessed the resident required extensive assistance of two (2) or more people with bed mobility. Review of MDS Section M: Skin Condition, revealed the facility assessed Resident #1 at risk for pressure ulcers and identified the resident had two (2) unhealed Stage IV pressure ulcers and one (1) unstageable pressure ulcer. Review of Resident #1's Comprehensive Care Plan titled, ADL Self-Care Performance Deficit, dated 02/27/2020, revealed the resident was totally dependent on two (2) staff for of repositioning and turning in bed, from SIDE TO SIDE ONLY, on back for meals only. Review of the resident's care plan titled, Pressure Ulcer Development related to disease process, Immobility, [CONDITION(S)] ([CONDITION(S)]), Diabetes, and Hypertension, dated 03/09/2020, revealed a goal for no complications related to skin breakdown while in this facility. Further review of the care plan revealed interventions to avoid positioning resident on the same side for more than two (2) hours, dated 03/09/2020. Observations of Resident #1, on 02/12/2021 at 12:00 PM, 1:00 PM, 2:00 PM, and 2:40 PM, (two {2} hours and forty {40} minutes) revealed the resident was positioned on his/her left side facing the bathroom. Observation of Resident #1's Wound Care, on 02/12/2021 at 11:55 AM, performed by the Assistant Director of Nursing (ADON), revealed Pressure Ulcer #1 (right hip) surface area was 1.0 cm, circular circumference with 10% slough, 60% granulation tissue, and 30% muscle involvement with moderate amount of serous drainage. Pressure Ulcer #2 (left lateral ankle) surface area was 1.04 cm width with 15% slough, 85% granulation tissue with a small amount of serous drainage. Pressure Ulcer #3 surface area was 10.5 cm surface area with 20% devitalized necrotic tissue, 60% granulation tissue, 20% other viable tissue (muscle, subcutaneous, tendon, and bone) with a moderate amount of serosanguineous drainage. Pressure Ulcer #4 surface area was 12.25 cm with fluid filled blister, periwound skin was intact. Observation of treatments to areas were consistent with ordered treatment. Review of Resident #1's Weekly Pressure Wound Observation assessments, dated 01/07/2021 through 02/11/2021, revealed Pressure Ulcer #1, #2 and #3 had improved as evidenced by decrease in necrotic tissue. Interview with SRNA #1, on 02/12/2021 at 2:10 PM, revealed Resident #1 was dependent on staff for turning and repositioning due to his/her immobility. SRNA #1 stated, Resident was care planned for side to side turn and reposition every 2 hours due to skin breakdown however, resident was not turned at 2 PM due to providing care to another resident. Interview with Licensed Practical Nurse (LPN) #1, on 02/12/2021 at 2:30, revealed Resident #1 was totally dependent on staff for mobility. She stated, the resident is care planned for turning and repositioning from side to side every 2 hours although, positioning to the right side is avoided due to the pressure ulcer on right hip, the resident is turned and positioned to back and left side. Further interview revealed she expected Resident #5 to be turned and repositioned every 2 hours and was not aware the resident was positioned on his/her left side past 2 hours. LPN #1 stated I make rounds, answer call lights, and assist with resident care as needed, which allows me monitor care provided to the residents. She revealed the failure to implement side to side turn would increase potential for further skin breakdown. Interview with the DON, on 02/23/2021 at 1:10 PM, revealed staff were expected to provide resident care as indicated on the resident's care guide and care plan. The DON stated she expected Resident #1 to be turned and repositioned according to his/her care plan. Interview (Post Survey), on 03/05/2021 at 1:40 PM) revealed the failure to turn the resident could cause wound to get worse and cause further skin breakdown.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop and implement a comprehensive person-centered care plan to meet two (2) of four (4) sampled residents' medical, nursing, mental, and psychosocial needs with services that were furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being (Residents #1 and #5). The facility readmitted Resident #5 from the hospital on 12/02/2020 with a Stage II pressure wound to his/her right buttock. The facility failed to implement interventions related to identifying type of tissue and if exudate, per care plan, when wound assessed on admission; failed to obtain treatment orders per care plan until 12/21/2020 (nineteen {19} days later); failed to conduct a Weekly Skin Assessment per care plan until 12/16/2020 (fourteen (14} days later), and Weekly Wound Assessment per care plan until 12/19/2020 (seventeen {17} days later. On 12/19/2020, staff identified Resident #5's Stage II pressure Ulcer to right buttock had increased in size, and two {2} Stage II pressure ulcers had developed to his/her left buttock. Record review revealed Resident #1's had a care plan titled, Pressure Ulcer Development related to disease process, dated 03/09/2020, with an intervention directing staff to avoid positioning resident on the same side for more than two (2) hours. However, observations of Resident #1, on 02/12/2021 at 12:00 PM, 1:00 PM, 2:00 PM, and 2:40 PM, revealed the resident was positioned on his/her left side facing the bathroom. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed the comprehensive, person-centered care plan should include measurable objectives, timeframes, and describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs should be developed and implemented for each resident. The care plan interventions should be derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 1. Closed record review revealed the facility readmitted Resident #5 on 12/02/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Admission Minimum Data Set (MDS) assessment, dated 12/08/2020, revealed the facility assessed Resident #5's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated the resident was interviewable. Review of the Comprehensive Care Plan titled, Stage ll Pressure Ulcer to Right Buttock, for Resident #5, dated 12/02/2020, revealed interventions for treatment as ordered, check for effect and effectiveness, check dressing every shift to ensure it was intact and adhering, report loose dressing to treatment nurse, weekly treatment documentation to include measurement of each area of skin breakdown width, length, depth, type of tissue and exudate. However, review of the Admission Nursing Assessment, dated 12/02/2020, revealed a Stage II pressure ulcer was identified to the right buttock, which measured 2.0 centimeters (cm) by 1.0 cm but there was no documentation of the wound characteristics (type of tissue and exudate); review of Weekly Skin and Wound Assessments revealed no weekly skin assessment was completed until 12/16/2020 and no wound assessment was completed until 12/19/2021; and, review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Progress Note, dated 12/19/2020, revealed Resident #5's pressure ulcer to the right buttock had increased in size and measured 4.0 cm length by 1.0 cm width by 0.2 cm depth. The pressure ulcer wound base was pink and red with irregular borders, and laterally positioned next to the gluteal fold of the right buttock. In addition, the note revealed the resident developed two (2) additional Stage II pressure ulcers on the left buttock. A pressure ulcer to left buttock next to buttock crevice measured 1.0 cm length by 0.3 cm with red and pink wound bed, and irregular borders; and, one on the left buttock that measured 5.0 cm. in length, 3.0 cm in width; and 0.2 cm depth with wound bed pink and red, with irregular borders. Interview with Registered Nurse (RN) #3, on 02/22/2021 at 3:15 PM, revealed she identified Resident #5's Stage 2 pressure ulcer to his/her right buttock, on 12/02/2020 at approximately 6:00 PM, when the facility readmitted the resident. RN #3 stated she assessed and measured the pressure ulcer; however, failed to document the identifying characteristics. RN #3 revealed there was no order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #3 stated, I had not received a reply for a treatment order before my shift ended, so I made the oncoming nurse aware. Unfortunately, an order was never received and barrier cream was used as a treatment to the pressure ulcer. Continued interview revealed she also worked 12/09/2020 when Resident #5's weekly wound assessment was due but not documented as completed. She stated, if I did not document the assessment, I did not do it. I should have documented the assessment was not done although, I did report it to the oncoming nurse. Interview with the Director of Nursing (DON), on 12/23/2021 at 8:50 AM, revealed the former DON was supposed to assess the wound and contact the resident's doctor for a treatment order. She stated she expected the nurse to notify the resident's doctor to obtain a treatment order when the wound was identified on admission. Further interview revealed the facility's policy was for skin assessments to be done weekly when populated in the User Defined Assessments (UDA) Board seven (7) days from admission and nurses were expected to do skin assessments when they were due. Continued interview (Post Survey) on 03/05/2021 at 1:40 PM, revealed if licensed nurses failed to conducted skin and wound assessments, there was no way to track the wound healing process. Interview with the Administrator, on 02/23/2021 at 9:10 AM, revealed weekly skin assessments for Resident #5 were not done as expected. The Administrator stated when a nurse identified a resident had any area of concern, he expected the nurse to assess the identified concern daily and implement a plan of care. 2. Record review revealed the facility admitted Resident #1 on 02/21/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS assessment, dated 11/12/2020 revealed the facility assessed Resident #1's cognition as severely impaired with a BIMS score of ninety-nine (99), which indicated the resident was not interviewable. Review the Resident #1's care plan titled, Pressure Ulcer Development related to disease process, Immobility, [CONDITION(S)] ([CONDITION(S)]), Diabetes, and Hypertension, dated 03/09/2020, revealed an intervention to avoid positioning resident on the same side for more than two (2) hours, dated 03/09/2020. However, observations of Resident #1, on 02/12/2021 at 12:00 PM, 1:00 PM, 2:00 PM, and 2:40 PM revealed the resident was positioned on his/her left side facing the bathroom. Observation of Resident #1's Wound Care, on 02/12/2021 at 11:55 AM, performed by the Assistant Director of Nursing (ADON), revealed the resident had four (4) Pressure Ulcers: one to right hip (Stage IV identified 09/16/2020) which measured 1.0 centimeter in circumference, left lateral ankle (Stage IV-identified 09/16/20) which measured 1.04 cm, Right heel (unstagable-identified 11/19/2020) which measured 10.5 cm surface area, and left heel (unstagable-identified 12/21/2020) which measured 12.25 cm with fluid filled blister. Review of Resident #1's Weekly Pressure Wound Observation assessments, dated 01/07/2021 through 02/11/2021, revealed Pressure Ulcer #1, #2, and #3 had improved as evidenced by decrease in 'necrotic tissue and/or decrease in surface area. In addition, review of Resident #1's Comprehensive Care Plan titled, ADL Activities Self-Care Performance Deficit, dated 02/27/2020, revealed intervention to check nail length, trim, and clean on bath day and as necessary. Report any changes to the nurse. However, observations on 02/12/2021 at 11:55 AM, revealed Resident #5's toenails on both feet were thick, yellow in color, and untrimmed; and toenail on right great toe was partially removed mid nailbed. Interview with State Registered Nurse Aide (SRNA) #1, on 02/12/2021 at 2:10 PM, and on 02/22/2021 at 3:45 PM, revealed the nurses were responsible to perform toenail care for Resident #1 due to the Resident being a diabetic. SRNA #1 stated Resident #1 was also dependent on staff for turning and repositioning due to his/her immobility. SRNA #1 revealed, Resident was care planned for side to side turn and reposition every 2 hours due to skin breakdown; however, resident was not turned at 2:00 PM due to providing care to another resident. Interview with Licensed Practical Nurse (LPN) #1, on 02/12/2021 at 10:49 AM and 02/22/2021 at 3:00 PM, revealed she expected all residents to be groomed and nail care performed. She stated, prior to COVID, a Podiatrist was performing nail care to the residents however, nail care is now the responsibility of all staff. LPN #1 stated the resident is care planned for turning and repositioning from side to side every 2 hours although, positioning to the right side is avoided due to the pressure ulcer on right hip, the resident is turned and positioned to back and left side. Further interview revealed she expected Resident #5 to be turned and repositioned every 2 hours as care planned, and she was not aware the resident was positioned on his/her left side for past 2 hours. LPN #1 stated I make rounds, answer call lights, and assist with resident care as needed, which allows me monitor care provided to the residents. Continued interview revealed the failure to implement side to side turn would increase potential for further skin breakdown Interview with the Director of Nursing (DON), on 02/23/2021 at 9:10 AM and 1:10 PM, revealed staff was expected to provide residents' care as indicated on the resident's care guide and care plan. She stated she expected staff to provide nail care and grooming to all residents if the resident allows. She stated only licensed staff were allowed to provide nail care to diabetic residents. Continued interview revealed she expected Resident #5 to be turned and repositioned according to his/her care plan. Interview (Post Survey) on 03/05/2021 at 1:40 PM, revealed the failure to reposition the resident side to side every two hours could cause the wound to get worse and cause further skin breakdown.

Based on interview, record review, review of Hospital Discharge Summary, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of three (3) residents reviewed for falls. Resident #4 was care planned for at risk for falls with interventions for a bed/chair sensor alarm and a bathroom alarm to make staff aware of resident attempting to get up without assistance and/or attempting to toilet self. However, on 04/08/19, staff failed to implement the care plan when they failed to ensure the resident's alarms were turned on and functioning. Staff found the resident on floor in bathroom, next to the commode with no alarms sounding. The resident sustained [REDACTED]. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Staff develops and implements a comprehensive, person-centered care plan for each resident. Record review revealed the facility readmitted Resident #4 on 10/18/18 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/16/19, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, Falls Risk, dated 10/30/18, and Certified Nursing Aide (CNA) Care Plan dated printed 03/26/19 revealed the resident was at risk for injury related to falls with interventions in place for sensor alarm to bed and wheelchair (w/c), bathroom door alarm to alert staff of resident attempting to toilet self, follow facility fall protocol, and physical therapy to evaluate and treat as ordered. Review of the Fall Investigation dated 04/08/19 and interviews with Licensed Practical Nurse (LPN) #3 on 04/24/19 at approximately 3:10 PM and Certified Nurse Aide (CNA) #4 on 04/23/19 at approximately 4:55 PM revealed CNA #4 found Resident #4 on the floor in the bathroom next to the commode with his/her pants and brief pulled down to his/her ankles. However, the facility failed to ensure the bed/chair sensor alarm and bathroom alarm were on and functioning to alert staff when the resident attempted to transfer to commode without staff assistance. CNA #4 stated she did not recall any alarms sounding (w/c sensor alarm and bathroom alarm) when she found Resident #4 and LPN #3 stated she later identified Resident #4's bathroom alarm was turned off at the nursing station. Review of the Hospital Discharge Summary, dated 04/08/19, revealed Resident #4 was diagnosed with [REDACTED]. Further review of the summary revealed the laceration required thirteen (13) sutures to close. Review of Resident #4's (MONTH) 2019 Medication Administration Record [REDACTED]. However, further review revealed Resident #4 required [MEDICATION NAME] and [MEDICATION NAME] daily for seven (7) days after returning to the facility on [DATE]. Resident #4 reported pain level at three (3), four (4), and five (5) on a scale of ten (10) being the worst. Interview with Director of Nursing (DON) on 04/26/19 at approximately 4:14 PM revealed staff will never know exactly what happened with Resident #1 but the outcome of the investigation was Resident #1 wheeled him/herself from activities and transferred unassisted to the toilet in his/her room before falling. The DON stated she expected the Care Plan interventions to be followed. The DON further revealed she expected alarms to be checked regularly.

Based on interview, record review, facility policy review, and Hospital Discharge Summary, it was determined the facility failed to ensure two (2) of three (3) sampled residents reviewed for falls received adequate supervision and assistance devices to prevent accidents (Resident #4 and Resident #5). Resident #4 was assessed and care planned for at risk for falls with interventions for a bed/chair sensor alarm and a bathroom alarm to make staff aware of resident attempting to get up without assistance and/or attempting to toilet self. On 04/08/19, Resident #4 was found by staff on floor in bathroom next to the commode. The resident sustained [REDACTED]. The facility failed to investigate the fall to determine the root cause of fall (transferred self or staff leaving on toilet without supervision); however, the facility determined the resident transferred self. The facility failed to ensure Resident #4's alarms were on and functioning per care plan. In addition, the facility failed to revise the care plan after the fall to try to prevent future falls and to ensure staff responded to the bathroom alarm timely. Resident #5 sustained a fall on 01/03/19 from his/her lift recliner when he/she raised the recliner to high and he/she slid from the chair on to the floor. The facility determined the lift recliner was not safe for the resident on 01/03/19; however, failed to remove the recliner. On 01/05/19, Resident #5 fell again from the lift recliner when he/she raised it to high and sustained a left hip dislocation. Resident #5 declined from being independent for all care to requiring extensive assistance of two (2) staff for care. In addition, the facility determined to add dysom to chair seat and cover with towel, and apply nonskid strips to floor in front of chair; however, the facility failed to revise the care plan. The findings include: Review of the facility policy titled, Assessing Falls and Their Causes, last revised (MONTH) 2010, revealed the purpose of this procedure was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. To prepare, staff should review the resident's care plan to assess for any special needs of the resident, identify the resident's current medications,and active medical conditions; and, assemble the equipment and supplies as needed. Within twenty-four (24) hours of a fall, the nursing staff should begin to try and identify possible or likely causes of the incident. They should refer to resident-specific evidence including medical history, known functional impairments, etc. Staff should evaluate chains of events or circumstances preceding a recent fall including the time of day of the fall; time of the last meal; what the resident was doing; whether the resident was standing, walking, reaching, or transferring from one position to another; whether the resident was among other people or alone; whether the resident was trying to get to the toilet; whether any environmental risk factors were involved, and whether there was a pattern of falls for this resident. Further review revealed staff should continue to collect and evaluate information until they either identify the cause of the fall or determine that the cause cannot be found. 1. Record review revealed the facility readmitted Resident #4 on 10/18/18 with [DIAGNOSES REDACTED]. Review of the type Minimum Data Set (MDS) assessment, dated 02/16/19, revealed the facility assessed Resident #18's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment revealed the resident required extensive assist of two (2) for transfers and toileting, was not steady, and was only able to stabilize with staff assistance when moving from seated to standing position and moving on and off toilet and, the resident had no falls. Review of the Comprehensive Care Plan for Falls Risk, dated 10/30/18, revealed the resident was at risk for injury related to falls due to a history of falls, ataxia and and [MEDICAL CONDITIONS] with weakness. Further review of the care plan revealed interventions for sensor alarm to bed, bathroom door alarm to alert staff of resident attempting to toilet self, to follow facility fall protocol, and for physical therapy to evaluate and treat as ordered. Review of the Certified Nursing Aide (CNA) Care Plan printed 03/26/19 revealed under safety there were interventions that resident has sensor alarm to bed and wheelchair (w/c), and bathroom door alarm to alert staff of resident's attempting to toilet self. Review of Nursing Progress Note, dated 04/08/19 at 18:34 by Licensed Practical Nurse (LPN) #6 revealed Resident #4 was found on the floor by nurse aide in the bathroom by commode and was sent to the emergency room (ER) for evaluation and treatment Review of Facility Fall Incident Report dated 04/08/19 revealed staff came to get nurse stating Resident #4 had fallen in the bathroom and was lying on the floor beside the commode with a laceration to the left side of face. The immediate action documented as taken was for staff to remain with resident at all times while toileting. However, further review revealed there was no documented evidence the sensor alarm to w/c or bathroom alarm sounded and no documented evidence an investigation was conducted to determine if the resident was left on the toilet by staff or how the resident had got to the bathroom to try to establish the root cause of the fall per facility policy. Review of the Hospital Discharge Summary, dated 04/08/19, revealed Resident #4 was diagnosed with [REDACTED]. Further review revealed the laceration was four (4) centimeters long and two (2) millimeters deep and required thirteen (13) sutures to close. Review of Resident #4's (MONTH) 2019 Medication Administration Record [REDACTED]. Further review revealed Resident #4 required [MEDICATION NAME] and [MEDICATION NAME] daily for seven (7) days after returning to the facility on [DATE]. Resident #4 reported pain level at three (3), four (4), and five (5) on various days. In addition, further review of the Comprehensive Care Plan for Falls Risk, dated 10/30/18, revealed there was no documented evidence Resident #4's care plan was revised to address the 04/08/19 fall. Interview with Resident #4's Family Member #3 on 04/24/19 at approximately 8:20 AM revealed LPN # 3 notified her the resident had a fall after being left alone in the bathroom by an aide. Family member #3 stated LPN #3 informed her Resident #4 had a small cut on his/her eye and asked Family Member #3 if she wanted Resident #4 to be sent to the hospital. Family Member #3 stated she immediately went to the facility and arrived while resident was still in the facility with Emergency Medical Services (EMS). Family member #3 stated when she met with Administrative staff after the incident she was informed by staff that the outcome of the fall investigation was that Resident #4 wheeled him/herself from the Activities room to his/her room without any staff assistance and put him/herself on the toilet unassisted. Family member #3 stated she was very upset since LPN #3 originally informed her Resident #4 was left alone by an aide and that it was highly unlikely given Resident #4's physical limitations that he/she could have wheeled herself to his/her room and got on to the toilet without any assistance from staff. Interview with CNA #4 on 04/23/19 at approximately 4:55 PM revealed she found Resident #4 on the floor of the bathroom when he/she fell on [DATE]. CNA #4 stated she came back from lunch about 3:05 PM and did not see Resident #4 anywhere, so she went to Resident #4's room to check on him/her and found him/her on the floor of his/her bathroom injured. CNA #4 revealed she observed a bowel movement in the toilet; but the resident was unable to provide any details as to how he/she got into the bathroom or how he/she fell . CNA #4 stated she did not remember hearing any alarm going off. CNA #4 stated Resident #4 went to Activities that day at 2:00 PM and she went to lunch after 2:00 PM so she was not sure how long Resident #4 was in activities. CNA #4 further stated she was not sure what interventions were care planned for Resident #4 prior to the fall on 04/08/19 but the new interventions were to toilet Resident #4 every two (2) hours and to not leave Resident #4 alone in the bathroom during toileting. CNA #4 stated Resident #4 has an alarm on her/his bed and chair but she was not sure if Resident #4 had an alarm in her/his bathroom. CNA #4 stated Resident #4 could self-propel in his/her wheelchair for short distances in the facility and that he/she required staff assistance of one (1) with transfers and toileting. Interview with LPN #3 on 04/24/19 at approximately 3:10 PM revealed CNA #4 came and got her on 04/08/19 and informed her that Resident #4 was on the floor in her/his bathroom. LPN #3 stated she went into Resident #4's bathroom and observed him/her lying on the floor bleeding and the resident's pants and brief were pulled down. LPN #3 revealed she stayed with Resident #4, and CNA #4 went to get the Assistant Director of Nursing (ADON). LPN #3 stated she obtained Resident #4's vitals, located the source of bleeding, then assisted Resident #4 on to his/her back and laid a pillow under him/her to make him/her more comfortable. LPN #3 revealed she notified the resident's daughter and told the daughter an aide left Resident #4 in the bathroom alone unsupervised. LPN #3 stated she did not know for certain how the fall occurred but that was her immediate thought that seemed the most likely situation. LPN #3 stated it was her professional opinion that staff assisted Resident #4 on to the toilet and then left him/her unsupervised because she does not believe Resident #4 was able to get him/herself out of his/her w/c and on to the toilet without assistance. LPN stated later that day after the fall occurred she checked the bathroom alarm on the nurse's station and realized the alarm was turned off. LPN #3 stated the bathroom alarm should be turned on twenty-four hours a day seven days a week and it should never be turned off for any reason. LPN #3 stated the facility protocol for a fall was for the nurse to document everything that was observed in a progress note; and to fill out an Incident Report, Post Fall Review, Change of Condition, and complete Neuro checks. LPN #3 stated the nurse should identify immediate interventions but she was not sure who was responsible for updating the care plan with new interventions. LPN #3 stated the Iinterdisciplianry Team (IDT) team will review each fall and identify appropriate new interventions. On 04/25/19 at approximately 10:30 AM, State Surveyor went into Resident #4's bathroom and stood in front of the toilet and observed that alarm indicator light was on. Surveyor could hear alarm going off at the nurse's station; however, it took staff five (5) minutes before coming into the bathroom to check. Interview with the Activities Director on 04/24/19 at approximately 10:00 AM revealed Resident #4 was in Activities on 04/08/19 at 2:00 PM. The Activities Director revealed Resident #4 stayed in the dining room to watch TV after the Activity was over. The Activities Director stated she usually brings Resident #4 to Activities but an aide usually takes Resident #4 back to his/her room. The Activities Director revealed when she left that day she observed Resident #4 still watching TV and she informed the aides on duty to keep an eye out for the residents that stayed to watch TV so they could help them when they were ready to leave. The Activities Director stated she did not remember which aides specifically she spoke with that day. Interview with CNA #3 on 04/23/19 at approximately 4:40 PM revealed she was familiar with Resident #1's care. CNA #3 stated Resident #4 could self-propel in her/his wheelchair short distances in the facility and that he/she required one (1) staff assist with Activities of Daily Living (ADL's). CNA #3 revealed staff usually assisted Resident #1 to activities and she was not aware if that was care planned but that when staff see Resident #4 in the facility in his/her wheelchair they will assist him/her to where he'/she was going. CNA #3 stated she was aware Resident #4 had a fall that resulted in a head injury recently but staff were not informed to remain with Resident #4 while she was toileting after the recent fall. She stated she always remained with Resident #4 while he/she was toileting because she knew Resident #4 was a falls risk and he/she was not steady on his/her feet. CNA #3 stated staff push Resident #4's w/c into the bathroom and he/she will use the grab bars to pull up and staff help turn Resident #4 and sit him/her down on the toilet. CNA #3 stated Resident #4 is not steady without staff assistance. Interview with CNA #5 on 04/24/19 at approximately 11:00 AM revealed Resident #4 has been a fall risk since he/she has been in the facility and required extensive assistance of one (1) staff with ADL's. CNA #5 stated staff push Resident #4's w/c into bathroom, then the resident uses the grab bars to lift up with staff assistance, and staff assist Resident #4 to turn to sit on the toilet. CNA #5 stated Resident #4 has attempted unassisted self-transfers in the past and has never been successful with getting up and on to the toilet without any assistance from staff. CNA #5 stated the bathroom alarm in the resident's bathroom was motion sensored and would go off as soon as anyone steps in front of the toilet. CNA #5 stated the alarm was supposed to be on at all times and should never be turned off. Interview with LPN #4 on 04/24/19 at approximately 4:50 PM revealed the facility protocol for falls was for the nurse to complete a Risk Management Assessment and pain assessment, and put interventions in place. LPN #4 stated the IDT should meet and discuss the falls and put documentation in alert charting book and update the care plan. LPN #4 stated she was not sure who was responsible for updating the CNA care plans. LPN #4 stated it was her professional opinion that Resident #4 could not have transferred unassisted out of his/her w/c and on to the toilet without staff assistance. LPN #4 stated staff have to assist Resident#4 to the toilet, then Resident #4 pulls up on the grab bars, but staff have to assist with turning Resident #4 and pulling down his/her pants and brief before placing him/her on to the toilet. LPN #4 stated it was her belief that someone put Resident #4 on to the toilet and then left her unsupervised. 2. Record review revealed the facility readmitted Resident #5 on 05/05/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #5 was independent for bed mobility, transfers, and toileting. Review of the Comprehensive Care Plan for Falls Risk, dated 10/30/18, revealed the resident was at risk for injury related to falls. Further review of the care plan revealed interventions for shoes in place for transfers, toilet resident after meals and before, and remind resident to use walker. In addition Resident #5 was care planned for impaired cognition function and impaired thought process related to dementia. Review of Facility Fall Incident Report dated 01/03/19 revealed Resident #5 was getting up to go to bathroom and put his/her lift recliner up to high and slid out and onto the floor with no injury noted. Immediate action was assisted resident bathroom and back into chair and vitals. Further review revealed new interventions identified were dysom to chair seat and cover with towel, and apply nonskid strips to floor in front of chair. Further review of the Comprehensive Care planned revealed the Care Plan was not updated to reflect the new interventions of dysom to chair seat and cover with towel and apply nonskid strips to floor in front of chair. However, the interventions added to the care plan was an Occupational Therapy screen for chair positioning. Review of Occupational Therapy Evaluation and Plan of Treatment dated 01/03/19 at 8:29 PM revealed the impression was Resident #5 demonstrated increased difficulty utilizing lift recliner safely. Interview with Occupational Therapist on 04/26/19 at approximately 2:10 PM revealed she completed the assessment for Resident #5's ability to manage the functioning of the lift recliner and she determined it was unsafe for Resident #5 to manage effectively. The Occupational Therapist stated nursing staff was already aware the chair was a safety concern since they put in the referral for Occupational Therapy due to the the concerns with safety in the chair. Review of Facility Fall Incident Report dated 01/05/19 revealed Resident #5 put his/her lift reciner up so high, he/she slid out and onto the floor. The resident complained of left hip pain, vitals were taken, and Resident #5 was sent to the hospital for evaluation. Immediate action taken was to re-educate Resident #5 on the use of the chair and asking for assistance even though the facility had already determined the chair was not safe for the resident. Review of Nursing Progress Note dated 01/05/19 at 7:45 PM revealed resident resting in bed, left leg immobilizer in place (dislocated left hip), pedal pulses present and palpable. Further review of the Comprehensive Care Plan revealed the Care Plan was updated on 01/05/15 to reflect a new intervention to add a bed alarm but Resident #5 did not have a bed in her/his room at the time. Review of a Nursing Progress Note dated 01/07/19 at 3:10 PM by RN #4 revealed staff removed Resident #5's recliner and replaced with bed in room. Review of Resident #5's quarterly MDS assessment, dated 01/12/19 revealed the resident had declined from being independent on 10/19/18 to requiring extensive assistance of two (2) staff for bed mobility, transfers, and toileting. Review of the Significant Change MDS assessment, dated 04/14/19, revealed the facility assessed Resident #5's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Interview with CNA #7 on 04/26/19 at approximately 10:20 AM revealed he was familiar with Resident #5's routine care. CNA #7 stated Resident #5 was 100% independent prior to his/her fall that occurred in (MONTH) 2019 that resulted in a left hip dislocation. CNA #7 revealed after the fall Resident #5 required about 60% assistance from staff with his/her daily ADL's. CNA #7 stated Resident #5 used to sleep in his/her lift recliner but that staff ended up removing the recliner and putting a bed back in the room. Interview with CNA #8 on 04/26/19 at approximately 11:40 AM revealed Resident #5 was 100% independent with ADL's prior to the left hip dislocation and only required set up for meals by staff. CNA #8 stated after the left hip dislocation Resident #5 required staff to assist with all her/his ADL's. CNA #8 revealed Resident #5 only had a lift recliner in her/his room but that it was taken out and a bed was put back in the room. Interview with DON on 04/26/19 at approximately 4:14 PM revealed it was not appropriate for the lift recliner to remain in Resident #5's room after he/she had the first fall from it. The DON stated staff will never know exactly what happened with Resident #4, but that the outcome of the investigation was that Resident #4 wheeled him/herself from activities and transferred unassisted to the toilet in his/her room before falling. The DON revealed she expected all alarms to be checked regularly and staff should respond immediately. She stated she was embarrassed that Surveyor observed staff taking five (5) minutes to respond to Resident #4's bathroom alarm. The DON further revealed she expected staff to identify interventions, update them on care plan and implement the interventions. The DON revealed she expected the falls protocol/policy to be followed. The DON stated the IDT team discusses all falls and assesses interventions and identifies appropriate interventions. She stated she expected CNA care plans to be updated and a new copy put into the book each time. The DON further stated she felt that better communication needed to happen to ensure there were no breakdowns or barriers to ensure the residents ongoing safety and well-being.

Based on interview, record review, and facility policy review, it was determine the facility failed to revise the care plan for three (3) of six (6) sampled residents (Resident #1, #4. and #5). Resident #5 sustained a fall on [DATE] from his/her recliner chair and Resident #4 sustained a fall from the commode on [DATE]; however, the facility failed to revise the care plans to try to prevent future falls. In addition, Resident #1 was seen at the wound center on [DATE] and a neuropathic ulcer to the right foot was identified with treatment orders written by wound center; however, the facility failed to revise the Comprehensive Care Plan to include the identification of the neuropathic ulcer and ordered treatments. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. The Interdisciplinary Team (IDT) must review and update the care plans when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly in conjunction with the required quarterly Minimum Data Set (MDS) Assessment. 1. Record review revealed the facility readmitted Resident #4 on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #18's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Review of Nursing Progress Note, dated [DATE] at 6:34 PM and Facility Fall Incident Report dated [DATE] revealed Resident #4 was found on the floor in the bathroom by the commode with a laceration to left side of face by a Certified Nurse Aide (CNA). The resident was sent to emergency room (ER) for evaluation and treatment. Further review of the incident report revealed no documented evidence an investigation was conducted to determine if the resident was left on the toilet by staff or how the resident had got to the bathroom. The facility determined the resident transferred to the commode per self and sustained the fall. However, review of the Comprehensive Care Plan for Falls Risk, dated [DATE], revealed there was no documented evidence the care plan was revised to address the [DATE] fall related to the resident transferring self and no alarms sounding to alert staff. 2. Record review revealed the facility readmitted Resident #5 on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated [DATE], revealed the facility assessed Resident #5's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was not interviewable. Review of Facility Fall Incident Reports dated [DATE] revealed Resident #5 was getting up to go to bathroom and put his/her chair up to high and slid out and onto the floor. Further review revealed new interventions identified were dysom to chair seat, cover with towel; and apply nonskid strips to floor in front of chair. However, further review of the Comprehensive Care Plan dated [DATE] revealed the care plan was not revised to reflect the new interventions. In addition, review of a Occupational Therapy Evaluation and Plan of Treatment completed after the [DATE] fall, dated [DATE] at 8:29 PM revealed Resident #5 demonstrated increased difficulty utilizing recline chair safely; however, there was no documented evidence the care plan was revised to address the resident not using the recline chair safely. Review of Facility Fall Incident Report dated [DATE] and Nursing Progress Note dated [DATE] at 3:10 PM revealed Resident #5 put his/her chair up so high, he/she slid out and onto the floor. The resident complained of left hip pain, vitals were taken and the resident was sent to the hospital for evaluation. Immediate action taken was to re-educate Resident #5 on the use of the chair and asking for assistance. Further review revealed no new interventions identified other than re-education to resident. Review of Nursing Progress Note dated [DATE] at 7:45 PM revealed resident resting in bed, left leg immobilizer in place (Left hip dislocation), pedal pulses present and palpable. Further review of the Comprehensive Care Plan dated [DATE] revealed the Care Plan was updated with an intervention to add a bed alarm; however, review of a Nursing Progress Note dated [DATE] at 3:10 PM by Registered Nurse (RN) #4, revealed staff removed Resident #5's recliner chair and replaced with bed in room. Interview with Licensed Practical Nurse (LPN) #3 on [DATE] at approximately 3:10 PM revealed the nurse should identify immediate interventions but she was not sure who was responsible for updating the care plan with the new interventions. LPN #3 stated the IDT team reviews each fall, and identifies appropriate new interventions. Interview with LPN #4 on [DATE] at approximately 4:50 PM revealed the nurse puts an immediate intervention in place after a fall. LPN #4 stated the IDT team will meet and discuss the falls and they update the care plan. Interview with Director Of Nursing (DON) on [DATE] at approximately 10:30 AM revealed there was no specific person that was responsible for updating care plans. The DON stated her, along with the Assistant Director of Nursing (ADON) or MDS Coordinator updated the care plans. The DON stated the IDT team reviewed the fall and the care plan should have been updated but she was not sure why it had not been done. 3. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The resident expired, while in the facility, on [DATE]. Review of the Wound Center's Visit Notes, dated [DATE], revealed a neuropathic ulcer of the right foot was identified measuring length 1.7 centimeters (cm), width was 1.2 cm, and depth was 0.1 cm with moderate clear drainage. In addition, review of the Wound Center's Visit Discharge/Physician Orders dated [DATE] revealed to wash the right foot with soap and water; apply Santyl (nickel-thickness) to the wound bed; cover with ,[DATE] strength dakins moistened gauze; cover with ABD (abdominal-thick gauze) pad; and, secure with [MEDICATION NAME] tape or hytape. Change the dressing twice daily. Off-load heels by applying heel-lift boots or float heels by placing pillows under calves so that heels do not touch mattress. However, review of the Comprehensive Care Plan, dated [DATE], revealed Resident #1 had a pressure ulcer to the right buttock and coccyx, however, the care plan was not updated to reflect the resident has an ulcer to the right foot, nor were interventions added to reflect the wound center's orders for treatment and care of the right foot ulcer. Interview with LPN #1 on [DATE] at 10:47 AM revealed she remembered working the day Resident #1 went to the wound center, but does not remember any orders from the wound center. Interview with the MDS Coordinator on [DATE] at 9:46 AM, revealed it was her responsibility to run an order report for any new orders put in the computer from the previous day and to update the care plans from the orders. She stated if the orders were not put in the computer, she had no way of knowing they existed to update the care plan. Interview with the DON on [DATE] at 8:53 AM revealed when a resident returned from wound care the nurse on shift at that time should have put the new orders in the computer, and the clinical administrative team, particularly the Minimum Data Set (MDS) Coordinator should have updated the care plan with the new wound/wound treatments.

Based on interview, record review, and review of the facility's Administrator's Job Description, it was determined the facility failed to be 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 for one (1) of four (4) sampled residents (Resident #1). The Administrator was aware the facility had past deficient practice related to revising the care plan, implementing the care plan, ongoing assessments with change in condition and care of a resident with catheters (F280, F282, F309, and F315). However, when Resident #1 was hospitalized from [DATE] through 08/09/16 with [DIAGNOSES REDACTED]. plan was implemented related to catheter care; and, failed to ensure ongoing assessments were conducted to identify signs and symptoms of UTI/Sepsis after his/her return to the facility. The facility's failure to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental and psychosocial well-being related to following facility policies and ensuring staff notified the physician with resident condition changes and provided the necessary care and services in a timely manner has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The findings include: Review of the facility's job description for the Center's Executive Director (Administrator), dated 01/01/16, revealed, the Administrator is to create an environment where staff members are highly engaged and are focused on providing the highest level of clinical care and [MEDICATION NAME] to residents and families; is responsible for assuring the Center operates in full compliance with Federal and State regulations while doing the right things, which will result in high levels of performance in each of the company's focus areas; is responsible for planning and is accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents and administers, directs and coordinates all activities of the Center to assure the highest degree of quality of care is consistently provided to the residents. Interview with the Administrator, on 09/08/16 at 8:30 AM, revealed the Administrator was expected to ensure her job description was followed and the expectations were for her to follow the job description to the best of her ability. She further stated, she expected staff to have provided the necessary care and services needed to take care of Resident #1 and she expected all staff to follow the facility's policy and procedures. Further interview (Post Survey) with the Administrator, on 10/06/16 at 8:25 AM revealed she was looking at previous facility POCs; however, she was focused on the most recent POC from February 2016 (F155, F224, F281, F282 and F514). She stated she was trying to ensure the facillity had completed the audits and tools related to the POC. The Administrator stated, I was aware of the facility's history, but my immediate focus was on our most recent identified deficient practices which were from February 2016. Post Survey interview with the Regional Vice President of Operations (RVPO), on 09/29/16 at 11:40 AM, revealed there was no continued specific oversight ongoing or in place related to the past repetitive deficient practice. The RVPO stated the facility and regional team felt the past deficient practice had been corrected by following the Plan of Correction and with continued random audits performed by both the facility and the corporate team. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview and review of the facility's policies and procedures, it was determined the Governing Body failed to provide oversight to assure the facility was administered in an effective manner to ensure adequate basic care and services were to promote the health and safety of each resident. The Governing Body also failed to ensure the facility established and implemented policies and procedures regarding the day-to-day management and operation of the facility; and, failed to ensure the facility sustained compliance as evidenced by repeated deficient practice. (Refer to F157, F280, F282, F309, F315, F514, and F520). The facility's failure to have a governing body in place to assure the facility was administered in a manner that promoted, protected and enhanced the health and safety of each resident, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, alleging the Immediate Jeopardy was removed on 09/14/16. The State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy Governing Body: Centers, revised 09/01/13, revealed the company has a governing body that consists of the Administrator, Director of Nursing (DON), Regional Vice President of Operations and the Division Manager of Clinical Operations. The policy further stated, the Governing Body was legally responsible for establishing and implementing policies regarding the management and operations of the Center. Review of the 09/18/15 Abbreviated/Extended Survey and the 02/13/16 Abbreviated Survey revealed the facility was cited previously for F280, F282, F309, and F514 with Plans of Corrections put in place to correct the deficiencies. These deficient practices were cited at the Immediate Jeopardy level. Interview with the Regional Vice President of Operations, on 09/21/16 at 2:05 PM, revealed she felt like the previous Administrator and Director of Nursing (DON) were not providing strong leadership at the facility or holding staff accountable to follow the facility's policies and procedures. She stated because both the previous Administrator and DON were not able to be strong leaders and hold staff accountable, a decision was made to terminate their employment. She stated the decision of terminating the previous management and bringing in new management in April 2016 was based on the overall determination that the previous administration struggled to run the building appropriately and ensure the building was administered properly. She stated the facility has gone through some adjustments with turnover in staff, but feels confident the new Administrator and new DON can provide the appropriate leadership and direction to get the facility back to the level they expect. Further interview (Post Survey) with the Regional Vice President of Operations, on 09/29/16 at 11:40 AM, revealed there was no continued specific oversight ongoing or in place related to the past repetitive deficient practice the facility had been identified as having. She stated the facility and regional team felt the past deficient practice had been corrected by following the Plan of Corrections and with continued random audits performed by both the facility and the corporate team. She stated the oversight had been discontinued related to the repeated deficiencies. She also stated, if the corporate team or facility would have identified any concerns or problems in relation to repeat past deficient practice the facility would have implemented a plan of action to resolve the issues identified and then there would have been oversight implemented once again. However, the Governing Body failed to identify the facility's inability to sustain compliance in these areas. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview, record review, review of the hospital reports, and facility policies and procedures, it was determined the facility failed to provide care in accordance with the written plan of care for one (1) of four (4) sampled residents (Resident #1). Resident #1 was care planned for the use of a catheter and insulin dependent Diabetes with interventions to monitor for signs and symptoms of infection and report to physician; monitor output for odor, color, consistency, amount, sediment, cloudy, blood and amount; and, monitor for signs and symptoms of hyper/[DIAGNOSES REDACTED] and report abnormal findings to physician. However, licensed staff failed to monitor the resident's catheter and urine for signs and symptoms of infection; and, failed to report to the physician when the resident had abnormal blood glucose findings related to accu-checks greater than 400 mg/dl. On 08/28/16 at 10:00 PM, Resident #1 was found unresponsive, had an accu-check of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit, and was sent to the emergency room (ER). Resident #1 was diagnosed with [REDACTED]. The facility's failure to provide services in accordance with each resident's written plan of care has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Care Plans, dated 01/02/14, revealed the interdisciplinary team should develop a comprehensive, individualized care plan for each resident. The care plan should include measurable objectives to meet resident needs and goals as identified by the assessment process. The purpose of the Care Plan was to provide necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review revealed the facility admitted Resident #1 on 03/16/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/16/16, revealed the facility assessed the resident's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable and the resident had a Urianry Tract Infection. Review of the Comprehensive Care Plan for requiring indwelling catheter due to [MEDICAL CONDITION] Bladder, dated 03/16/16, revealed interventions to provide catheter care two (2) times a day and as needed; monitor for signs and symptoms of infection and report to physician; monitor output for odor, color, consistency and amount; and, monitor urine for sediment, odor, blood and amount. Review of the Comprehensive Care Plan for Diabetes/insulin dependent, dated 03/17/16, revealed interventions to monitor for signs and symptoms of hyper/[DIAGNOSES REDACTED] and report abnormal findings to physician; and, monitor for signs and symptoms of infection and report as indicated. Review of Resident #1's August 2016 Medication Administration Record (MAR) and interview with Licensed Practical Nurse (LPN) #1 on 09/05/16 at 5:25 PM, revealed the resident's accu-check was four-hundred forty-three (443) mg/dl on 08/27/16 at 8:00 PM. In addition, LPN #1 administered Tylenol per [DEVICE] (gastrostomy - feeding tube) for an increased temperature on 08/27/16 at 10:20 PM and again on 08/28/16 at 2:30 AM. given. Further review of the August 2016 MAR revealed on 08/28/16 at 6:00 AM, Resident #1's accu-check was four-hundred eighty-six (486) mg/dl and review of Resident #1's Output Records for August 2016, revealed Resident #1 had 100 milliliters (ml) of urinary output during the 3:00 PM-11:00 PM shift and no urinary output (marked zero) from his/her indwelling urinary catheter on 08/27/16 during the 11:00 PM-7:00 AM shift. Further review revealed the resident had no urinary output on 08/28/16 on the 3:00 PM-11:00 PM shift. LPN #1 stated Resident #1 had been running a fever since 08/27/16. She stated she did not assess the resident for signs and symptoms of infection nor did she notify the physician of the resident's abnormal accu-checks, per the care plan. She stated she did not assess Resident #1's indwelling urinary catheter prior to sending Resident #1 out to the ER. LPN #1 stated after Resident #1 was sent to the ER, CNA #1 informed her of Resident #1 having no urinary output for the 3:00 PM - 11:00 PM shift on 08/28/16. She stated she was not aware of what the care plan interventions were, as she had not had time to look at them, but she was aware she was expected to know the resident care plans and follow them. Review of Resident #1's Nursing Note, dated 08/29/16 at 2:00 AM, revealed at 10:00 PM on 08/28/16, Resident #1 had a accu-check (blood sugar reading) of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit and was sent to the emergency room (ER). Review of pictures taken by the local hospital on [DATE] at 11:40 PM, and interviews with Paramedic #1 on 09/08/16 at 9:26 AM and the ER Director on 09/07/16 at 11:00 AM, revealed Resident #1's indwelling urinary catheter tubing had a crust-like material coated over the catheter and green drainage noted all over the perineal area and on the catheter, and a thick sediment and a purulent drainage in the catheter drainage tubing. Interviews with Certified Nurse Aide (CNA) #9 on 09/03/16 at 3:57 PM, who worked with Resident #1 during the 7:00 AM-3:00 PM shift on 08/27/16, CNA #2 on 09/07/16 at 10:17 AM, who worked with Resident #1 on 08/27/16 during the 11:00 PM-7:00 AM shift, CNA #4 on 09/02/16 at 2:35 PM, who worked with Resident #1 on 08/28/16 on the 7:00 AM-3:00 PM shift, and CNA #1 on 09/02/16 at 3:35 PM, who worked the 3:00 PM-11:00 PM shift on 08/28/16 revealed the CNAs did not recall any drainage from Resident #1's catheter insertion site or in the catheter tubing or drainage bag during incontinent care and/or catheter care. However, the resident was identified as having a crust-like material coated over the catheter, green drainage noted all over the perineal area and on the catheter, and sediment and a purulent drainage in the catheter drainage tubing on 08/28/16 by the Paramedic and hospital ER staff. Review of the Hospital Discharge Summary, dated 09/01/16, revealed Resident #1 was admitted to the hospital from 08/28/16-09/01/16 with [DIAGNOSES REDACTED]. Interview with the Director of Nursing, on 09/08/16 at 8:15 PM, revealed she expected staff to follow the care plans. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview, record review, review of hospital reports, and facility policy review, it was determined the facility's system for ensuring appropriate treatment and services to identify complications of an indwelling urinary catheter was ineffective for one (1) of four (4) sampled residents (Resident #1). Resident #1 was identified as having 100-milliliter (ml) urinary output on the 3:00 PM-11:00 PM shift, and no urinary output on the 11:00 PM-7:00 AM shift on 08/27/16; and no urinary output on the 3:00 PM- 11:00 PM shift on 08/28/16. However, there was no documented evidence licensed staff assessed the resident to determine the reason for the lack of output. On 08/28/16 at 10:00 PM, Licensed Practical Nurse (LPN) #1 found Resident #1 unresponsive with an elevated temperature of 105.4 degrees Fahrenheit (F) and an elevated accu-check with results of HI (above 600 milligrams/deciliter (mg/dl), normal range is 70-100 mg/dl. Resident #1 was sent to the emergency room (ER) and was identified as having green drainage all over the perineal area and catheter, a distended bladder and the catheter was occluded. Resident #1 was diagnosed with [REDACTED]. The facility's failure to provide appropriate treatment and services to identify complications of an indwelling urinary catheter has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Catheter: Indwelling Urinary - Care of, last revised 01/02/14, revealed that any abnormal findings should be reported to the nurse or physician/mid-level provider. Documentation should include any abnormal findings and physician/mid-level provider notification, if indicated. Record review, revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 08/16/16, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated this resident was interviewable. Review of the Comprehensive Care Plan for the indwelling catheter, dated 03/16/16, revealed interventions for nursing to monitor for signs and symptoms of infection and report to physician; and monitor output for odor, color, consistency and amount. Review of the August 2016 Intake and Output document revealed Resident #1 had an indwelling catheter and had 100 milliliter (ml) output on 08/27/16 on the 3:00 PM - 11:00 PM shift; and no output on the 11:00 PM - 7:00 AM shift on 08/27/16 and on the 3:00 PM-11:00 PM shift on 08/28/16. Review of Resident #1's August 2016 Nurses Notes, from 08/27/16 through 08/28/16 revealed there was no documented evidence LPN #1 assessed Resident #1's indwelling urinary catheter related to the decreased output. Review of Nursing Note, dated 08/29/16 at 2:00 AM, revealed at 10:00 PM Resident #1's accu-check read HI with scheduled insulin given, resident felt warm to touch with a temperature of 105.4 degrees F with Tylenol 650 mg given per [DEVICE]. Further review revealed the resident moaned when asked if he/she was hurting. Resident #1's spouse was called about the resident's condition and it was agreed to send the resident to ER (emergency room ). Review of the Hospital History and Physical, dated 08/29/16, revealed Resident #1 presented at the ER in a critically ill state and in a very concerning shape. The Emergency Department notified Social Services. Review of Hospital Discharge Summary, dated 09/01/16, revealed Resident #1 had been discharged from this hospital approximately two (2) weeks ago for treatment of [REDACTED]. Further review of this Discharge Summary, revealed Resident #1 was hospitalized from [DATE]- 09/01/16 with [DIAGNOSES REDACTED]. This Discharge Summary stated Resident #1 was found at the Nursing Facility unresponsive, the indwelling urinary catheter was blocked and had to be changed at the ER and during the catheter change resident had Frank Pus noted. Review of pictures taken at the hospital on [DATE] at 11:40 PM, revealed Resident #1's indwelling urinary catheter tubing had a crust-like material coated over the catheter. Further review of the pictures, revealed purulent (thick drainage) drainage present at the catheter insertion site and thick sediment and a purulent drainage in the catheter drainage tubing. Interview with Certified Nurse Aide (CNA) #2 on 09/07/16 at 10:17 AM, revealed she was the CNA responsible for Resident #1's care on 08/27/16 during the 11:00 PM to 7:00 AM shift. She also stated she recalled Resident #1 had virtually no output from his/her indwelling urinary catheter. CNA #2 stated LPN #1 was aware because she had reported this to LPN #1. She further stated she did not recall any drainage from Resident #1's catheter insertion site or in the catheter tubing or drainage bag when providing catheter care during her shift. Interview with CNA #1, on 09/02/16 at 3:35 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 08/28/16 and provided care for Resident #1. She stated she had informed LPN #1 during the 3:00 PM - 11:00 PM shift on 08/28/16 of Resident #1 not having any urinary output, but she was unsure if LPN #1 assessed the resident. CNA #1 stated she did not recall Resident #1 having any kind of drainage from the urinary catheter insertion site or recall any purulent drainage in Resident #1's catheter tubing or drainage bag when providing incontinent care for the resident or during catheter care during her shift. Interview with Licensed Practical Nurse (LPN) #1, on 09/05/16 at 5:25 PM, revealed she was the Charge Nurse on Resident #1's unit on the 7:00 PM to 7:00 AM shift for 08/27/16 and for 08/28/16. She stated she was unaware of any type of drainage coming from Resident #1's catheter insertion site or of any drainage noted in the catheter drainage tubing or drainage bag. LPN #1 stated the CNAs were responsible for providing catheter care and reporting to the nurse if there were any adverse findings. She stated the CNAs were supposed to let the nurse know if there was decreased output. Interview with LPN #4 on 09/06/16 at 11:41 AM, revealed he was the nurse in charge of Resident #1's unit on 08/28/16 from 7:00 AM - 3:00 PM. He stated he was not informed by any staff member during that time of Resident #1 having any purulent drainage coming from the catheter insertion site nor was he informed of any purulent drainage noted in Resident #1's catheter drainage tubing or drainage bag. He stated the CNAs do the catheter care and let the nurse know when it was completed so the Treatment Administration Record (TAR) could be initialed. He stated the CNAs record the output and should inform the nurse if there was a decline in output. Interview with Paramedic #1, on 09/08/16 at 9:26 AM, revealed she arrived at the facility to transport Resident #1 to theER on [DATE]. She stated upon arrival LPN #1 could not provide any pertinent information about Resident #1 in regards to an overall assessment of the resident's condition other than the resident had a high fever and increased accu-check; and had a fever the night before on Saturday 08/27/16. She also stated, upon assessing Resident #1 it was noted that the resident had cream and powder all over his/her indwelling urinary catheter with green drainage noted all over the perineal area and also on the catheter. She stated Resident #1 had a very distended abdomen and only about 10 milliliters of urine in the catheter drainage bag. Interview with the ER Director, on 09/07/16 at 11:00 AM, revealed Resident #1 presented to theER on [DATE]. He stated Resident #1 had an increased fever and an occluded indwelling urinary catheter with green purulent drainage coming out of the catheter insertion site. He stated the catheter was changed at the ER and when the catheter was removed, frank pus came out as urinary output. He also stated upon Resident #1's arrival to the ER, [MEDICAL CONDITION] screen was performed and it came back positive [MEDICAL CONDITION]. Interview with the Director of Nursing (DON), on 09/21/16 at 2:26 PM, revealed the licensed staff initial on the TARs that catheter care was done. She stated licensed staff were supposed to observe the catheter care being done or provide it themselves if they were unable to observe it. She further stated the licensed nurses were responsible to look at the output results of the residents during their shift to determine if there was a change and a possible need to notify the physician. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview, record review, review of hospital reports, and review of facility policy, it was determined the facility failed to notify the physician for one (1) of four (4) sampled residents (Resident #1) when he/she had a significant change in condition. Licensed staff failed to notify the resident's physician of the resident's significant change in condition to include increased lethargy, decreased urinary output, and increased temperatures for approximately twenty-six (26) hours. On 08/27/16 between 7:00 PM and 8:00 PM, Resident #1 was identified as having an accu-check of approximately four-hundred forty-three (443) milligrams/deciliter (mg/dl)(normal:70-100 mg/dl), a temperature of 101.3 degrees Fahrenheit (F) (normal: 98.6 F), and only 100 milliliters (ml.) of urinary output. In addition, the resident was not verbally communicating and moaned a lot when incontinent care and or turning and repositioning were provided. On 08/27/16 during the 11:00 PM-7:00 AM shift, the resident was identified as having no urinary output and having temperatures of 99.0 -101.0 F, throughout the shift. On 08/28/16 at 6:00 AM, the resident's accu-check was four-hundred eighty-six (486) mg/dl. On 08/28/16, two (2) licensed staff were made aware at 6:00 PM and one at 8:00 PM. However, there was no documented evidence the licensed staff assessed the resident and notified the physician. On 08/28/16 at 10:00 PM, Licensed Practical Nurse (LPN) #1 identified Resident #1's accu-check result was HI (above 600 mg/dl) and the resident was unresponsive with a temperature of 105.4 degrees Fahrenheit. LPN #1 did not notify the physician, but notified Resident #1's responsible party and the responsible party wanted Resident #1 sent to the ER. Resident #1 was diagnosed with [REDACTED]. The facility's failure to notify the physician of significant changes in the resident's condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, alleging the Immediate Jeopardy was removed on 09/14/16. The State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Physician/Mid-level Provider Notification, last revised 03/15/16, revealed upon identification of a resident who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to physician/mid-level provider. Further review of this policy, revealed the purpose of this policy was to communicate a change in the resident's condition to physician/mid-level provider and initiate interventions as needed/ordered. Review of the facility's Diabetic Care Protocol, dated 08/01/15, revealed the facility is to evaluate for and respond to any change in condition. Further review of this protocol, revealed the facility is to notify the physician/mid-level provider immediately of any blood glucose level greater than 400 mg/dl (which is considered Urgent) for any resident that does not have ordered parameters. The protocol also states to notify the physician/mid-level provider as soon as possible during normal business hours if blood glucose is greater than 350 mg/dl or greater than 300 mg/dl on two (2) consecutive readings. Record review revealed the facility admitted Resident #1 on 03/16/16 with [DIAGNOSES REDACTED]. Review of Resident #1's August 2016 Medication Administration Record (MAR), and interview with LPN #1, on 09/05/16 at 5:25 PM, revealed the resident's accu-check was four-hundred forty-three (443) mg/dl on 08/27/16 at 8:00 PM. In addition, LPN #1 administered Tylenol per [DEVICE] (gastrostomy feeding tube), as the resident's temperature was elevated on 08/27/16 at 10:20 PM and Tylenol was administered again on 08/28/16 at 2:30 AM; however there was no documentation to indicate why. Further review of the August 2016 MAR revealed on 08/28/16 at 6:00 AM, Resident #1's accu-check was four-hundred eighty-six (486) mg/dl. Review of Resident #1's Output Records for August 2016, revealed Resident #1 had 100 milliliters (ml) of urinary output during the 3:00 PM-11:00 PM shift and no urinary output from his/her indwelling urinary catheter on 08/27/16 during the 11:00 PM-7:00 AM shift; and, no urinary output on 08/28/16 on the 3:00 PM-11:00 PM shift. Review of Resident #1's Nursing Note, dated 08/29/16 at 2:00 AM, revealed at 10:00 PM on 08/28/16, Resident #1 had a accu-check (blood sugar reading) of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit and was sent to the emergency room (ER). Review of the Hospital Discharge Summary, dated 09/01/16, revealed Resident #1 was hospitalized from [DATE]-09/01/16 with [DIAGNOSES REDACTED]. Interview with Certified Nurse Aide (CNA) #3 on 09/06/16 at 10:36 AM, revealed she worked on 08/27/16 on the 3:00 PM to 11:00 PM shift and was the CNA who was responsible for Resident #1's section. She stated at approximately 7:00 PM, Resident #1's temperature was 101.3 degrees Fahrenheit (F) and the resident was not acting like his/her normal self as this resident was not verbally communicating and moaned a lot when incontinent care and or turning and repositioning was provided. She stated she informed LPN #1 of the resident's change in condition. Interview with CNA #2 on 09/07/16 at 10:17 AM, revealed she was the CNA responsible for Resident #1's unit on 08/27/16 during the 11:00 PM to 7:00 AM shift. She stated she recalled Resident #1 ran an increased temperature of ninety-nine (99) degrees Fahrenheit to one-hundred one (101) degrees Fahrenheit throughout her shift. She stated she recalled Resident #1 had no output from his/her indwelling urinary catheter. CNA #2 stated LPN #1 was aware of this because she had reported this to her. Interview with CNA #1 on 09/02/16 at 3:35 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 08/28/16 and provided care for Resident #1. She stated at approximately 5:30 PM to 6:00 PM, Resident #1 would not arouse, she could not get him/her to wake up. She stated a nurse from another unit, Registered Nurse (RN) #1 was in the room feeding Resident #1's roommate supper. She let the RN know and was told by the RN to just monitor Resident #1. CNA #1 stated she knew this was not Resident #1's normal behavior so she reported this to LPN #1 also, who was the Charge Nurse for the unit. She stated LPN #1 also told her to just monitor Resident #1. CNA #1 stated LPN #1 never did check on the resident. CNA #1 also stated at approximately 8:00 PM while doing an incontinent check on Resident #1, the resident was still unable to be aroused or woken up. She reported this to LPN #1, who again said to just monitor Resident #1. The CNA also stated she did not recall Resident #1 having drainage from the urinary catheter insertion site or recall any purulent drainage in Resident #1's catheter tubing or drainage bag. Interview with RN #1 on 09/06/16 at 10:25 AM, revealed she was in Resident #1's room on 08/28/16 at some time between approximately 6:00 PM and 6:30 PM assisting Resident #1's roommate with supper. She stated she recalled CNA #1 coming into the room. RN #1 stated the CNA could not arouse Resident #1 so she told CNA #1 to just monitor Resident #1 and let the resident rest, as he/she was probably just sleepy. She stated shortly after she finished feeding Resident #1's roommate she informed LPN #1 of staff not being able to wake Resident #1 up at suppertime. Review of the Nursing Notes from 08/27/16-08/28/16, revealed there was no documented evidence the physician was notified at any time of Resident #1's change in condition to include increased temperatures, lethargy, decreased urinary output, and accu-checks greater than 400. Interview with LPN #1 on 09/05/16 at 5:25 PM, revealed she was the Charge Nurse on Resident #1's unit on the 7:00 PM to 7:00 AM shift on 08/27/16 and on 08/28/16. She stated she obtained accu-checks of four-hundred forty-three (443) mg/dl on 08/27/16 at 8:00 PM and obtained accu-check results of four-hundred eighty-six (486) mg/dl accu-check results on 08/28/16 at 6:00 AM for Resident #1. She further stated in hindsight maybe she ought to have called the resident's physician when she noted these elevated accu-check results, but she felt the resident's blood sugars would come down because she had stopped Resident #1's gastrostomy tube feeding at intervals. LPN #1 stated she did not have an order to stop the tube feeding. She also stated she did not perform Resident #1's scheduled 8:00 PM accu-check on 08/28/16 until 10:00 PM, two (2) hours after it was scheduled and the results of that late accu-check read HI. The LPN stated that at the time of obtaining Resident #1's scheduled 8:00 PM accu-check at 10:00 PM on 08/28/16, she also noticed the resident felt warm. LPN #1 stated she took Resident #1's temperature, which was 105.4 degrees Fahrenheit at that time. She stated she did not call the physician at this time; she notified the resident's spouse who wanted the resident sent to the emergency room . Further interview with LPN #1 revealed she did not call the physician for an order to administer Tylenol to the resident on 08/27/16 and on 08/28/16, she stated she just wrote the order. Interview with the Director of Nursing (DON) on 09/08/16 at 8:15 AM, revealed she expected LPN #1 to have notified the physician of Resident #1's condition changes and increased blood sugars. She also stated it was not acceptable for a licensed staff to write a physician's orders [REDACTED]. Interview with the Administrator, on 09/08/16 at 8:30 AM, revealed she expected staff to provide the necessary care and services needed to take care of Resident #1. She stated she expected all staff to follow facility policy and procedures. Interview with Resident #1's Physician, on 09/01/16 at 3:45 PM, revealed he was also the facility's medical director. He stated he expected his physician's orders [REDACTED]. He stated he expected the staff to have charted the reason he would be called and the rationale of the need for physician notification along with the condition of the resident. He stated he would have expected to have been called in regards to Resident #1's condition changes related to elevated temperatures, decreased urinary output, decreased alertness and elevated accu-checks. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview, record review, review of hospital reports and review of the facility's policy and procedure, it was determined the facility failed to have an effective system in place to ensure the residents' comprehensive care plans were reviewed and revised with changes in condition for one (1) of four (4) sampled residents (Resident #1) when the resident's status changed. On 08/01/16, Resident #1 was sent to the emergency room (ER) related to an increased fever, and altered mental status and was admitted with [DIAGNOSES REDACTED]. Resident #1 returned to the facility on [DATE]. However, the facility failed to review and revise the Comprehensive Care Plan related to the resident's recent hospital stay and condition changes. On 08/28/16 at 10:00 PM, Resident #1 was sent to the ER related to being unresponsive, having a fever and elevated accu-check. Resident #1 was ultimately admitted to the hospital, on 08/28/16 with [DIAGNOSES REDACTED]. The facility's failure to provide review and revise the care plan has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, Care Plans, revised 01/02/14, revealed the interdisciplinary team will develop a comprehensive, individualized care plan for each resident. The care plan will include measurable objectives to meet resident needs and goals as identified by the assessment process. Further review of this policy, revealed the purpose of this policy is to provide necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Under Practice Standards under section two (2) it states the comprehensive care plan is reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. Record review revealed the facility admitted Resident #1 on 03/16/16 with diagnoses, which included [MEDICAL CONDITION]/[MEDICAL CONDITIONS], Type 2 Diabetes, and Flaccid Neuropathic Bladder. Review of a Hospital Admission History and Physical, dated 08/01/16, and Discharge Summary, dated 08/09/16, revealed Resident #1 presented to the emergency room from the facility with altered mental status, nausea/vomiting and a temperature of 105.3 degrees Fahrenheit. The resident was unable to interact and just moaned. The resident's indwelling urinary catheter was full of Frank Pus and it was unclear how long that catheter had been in place. Resident #1 was diagnosed with [REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/16/16, revealed the facility assessed the resident's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. However, review of Resident #1's current Comprehensive Care Plans, dated 03/16/16 and 03/17/16, revealed there were no revisions to the care plans to address Resident #1's hospital stay of 08/01/16 through 08/09/16 in which the resident was diagnosed as having [MEDICAL CONDITION] related to a Urinary Tract Infection and an Acute Kidney Injury. Further review revealed the care plan was not revised to include the type of signs and symptoms that may present with a UTI [MEDICAL CONDITION]. Interview (Post Survey) with Licensed Practical Nurse (LPN) #6, on 09/28/16 at 3:49 PM, revealed she readmitted Resident #1 to the facility upon Resident #1's return from a hospital stay. She stated it was a strong possibility she did not get a chance to review and revise Resident #1's care plans when the resident was readmitted to the facility from the local hospital on [DATE]. She stated it was probably a shift where it was extra busy and there was not enough time to review and revise the care plans. LPN #6 stated she was familiar with the facility's care plan policy that states care plans should be reviewed and revised to reflect changing needs and goals of the residents. Review of the August 2016 Medication Administration Records, Output Records and interviews with Certified Nurse Aide (CNA) #3, on 09/06/16 at 10:36 AM, who worked 3PM-11 PM on 08/27/16; CNA #2, on 09/07/16 at 10:17 AM, who worked 11P -7 AM on 08/27/16; CNA #1, on 09/02/16 at 3:35 PM, who worked 3 PM-1 PM shift on 08/28/16; Licensed Practical Nurse (LPN) #1, on 09/05/16 at 5:25 PM and on 09/07/16 at 1:14 PM, who worked 7P-7A shift on 08/27/16 and 08/28/16, and Registered Nurse (RN) #1, on 09/06/16 at 10:36 AM, who worked 7P-7A on 08/28/16 revealed on 08/27/16 during the 3:00 PM-11:00 PM shift, Resident #1 was identified as having temperatures ranging between 99 degrees F to 101 degrees Fahrenheit (normal 98.6 F.). The resident had 100 milliliters (ml) of urinary output during the 3:00 PM-11:00 PM shift and no urinary output during the 11:00 PM-7:00 AM shift on 08/27/16 and 3:00 PM-11:00 PM shift on 08/28/16. In addition, the resident was identified as non-responsive at approximately 6:30 PM and 8:00 PM. On 08/28/16 at 10:00 PM, Resident #1 was unresponsive, had an accu-check of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit and was sent to the emergency room (ER). Resident #1 was admitted to the hospital, on 08/29/16 and discharged on [DATE], with [DIAGNOSES REDACTED]. Interview with Minimum Data Set (MDS) Coordinator #1 on 09/01/16 at 12:23 PM, revealed all nurses were responsible to update the residents' care plans with any condition changes or pertinent information that arises. She stated the MDS Coordinators review and revise the care plans during the time MDS assessments were being done. She stated she expected all licensed nurses to update resident care plans with any pertinent data or resident condition changes. Interview with MDS Coordinator #2 on 09/20/16 at 4:00 PM, revealed all nurses were responsible for reviewing and revising the care plans. She stated the nurse on duty when a resident was readmitted would be responsible for reviewing and revising the resident's care plan. Interview with the Director of Nursing (DON), on 09/08/16 at 8:15 AM, revealed she expected care plans to be updated on an ongoing basis with any clinical condition changes or with any new high-risk conditions that arise for residents. She stated Resident #1's care plans should have been updated with his/her condition changes and identified problems that arose from his/her acute medical conditions that led to a hospitalization . The DON stated all nurses were able to update care plans and were responsible for updating care plans with new orders, treatments, and changes that were pertinent to the resident. Interview with the Administrator, on 09/08/16 at 08:30 AM, revealed she expected the facility to follow the care plan policy and procedure. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview, record review, facility policy review and the Kentucky Board of Nursing (KBN) Advisory Opinion Statements (AOS) #19 and #27, it was determined the facility failed to ensure the services provided by the facility met professional standards of quality for one (1) of four (4) sampled residents (Resident #1). On 08/27/16 at 8:00 PM, Resident #1 was identified as having an accu-check (blood sugar level) of approximately four-hundred forty-three (443) milligrams/deciliter {mg/dl} (normal: 70-100 mg/dl). The resident's temperature ranged between 99 degrees Fahrenheit (F) to 101 degrees Fahrenheit (normal 98.6 F). The resident had 100 milliliters (ml) of urinary output during the 3:00 PM-11:00 PM shift and no urinary output during the 11:00 PM-7:00 AM shift on 08/27/16. On 08/28/16 at 6:00 AM, the resident's accu-check was four-hundred eighty-six (486) mg/dl; and, the resident had no urinary output during the 3:00 PM -11:00 PM shift. On 08/28/16, during the 3:00 PM-11:00 PM shift, the resident was identified as being non-responsive and two (2) licensed staff were made aware. However, there was no documented evidence the facility assessed the resident, nor had the physician been notified related to the resident's high blood sugar, no urinary output, and increased temperatures per facility policy and care plan. The resident continued to decline and on 08/28/16 at 10:00 PM, Resident #1 was found unresponsive, had an accu-check of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit. The accu-check was supposed to be completed at 8:00 PM on 08/28/16, but was not completed until 10:00 PM. Resident #1 was sent to the emergency room (ER) and admitted to the hospital, on 08/29/16, with [DIAGNOSES REDACTED]. The facility's failure to provide services in accordance with acceptable standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Job Description for Registered Nurses (RN), last revised 02/11/16, revealed the Registered Nurse delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction and performs nursing functions and provides care within their scope of practice. Review of the Job Description for Licensed Practical Nurses (LPN), revised 10/22/12, revealed under the direction of an RN, the LPN delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction; he/she operates within the scope of practice defined by the State Nurse Practice Act; contributes to nursing assessments, care planning, provides direct resident care, and supervises resident care provided by unlicensed staff. Further review of this job description, revealed the LPN is to collect, report and document objective/subjective data; document accurately and thoroughly; observe conditions and report changes and communicate pertinent data to the RN and/or physician. Review of the KBN AOS #19, Responsibility and Accountability of Nurses for Patient Care Assignments and Nursing Care Delivery approved October 1988, revised April 2015, revealed nurses are responsible and accountable for making decisions that are based upon the individuals' educational preparations and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Review of the KBN AOS #27 Components of Licensed Practical Nursing (LPN) Practice, last revised 06/2014, revealed components of the LPN practice included assessment and interpretation of data. Assessment includes observations of appearance and behavior; measurements of physical structure and physiologic function; and observations of a resident's subjective and objective signs and symptoms. Interpreting data includes recognizing existing relationships between data gathered and a resident's health status, established plan of care and medical treatment regimen; determining the resident's need for nursing intervention based upon data gathered regarding the resident's health status, ability to care for self, and established plan of care; and appropriate consultation. Record review revealed the facility admitted Resident #1 on 03/16/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/16/16, revealed the facility assessed the resident's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Interview with Certified Nurse Aide (CNA) #3, on 09/06/16 at 10:36 AM, revealed she worked on 08/27/16 on the 3:00 PM to 11:00 PM shift and was the CNA responsible for Resident #1's section. She stated at one (1) point Resident #1's temperature was 101.3 degrees F and the resident was not acting like his/her normal self as the resident was not verbally communicating. He/she moaned a lot when they provided incontinent care and/or turned and repositioned him/her. She stated she informed Licensed Practical Nurse (LPN) #1 of these changes in the resident's condition. Interview with CNA #2, on 09/07/16 at 10:17 AM, revealed she was the CNA responsible for Resident #1's unit on 08/27/16 during the 11:00 PM to 7:00 AM shift. She stated she recalled Resident #1 ran an increased temperature of ninety-nine (99) degrees F to one-hundred one (101) degrees F throughout her shift. CNA #2 stated LPN #1 was providing Resident #1's extra Gastrostomy Tube flushes throughout the shift due to Resident #1 having increased temperatures. She also stated she recalled Resident #1 had virtually no output from his/her indwelling urinary catheter and LPN #1 was aware of this because she had reported this to LPN #1. CNA #2 stated she did not recall any drainage from Resident #1's catheter insertion site or in the catheter tubing or drainage bag. Interview with CNA #1, on 09/02/16 at 3:35 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 08/28/16 and had Resident #1's section and cared for Resident #1. She stated at approximately 5:30 PM to 6:00 PM, Resident #1 could not be aroused or awakened. CNA #1 stated a nurse from another unit, Registered Nurse (RN) #1 was in the room feeding supper to Resident #1's roommate. She notified RN #1 regarding the resident's condition and was told by RN #1 to monitor Resident #1. CNA #1 stated she knew this was not Resident #1's normal behavior so she reported to LPN #1 also, who was the Charge Nurse for the unit. She stated LPN #1 also told her to monitor Resident #1. CNA #1 stated LPN #1 never did check on the resident at the time. Further interview with the CNA revealed at approximately 8:00 PM, while doing an incontinent check on Resident #1, the resident was still unable to be aroused or awakened. CNA #1 stated she again reported this to LPN #1, who again said to monitor the resident. She stated LPN #1 did not assess the resident at the time. CNA #1 stated she had informed LPN #1 during the 3:00 PM-11:00 PM shift on 08/28/16 of Resident #1 not having any urinary output, but she was unsure if LPN #1 assessed the resident. Interview with Registered Nurse (RN) #1, on 09/06/16 at 10:25 AM, revealed she was in Resident #1's room on 08/28/16 at approximately 6:00 PM to 6:30 PM assisting Resident #1's roommate with supper. RN #1 stated she recalled CNA #1 coming in to the room and not being able to arouse Resident #1. RN #1 stated she told CNA #1 to just monitor the resident and let the resident rest as he/she was probably just sleepy. She stated she did not assess the resident, but when she finished feeding Resident #1's roommate, she informed LPN #1 of staff not being able to arouse Resident #1 at supper time. Interview with LPN #1, on 09/05/16 at 5:25 PM, revealed she was the Charge Nurse on Resident #1's unit on the 7:00 PM to 7:00 AM shift on 08/27/16 and 08/28/16. She stated she obtained accu-check results for Resident #1 of four-hundred forty-three (443) mg/dl on 08/27/16 at 8:00 PM, and she obtained accu-check results of four-hundred eighty-six (486) mg/dl on 08/28/16 at 6:00 AM for Resident #1. She stated she did not assess the resident further after the elevated accu-checks, nor did she notify the physician. LPN #1 stated, in hindsight, maybe she should have called the resident's physician when she noted these elevated accu-check results, but she felt the resident's blood sugars would come down because she had stopped Resident #1's Gastrostomy Tube feeding at intervals thinking that would bring the resident's blood sugar down. However, further interview revealed she did not have a physician's orders [REDACTED]. LPN #1 further stated she did not perform Resident #1's scheduled 8:00 PM accu-check on 08/28/16 until 10:00 PM, two (2) hours after it was scheduled. She stated the results of the late accu-check read HI. LPN #1 stated at the time of obtaining Resident #1's scheduled 8:00 PM accu-check at 10:00 PM on 08/28/16, that she also noticed the resident felt warm. At this time, she took the resident's temperature, which was 105.4 degrees F. LPN #1 stated Resident #1 had been running a fever since 08/27/16. She stated she did not call the physician at this time. LPN #1 stated because of the elevated temperature and accu-check, she sent the resident to the ER after notifying Resident #1's spouse. LPN #1 stated she did not contact the physician, but wrote a physician's orders [REDACTED].#1 on 08/27/16 at 10:20 PM and on 08/28/16 at 2:30 AM due to Resident #1's continued fever. She stated she wrote the order because she believed the physician would not want to be bothered over a simple Tylenol order, so therefore, she wrote the order herself. She also stated she did not assess Resident #1's indwelling urinary catheter prior to sending Resident #1 out to the ER. LPN #1 stated after Resident #1 was sent to the ER, CNA #1 informed her of Resident #1 having no urinary output for the 3:00 PM - 11:00 PM shift on 08/28/16. She stated the facility had multiple policies and she could not remember the specifics of all the policies off hand. Interview with Paramedic #1, on 09/08/16 at 9:26 AM, revealed she was the paramedic that was called and transported Resident #1 to theER on [DATE]. She stated upon arrival LPN #1 could not provide any pertinent information about Resident #1 in regard to an overall assessment of the resident's condition other than Resident #1 had a high fever and increased accu-check. She further stated LPN #1 mentioned Resident #1 had a fever the night before on Saturday 08/27/16. She also stated, upon assessing Resident #1, it was noted that Resident #1 had cream and powder all over his/her indwelling urinary catheter with green drainage noted all over the perineal area and on the catheter also. She stated Resident #1 had a much distended abdomen and only about ten (10) milliliters (ml) of urine in the catheter drainage bag. Paramedic #1 stated Resident #1 had green sputum coming out of his/her nose and mouth. She revealed LPN #1 stated, She was sorry the resident was in such bad shape but it had been busy. Interview with the ER Director, on 09/07/16 at 11:00 AM, revealed Resident #1 presented to theER on [DATE] with a chief complaint of unresponsiveness. He stated the resident responded to painful stimuli only. The ER Director stated Resident #1 arrived to the ER with purulent thick green sputum in his/her nose, mouth, and purulent drainage coming from the resident's urinary catheter insertion site. He stated Resident #1 had an increased fever and an accu-check of six-hundred forty-eight (648) mg/dl along with an occluded indwelling urinary catheter. The ER Director stated he felt Resident #1 did not become this ill in a short period and that Resident #1's condition changes should have been observed by the facility as the resident's condition deteriorated. Interview with the Director of Nursing (DON), on 09/08/16 at 8:15 AM, revealed she expected LPN #1 to have further assessed Resident #1 with the noted changes in condition, provided the necessary care and services, notify the physician of the condition changes and follow the care plans for Resident #1. The DON also stated it was not acceptable for a licensed staff to write a physician's orders [REDACTED]. The DON stated the facility had terminated LPN#1's employment at the facility due to LPN #1's negligence in performance of her job duties. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on observation, interview, record review, review of hospital reports, and review of the facility's policy and procedure, it was determined the facility failed to ensure the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one (1) of four (4) sampled residents (Resident #1). On 08/27/16 at 8:00 PM, Resident #1 was identified as having an accu-check (blood sugar level) of approximately four-hundred forty-three (443) milligrams/deciliter {mg/dl} (normal: 70-100 mg/dl). The resident's temperature ranged between 99 degrees F to 101 degrees Fahrenheit (normal 98.6 F). The resident had 100 milliliters (ml) of urinary output during the 3:00 PM-11:00 PM shift and no urinary output during the 11:00 PM-7:00 AM shift on 08/27/16. On 08/28/16 at 6:00 AM, the resident's accu-check was four-hundred eighty-six (486) mg/dl; and, the resident had no urinary output during the 3:00 PM -11:00 PM shift. On 08/28/16, during the 3:00 PM-11:00 PM shift, the resident was identified as being non-responsive and two (2) licensed staff were made aware. However, there was no documented evidence the facility assessed the resident and the physician was notified related to the resident's high blood sugar, no urinary output, and increased temperatures per facility policy and care plan. On 08/28/16 at 10:00 PM, Resident #1 was found unresponsive, had an accu-check of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit. The accu-check was supposed to have been completed at 8:00 PM on 08/28/16, but was not completed until 10:00 PM. Resident #1 was sent to the emergency room (ER) and admitted to the hospital, on 08/29/16, with [DIAGNOSES REDACTED]. The facility's failure to ensure necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care when a resident had a change in condition and function has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, alleging the removal of Immediate Jeopardy on 09/14/16 and the State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QUA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's Diabetic Care Protocol, dated 08/01/15, revealed the facility is to evaluate for and respond to any change in condition. Further review of this protocol, revealed the facility is to notify the physician/mid-level provider immediately of any blood glucose level greater than 400 mg/dl (which is considered Urgent) for any resident that does not have ordered parameters. The protocol also states to notify the physician/mid-level provider as soon as possible during normal business hours if the blood glucose is greater than 350 mg/dl or greater than 300 mg/dl on two (2) consecutive readings. Review of the facility's policy Physician/Mid-level Provider Notification, last revised 03/15/16, revealed upon identification of a resident who has a change in condition or abnormal lab values, a licensed nurse will perform appropriate clinical observations and data collection and report to the physician/mid-level provider. Further review of this policy, revealed the purpose of this policy was to communicate a change in resident's condition to physician/mid-level provider and initiate interventions as needed/ordered. Record review revealed the facility admitted Resident #1 on 03/16/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 08/16/16, revealed the facility assessed the resident's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of Resident #1's Physician Orders, dated 08/09/16, revealed to administer Freesia Flex Touch Solution Pen-Injector (insulin) twenty-five (25) units subcutaneously at bedtime. In addition, there was an order to complete a finger stick blood glucose two (2) times a day. Further review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan for [DIAGNOSES REDACTED]. Review of Resident #1's August 2016 Medication Administration Record (MAR) revealed the resident's accu-checks mostly ran in the two-hundred (200) milligrams per deciliter (mg/dl) range with a few sporadic results which were in the three-hundred (300) range. However, on 08/27/16 at 8:00 PM, Resident #1 accu-check was four-hundred forty-three (443) mg/dl and there was no documented evidence LPN #1 assessed the resident and/or notified the physician of the accu-check above 400 mg/dl per facility policy. In addition, LPN #1 initialed the MAR indicating she administered Tylenol 650 mg via [DEVICE] (gastrostomy feeding tube) to Resident #1 on 08/27/16 at 10:20 PM related to a temperature. LPN #1 also initialed the MAR that she administered Tylenol 650 mg via [DEVICE] on 08/28/16 at 2:30 AM. However, there was no documentation as to what the resident's temperature was at the time. Interview with Certified Nurse Aide (CNA) #3 on 09/06/16 at 10:36 AM, revealed she worked on 08/27/16 on the 3:00 PM to 11:00 PM shift and was the CNA who was responsible for Resident #1's section. She stated at one point Resident #1's temperature was 101.3 degrees F and the resident was not acting like his/her normal self as this resident was not verbally communicating and moaned a lot when they provided incontinent care and or turned and repositioned him/her. She stated she informed LPN #1 of these changes in the resident's condition. Further review of the August 2016 MAR revealed on 08/28/16 at 2:30 AM, LPN #1 administered Tylenol again; however, there was no documentation of why it was administered and no documented evidence Resident #1 was assessed after the administration of the Tylenol at 2:30 AM to determine if the medication was effective. Further review of the August 2016 MAR revealed on 08/28/16 at 6:00 AM, Resident #1's accu-check was four-hundred eighty-six (486) mg/dl and review of the resident's Output Records for August 2016, revealed Resident #1 had no output (marked zero) from his/her indwelling urinary catheter on 08/27/16 during the 11:00 PM-7:00 AM shift. However, there was no documented evidence LPN #1 assessed the resident and notified the physician of the resident's change in condition and elevated accu-check, per facility policy. Interview with CNA #2, on 09/07/16 at 10:17 AM, revealed she was the CNA responsible for Resident #1's unit on 08/27/16 during the 11:00 PM to 7:00 AM shift. She stated she recalled Resident #1 ran an increased temperature of ninety-nine (99) degrees F to one-hundred one (101) degrees F throughout her shift. CNA #2 stated LPN #1 was providing Resident #1 extra Gastrostomy Tube flushes throughout the shift due to Resident #1 having increased temperatures. She also stated she recalled Resident #1 had virtually no output from his/her indwelling urinary catheter and LPN #1 was aware of this because she had reported this to LPN #1. CNA #2 stated she did not recall any drainage from Resident #1's catheter insertion site or in the catheter tubing or drainage bag. Further review of the Output Records revealed on 08/28/16, Resident #1 had no output from his/her urinary catheter on the 3:00 PM-11:00 PM shift. Review of Resident #1's clinical record, revealed there was no documented evidence licensed staff had conducted an assessment related to the resident's decreased urinary output. Interview with CNA #1, on 09/02/16 at 3:35 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 08/28/16 and had Resident #1's section and cared for Resident #1. She stated at approximately 5:30 PM to 6:00 PM, Resident #1 could not be aroused or awaken. CNA #1 stated a nurse from another unit, Registered Nurse (RN) #1 was in the room feeding Resident #1's roommate supper. She notified RN #1 of the resident's condition and was told by RN #1 to monitor Resident #1. CNA #1 stated she knew this was not Resident #1's normal behavior so she reported this to LPN #1 also, who was the Charge Nurse for the unit. She stated LPN #1 also told her to monitor Resident #1. CNA #1 stated LPN #1 never did check on the resident at the time. Further interview with the CNA revealed at approximately 8:00 PM while doing an incontinent check on Resident #1, the resident was still unable to be aroused or awaken. CNA #1 stated she again reported this to LPN #1, who again said to monitor the resident. She stated LPN #1 did not assess the resident at the time. CNA #1 stated she had informed LPN #1 during the 3:00 PM-11:00 PM shift on 08/28/16 of Resident #1 not having any urinary output, but she was unsure if LPN #1 assessed the resident. Interview with Registered Nurse (RN) #1, on 09/06/16 at 10:25 AM, revealed she was in Resident #1's room on 08/28/16 at approximately 6:00 PM to 6:30 PM assisting Resident #1's roommate with supper. RN #1 stated she recalled CNA #1 coming in to the room and not being able to arouse Resident #1. RN #1 stated she told CNA #1 to just monitor the resident and let the resident rest as he/she was probably just sleepy. She stated she did not assess the resident, but when she finished feeding Resident #1's roommate, she informed LPN #1 of staff not being able to arouse Resident #1 at supper time Review of Resident #1's Nursing Note, dated 08/29/16 at 2:00 AM, revealed at 10:00 PM on 08/28/16, Resident #1 had a accu-check (blood sugar reading) of HI (above 600 mg/ml) and a temperature of 105.4 degrees Fahrenheit and was sent to the emergency room (ER). Review of Hospital History and Physical, dated 08/29/16, revealed, This patient is critically ill. (He/she) came in sick last time, but is actually much sicker now. (He/she) is at a very high risk for deterioration. He/she did come in a very concerning shape and therefore social services to be notified. Further review of the History and Physical, revealed this resident had a history of [REDACTED]. It was also noted the resident's diabetes was uncontrolled. Review of Hospital Discharge Summary, dated 09/01/16, revealed Resident #1 was was hospitalized for [REDACTED]. Further review of this Discharge Summary, revealed Resident #1 was found at the Nursing Facility unresponsive, the indwelling urinary catheter was blocked and had to be changed at the ER and during the catheter change, the resident had Frank Pus noted. The Summary also noted the resident had poor oral hygiene. Resident #1 had to be suctioned to remove the material from his/her mouth. Interview with Licensed Practical Nurse (LPN) #1, on 09/05/16 at 5:25 PM, revealed she was the Charge Nurse on Resident #1's unit on the 7:00 PM to 7:00 AM shift on 08/27/16 and 08/28/16. She stated she obtained accu-checks for Resident #1 of four-hundred forty-three (443) mg/dl on 08/27/16 at 8:00 PM and she obtained accu-check results of four-hundred eighty-six (486) mg/dl accu-check results on 08/28/16 at 6:00 AM for Resident #1. She stated she did not assess the resident further after the elevated accu-checks, nor did she notify the physician. LPN #1 stated that in hindsight maybe she should have called the resident's physician when she noted these elevated accu-check results, but she felt the resident's blood sugars would come down because she had stopped Resident #1's Gastrostomy Tube feeding at intervals thinking that would bring the resident's blood sugar down. However, further interview revealed she did not have a physician's orders [REDACTED]. LPN #1 further stated she did not perform Resident #1's scheduled 8:00 PM accu-check on 08/28/16 until 10:00 PM, two (2) hours after it was scheduled. She stated the results of that late accu-check read HI. LPN #1 stated at the time of obtaining Resident #1's scheduled 8:00 PM accu-check at 10:00 PM on 08/28/16, that she also noticed the resident felt warm. At this time, she took the resident's temperature, which was 105.4 degrees F. LPN #1 stated Resident #1 had been running a fever since 08/27/16. She stated she did not call the physician at this time. LPN #1 stated because of the elevated temperature and accu-check, she sent the resident to the ER after notifying Resident #1's spouse. She also stated she did not assess Resident #1's indwelling urinary catheter prior to sending Resident #1 out to the ER. LPN #1 stated after Resident #1 was sent to the ER, CNA #1 informed her of Resident #1 having no urinary output for the 3:00 PM - 11:00 PM shift on 08/28/16. She stated the facility had multiple policies and she could not remember the specifics of all the policies off hand. Interview with Paramedic #1, on 09/08/16 at 9:26 AM, revealed she was the paramedic that was called and transported Resident #1 to theER on [DATE]. She stated upon arrival LPN #1 could not provide any pertinent information about Resident #1 in regards to an overall assessment of the resident's condition other than Resident #1 had a high fever and increased accu-check. She further stated LPN #1 mentioned Resident #1 had a fever the night before on Saturday 08/27/16. She also stated, upon assessing Resident #1 it was noted that Resident #1 had cream and powder all over his/her indwelling urinary catheter with green drainage noted all over the perineal area and on the catheter also. She stated Resident #1 had a much distended abdomen and only about 10 milliliters of urine in the catheter drainage bag. Paramedic #1 stated Resident #1 had green sputum coming out of his/her nose and mouth. She stated LPN #1 stated, She was sorry the resident was in such bad shape but it had been busy. Interview with the ER Director on 09/07/16 at 11:00 AM, revealed Resident #1 presented to theER on [DATE] with a chief complaint of unresponsiveness. He stated this resident responded to painful stimuli only. The ER Director stated Resident #1 arrived to the ER with purulent thick green sputum in his/her nose, mouth, and purulent drainage coming from the resident's urinary catheter insertion site. He stated Resident #1 had an increased fever and an accu-check of six-hundred forty-eight (648) mg/dl along with an occluded indwelling urinary catheter. The ED Director stated he felt Resident #1 did not become this ill in a short period and that Resident #1's condition changes should have been observed by the facility as this resident's condition deteriorated. Interview with Resident #1's Physician on 09/01/16 at 3:45 PM revealed he was also the facility's Medical Director. He stated he would have expected licensed staff to have assessed Resident #1 thoroughly upon noting the condition changes the resident was experiencing and to have notified him of these changes. Interview with the Director of Nursing (DON) on 09/08/16 at 8:15 AM, revealed she expected LPN #1 to have further assessed Resident #1 with the noted changes in condition, provided the necessary care and services, notify the physician of the condition changes and follow the care plans for Resident #1. Interview with the facility's Administrator on 09/08/16 at 08:30 AM, revealed she would have expected staff to have provided the necessary care and services needed to take care of Resident #1. She stated she expected all staff to follow facility policy and procedures. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identif

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the clinical record for one (1) of four (4) sampled residents (Resident #1) was maintained in accordance with accepted professional standards and practices that were complete and accurately documented. On 08/27/16 at approximately 7:00 PM through 08/28/16 at 8:00 PM, staff indicated Resident #1 was having a decline in alertness, an increased temperature, and decreased urinary output. However, the licensed staff failed to document any of the above changes in the resident's condition and/or any assessments that were completed during this twenty-six (26) hour period. On 08/28/16 at 10:00 PM, Licensed Practical Nurse (LPN) #1 identified Resident #1 was unresponsive with an elevated temperature of 105.4 degrees Fahrenheit and accu-check reading of HI. LPN #1 stated she called Resident #1's spouse and per family request made a decision to send Resident #1 to the emergency room (ER). Resident #1 was admitted to the hospital, on 08/29/16, with [DIAGNOSES REDACTED]. The facility's failure to ensure the clinical record was maintained in accordance with accepted professional standards and practices that were complete and accurately documented has caused or is likely to cause serious injury, harm, or impairment or death to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility's policy Charting and Documentation revised 01/01/13, revealed the purpose of this policy is to provide a complete account of the resident's total stay from admission through discharge, provide information about the resident that will be used in developing a plan of care, and as a tool for measuring the quality of care provided to the patient. Further review of this policy, revealed the facility is to chart pertinent changes in the resident's condition, reaction to treatment, medication, as well as routine observations. It also states to be concise, accurate, complete, factual, and objective. Record review revealed the facility admitted Resident #1 on 03/16/16 with [DIAGNOSES REDACTED]. Review of Resident #1's Medication Administration Records (MARS) for August 2016, revealed LPN #1 administered Tylenol 650 MG via Resident #1's Gastrostomy Tube ([DEVICE]) on 08/27/16 at 10:20 PM related to a temperature; however, she failed to document the resident's actual temperature reading. Further review of the MARS, revealed LPN #1 administered Tylenol 650 MG via Resident #1's [DEVICE] again on 08/28/16 at 2:30 AM, but she did not document the resident's temperature or reason for giving the Tylenol, nor did she chart the results from the Tylenol that was given at that time. Interview with Certified Nurse Aide (CNA) #3 on 09/06/16 at 10:36 AM, revealed she worked on 08/27/16 on the 3:00 PM to 11:00 PM shift. She stated at approximately 7:00 PM, Resident #1's temperature was 101.3 degrees Fahrenheit (F) and the resident was not acting like his/her normal self as this resident was not verbally communicating and moaned a lot when incontinent care and or turning and repositioning was provided. She stated she informed LPN #1 of these resident changes in condition. However, review of the clinical record revealed no documented evidence in the Nurse's Notes LPN #1 assessed the resident. The only documentation was on the August 2016 MAR that indicated LPN #1 administered Tylenol on 08/27/16 at 10:20 PM for an increased temperature (no temperature documented) with the results documented as a temperature of 100.6 degrees F. Interview with CNA #2 on 09/07/16 at 10:17 AM, revealed she worked the 11:00 PM-7:00 AM shift on 08/27/16. She stated Resident #1 ran an increased temperature of ninety-nine (99) degrees Fahrenheit to one-hundred one (101) degrees Fahrenheit throughout her shift. She stated she recalled Resident #1 had no output from his/her indwelling urinary catheter and LPN #1 was aware because she had reported this to LPN #1. However, review of the clinical record revealed no documented evidence LPN #1 assessed the resident. The only documentation was on the August 2016 MAR that indicated LPN #1 administered Tylenol at 2:30 AM on 08/28/16. However, LPN #1 did not document the reason for giving the Tylenol or the results of the Tylenol. Interview with CNA #1 on 09/02/16 at 3:35 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 08/28/16. She stated at approximately 5:30 PM to 6:00 PM Resident #1 could not be aroused or awaken. She revealed Registered Nurse (RN) #1 was in the room feeding Resident #1's roommate supper and the RN said to monitor Resident #1. CNA #1 stated she knew this was not Resident #1's normal behavior so she reported this to LPN #1 also, who was the Charge Nurse for the unit. She stated LPN #1 also told her to monitor Resident #1 and LPN #1 never did check on the resident. She also stated at approximately 8:00 PM while doing an incontinent check on Resident #1, Resident #1 was unable to still be aroused or woken up and she again reported this to LPN #1 who again said to just monitor Resident #1. However, review of the clinical record revealed no documented evidence licensed staff assessed the resident. Review of computer documented Nursing Notes for Resident #1, revealed there was no documentation of the condition changes Resident #1 was identified as having on 08/27/16 through 08/28/16 until a late entry Nursing Note by LPN #1 on 08/29/16 at 2:00 AM. Further review of this Nursing Note, revealed LPN #1 found Resident #1 at 10:00 PM on 08/28/16 to be unresponsive with a temperature of 105.4 degrees Fahrenheit (F) and an accu-check result of HI (greater than 600). Interview with Registered Nurse (RN) #1 on 09/06/16 at 10:25 AM, revealed she did have an explanation as to why she did not assess or document Resident #1 condition. RN #1 stated she did inform LPN #1 of staff not being able to wake Resident #1 up. Interview with LPN #1, on 09/07/16 at 3:00 PM, revealed she had no explanation why she failed to document Resident #1's condition changes on 08/27/16 and on 08/28/16 prior to finding Resident #1 unresponsive at 10:00 PM on 08/28/16 with an elevated temperature of 105.4 and accu-check result of HI. She stated she had no explanation as to why she did not chart the actual temperature Resident #1 had on 08/27/16 at 10:20 PM in which she administered Tylenol. She also stated she had no explanation as to why on 08/28/16 at 2:30 AM she did not chart the reason or the temperature Resident #1 had or chart the follow up results of giving the Tylenol. Interview with the Director of Nursing (DON), on 09/08/16 at 8:15 PM, revealed she expected the resident's clinical records to be clear, concise, and accurately documented. She stated she would have expected LPN #1 to document Resident #1's condition changes that occurred on 08/27/16 and 08/28/16 and she would have expected LPN #1 to document the exact reason Tylenol was given and the follow up results of the Tylenol. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview, record review, and review of facility policy and the facility's Plan of Correction (POC) for the Abbreviated Survey conducted 09/08/15 through 09/18/16 and the POC for the Abbreviated Survey on 01/28/16 through 02/13/16, it was determined the facility failed to maintain a Quality Assessment and Assurance Program that developed and implemented appropriate plans of action to correct quality deficiencies. This was evidenced by repeated deficiencies at F280, F282, F309, and F315. The facility's failure to have an effective Quality Assessment and Assurance Program to identify and implement appropriate plans of action to correct identified quality deficiencies related was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/08/16 and determined to exist on 08/27/16. The facility was notified of the Immediate Jeopardy on 09/08/16. An acceptable Allegation of Compliance (AoC) was received on 09/20/16, alleging the Immediate Jeopardy was removed on 09/14/16. The State Survey Agency validated the Immediate Jeopardy was removed on 09/14/16, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility's policy Center Quality Improvement Process revised 04/01/03, revealed the Administrator directs the development of the Quality Improvement Plan and is responsible for development, maintenance and ongoing evaluation of an active and effective Quality Improvement Committee. The policy further revealed, it is the responsibility of the Quality Improvement Committee to assess and evaluate Survey results and Plans of Correction. 1. Based on interview and record review, it was determined the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised to reflect response to care and changing needs/goals (Refer to F-280). This was a repeat deficiency for the facility, which was cited during an Abbreviated Survey conducted 09/08/15 through 09/18/15. Review of the facility's Plan of Correction (POC), with a compliance date of 10/15/15, revealed beginning on 09/18/15 the Administrator, DON, Activities Director, Social Services Director or licensed nurse were to review care plans to ensure timely revision of care plans to reflect responses to care and changing needs/goals three (3) times a per week for four (4) weeks, then as determined by the monthly Quality Improvement Committee with corrective action upon discovery by the Nurse Practice Educator, RN, DON or Administrator. Interview with the DON, on 09/08/16 at 8:15 AM, record review and review of the facility's Care Plan Policy, revealed, on 08/09/16 after return from a hospital stay, facility staff failed to review and revise Resident #1's Comprehensive Care Plans related to recent condition changes which required Resident #1 to be hospitalized . Resident #1 was again admitted to the hospital on [DATE] with virtually the same conditions related to the hospitalized from [DATE] through 08/09/16. 2. Based on interview and record review, it was determined the facility failed to ensure services were provided in accordance with resident's Comprehensive Plan of Care (Refer to F282). This was a repeat deficiency for the facility, which was cited during an Abbreviated Survey conducted 09/08/15 through 09/18/15, and an Abbreviated Survey conducted 01/28/16 through 02/13/16. Review of the facility's POC, with a compliance date of 10/15/15, revealed beginning on 09/17/16 the DON, Nurse Practice Educator or licensed nurse would observe residents with urinary catheters to ensure the care plans were followed related to monitoring urinary output which includes the odor, color, consistency, and amount across all shifts for fourteen (14) days including weekends, then three (3) times per week times two (2) weeks then as determined by the monthly Quality Improvement Committee with corrective action upon discovery. Review of the facility's POC, with a compliance date of 03/15/16, revealed beginning on 02/03/16, the Health Information Manager, Administrator, Nurse Practice Educator, DON, ADON, RN, LPN, Admissions Director, Payroll Benefits Coordinator or Social Services Director would interview at least five (5) non-licensed staff and or CNAs and at least three (3) licensed staff daily across all shifts for fourteen (14) days to include weekends then three (3) times per week for two (2) weeks then four (4) times per month for five (5) months then as indicated by the Quality Improvement Committee to validate that staff could articulate the purpose of the resident care plan. Interview with the DON, on 09/08/16 at 8:15 AM, record review and review of the facility's Care Plan Policy, revealed on 08/27/16 and on 08/28/16, facility staff failed to implement Resident #1's Comprehensive Plans of Care related to interventions to: monitor for signs and symptoms of infection and report to physician; monitor output for odor, color, consistency and amount and monitor urine for sediment, cloudy, odor, blood and amount and monitor for signs and symptoms of hyper/[DIAGNOSES REDACTED] and report abnormal findings to physician. 3. Based on interview, record review and review of the facility's policies, it was determined the facility failed to ensure resident's received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and care plan (Refer to F309). This was a repeat deficiency for the facility, which was cited during an Abbreviated Survey conducted 09/08/15 through 09/18/15. Review of the facility's POC, with a compliance date of 10/15/15, revealed beginning on 09/18/15, the DON, Nurse Practice Educator, RN Supervisor or Charge Nurse would review residents with a change of condition and audit that change of condition by completing head to toe assessment and documenting on an audit tool that verifies the change of condition is accurately documented and followed up on timely daily times fourteen (14) days to include weekends, then three (3) times a week for two (2) weeks, then as determined by the Quality Improvement Committee with corrective action upon discovery. Interview with the DON on 09/08/16 at 8:15 AM, record review and review of the facility's policies, Diabetic Care Protocol, dated 08/01/15 and Physician/Mid-level Provider Notification revised 03/15/16, revealed staff failed to follow the policies as related to monitoring for and reporting to Resident #1's physician, signs and symptoms of [MEDICAL CONDITION] and signs and symptoms of infection. 4. Based on interview, record review and review of the facility's policies, it was determined the facility failed to provide appropriate treatment and services to identify complications of an indwelling urinary catheter (Refer to F315). This was a repeat deficiency for the facility, which was cited during an Abbreviated Survey conducted 09/08/15 through 09/18/15. Review of the facility's POC, with a compliance date of 10/15/15, revealed beginning on 09/18/15 the DON, Nurse Practice Educator or licensed nurse would review all residents with urinary catheters for signs and symptoms of a Urinary Tract Infection [MEDICAL CONDITION] with appropriate treatment across all shifts daily for fourteen (14) days including weekends, then three (3) times per week for two (2) weeks, then as determined by monthly Quality Improvement Committee to ensure appropriate treatment for [REDACTED]. Interview with the DON on 09/08/16 at 8:15 AM, record review and review of the facility's policy Catheter: Indwelling Urinary - Care of, last revised 01/02/14, revealed the facility failed to identify and notify the physician of signs and symptoms of a Urinary Tract Infection [MEDICAL CONDITION]. Resident #1 had to be hospitalized do to being critically ill and was hospitalized with a [DIAGNOSES REDACTED]. Interview with the Administrator, on 09/08/16 at 8:30 AM, who was over the facility's Quality Assurance (QA) Committee, revealed the facility had not identified any concerns with the reviewing and revising of resident care plans, care plan implementation, staff providing the necessary care and services, and staff providing appropriate indwelling urinary catheter care during the monthly Quality Improvement Committee meetings. Post Survey nterview with the Regional Vice President of Operations (RVPO), on 09/29/16 at 11:40 AM, revealed there was no continued specific oversight ongoing or in place related to the past repetitive deficient practice. The RVPO stated the facility and regional team felt the past deficient practice had been corrected by following the Plan of Corrections and with continued random audits performed by both the facility and the corporate team. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility terminated LPN #1 on 09/07/16. 2. On 09/08/16, the Regional Vice President of Operation provided re-education, via phone, to the Administrator and DON which included: Information from CMS resources including: Five Elements of Quality Assurance Performance Improvement (QAPI), Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description, and Center Nurse Executive (DON) job description. 3. On 09/09/16 through 09/10/16, the facility assessed all seven (7) residents who utilized an indwelling urinary catheter. The facility utilized their urinary tract infection - infection control reporting form to assess these residents. The facility also implemented licensed staff either will visually assess each resident's catheter care to validate catheter care or licensed staff will provide catheter care. 4. On 09/10/16, the DON reviewed all medical change in condition assessments for the last thirty (30) days and found thirty (30) of seventy-two (72) residents had medical change in condition assessments. The DON reviewed and read the medical change in condition assessments in the medical record to validate the completion of the assessments by the licensed staff, which included the timely notification of the physician and the updating and implementation of the care plan. 5. On 09/11/16, the DON and RN Nurse Practice Educator reviewed all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16 to identify if any resident had elevated temperatures during that period of time of 101 degrees Fahrenheit or greater. The DON and RN Nurse Practice Educator then reviewed the Medication Administration Records (MARs) to ensure medication was provided as ordered for elevated temperatures. The DON and RN Nurse Practice Educator also reviewed the residents' medical records to ensure a medical change in condition was initiated by the licensed staff on duty at the time and to ensure the physician and responsible party were notified timely of the change in condition. The DON and RN Nurse Practice Educator further reviewed the residents' care plans to ensure the care plans were updated to reflect the medical change in conditions. 6. On 09/11/16, the DON and RN Nurse Practice Educator reviewed the MARs and Treatment Administration Records (TARs) of all residents (who had physician's orders [REDACTED]. 7. On 09/12/16, the RN Clinical Reimbursement Coordinator and RN MDS Coordinator reviewed the care plans of all seven (7) residents who had indwelling urinary catheters and all sixteen (16) residents who had Physicians' Orders to receive accu-checks to ensure these residents' care plans were up to date and current. 8. On 08/31/16 through 09/13/16, the facility initiated re-education to all RNs and LPNs. The re-education included: physician notification related to resident condition changes; the timely reviewing/revising and implementing of care plans; providing necessary care and services to all residents; providing appropriate monitoring/assessment of indwelling urinary catheters/care of catheters; utilizing the facility's Stop and Watch Early Warning Tool and complete/accurate clinical records including sufficient information to identify the resident. The facility utilized competency/posttests after this education was provided and presented to the licensed staff. 9. On 09/01/16 through 09/13/16, the facility initiated re-education to all CNAs. The re-education included the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. The facility utilized posttests after the re-education was given. 10. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and or Registered Nurse reviewed and will continue to review all medical changes in condition assessments and transfer/discharges out of the facility to visually validate physician and responsible party notification by a licensed nurse on duty; that documentation has been done in the medical record; and, care plans have been revised as needed. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks. Areas of concern will be corrected upon discovery. 11. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and license nurses reviewed and will continue to review the MAR and TAR and the medical record, for residents who have physician's orders [REDACTED].(3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks, then twice a week for eight (8) week, then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 12. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and RN or LPN did observe and will continue to observe for signs and symptoms of UTI related to indwelling urinary catheter use and visually validate the care plan is current and implemented related to catheter care. A licensed nurse on duty, which includes RNs and or LPNs, will perform and or observe indwelling catheter care daily with documentation on the TAR. This will be completed daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks and areas of concern will be corrected upon discovery. 13. Beginning on 09/13/16, the DON, Nurse Practice Educator, RN Clinical Reimbursement Coordinator, RN MDS Coordinator and/or RN interviewed and will continue to interview at least two (2) licensed nurses including RNs or LPNs daily over a period of fourteen (14) days for a minimum of three (3) audits per shift over the fourteen (14) days including weekends, then three (3) times a week for two (2) weeks then twice a week for eight (8) weeks then weekly times twelve (12) weeks to validate knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, the documentation requirements for a change of condition including physician notification. Areas of concern will be corrected upon discovery. 14. Beginning on 09/13/16, the Administrator and DON conducted and will continue to conduct rounds and utilize the QAPI Leadership Rounding Guide/Form. Rounds were and will be conducted and documented at least once weekly for eight (8) weeks to include at least two (2) rounds of each shift over the first eight (8) weeks and then monthly for four (4) months. Information gathered on the Rounding Guide will be brought to the Quality Improvement Committee by the Administrator. 15. The Regional Vice President of Operations or the Regional Manager of Clinical Operations will review the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months. Additional audits will be conducted based on recommendations from the Quality Improvement Committee. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Individual Performance Improvement Plan for LPN #1, dated 09/07/16, revealed LPN #1 was terminated from employment from the facility due to negligence in performance of job duties and failed to notify the physician with a resident's change in condition. 2. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she did provide re-education/training, via phone on 09/08/16, to the Administrator and DON which included: Information from CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. The Regional Vice President of Operation also provided additional re-education which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. Interview with Administrator and DON on 09/20/16 at 11:20 AM, revealed they did receive re-education/training from the Regional Vice President of Operation on 09/08/16 regarding CMS resources including: Five Elements of QAPI, Guide for Developing a QAPI Plan and QAPI Leadership Rounding Guide. They stated the Regional Vice President of Operation also provided additional re-education, which included: Regulation details regarding F-490 related to administration, Center Executive (Administrator) job description and Center Nurse Executive (DON) job description. 3. On 09/20/16, the SSA reviewed the facility's completed Urinary Tract Infection-Infection Control Reporting Forms which were completed between 09/09/16 through 09/10/16 on all seven (7) residents who utilized indwelling urinary catheters with no concerns identified. Interview with RN #2 on 09/21/16 at 8:05 AM and RN #3 on 09/21/16 at 2:50 PM, revealed they had been educated in regards to catheter care. They stated that licensed staff must observe catheter care or if licensed staff was unable to observe it, licensed staff would have to perform the catheter care. 4. On 09/20/16, the SSA reviewed the facility's completed audit, dated 09/10/16 of the DON's review of all residents' medical change in condition assessments for the last thirty (30) days with no concerns identified. 5. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident temperatures in the vital signs portal for seventy-two (72) of seventy-two (72) residents from 09/01/16 through 09/10/16; review of the MARS; review of the residents' medical records; and, review of the residents' care plans with no concerns identified. 6. On 09/20/16, the SSA reviewed the facility's completed audit of the DON and RN Nurse Practice Educator's review of all resident's accu-check readings from 09/01/16 through 09/10/16 and review of physician notifications for any accu-check results of less than 70 mg/dl or any accu-check results greater than 400 mg/dl with no concerns identified. 7. On 09/20/16, the SSA reviewed the facility's completed 09/12/16 audit conducted by the RN, Clinical Reimbursement Coordinator, and RN MDS Coordinator of the residents' care plans for residents who utilized indwelling urinary catheter and for residents who had orders to receive accu-checks. No concerns were identified. 8. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 08/31/16 through 09/13/16, and completed competency/post tests for all licensed staff related to the education the facility provided to all licensed staff regarding: physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. Interviews on 09/20/16 with LPN #3 at 1:55 PM, LPN #4 at 2:07 PM, RN #3 at 2:21 PM, LPN #5 at 2:33 PM and RN #4 at 2:50 PM, revealed they all had the facility's re-education training on physician notification, timely reviewing/revising care plans, indwelling urinary catheter care/assessment/observation of, complete/accurate clinical records, necessary care and services provided to residents and the facility's Stop and Watch Early Warning Tool. They all also confirmed they had to take posttests over the re-education training the facility provided 9. On 09/20/16, the SSA reviewed the facility's sign in sheets, dated 09/01/16 through 09/13/16 and completed post tests for all CNAs related to the education the facility provided to all CNAs regarding: the facility's Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. Interviews on 09/20/16 with CNA #5 at 12:40 PM, CNA #6 at 12:48 PM, CNA #7 at 1:12 PM, CNA #8 at 1:23 PM and CNA #9 at 1:38 PM, revealed they all had the facility re-education training on the Stop and Watch Early Warning Tool and how licensed staff and CNAs should utilize this tool and how to identify symptoms of infection in geriatric residents. They all also confirmed they had to take posttests over the re-education training the facility provided. 10. On 09/20/16, the SSA reviewed the current and ongoing audits completed daily from 09/13/16-09/19/16, and determined the facility reviewed all medical changes in condition assessments and transfer/discharges out of the facility and the visual validation of physician and responsible party notification by a licensed nurse on duty and the documentation in the medical record along with the review of care plans to ensure they have been revised as needed. No concerns were identified. 11. On 09/20/16, the SSA reviewed the current and ongoing audits dated 09/13/16 -09/19/16 and determined the facility reviewed the MAR and TAR and the medical record for residents who had physician's orders [REDACTED]. The facility visually validated that physician notifications were documented in the medical record by a licensed nurse on duty for accu-check readings less than 70 mg/dl and or greater than 400 mg/dl and the visually validated to ensure the care plan was current and implemented. No concerns were identified. 12. On 09/20/16, the SSA reviewed the current and ongoing audit, dated 09/13/16 through 09/19/16, and determined the facility observed for signs and symptoms of UTI related to indwelling urinary catheter use and visually validated if the care plan was current and implemented related to catheter care. No concerns were identified. 13. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16-09/19/16, and determined the facility interviewed at least two (2) licensed nurses including RNs or LPNs daily for a minimum of three (3) audits per shift. The interviews validated knowledge of proper documentation in the medical record, knowledge of the identification and assessment of a change in condition, and the documentation requirements for a change of condition including physician notification. No concerns were identified. 14. On 09/20/16, the SSA reviewed the current and ongoing audits, dated 09/13/16, and determined the Administrator and DON conducted rounds and utilized the QAPI Leadership Rounding Guide/Form. No concerns were identified. 15. Interview with the Regional Vice President of Operation on 09/21/16 at 2:05 PM, revealed she will be reviewing the QAPI Leadership Rounding Form and the Quality Improvement Committee minutes for at least three (3) months and additional audits will be conducted based on recommendations from the Quality Improvement Committee.

Based on interview, record review, facility policy review and the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #36, it was determined the facility failed to ensure the services provided by the facility meet professional standards of quality for one (1) of three (3) sampled residents (Resident #1). Resident #1, who was a full code status in the event of cardiac or respiratory arrest, was not provided cardiopulmonary resuscitation (CPR) when found without respirations and unresponsive. Registered Nurse (RN) #1 called a Code Blue and called 911 for the Emergency Medical System (EMS) on [DATE]; however, RN #1 and RN #2 decided the resident was already dead and did not provide CPR. EMS arrived and found the resident unresponsive and no staff was present. The Paramedic found RN #1 at the nursing station and requested the resident's code status and was informed by RN #1 that Resident #1 was a full code. RN #1 informed the Paramedic CPR they had stopped CPR because a pulse could not be obtained. CPR was initiated by the Paramedic and two (2) Emergency Medical Technicians. Resident #1 was transferred to the hospital emergency room . CPR continued at the emergency room until the resident was pronounced dead. The facility's failure to provide services in accordance with acceptable standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the Job Description for Registered Nurse, last revised [DATE], revealed the Registered Nurse delivers efficient and effective nursing care while achieving positive clinical outcomes and patient/family satisfaction and performs nursing functions and provides care within scope of practice. Review of the KBN AOS #36 Resuscitation, approved ,[DATE] and revised ,[DATE], revealed a nurse would not start CPR when: * There is a valid order for the patient not to attempt resuscitation in the event of an apparent cardiac/pulmonary arrest (absence of pulse and respiration, determined by assessment using inspection, palpitation and auscultation); these are often referred to as do not attempt resuscitation; (DNAR) or do not resuscitate (DNR) orders; * Obvious signs of death are present. The most reliable are: dependent livido (general bluish discoloration of the skin as in pooling of blood in dependent body parts); rigor mortis (harding of muscles or rigidity); algo mortis (cooling of the body following death); and injuries that are incompatible with life. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the resident was assessed as requiring total assistance with all activities of daily living. Review of Resident #1's record (chart) revealed a green sticker on it that indicated the resident was a full code. Review of the care plan titled, Resident has an established Advanced Directive, revealed the resident was a full code. The care plan was initiated on [DATE] to address the resident's desire to be a full code in the event a respiratory or [MEDICAL CONDITION] occurred. The intervention stated to Activate resident's Advanced Directive as indicated. Review of Nursing Notes by RN #1, dated [DATE] at 6:00 PM, revealed the nurse determined Resident #1 was unresponsive, not breathing, there were no lung sounds, no pulse, the resident's pupils were dilated and fixed, his/her tongue was displaced to the left, and skin was cool to touch. Further review revealed she sent the NA (nurse aide) for help, validated the resident's code status, called code blue, called 911, returned to room, two (2) licensed nurses were at bedside to assist, lifted hand and observed hands to be mottled, determined time of death, notifications documented as made, EMS arrived and EMS transported to the hospital. Interview with RN #1, on [DATE] at 1:50 PM, revealed, on [DATE], CNA #1 called for her when he identified the resident was unresponsive while picking up meal trays. RN #1 stated when she entered Resident #1's room, Resident #1's tongue was to the side, pupils were big and in her heart she knew Resident #1 was dead. RN #1 stated she screamed for CNA #1 to get RN #2. RN #1 stated she went to check the resident's chart for code status and called 911, then returned to Resident #1's room finding RN #2 standing by the resident's bed. RN #1 stated RN #2 asked her, Do you really want to do this to him/her? (meaning CPR). RN #1 revealed she picked up the resident's hand and it was dark and discolored with no capillary refill so she and RN #2 looked at their watches and agreed the time of death was 6:08 PM. RN #1 stated she then went to the nursing station to notify the family. EMS had arrived about this time and the Paramedic came to her and asked why the code had been stopped. RN #1 was not current in CPR; however, RN #2 was current in CPR. RN #1 called the code, then decided the resident was dead. RN #1 told the Paramedic that they stopped CPR because there was no pulse. She did not tell the Paramedic that they determined the resident was dead. She did not answer the Paramedic when asked who told them to stop CPR. The RNs did not perform CPR, only called the code. Interview with RN #2, on [DATE] at 10:12 AM, revealed she was summoned to Resident #1's room by CNA #1 and observed the resident was blue around the mouth and felt cold when she touched his/her chest when checking for breathing. RN #2 stated when RN #1 came into the room, she and RN #1 discussed CPR and she asked RN #1, Are we doing this because he/she is gone and RN #2 said No, let (him/her) be. RN #2 stated Resident #1 had no respirations, no pulse, was cyanotic around the mouth, and was stiff with rigor when they rolled him/her to place the back board. Interview with CNA #2, on [DATE] at 10:50 AM, revealed she and CNA #1 were picking up supper trays on [DATE]. When they entered Resident #1's room, they found the resident unresponsive. CNA #2 stated RN #1 was summoned by CNA #1. CNA #2 stated she opened Resident #1's eyes and they were not moving and his/her pupils were big; and, the resident's skin was warm. CNA #2 stated she told RN #1 to call a Code Blue. CNA #2 stated RN #1 went to the nursing station and announced a code blue over the intercom and told CNA #1 to go get RN #2. CNA #2 stated she lifted the sheet over the resident to assist placing the CPR board under the resident while RN #2 was searching for the bag used for rescue breathing. RN #2 wanted the oxygen set at 10/Liters (L) and she (CNA #2) set the regulator for 10/L. CNA #2 stated RN #2 asked RN #1 who was going to do compressions and they discussed CPR and one (1) of the RNs said, Let's agree that we did the CPR and be done with it. CNA #2 stated she had touched Resident #1's chest and it felt warm and the resident's tongue was not sticking out. RN #1 called a code because the resident was a full code. When returning to the resident's room, the two (2) RNs together discussed the Code Status, and whether they wanted to crack the resident's ribs (see interview) and decided to pronounce death. Interview with CNA #1, on [DATE] at 3:00 PM, revealed when he and CNA #2 went into Resident #1's room to gather supper trays they found Resident #1 unresponsive. CNA #1 stated he immediately informed RN #1, and she went to the resident's room. He stated RN #1 instructed him to get RN #2 and he went to the ,[DATE] Hall nursing station to get her. CNA #1 stated RN #1 and RN #2 discussed the resident's code status and RN #2 asked RN #1, Do you really want to crack his/her ribs? It's obvious he/she is dead. and they did not start rescue ventilations or chest compressions. The RNs left the room and EMS arrived and questioned the resident's code status. EMS started CPR and transferred Resident #1 to the hospital. Review of EMS run report, dated [DATE], revealed On arrival found . lying supine in bed unresponsive and not breathing. No staff was in the room and CPR was not being performed. Charge nurse was located and asked if patient was full code or DNR. Nurse stated patient was full code. Nurse was then asked why CPR was not being performed on the patient. Nurse stated she was unsure but they were doing CPR and decided to stop because they could not get a pulse. She was then asked who advised them to stop CPR and she never answered and walked away. Patient presents unresponsive with GCS-3. Airway patent and clear, breathing is absent, absent pulses with a long capillary refill time. Skin is warm, pale and pupils are non reactive. No JVD noted. Breath sounds are absent. No abnormalities to abdomen. Extremities are flaccid. No injuries found. Interview with Paramedic #1, on [DATE] at 11:55 AM, revealed, on [DATE], he responded to a call for an unresponsive resident and when he arrived at Resident #1's room, there was no one in the room but the resident. He stated the resident was not breathing and he did not know the resident's code status. He located RN #1 and asked the resident's code status. The nurse responded full code. The paramedic stated he then asked why CPR was not being done and the nurse replied, We were, we stopped, we couldn't get a pulse. Paramedic #1 stated he asked RN #1 who authorized you to stop CPR and RN #1 just walked away and didn't answer. EMS initiated CPR with Emergency Medical Technician (EMT) #1 and #2. Paramedic #1 stated Resident #1 was not cold but was warm and pale and he did not see any cyanosis. He stated there was no rigor in the patient and no lividity (bluish discoloration). He stated CPR continued as the resident was transported to the emergency department and the resident received interventions in the emergency room until he/she was pronounced dead. Paramedic #1 stated If CPR is the resident's choice, then that's what you need to do. Interview with the Administrator, on [DATE] at 1:25 PM, revealed RN #1 and RN #2 did not initiate chest compressions and rescue ventilations because they determined there was an indication of irreversible death and they pronounced Resident #1 dead. Further interview with the Administrator, on [DATE] at 11:30 AM, revealed she did not know if RN #1 should have stayed in Resident #1's room and an over head page could not be done from a resident room, but RN #1 could have called 911 from the resident's room. The Administrator stated it was a mis-communication between EMS and the nurse. RN #1 said We started then stopped, which may have meant that a code and 911 was called, then RN #1 and RN #2 decided the resident was dead. They were supposed to provide CPR unless there were irreversible signs of death. Interview with the Clinical Reimbursement Coordinator (CRC), on [DATE] at 11:40 AM, revealed she expected nurses to do what is necessary in a code situation unless two (2) or more signs of death were present. Interview, on [DATE] with CRC #2 at 11:50 AM, revealed she would expect CPR to be provided if that was a resident's choice and would continue until relieved by EMS. She also stated signs of irreversible death would be an indication to not initiate CPR. Interview with the Director of Nursing (DON), on [DATE] at 12:00 PM, revealed when a resident is found unresponsive staff were to call for help, validate the code status, and call 911 as long as there were no signs of death. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (76 of 76) by a licensed nurse and/or the Director of Social Services on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical POA wishes. No concerns were identified. 2. All resident care plans (76 of 76) were audited by a licensed nurse or Social Service Director (SSD) on [DATE] and [DATE] to determine that resident code status was on the resident's plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. The facility's policy revealed that CPR certified staff would be on duty at all times. Beginning on [DATE] and ending on [DATE], all facility staff personnel files (82 of 82) were reviewed by the Payroll Benefits Coordinator to identify and track who held a current CPR certification as indicated by a current CPR card. Contract staff including housekeeping, laundry and therapy were not considered to meet this requirement. Corrective action included contacting the employee to determined if he/she had a current CPR certification with proof to be provided and placed in the certification book. The Payroll Benefits Coordinator, Center Nurse Executive (CNE), Center Executive Director (CED), Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE) or Receptionist will obtain a copy of the employee's CPR card to verify active dates and place in the certification book and/or personnel file. Beginning on [DATE] and completed on [DATE], the facility's schedule was reviewed for the past thirty (30) days by the Payroll Benefits Coordinator to validate that at least one (1) CPR certified staff member was on duty at all times. All CPR certified staff was listed and placed in the staffing book at each nurse's station. The master nursing schedule is highlighted by the Payroll Benefits Coordinator to ensure CPR certified staff will be on duty at all times per facility policy. The Charge Nurse will review daily to validate CPR certified staff are scheduled with corrective action upon discovery. Facility staff obtained CPR certification independently of the facility through approved programs. The facility requires CPR certified staff to obtain CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessments. 4. Two (2) of the two (2) emergency crash carts were reviewed on [DATE] by a licensed nurse on the front nurses' station; and, on [DATE] by the Clinical Reimbursement Coordinator on the back nurses's station to validate all items on the emergency cart daily check list form were available and in working order. No concerns were identified. 5. A Code Blue drill was conducted on [DATE] by the ADON for the 7:00 AM to 3:00 PM shift; and, on [DATE] for the 11:00 PM to 7:00 AM, and 3:00 PM to 11:00 PM shifts. The facility's Executive Nurse, ADON, Nurse Practice Educator (NPE) or Regional RN support staff will continue drills weekly for four (4) weeks to include weekends using different scenarios to audit individual critical thinking skills and validate that Cardiac and/or Respiratory arrest procedures are followed. Any issues identified will be immediately addressed. Audits will continue monthly for five (5) months, then as determined by the Quality Improvement Committee. 6. On [DATE], all alert and oriented residents (31 of 72) with a BIMS score of eight (8) or greater were interviewed by the Director of Social Services to determine if the resident felt abused and/or neglected. The interviews included questions regarding: concerns related to care provided by any caregiver, concerns with not receiving care and services needed and who to report to if they felt abused or neglected. No concerns specifically regarding abuse or neglect were identified. Any other concerns were addressed through a formal grievance process by the Director of Social Services immediately upon discovery. 7. On [DATE], residents with a BIMS score lower than eight (8) or who declined to participate in the interview process (39 of 72) received a body audit performed by the licensed nurse to identify any physical signs of abuse or neglect including a change in mood or behavior. No concerns were identified. On [DATE], residents who were admitted to the facility that day (2 of 72) received a baseline body audit performed by a licensed nurse. The Center Executive Director or the Center Nurse Executive met with each resident and informed him/her of who to contact if they felt abused or neglected during their stay. 8. The Center Nurse Executive, ADON, Nurse Practice Educator (NPE) or Licensed Nurse reviewed all current resident Progress Notes from [DATE] for timeliness and accuracy. No concerns were identified. 9. Education was provided for all staff on two (2) separate occasions, defined in the following timeline: On [DATE], the Manager of Clinical Operations provided re-education to the Center Executive Director, Center Nurse Executive and ADON; then the Center Executive Director provided re-education to the Health Information Director, Admissions, Maintenance Director, Director of Recreation, Payroll/Benefits Coordinator, Director of Rehab and Housekeeping/Laundry Supervisor on [DATE]. A post-test with a required score of 100% was included which was graded by the Center Executive Director. The Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive, or Center Executive Director provided re-education to all non-licensed staff on [DATE] through [DATE]. A post-test with a required score of 100% was included which was graded by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive or Center Executive Director (57 of 59). All staff not available for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * How to quickly locate a resident's code status. * Procedure for identifying a resident unresponsive. * Policy NSG102 Care plans including development, communication & implementation. * Death pronouncement and Certification by State. 10. The Nurse Practice Educator (NPE), Center Nurse Executive, ADON or Registered Nurse provided re-education to the licensed staff (RNs & LPNs) from [DATE] to [DATE]. All licensed staff completed a post-test with a required score of 100% which was graded by the Nurse Practice Educator, Center Nurse Executive, ADON, Center Executive Director or Registered Nurse (22 of 23). All staff not available for re-education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * Policy NSG107 and procedure for Emergency Medical Response. * Policy NSG 208 and procedure for Cardiac and/or Respiratory Arrest. * Specific instruction will be provided to include evaluation of signs of irreversible death. * Policy NSG 102 Care Plans including development, communication & implementation. * Death pronouncement and certification by State. 11. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all non-licensed staff to include contract employees (31 of 59). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All staff not available for re-education will be provided the education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse and Neglect Prohibition - State of Kentucky. 12. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all licensed staff (18 of 23). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All licensed staff not available for re-education will be provided the re-education prior to initiating work assignments and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse & Neglect Prohibition - State of Kentucky. * Policy NSG4.20 Charting Errors and/or Omissions including late entries. 13. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), Center Nurse Executive, ADON, RN MDS Coordinator or RN provided education to all licensed staff (6 of 23). All licensed staff not available for education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: In the event there is not a Registered Nurse (RN) available to pronounce death, the Licensed Practical Nurse (LPN) must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. 14. Beginning [DATE], the Health Information Manager, Center Nurse Executive, ADON, RN, LPN, Certified Nursing Executive, Executive, Admissions Director, Payroll Benefits Coordinator and/or Social Services Director will interview at least five (5) non-licensed staff and/or CNAs daily, across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Where a resident's code status can be quickly located * Response steps for a non-licensed staff. * Articulate the purpose of a resident care plan/care card. * Articulate the definition of neglect and appropriate * Reporting steps. Following the initial fourteen (14) days, five (5) non-licensed staff and/or CNAs will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the Quality Improvement (QI) Committee with corrective action upon discovery. 15. Beginning [DATE], the Center Executive Director, Center Nurse Executive, Nurse Practice Educator (NPE), ADON and/or Licensed Nurse will interview at least three (3) licensed staff (RN or LPN), across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Expected medical response to an emergency. * Process steps expected in response to a Cardiac and/or Respiratory Arrest. * Signs of irreversible death. * Where a resident's code status can be quickly located. * Kentucky requirements related to death pronouncement. * Articulate the definition of neglect and appropriate reporting steps. * Definition of a complete medical record. Beginning [DATE], the interview tool will include validation of understanding that in the event an RN is not available to pronounce death, the LPN must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. Following the initial fourteen (14) days, three (3) licensed staff will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 16. Beginning [DATE], the Center Nurse Executive, ADON, Nurse Practice Educator (NPE), or Licensed Nurse will audit all nursing progress notes associated with unplanned transfers and associated care plans daily for fourteen (14) days to include weekends to validate: * Advanced Directives are honored according to the care plan. * Goods and services provided as necessary to avoid mental anguish and physical harm according to the Advanced Directive in the event that CPR is indicated. Following the initial fourteen (14) days, unplanned transfers will be audited three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 17. Audit results will be brought to the QI Committee by the Center Nurse Executive, Center Executive Director, or Licensed Nurse until the issue is resolved and ongoing thereafter. The QI Committee consists of at least the Medical Director, Center Nurse Executive, Center Executive Director, Social Service Director, Maintenance Director, Health Information Manager, ADON, Business Office Manager, and the Nurse Practice Educator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of an audit log, dated [DATE], revealed the Social Service Director (SSD) and an LPN reviewed all residents' records related to Advanced Directives to ensure clear documentation related to Advanced Directives. 2. All care plans were also audited by SSD and check off sheets were verified to ensure residents' code status were on the care plan. Interviews, on [DATE] with the SSD at 11:15 AM, and LPN #1 at 2:55 PM, revealed all resident records related to Advanced Directives were reviewed on [DATE] to verify documentation and care plans were also audited to ensure code status was addressed. 3. Review of the log book that was implemented to verify which licensed staff was current revealed all current CPR certified staff was verified by the Payroll Benefits Coordinator on [DATE]. The log book was tabbed by month to indicate when certifications will expire. Observation on [DATE], revealed a current CPR certification list was located on each of the two (2) nursing stations. Interview conducted with the Center Nurse Executive (CNE), on [DATE] at 9:00 AM revealed CPR status was verified by the Payroll Benefits Coordinator on [DATE] and a log book was implemented to maintain current CPR certification of staff and when certifications will expire. A system to address and ensure coverage of CPR certified staff on duty was implemented. 4. Crash carts were reviewed by LPN #1 on [DATE]. The check list was updated and will be validated daily on the 11:00 PM to 7:00 AM shift. Review of the check list on [DATE] revealed daily signatures by licensed staff on the 11:00 PM to 7:00 AM shift. Interview with LPN #1, on [DATE] at 2:55 PM, verified she had inspected the crash carts on [DATE]. She revealed the carts will be inspected daily by the night shift nurse and documented on the check list. 5. Review of the Code Blue Drill audit revealed a drill was completed, on [DATE], by the ADON on all shifts and weekly drills are being completed through [DATE]. Monthly drills are scheduled to start [DATE] and will be completed by [DATE]. Interview with the ADON, on [DATE] at 9:45 AM, revealed a Code Blue drill was conducted by her on [DATE] and drills are being done weekly on varied shifts by the ADON, the Nurse Practice Educator (NPE) and Center Nurse Executive (CNE). 6. Documented interviews of interviewable residents were reviewed and determined to have been completed by the Social Service Director. There were thirty-one (31) interviewable residents with two (2) refusing to participate. The interviews were directed to care by care givers, not receiving care, whom to report to if they were feeling abused/neglected. No concerns were identified. Concerns identified not related to abuse neglect were resolved through the grievance process. Interview with the SSD, on [DATE] at 11:15 AM, revealed she conducted interviews with all interviewable residents on [DATE] and no concerns were identified related to abuse or neglect. She did resolve some grievance issues about other things that came from the interviews. 7. Review of body audits of non interviewable residents were completed by licensed nurses on [DATE]; and, there were no concerns identified. Two (2) new residents received base line audits and met with the Center Nurse Executive (CNE). Interview, on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE) revealed the skin assessments were divided and completed on [DATE] and two (2) new admissions were included. 8. Resident Progress Notes from [DATE] through [DATE], were reviewed for time and accuracy by the Center Nurse Executive (CNE). Review of the list of Progress Notes audited revealed no concerns. Interview with the Center Nurse Executive (CNE), on [DATE] starting at 9:00 AM, revealed she had completed the audit of Progress Notes with no concern identified. 9. The Manager of Clinical Operations educated the Center Executive Director (CED), and the Center Nurse Executive (CNE), then the Center Executive Director provided education to the Admissions Director, Director of Recreation, Payroll Benefits Coordinator, Director of Rehabilitation, and the Housekeeping/Laundry Supervisor on [DATE]. Post tests were given. The education included resident code status, the unresponsive resident, care plans and death pronouncement. Review of the tests revealed 100% passed with a 100%; the test was graded by the Executive Director. Interview, conducted on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE), revealed she received education from the Manager of Clinical Operations on [DATE] and passed a post test with 100%. Interviews, on [DATE] at 11:03 AM with the Admissions Director, 10:01 AM with the Housekeeping/Laundry Supervisor, and the Nurse Practice Educator (NPE), revealed they had received the education and it was about locating a resident's code status, identifying an unresponsive resident, care plans and death pronouncement. Review of education that was provided to non-licensed staff by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive (CNE) and Executive Director on [DATE] through [DATE]. The post test required 100% and was graded by the Admissions Director. Two (2) staff, the Dietary Manager and Activity staff were the only remaining staff not provided the training and will receive the training prior to initiating any assignment on return to work. That education included how to locate code status, procedure for identifying a resident unresponsive, Policy NSG102 Care Plans and Death Pronouncement and Certification by State. Review of the POS [REDACTED]. Interviews on [DATE] with the Admissions Director at 11:03 AM, Restorative Aide #1 at 10:29 AM, CNA #5 at 10:24 AM, Dietary Aide #1 at 10:19 AM, the Housekeeping/Laundry Supervisor at 10:01 AM, and CNA #4 at 9:40 AM, revealed they had received education related to a resident's code status and where to find that information, related to unresponsive resident and what to do, care plans and death pronouncement by the RN. 10. Review of documented education and post tests, on [DATE], revealed 22 of 23 RNs and LPNs were educated by the Nurse Practice Educator (NPE), Center Nurse Executive (CNE), and ADON on [DATE] through [DATE]. All had post test with 100% pass rate graded by the Nurse Practice Educator (NPE), CNA, and ADON. One (1) licensed staff remains to be re-educated. The Scheduling Supervisor is to ensure that education is com

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the clinical record for one (1) of three (3) sampled residents (Resident #1) was maintained in accordance with accepted professional standards and practices that were complete and accurately documented. Resident #1 was found unresponsive, not breathing and had no pulse on [DATE]. Record review revealed documentation in the Nursing Notes, dated [DATE], that was titled late entry that a Code Blue was called when Resident #1 was found unresponsive. The Note indicated when returning to the room the resident's hand was observed to be mottled and a time of death was determined. Notifications were documented. The same Nursing Note revealed Emergency Medical System (EMS) was notified and EMS arrived, and transported the resident to the hospital. The same Nursing Note entry was stricken out on [DATE] and then re-documented on [DATE] as another late entry for [DATE]. The facility's failure to ensure the clinical record was maintained in accordance with accepted professional standards and practices that were complete and accurately documented has caused or is likely to cause serious injury, harm, or impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Charting Errors and/or Omissions, dated as last revised [DATE], revealed documentation to include: Facilities will follow professional standards of practice when changes or clarifications to medical records are necessary. Changes or clarifications may be made to paper and/or electronic medical records. The Purpose: to accurately correct errors or omissions to medical records; Correcting an error in an electronic health information system. If it is necessary to change or add information in a patient's medical record, the person making the entry will: Use one of the following words to identify change/addition: Addendum to add information; Late Entry when pertinent information was missed or not written in a timely manner; Clarification to avoid incorrect interpretation of information that was been previously documented. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 with severe cognitive impairment and required total assistance with all activities of daily living. On [DATE] at 6:01 PM, Resident #1 was found unresponsive by Certified Nurse Aide (CNA ) #1 and CNA #2 who summoned Registered Nurse (RN) #1, and RN #1 initiated a Code Blue and called 911 Emergency Medical System (EMS) at 6:06 PM. RN #1 and RN #2 discussed Resident #1's full code status but felt the resident had expired; the RNs did not initiate cardiopulmonary resuscitation (CPR), which included no rescue ventilations or chest compressions. EMS arrived to Resident #1's room at 6:16 PM finding the resident alone, unresponsive and no staff present. Paramedic #1 requested the resident's code status; RN #1 revealed the resident was a full code. EMS initiated CPR and transferred the resident to the Emergency Department (ED). Resident #1 arrived to the ED with CPR in progress and the ED continued CPR interventions until 6:51 PM when Resident #1 was pronounced dead. Review of computer documented Nursing Notes by RN #1, dated [DATE] at 6:00 PM (actual entry time), that had been stricken out on [DATE] at 4:11 PM by RN #1, revealed a Late Entry 6:01 PM (after actual entry time) resident unresponsive, observed resident not breathing, no lung sounds, no pulse, pupils dilated, fixed, tongue displaced to the left, skin cool to touch, sent NA #1 (nurse aide) for help, validated code status, called code blue, called 911, returned to room, two (2) licensed nurses at bedside to assist, lifted hand and observed hands to be mottled, determined time of death, notifications documented as made and, 18:06 (6:06 PM) EMS arrived, EMS transported to hospital. Review of a late entry Nursing Note by RN #1, dated [DATE] at 6:34 PM, revealed documentation to include resident had an unplanned transfer. Contact person was notified of the transfer with name listed. Review of a Nursing Note, dated [DATE] at 4:09 PM (actual entry time), revealed documentation by RN #1 including Late Entry for [DATE] at 6:01 PM, resident non responsive, observed resident not breathing, no lung sounds, no pulse, pupils dilated, fixed, tongue displaced to left, skin cool to touch, sent NA #1 (nurse aide) for help, validated code status, called code blue, called 911, returned to room, two (2) licensed nurses at bedside to assist, lifted hand and observed hands to be mottled, determined time of death, notifications listed and, at 6:06 PM, EMS arrived, EMS transported to hospital. Interview with RN #1, on [DATE] at 3:00 PM, revealed no explanation why her documentation on [DATE] reflected Resident #1 was non-responsive with a Code Blue called, but no information related to CPR was documented. She gave no explanation about why she had documented a Code Blue for the resident and determined death of the resident without a time. Additionally, RN #1 did not provide an explanation why she had struck through the Nursing Note entry made on [DATE] at 6:00 PM, and on [DATE] at 4:11 PM, and had re-documented the same information on [DATE] at 4:09 PM. Interview with the Director of Nursing (DON), conducted on [DATE] at 12:00 PM, revealed she expected the resident's clinical records to be clear (not confusing), concise, and accurately documented. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (76 of 76) by a licensed nurse and/or the Director of Social Services on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical POA wishes. No concerns were identified. 2. All resident care plans (76 of 76) were audited by a licensed nurse or Social Service Director (SSD) on [DATE] and [DATE] to determine that resident code status was on the resident's plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. The facility's policy revealed that CPR certified staff would be on duty at all times. Beginning on [DATE] and ending on [DATE], all facility staff personnel files (82 of 82) were reviewed by the Payroll Benefits Coordinator to identify and track who held a current CPR certification as indicated by a current CPR card. Contract staff including housekeeping, laundry and therapy were not considered to meet this requirement. Corrective action included contacting the employee to determined if he/she had a current CPR certification with proof to be provided and placed in the certification book. The Payroll Benefits Coordinator, Center Nurse Executive (CNE), Center Executive Director (CED), Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE) or Receptionist will obtain a copy of the employee's CPR card to verify active dates and place in the certification book and/or personnel file. Beginning on [DATE] and completed on [DATE], the facility's schedule was reviewed for the past thirty (30) days by the Payroll Benefits Coordinator to validate that at least one (1) CPR certified staff member was on duty at all times. All CPR certified staff was listed and placed in the staffing book at each nurse's station. The master nursing schedule is highlighted by the Payroll Benefits Coordinator to ensure CPR certified staff will be on duty at all times per facility policy. The Charge Nurse will review daily to validate CPR certified staff are scheduled with corrective action upon discovery. Facility staff obtained CPR certification independently of the facility through approved programs. The facility requires CPR certified staff to obtain CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessments. 4. Two (2) of the two (2) emergency crash carts were reviewed on [DATE] by a licensed nurse on the front nurses' station; and, on [DATE] by the Clinical Reimbursement Coordinator on the back nurses's station to validate all items on the emergency cart daily check list form were available and in working order. No concerns were identified. 5. A Code Blue drill was conducted on [DATE] by the ADON for the 7:00 AM to 3:00 PM shift; and, on [DATE] for the 11:00 PM to 7:00 AM, and 3:00 PM to 11:00 PM shifts. The facility's Executive Nurse, ADON, Nurse Practice Educator (NPE) or Regional RN support staff will continue drills weekly for four (4) weeks to include weekends using different scenarios to audit individual critical thinking skills and validate that Cardiac and/or Respiratory arrest procedures are followed. Any issues identified will be immediately addressed. Audits will continue monthly for five (5) months, then as determined by the Quality Improvement Committee. 6. On [DATE], all alert and oriented residents (31 of 72) with a BIMS score of eight (8) or greater were interviewed by the Director of Social Services to determine if the resident felt abused and/or neglected. The interviews included questions regarding: concerns related to care provided by any caregiver, concerns with not receiving care and services needed and who to report to if they felt abused or neglected. No concerns specifically regarding abuse or neglect were identified. Any other concerns were addressed through a formal grievance process by the Director of Social Services immediately upon discovery. 7. On [DATE], residents with a BIMS score lower than eight (8) or who declined to participate in the interview process (39 of 72) received a body audit performed by the licensed nurse to identify any physical signs of abuse or neglect including a change in mood or behavior. No concerns were identified. On [DATE], residents who were admitted to the facility that day (2 of 72) received a baseline body audit performed by a licensed nurse. The Center Executive Director or the Center Nurse Executive met with each resident and informed him/her of who to contact if they felt abused or neglected during their stay. 8. The Center Nurse Executive, ADON, Nurse Practice Educator (NPE) or Licensed Nurse reviewed all current resident Progress Notes from [DATE] for timeliness and accuracy. No concerns were identified. 9. Education was provided for all staff on two (2) separate occasions, defined in the following timeline: On [DATE], the Manager of Clinical Operations provided re-education to the Center Executive Director, Center Nurse Executive and ADON; then the Center Executive Director provided re-education to the Health Information Director, Admissions, Maintenance Director, Director of Recreation, Payroll/Benefits Coordinator, Director of Rehab and Housekeeping/Laundry Supervisor on [DATE]. A post-test with a required score of 100% was included which was graded by the Center Executive Director. The Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive, or Center Executive Director provided re-education to all non-licensed staff on [DATE] through [DATE]. A post-test with a required score of 100% was included which was graded by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive or Center Executive Director (57 of 59). All staff not available for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * How to quickly locate a resident's code status. * Procedure for identifying a resident unresponsive. * Policy NSG102 Care plans including development, communication & implementation. * Death pronouncement and Certification by State. 10. The Nurse Practice Educator (NPE), Center Nurse Executive, ADON or Registered Nurse provided re-education to the licensed staff (RNs & LPNs) from [DATE] to [DATE]. All licensed staff completed a post-test with a required score of 100% which was graded by the Nurse Practice Educator, Center Nurse Executive, ADON, Center Executive Director or Registered Nurse (22 of 23). All staff not available for re-education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * Policy NSG107 and procedure for Emergency Medical Response. * Policy NSG 208 and procedure for Cardiac and/or Respiratory Arrest. * Specific instruction will be provided to include evaluation of signs of irreversible death. * Policy NSG 102 Care Plans including development, communication & implementation. * Death pronouncement and certification by State. 11. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all non-licensed staff to include contract employees (31 of 59). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All staff not available for re-education will be provided the education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse and Neglect Prohibition - State of Kentucky. 12. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all licensed staff (18 of 23). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All licensed staff not available for re-education will be provided the re-education prior to initiating work assignments and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse & Neglect Prohibition - State of Kentucky. * Policy NSG4.20 Charting Errors and/or Omissions including late entries. 13. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), Center Nurse Executive, ADON, RN MDS Coordinator or RN provided education to all licensed staff (6 of 23). All licensed staff not available for education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: In the event there is not a Registered Nurse (RN) available to pronounce death, the Licensed Practical Nurse (LPN) must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. 14. Beginning [DATE], the Health Information Manager, Center Nurse Executive, ADON, RN, LPN, Certified Nursing Executive, Executive, Admissions Director, Payroll Benefits Coordinator and/or Social Services Director will interview at least five (5) non-licensed staff and/or CNAs daily, across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Where a resident's code status can be quickly located * Response steps for a non-licensed staff. * Articulate the purpose of a resident care plan/care card. * Articulate the definition of neglect and appropriate * Reporting steps. Following the initial fourteen (14) days, five (5) non-licensed staff and/or CNAs will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the Quality Improvement (QI) Committee with corrective action upon discovery. 15. Beginning [DATE], the Center Executive Director, Center Nurse Executive, Nurse Practice Educator (NPE), ADON and/or Licensed Nurse will interview at least three (3) licensed staff (RN or LPN), across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Expected medical response to an emergency. * Process steps expected in response to a Cardiac and/or Respiratory Arrest. * Signs of irreversible death. * Where a resident's code status can be quickly located. * Kentucky requirements related to death pronouncement. * Articulate the definition of neglect and appropriate reporting steps. * Definition of a complete medical record. Beginning [DATE], the interview tool will include validation of understanding that in the event an RN is not available to pronounce death, the LPN must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. Following the initial fourteen (14) days, three (3) licensed staff will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 16. Beginning [DATE], the Center Nurse Executive, ADON, Nurse Practice Educator (NPE), or Licensed Nurse will audit all nursing progress notes associated with unplanned transfers and associated care plans daily for fourteen (14) days to include weekends to validate: * Advanced Directives are honored according to the care plan. * Goods and services provided as necessary to avoid mental anguish and physical harm according to the Advanced Directive in the event that CPR is indicated. Following the initial fourteen (14) days, unplanned transfers will be audited three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 17. Audit results will be brought to the QI Committee by the Center Nurse Executive, Center Executive Director, or Licensed Nurse until the issue is resolved and ongoing thereafter. The QI Committee consists of at least the Medical Director, Center Nurse Executive, Center Executive Director, Social Service Director, Maintenance Director, Health Information Manager, ADON, Business Office Manager, and the Nurse Practice Educator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of an audit log, dated [DATE], revealed the Social Service Director (SSD) and an LPN reviewed all residents' records related to Advanced Directives to ensure clear documentation related to Advanced Directives. 2. All care plans were also audited by SSD and check off sheets were verified to ensure residents' code status were on the care plan. Interviews, on [DATE] with the SSD at 11:15 AM, and LPN #1 at 2:55 PM, revealed all resident records related to Advanced Directives were reviewed on [DATE] to verify documentation and care plans were also audited to ensure code status was addressed. 3. Review of the log book that was implemented to verify which licensed staff was current revealed all current CPR certified staff was verified by the Payroll Benefits Coordinator on [DATE]. The log book was tabbed by month to indicate when certifications will expire. Observation on [DATE], revealed a current CPR certification list was located on each of the two (2) nursing stations. Interview conducted with the Center Nurse Executive (CNE), on [DATE] at 9:00 AM revealed CPR status was verified by the Payroll Benefits Coordinator on [DATE] and a log book was implemented to maintain current CPR certification of staff and when certifications will expire. A system to address and ensure coverage of CPR certified staff on duty was implemented. 4. Crash carts were reviewed by LPN #1 on [DATE]. The check list was updated and will be validated daily on the 11:00 PM to 7:00 AM shift. Review of the check list on [DATE] revealed daily signatures by licensed staff on the 11:00 PM to 7:00 AM shift. Interview with LPN #1, on [DATE] at 2:55 PM, verified she had inspected the crash carts on [DATE]. She revealed the carts will be inspected daily by the night shift nurse and documented on the check list. 5. Review of the Code Blue Drill audit revealed a drill was completed, on [DATE], by the ADON on all shifts and weekly drills are being completed through [DATE]. Monthly drills are scheduled to start [DATE] and will be completed by [DATE]. Interview with the ADON, on [DATE] at 9:45 AM, revealed a Code Blue drill was conducted by her on [DATE] and drills are being done weekly on varied shifts by the ADON, the Nurse Practice Educator (NPE) and Center Nurse Executive (CNE). 6. Documented interviews of interviewable residents were reviewed and determined to have been completed by the Social Service Director. There were thirty-one (31) interviewable residents with two (2) refusing to participate. The interviews were directed to care by care givers, not receiving care, whom to report to if they were feeling abused/neglected. No concerns were identified. Concerns identified not related to abuse neglect were resolved through the grievance process. Interview with the SSD, on [DATE] at 11:15 AM, revealed she conducted interviews with all interviewable residents on [DATE] and no concerns were identified related to abuse or neglect. She did resolve some grievance issues about other things that came from the interviews. 7. Review of body audits of non interviewable residents were completed by licensed nurses on [DATE]; and, there were no concerns identified. Two (2) new residents received base line audits and met with the Center Nurse Executive (CNE). Interview, on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE) revealed the skin assessments were divided and completed on [DATE] and two (2) new admissions were included. 8. Resident Progress Notes from [DATE] through [DATE], were reviewed for time and accuracy by the Center Nurse Executive (CNE). Review of the list of Progress Notes audited revealed no concerns. Interview with the Center Nurse Executive (CNE), on [DATE] starting at 9:00 AM, revealed she had completed the audit of Progress Notes with no concern identified. 9. The Manager of Clinical Operations educated the Center Executive Director (CED), and the Center Nurse Executive (CNE), then the Center Executive Director provided education to the Admissions Director, Director of Recreation, Payroll Benefits Coordinator, Director of Rehabilitation, and the Housekeeping/Laundry Supervisor on [DATE]. Post tests were given. The education included resident code status, the unresponsive resident, care plans and death pronouncement. Review of the tests revealed 100% passed with a 100%; the test was graded by the Executive Director. Interview, conducted on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE), revealed she received education from the Manager of Clinical Operations on [DATE] and passed a post test with 100%. Interviews, on [DATE] at 11:03 AM with the Admissions Director, 10:01 AM with the Housekeeping/Laundry Supervisor, and the Nurse Practice Educator (NPE), revealed they had received the education and it was about locating a resident's code status, identifying an unresponsive resident, care plans and death pronouncement. Review of education that was provided to non-licensed staff by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive (CNE) and Executive Director on [DATE] through [DATE]. The post test required 100% and was graded by the Admissions Director. Two (2) staff, the Dietary Manager and Activity staff were the only remaining staff not provided the training and will receive the training prior to initiating any assignment on return to work. That education included how to locate code status, procedure for identifying a resident unresponsive, Policy NSG102 Care Plans and Death Pronouncement and Certification by State. Review of the POS [REDACTED]. Interviews on [DATE] with the Admissions Director at 11:03 AM, Restorative Aide #1 at 10:29 AM, CNA #5 at 10:24 AM, Dietary Aide #1 at 10:19 AM, the Housekeeping/Laundry Supervisor at 10:01 AM, and CNA #4 at 9:40 AM, revealed they had received education related to a resident's code status and where to find that information, related to unresponsive resident and what to do, care plans and death pronouncement by the RN. 10. Review of documented education and post tests, on [DATE], revealed 22 of 23 RNs and LPNs were educated by the Nurse Practice Educator (NPE), Center Nurse Executive (CNE), and ADON on [DATE] through [DATE]. All had post test with 100% pass rate graded by the Nurse Practice Educator (NPE), CNA, and ADON. One (1) licensed staff remains to be re-educated. The Scheduling Supervisor is to ensure that education is completed when that staff returns. Review of the education revealed it included Policy NSG 107 related to the procedure for Emergency Medical Response, Policy NSG 208 for cardiac and/or respiratory arrest, specific instructions which included evaluation of irreversible death and care plans policy NSG 102 related to care plan development, implementation and communication and death pronouncement. Interviews on [DATE] with RN #2 at 10:36 AM, LPN #3 at 10:13 AM, LPN #2 at 9:48 AM, RN #3 at 9:02 AM, and the Clinical Reimbursement Coordinator (CRC) at 10:50 AM, revealed they had education related to emergency medical response, cardiac and respiratory arrest, irreversible death and care plans. They were required to pass a post test with 100%. 11. Review on [DATE] of education and post tests of non-licensed staff and contract employees revealed 31 of 59 had completed the education. All staff not available for re-education will be provided that education prior to initiating work assignment and new staff will be educated during orientation. Review of the education revealed Policy NSG 102 related to care plans for Advanced Directives, Policy OS310 related to abuse/neglect was provided by the Nurse Practice Educator (NPE), ADON, Center Nurse Executive (CNE). Review of the POS [REDACTED]. Interviews, on [DATE] with CNA #4 at 9:40 AM, the Housekeeping/Laundry Supervisor at 10:01 AM, Dietary Aide #1 at 10:19 AM, CNA #5 at 10:24 AM, and Restorative Aide #1 at 10:29 AM, revealed they received education related to Advanced Directives and the facility's policy for Abuse and Neglect. They were all required to pass a post test with 100%. 12. Review of the education post tests completed [DATE] through [DATE] revealed a 100% pass rate of licensed staff (18 of 23). The education was given by the Nurse Practice Educator (NPE), ADON, and Center Nurse Executive (CNE). The education included Policy NSG102 related to care plan development, communication and implementation for following the care plan for Advanced Directives. The education also included Policy OPS310 related to Abuse and Neglect Prohibition and Policy NSG 4.20 related to charting errors and/or omissions. Interviews, on [DATE] with RN #2 at 10:36 AM, LPN #3 at 10:13 AM, LPN #2 at 9:48 AM, RN #3 at 9:02 AM, and the Clinical Reimbursement Coordinator (CRC) at 10:50 AM, revealed they had education related to implementing the care plan for Advanced Directives and the facility's Abuse and Neglect Policy, as well as charting errors and/or omissions. They were required to pass a post test with 100%. 13. The Nurse Practice Educator (NPE), Center Nurse Executive (CNE), ADON, and Clinical Reimbursement Coordinator (CRC) provided education to all licensed staff (6 of 23). This education was to ensure staff could state where code status could be quickly located, response steps for non licensed staff, articulate the purpose of resident care plan/care card, and articulate the definition of neglect and appropriate reporting steps. Staff not available for education will be provided education prior to initiating work assignment and new staff will be educated during orientation. Review of sign off sheets, dated [DATE], of additional education that was conducted for six (6) of 23 licensed staff related to an RN available to pronounce death, the LPN must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the funeral home. This education was given by the Nurse Practice Educator (NPE), Center Nurse Executive (CNE), ADON, and Clinical Reimbursement Coordinator (CRC). Staff not available for education will be provided prior to initiating work assignment and new staff will receive the education in orientation. Interviews, conducted on [DATE] with LPN #1 at 2:55 PM, RN #3 at 9:02 AM, LPN #2 at 9:48 AM, LPN #3 at 10:13 AM and RN #2 at 10:36 AM, revealed they had received education related to death pronouncement by the RN or Physician and the KY Provisional Report of Death form in the Facility Note section. 14. Review of interviews of five (5) non-licensed staff and/or CNAs revealed interviews were conducted daily from [DATE] through [DATE] related to understanding of where a resident's code status can be located, response steps for non-licensed staff, the purpose of care plan/care card, the definition of neglect and reporting steps. Interview with the Center Nurse Executive (CNE), on [DATE] at 9:00 AM, revealed daily interviews will be completed [DATE], and then interviews will be conducted three (3) times a week for four (4) weeks, then one (1) time monthly for four (4) months projected to be complete [DATE]. Interviews, conducted on [DATE] with CNA #4 at 9:40 AM, Dietary Aide #1 at 10:19 AM, CNA #5 at 10:24 AM, and Restorative Aide #1 at 10:29 AM, revealed they received education related to where a resident's code status was located and the response steps for non-licensed staff to follow, as well as the purpose of the care plan and care card. Additionally, the definition of neglect and the reporting steps. 15. Beginning [DATE], licensed staff interviews were conducted by the Center Nurse Executive (CNE), Nurse Practice Educator (NPE), and ADON. Review revealed the interviews addressed expected medical response to an emergency, process steps expected in response to a Cardiac and/or Respiratory Arrest, signs of irreversible death, where a resident's code status could be located, Kentucky requirements related to death pronouncement, the definition of neglect and appropriate rep

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure care was provided in accordance with the written plan of care for one (1) of three (3) sampled residents (Resident #1). The facility care planned Resident #1 as a full code in the event of cardiac or respiratory arrest. On [DATE], Resident #1 was found unresponsive and without a pulse or respirations. A Code Blue was called and Emergency Medical System (EMS) was activated. However, rescue ventilations and chest compressions were not provided to Resident #1 by Registered Nurse (RN) #1 and RN #2 because they felt the resident was already deceased . EMS responded to the 911 call and found Resident #1 alone in his/her room and Cardiopulmonary Resuscitation (CPR) had not been initiated. CPR was initiated by EMS personnel and the resident was transported to the hospital where CPR continued until the resident was pronounced dead in the Emergency department. The facility's failure to provide services in accordance with each resident's written plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Care Plans, last revised [DATE], revealed a comprehensive, individualized care plan will be developed by the interdisciplinary team for each resident. The care plan will include measurable objectives to meet resident needs and goals as identified by the assessment process. The purpose of the policy was to provide necessary care and services to attain or maintain the resident's highest practicable physical, mental and psychosocial well being. The policy also revealed the care plan was communicated to appropriate staff and reviewed and revised a minimum of quarterly and as needed to reflect responses to care and changing needs and goals. Review of the Job Description for a Registered Nurse, dated last revised [DATE], revealed a nurse performs nursing functions and provides care within the scope of practice. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired. The facility assessed Resident #1 to require total assistance with all activities of daily living. The resident's record had a green sticker that indicated the resident was a full code, desiring to receive CPR . Review of Resident #1's Comprehensive Care Plan revealed the resident had established an Advanced Directive as being full code, dated [DATE]. The resident's desire was to be a full code (administer chest compressions, breaths and activate 911) in the event respiratory or [MEDICAL CONDITION] occurred. The intervention was to Activate resident's Advanced Directive as indicated. Review of Nursing Notes, dated [DATE] at 6:01 PM, and interview with Registered Nurse (RN) #1 on [DATE] at 1:50 PM, and RN #2 on [DATE] at 10:12 AM, revealed on [DATE] at 6:01 PM, Certified Nurse Aide (CNA) #1 and CNA #2 found Resident #1 unresponsive. The CNAs summoned RN #1 who initiated a Code Blue and called 911 (Emergency Medical System) at 6:06 PM, for an ambulance. The resident was unresponsive, not breathing, had no lung sounds, no pulse, pupils were dilated and fixed, tongue was displaced to the left, and skin was cool to touch, according to Nursing Notes dated [DATE] at 6:01 PM. RN #1 and RN #2 discussed Resident #1's full code status but felt the resident had expired and the RNs did not initiate rescue ventilations or chest compressions. RN #2 then returned to her workstation located by the ,[DATE] Hall and RN #1 went to the 100 Hall nursing station to make notifications. EMS arrived to the resident's room at 6:16 PM finding the resident alone, unresponsive and no staff present. Paramedic #1 requested the resident's code status and RN #1, who was at the nurse's station, informed him the resident was a full code. Paramedic #1 asked why CPR was not being performed and RN #1 walked away from Paramedic #1 without response when he asked who authorized the code to be stopped. Review of the EMS run report, dated [DATE], and interview with Paramedic #1, on [DATE] at 11:55 AM, revealed he responded to a call for an unresponsive resident and when he arrived at the resident's room there was no one in the room but the resident. The resident was not breathing and he did not know the resident's code status. Paramedic #1 stated he located RN #1 at the nursing station and asked the resident's code status and the nurse responded full code. The Paramedic stated he then asked why CPR was not being performed, the nurse replied We were, we stopped, we couldn't get a pulse. He stated he returned to Resident #1 and initiated CPR with Emergency Medical Technicians (EMT) #1 and #2. Paramedic #1 stated Resident #1 was not cold but was warm and pale and he did not see any cyanosis. He stated there was no rigor in the resident and no lividity (bluish discoloration). The Paramedic and Emergency Medical Technicians (EMT) #1 and #2 initiated CPR. Resident #1 was transported to the emergency room via ambulance. The Emergency Department received Resident #1 at 6:48 PM with CPR in progress. The Emergency Department staff continued CPR interventions until 6:51 PM when Resident #1 was pronounced dead. Interviews with CNA #1 on [DATE] at 3:00 PM, and CNA #2 on [DATE] at 10:50 AM, revealed on [DATE], CNA #1 was assisting Resident #1 with the supper meal when they noticed the resident was not acting right so he informed RN #1 who was in the dining room. CNA #1 stated RN #1 looked at the resident and told him (CNA #1) to stop feeding the resident and leave his/her head in the upright position. The CNAs stated when they returned to the resident's room to gather the supper trays they found Resident #1 unresponsive. CNA #1 immediately informed RN #1, who was still in the dining room; RN #1 then returned to the resident's room. CNA #1 went to the ,[DATE] Hall nursing station and got RN #2 to assist. The CNAs stated RN #1 and RN #2 discussed the resident's code status and RN #2 asked RN #1, Do you really want to crack his/her ribs? It's obvious he/she is dead. The CNAs stated then one (1) of the RNs stated, Lets agree that we did the CPR and be done with it. CNA #2 stated she had touched Resident #1's chest and it felt warm and the resident's tongue was not sticking out of his/her mouth. They stated RN #1 and RN #2 did not start rescue ventilations or chest compressions. The RNs left the resident's room. Further interview revealed EMS arrived and questioned the resident's code status and started CPR. EMS transferred the resident to the hospital. Interview with the Administrator, on [DATE] at 1:25 PM, revealed the RNs did not initiate chest compressions and rescue ventilations per the care plan because they determined there was an indication of irreversible death and they pronounced Resident #1 dead. However, she stated that all the nurses were responsible to implement the care plans. Interview with the Clinical Reimbursement Coordinator (CRC), on [DATE] at 11:40 AM, revealed she expected resident care plans to be implemented and all nurses were responsible for implementing care plans. Interview with CRC #2, on [DATE] at 11:50 AM, revealed all licensed staff was responsible to provide care according to the care plan. She additionally stated she would expect CPR to be provided if that was a resident's choice unless there were signs of irreversible death. Interview with the Director of Nursing (DON), on [DATE] at 12:00 PM, revealed all nurses were responsible to ensure care plan interventions were implemented. Interview was Resident #1's Primary Physician, on [DATE] at 12:20 PM, revealed he could not remember if or when he was notified of Resident #1's condition prior to the transfer to the hospital. The Physician stated he expected the nurses to provide care according to the care plan. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (76 of 76) by a licensed nurse and/or the Director of Social Services on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical POA wishes. No concerns were identified. 2. All resident care plans (76 of 76) were audited by a licensed nurse or Social Service Director (SSD) on [DATE] and [DATE] to determine that resident code status was on the resident's plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. The facility's policy revealed that CPR certified staff would be on duty at all times. Beginning on [DATE] and ending on [DATE], all facility staff personnel files (82 of 82) were reviewed by the Payroll Benefits Coordinator to identify and track who held a current CPR certification as indicated by a current CPR card. Contract staff including housekeeping, laundry and therapy were not considered to meet this requirement. Corrective action included contacting the employee to determined if he/she had a current CPR certification with proof to be provided and placed in the certification book. The Payroll Benefits Coordinator, Center Nurse Executive (CNE), Center Executive Director (CED), Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE) or Receptionist will obtain a copy of the employee's CPR card to verify active dates and place in the certification book and/or personnel file. Beginning on [DATE] and completed on [DATE], the facility's schedule was reviewed for the past thirty (30) days by the Payroll Benefits Coordinator to validate that at least one (1) CPR certified staff member was on duty at all times. All CPR certified staff was listed and placed in the staffing book at each nurse's station. The master nursing schedule is highlighted by the Payroll Benefits Coordinator to ensure CPR certified staff will be on duty at all times per facility policy. The Charge Nurse will review daily to validate CPR certified staff are scheduled with corrective action upon discovery. Facility staff obtained CPR certification independently of the facility through approved programs. The facility requires CPR certified staff to obtain CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessments. 4. Two (2) of the two (2) emergency crash carts were reviewed on [DATE] by a licensed nurse on the front nurses' station; and, on [DATE] by the Clinical Reimbursement Coordinator on the back nurses's station to validate all items on the emergency cart daily check list form were available and in working order. No concerns were identified. 5. A Code Blue drill was conducted on [DATE] by the ADON for the 7:00 AM to 3:00 PM shift; and, on [DATE] for the 11:00 PM to 7:00 AM, and 3:00 PM to 11:00 PM shifts. The facility's Executive Nurse, ADON, Nurse Practice Educator (NPE) or Regional RN support staff will continue drills weekly for four (4) weeks to include weekends using different scenarios to audit individual critical thinking skills and validate that Cardiac and/or Respiratory arrest procedures are followed. Any issues identified will be immediately addressed. Audits will continue monthly for five (5) months, then as determined by the Quality Improvement Committee. 6. On [DATE], all alert and oriented residents (31 of 72) with a BIMS score of eight (8) or greater were interviewed by the Director of Social Services to determine if the resident felt abused and/or neglected. The interviews included questions regarding: concerns related to care provided by any caregiver, concerns with not receiving care and services needed and who to report to if they felt abused or neglected. No concerns specifically regarding abuse or neglect were identified. Any other concerns were addressed through a formal grievance process by the Director of Social Services immediately upon discovery. 7. On [DATE], residents with a BIMS score lower than eight (8) or who declined to participate in the interview process (39 of 72) received a body audit performed by the licensed nurse to identify any physical signs of abuse or neglect including a change in mood or behavior. No concerns were identified. On [DATE], residents who were admitted to the facility that day (2 of 72) received a baseline body audit performed by a licensed nurse. The Center Executive Director or the Center Nurse Executive met with each resident and informed him/her of who to contact if they felt abused or neglected during their stay. 8. The Center Nurse Executive, ADON, Nurse Practice Educator (NPE) or Licensed Nurse reviewed all current resident Progress Notes from [DATE] for timeliness and accuracy. No concerns were identified. 9. Education was provided for all staff on two (2) separate occasions, defined in the following timeline: On [DATE], the Manager of Clinical Operations provided re-education to the Center Executive Director, Center Nurse Executive and ADON; then the Center Executive Director provided re-education to the Health Information Director, Admissions, Maintenance Director, Director of Recreation, Payroll/Benefits Coordinator, Director of Rehab and Housekeeping/Laundry Supervisor on [DATE]. A post-test with a required score of 100% was included which was graded by the Center Executive Director. The Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive, or Center Executive Director provided re-education to all non-licensed staff on [DATE] through [DATE]. A post-test with a required score of 100% was included which was graded by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive or Center Executive Director (57 of 59). All staff not available for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * How to quickly locate a resident's code status. * Procedure for identifying a resident unresponsive. * Policy NSG102 Care plans including development, communication & implementation. * Death pronouncement and Certification by State. 10. The Nurse Practice Educator (NPE), Center Nurse Executive, ADON or Registered Nurse provided re-education to the licensed staff (RNs & LPNs) from [DATE] to [DATE]. All licensed staff completed a post-test with a required score of 100% which was graded by the Nurse Practice Educator, Center Nurse Executive, ADON, Center Executive Director or Registered Nurse (22 of 23). All staff not available for re-education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * Policy NSG107 and procedure for Emergency Medical Response. * Policy NSG 208 and procedure for Cardiac and/or Respiratory Arrest. * Specific instruction will be provided to include evaluation of signs of irreversible death. * Policy NSG 102 Care Plans including development, communication & implementation. * Death pronouncement and certification by State. 11. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all non-licensed staff to include contract employees (31 of 59). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All staff not available for re-education will be provided the education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse and Neglect Prohibition - State of Kentucky. 12. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all licensed staff (18 of 23). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All licensed staff not available for re-education will be provided the re-education prior to initiating work assignments and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse & Neglect Prohibition - State of Kentucky. * Policy NSG4.20 Charting Errors and/or Omissions including late entries. 13. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), Center Nurse Executive, ADON, RN MDS Coordinator or RN provided education to all licensed staff (6 of 23). All licensed staff not available for education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: In the event there is not a Registered Nurse (RN) available to pronounce death, the Licensed Practical Nurse (LPN) must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. 14. Beginning [DATE], the Health Information Manager, Center Nurse Executive, ADON, RN, LPN, Certified Nursing Executive, Executive, Admissions Director, Payroll Benefits Coordinator and/or Social Services Director will interview at least five (5) non-licensed staff and/or CNAs daily, across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Where a resident's code status can be quickly located * Response steps for a non-licensed staff. * Articulate the purpose of a resident care plan/care card. * Articulate the definition of neglect and appropriate * Reporting steps. Following the initial fourteen (14) days, five (5) non-licensed staff and/or CNAs will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the Quality Improvement (QI) Committee with corrective action upon discovery. 15. Beginning [DATE], the Center Executive Director, Center Nurse Executive, Nurse Practice Educator (NPE), ADON and/or Licensed Nurse will interview at least three (3) licensed staff (RN or LPN), across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Expected medical response to an emergency. * Process steps expected in response to a Cardiac and/or Respiratory Arrest. * Signs of irreversible death. * Where a resident's code status can be quickly located. * Kentucky requirements related to death pronouncement. * Articulate the definition of neglect and appropriate reporting steps. * Definition of a complete medical record. Beginning [DATE], the interview tool will include validation of understanding that in the event an RN is not available to pronounce death, the LPN must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. Following the initial fourteen (14) days, three (3) licensed staff will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 16. Beginning [DATE], the Center Nurse Executive, ADON, Nurse Practice Educator (NPE), or Licensed Nurse will audit all nursing progress notes associated with unplanned transfers and associated care plans daily for fourteen (14) days to include weekends to validate: * Advanced Directives are honored according to the care plan. * Goods and services provided as necessary to avoid mental anguish and physical harm according to the Advanced Directive in the event that CPR is indicated. Following the initial fourteen (14) days, unplanned transfers will be audited three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 17. Audit results will be brought to the QI Committee by the Center Nurse Executive, Center Executive Director, or Licensed Nurse until the issue is resolved and ongoing thereafter. The QI Committee consists of at least the Medical Director, Center Nurse Executive, Center Executive Director, Social Service Director, Maintenance Director, Health Information Manager, ADON, Business Office Manager, and the Nurse Practice Educator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of an audit log, dated [DATE], revealed the Social Service Director (SSD) and an LPN reviewed all residents' records related to Advanced Directives to ensure clear documentation related to Advanced Directives. 2. All care plans were also audited by SSD and check off sheets were verified to ensure residents' code status were on the care plan. Interviews, on [DATE] with the SSD at 11:15 AM, and LPN #1 at 2:55 PM, revealed all resident records related to Advanced Directives were reviewed on [DATE] to verify documentation and care plans were also audited to ensure code status was addressed. 3. Review of the log book that was implemented to verify which licensed staff was current revealed all current CPR certified staff was verified by the Payroll Benefits Coordinator on [DATE]. The log book was tabbed by month to indicate when certifications will expire. Observation on [DATE], revealed a current CPR certification list was located on each of the two (2) nursing stations. Interview conducted with the Center Nurse Executive (CNE), on [DATE] at 9:00 AM revealed CPR status was verified by the Payroll Benefits Coordinator on [DATE] and a log book was implemented to maintain current CPR certification of staff and when certifications will expire. A system to address and ensure coverage of CPR certified staff on duty was implemented. 4. Crash carts were reviewed by LPN #1 on [DATE]. The check list was updated and will be validated daily on the 11:00 PM to 7:00 AM shift. Review of the check list on [DATE] revealed daily signatures by licensed staff on the 11:00 PM to 7:00 AM shift. Interview with LPN #1, on [DATE] at 2:55 PM, verified she had inspected the crash carts on [DATE]. She revealed the carts will be inspected daily by the night shift nurse and documented on the check list. 5. Review of the Code Blue Drill audit revealed a drill was completed, on [DATE], by the ADON on all shifts and weekly drills are being completed through [DATE]. Monthly drills are scheduled to start [DATE] and will be completed by [DATE]. Interview with the ADON, on [DATE] at 9:45 AM, revealed a Code Blue drill was conducted by her on [DATE] and drills are being done weekly on varied shifts by the ADON, the Nurse Practice Educator (NPE) and Center Nurse Executive (CNE). 6. Documented interviews of interviewable residents were reviewed and determined to have been completed by the Social Service Director. There were thirty-one (31) interviewable residents with two (2) refusing to participate. The interviews were directed to care by care givers, not receiving care, whom to report to if they were feeling abused/neglected. No concerns were identified. Concerns identified not related to abuse neglect were resolved through the grievance process. Interview with the SSD, on [DATE] at 11:15 AM, revealed she conducted interviews with all interviewable residents on [DATE] and no concerns were identified related to abuse or neglect. She did resolve some grievance issues about other things that came from the interviews. 7. Review of body audits of non interviewable residents were completed by licensed nurses on [DATE]; and, there were no concerns identified. Two (2) new residents received base line audits and met with the Center Nurse Executive (CNE). Interview, on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE) revealed the skin assessments were divided and completed on [DATE] and two (2) new admissions were included. 8. Resident Progress Notes from [DATE] through [DATE], were reviewed for time and accuracy by the Center Nurse Executive (CNE). Review of the list of Progress Notes audited revealed no concerns. Interview with the Center Nurse Executive (CNE), on [DATE] starting at 9:00 AM, revealed she had completed the audit of Progress Notes with no concern identified. 9. The Manager of Clinical Operations educated the Center Executive Director (CED), and the Center Nurse Executive (CNE), then the Center Executive Director provided education to the Admissions Director, Director of Recreation, Payroll Benefits Coordinator, Director of Rehabilitation, and the Housekeeping/Laundry Supervisor on [DATE]. Post tests were given. The education included resident code status, the unresponsive resident, care plans and death pronouncement. Review of the tests revealed 100% passed with a 100%; the test was graded by the Executive Director. Interview, conducted on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE), revealed she received education from the Manager of Clinical Operations on [DATE] and passed a post test with 100%. Interviews, on [DATE] at 11:03 AM with the Admissions Director, 10:01 AM with the Housekeeping/Laundry Supervisor, and the Nurse Practice Educator (NPE), revealed they had received the education and it was about locating a resident's code status, identifying an unresponsive resident, care plans and death pronouncement. Review of education that was provided to non-licensed staff by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive (CNE) and Executive Director on [DATE] through [DATE]. The post test required 100% and was graded by the Admissions Director. Two (2) staff, the Dietary Manager and Activity staff were the only remaining staff not provided the training and will receive the training prior to initiating any assignment on return to work. That education included how to locate code status, procedure for identifying a resident unresponsive, Policy NSG102 Care Plans and Death Pronouncement and Certification by State. Review of the POS [REDACTED]. Interviews on [DATE] with the Admissions Director at 11:03 AM, Restorative Aide #1 at 10:29 AM, CNA #5 at 10:24 AM, Dietary Aide #1 at 10:19 AM, the Housekeeping/Laundry Supervisor at 10:01 AM, and CNA #4 at 9:40 AM, revealed they had received education related to a resident's code status and where to find that information, related to unresponsive resident and what to do, care plans and death pronouncement by the RN. 10. Review of documented education and post tests, on [DATE], revealed 22 of 23 RNs and LPNs were educated by the Nurse Practice Educator (NPE), Center Nurse Executive (CNE), and ADON on [DATE] through [DATE]. All had post test with 100% pass rate graded by the Nurse Practice Educator (NPE), CNA, and ADON. One (1) licensed staff remains to be re-educated. The Scheduling Supervisor is to ensure that education is completed when that staff returns. Review of the education revealed it included Policy NSG 107 related to the procedure for Emergency Medical Response, Policy NSG 208 for cardiac and/or respiratory arrest, specific instructions which included evaluation of irreversible death and care plans policy NSG 102 related to care plan development, implementation and communication and death pronouncement. Interviews on [DATE] with RN #2 at 10:36 AM, LPN #3 at 10:13 AM, LPN #2 at 9:48 AM, RN #3 at 9:02 AM, and the Clinical Reimbursement Coordinator (CRC) at 10:50 AM, revealed they had education related to emergency medical response, cardiac and respiratory arrest, irreversible death and care plans. They were required to pass a post test with 100%. 11. Review on [DATE] of education and post tests of non-licensed staff and contract employees revealed 31 of 59 had completed the education. All staff not available for re-education will be provided that education prior to initiating work assignment and new staff will be educated during orientation. Review of the education revealed Policy NSG 102 related to care plans for Advanced Directives, Policy OS310 related to abuse/neglect was provided by the Nurse Practice Educator (NPE), ADON, Center Nurse Executive (CNE). Review of the POS [REDACTED]. Interviews, on [DATE] with CNA #4 at 9:40 AM, the Housekeeping/Laundry Supervisor at 10:01 AM, Dietary Aide #1 at 10:19 AM, CNA #5 at 10:24 AM, and Restorative Aide #1 at 10:29 AM, revealed they received education related to Advanced Directives and the facility's policy for Abuse and Neglect. They were all required to pass a post test with 100%. 12. Review of the education post tests completed [DATE] through [DATE] revealed a 100% pass rate of licensed staff (18 of 23). The education was given by the Nurse Practice Educator (NPE), ADON, and Center Nurse Executive (CNE). The education included Policy NSG102 related to care plan development, communication and implementation for following the care plan for Advanced Directives. The education also included Policy OPS310 related to Abuse and Neglect Prohibition and Policy NSG 4.20 related to charting errors and/or omissions. Interviews, on [DATE] with RN #2 at 10:36 AM, LPN #3 at 10:13 AM, LPN #2 at 9:48 AM, RN #3 at 9:02 AM, and the Clinical Reimbursement Coordinator (CRC) at 10:50 AM, revealed they had education related to implementing the care plan for Advanced Directives and the facility's Abuse and Neglect Policy, as well as charting errors and/or omissions. They were required to pass a post test with 100%. 13. The Nurse Practice Educator (NPE), Center Nurse Executive (CNE), ADON, and Clinical Reimbursement Coordinator (CRC) provided education to all licensed staff (6 of 23). This education was to ensure staff could state where code status could be quickly located, response steps for non licensed staff, articulate the purpose of resident care plan/care card, and articulate the definition of neglect and appropriate reporting steps. Staff not available for education will be provided education prior to initiating work assignment and new staff will be educated during orientation. Review of sign off

Based on interview, record review, review of the facility's policies, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #36, it was determined the facility neglected to provide care and services that were necessary when one (1) of three (3) sampled residents (Resident #1) was found unresponsive. Resident #1 was not provided Cardio/pulmonary resuscitation (CPR) after a Code Blue was called. Certified Nurse Aide (CNA) #1 and CNA #2 found Resident#1 unresponsive on [DATE] at 6:01 PM when they entered the resident's room to pick up the supper tray. The CNAs summoned Registered Nurse (RN) #1 who initiated a Code Blue by announcing it on the intercom and calling 911 (Emergency Medical System) for an ambulance. RN #2 had responded to the Code Blue and was already in Resident #1's room when RN #1 returned to the resident's room. RN #1 and RN #2 discussed that Resident #1 was a full code; however, they failed to initiate rescue ventilations or chest compressions. RN #2 returned to the ,[DATE] Hall nursing station and RN #1 returned to the ,[DATE] Hall nursing station to make notifications. EMS arrived to Resident #1's room at 6:16 PM finding the resident alone, unresponsive and no staff present. Upon requesting Resident #1's code status, RN #1 informed Paramedic #1 that the resident was a full code. When Paramedic #1 asked why the Code had been stopped, RN #1 walked away without giving Paramedic #1 an answer. Paramedic #1 immediately returned to Resident #1 and CPR was initiated. Resident #1 was transported to the emergency room (ER) with CPR in progress and the ER continued CPR until the resident was pronounced dead at 6:51 PM. The facility's failure to ensure residents were free from mistreatment or 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]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Prohibition, last revised [DATE], revealed the purpose of the policy was to ensure that Center's staff was doing all that was within their control to prevent occurrences of abuse, mistreatment, neglect, involuntary seclusion, injuries of unknown origin and misappropriation of property for all residents. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the KBN AOS #36 Resuscitation, approved ,[DATE] and revised ,[DATE], revealed a nurse would not start CPR when: * There is a valid order for the patient, not to attempt resuscitation in the event of an apparent cardiac/pulmonary arrest (absence of pulse and respiration, determined by assessment using inspection, palpitation and auscultation); these are often referred to as do not attempt resuscitation; (DNAR) or do not resuscitate (DNR) orders; * Obvious signs of death are present. The most reliable are: dependent livido (general bluish discoloration of the skin as in pooling of blood in dependent body parts); rigor mortis (harding of muscles or rigidity); algo mortis (cooling of the body following death); and injuries that are incompatible with life. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as severely impaired and the resident was totally dependent on staff for assistance with all activities of daily living. The resident's chart was marked with a green sticker, which indicated the resident was a full code (initiate CPR). Review of the care plan, titled Resident has an established Advanced Directive as being full code and was dated and initiated on [DATE] to address the resident's desire to be a full code in the event respiratory or [MEDICAL CONDITION] occurred. Review of a Late Entry Nursing Note written by RN #1, dated [DATE] at 1800 (6:00 PM), with a strike out date of [DATE] at 4:11 PM, revealed Resident was unresponsive, observed resident not breathing, no lung sounds, no pulse, pupils dilated, fixed, tongue displaced to the left, skin cool to touch, sent NA (Nurse Aide) for help, validated code status, called code blue, called 911, returned to room, two (2) licensed nurses at bedside to assist, lifted hand and observed hands to be mottled, determined time of death, notifications documented as made, and at 18:06 (6:06 PM) EMS arrived, EMS transported to hospital; however, review of this Nursing Note revealed all of the documentation had a line marked through it. Further review of a Nursing Note re-written by RN #1, dated [DATE] at 4:09 PM, and documented as a Late Entry for [DATE] at 18:01 (6:01 PM), revealed the same information as the Nursing Note, dated [DATE] at 1800 (6:00 PM); however, the documentation had no lines marked through it. RN #1 gave no explanation why the [DATE] note was stricken out, and then re-written on [DATE]. Interview with CNA #1, on [DATE] at 3:00 PM, revealed on [DATE], he was assisting Resident #1 with the supper meal and the resident was not acting right . He stated he informed RN #1, who was in the dining room, and the RN looked at the resident and told CNA #1 to stop feeding the resident and leave his/her head in the upright position. CNA #1 stated he left to assist another resident and when he and CNA #2 returned to gather the resident's supper tray they found Resident #1 unresponsive. CNA #1 stated he immediately informed RN #1, who was still in the dining room, and she returned to the resident's room. He stated RN #1 instructed him to get RN #2 and he went to the ,[DATE] Hall nursing station to get her. CNA #1 stated when he returned to Resident #1's room, RN #1 and RN #2 were discussing the resident's code status. He stated RN #2 asked RN #1, Do you really want to crack his/her ribs? It's obvious he/she is dead. CNA #1 stated RN #1 and RN #2 did not start rescue ventilations or chest compressions. Further interview revealed the RNs left the room. When the EMS arrived, they questioned the resident's code status, started CPR, and left with Resident #1 in the ambulance. Interview with CNA #2, on [DATE] at 10:50 AM, revealed she and CNA #1 were picking up supper trays on [DATE]. When they entered Resident #1's room, they found the resident unresponsive. CNA #2 stated CNA #1 went to get RN #1. She stated when she opened Resident #1's eyes, they were not moving and the resident's pupils were big. She stated Resident #1's skin was warm when she touched him/her. CNA #2 stated she told RN #1 to call a Code Blue and RN #1 went to the nursing station and announced a Code Blue over the intercom. RN #1 told CNA #1 to go get RN #2. CNA #2 stated she lifted the sheet over the resident to assist placing the CPR backboard under the resident while RN #2 was searching for the bag used for rescue breathing. She stated RN #2 wanted oxygen set at 10/L and CNA #2 set the regulator for 10/L. CNA #2 said RN #2 asked RN #1 (when RN #1 re-entered the room), which one of them was going to do compressions. CNA #2 stated they discussed CPR, and one of the RNs said, Let's agree that we did the CPR and be done with it. CNA #2 stated she had touched Resident #1's chest and it felt warm and the resident's tongue was not sticking out of his/her mouth. Interview with RN #1, on [DATE] at 1:50 PM, revealed she was doing dining room duty on [DATE] and was summoned to Resident #1's room; CNA #1 reported to her that Resident #1 was acting funny. RN #1 stated she determined whatever had alarmed CNA #1 had passed and instructed CNA to stop feeding Resident #1 and to leave the resident's head in an upright position she (RN #1) returned to the dining room. She stated CNA #1 hollered again when all the trays were being picked up. RN #1 stated when she entered the resident's room, Resident #1's tongue was to the side and his/her pupils were big. RN #1 stated that she knew in her heart that Resident #1 was dead. She stated she screamed for CNA #1 to get RN #2 and she went to check the resident's chart for the code status and called 911. When she returned to Resident #1's room, RN #2 was standing by the resident's bed. RN #1 stated RN #2 asked her, Do you really want to do this to him/her? (meaning CPR). She (RN #1) picked up the resident's hand and it was dark and discolored with no capillary refill, so she and RN #2 looked at their watches and agreed on a time of death at 6:08 PM. RN #1 stated she then went to the nursing station to make notifications. She stated EMS arrived about that time and the Paramedic came to her and asked why the code had been stopped. RN #1 said she did not think she told him, Because there was no pulse, but that is how she thinks the Paramedic said she responded. She said the Paramedic asked a second time why the CPR was stopped and she . didn't have an answer for him. RN #1 additionally stated, I regret walking out of the room, I know in my mind if I brought (him/her) back, (he/she) would have nothing in (his/her) mind. Interview with RN #2, on [DATE] at 10:12 AM, revealed she was summoned to Resident #1's room by CNA #1. She stated Resident #1 was blue around the mouth and felt cold when she touched his/her chest when checking for breathing. RN #2 stated she was not sure of Resident #1's code status, but she got the breathing mask out to be ready. When RN #1 came into the room, they (RN #1 and RN #2) discussed CPR and she asked RN #1, Are we doing this, because (he/she) is gone. RN #2 stated there was nothing they could do and RN #1 said No, let (him/her) be. RN #2 stated, We did not start CPR. She stated Resident #1 was not her resident and she wasn't sure how long (Resident #1) had been down. RN #2 stated, You have to make a decision about the quality of (his/her) life. She stated RN #1 had called 911 and that is what you do if a resident is a full code status. RN #2 stated Resident #1 had no respirations and no pulse and was cyanotic around the mouth and was stiff with rigor when they rolled him/her to place the back board (for CPR), and the resident rolled all together like a log. Interview with Unsampled Resident A (BIMS score of 15), on [DATE] at 2:30 PM, revealed he/she was near Resident #1's room on [DATE] and a code blue was called. The resident stated somebody parked the crash cart outside the room but he/she did not see anyone take anything off the cart. He/She stated RN #1 and RN #2 . were not in the room thirty (30) seconds. The resident stated the Paramedic that came to the Code Blue was really upset and asking Who told you to stop CPR to RN #1. Unsampled Resident A stated he/she did not hear a response from RN #1. Review of the Emergency Medical Service (EMS) run report, dated [DATE], revealed documentation in the narrative section which included, On arrival found . lying supine in bed unresponsive and not breathing. No staff was in the room and CPR was not being performed. Charge nurse was located and asked if patient was full code or DNR. Nurse stated patient was full code. Nurse was then asked why CPR was not being performed on the patient. Nurse stated she was unsure but they were doing CPR and decided to stop because they could not get a pulse. She was then asked who advised them to stop CPR and she never answered and walked away. Patient presents unresponsive with GCS-3. Airway patent and clear, breathing is absent, absent pulses with a long capillary refill time. Skin is warm, pale and pupils are non-reactive. No JVD noted. Breath sounds are absent. No abnormalities to abdomen. Extremities are flaccid. No injuries found. Interview with Paramedic #1, on [DATE] at 11:55 AM, and review of the EMS run report, dated [DATE], revealed EMS arrived to the resident's room at 6:16 PM finding the resident alone, unresponsive, not breathing, and there was no staff present. Paramedic #1 located RN #1 at the nursing station and requested the resident's code status. RN #1 informed the EMS the resident was a full code. Paramedic #1 asked why CPR was not being performed on the resident and RN #1 replied the code was stopped due to the resident not having a pulse. RN #1 walked away from Paramedic #1 without response when he asked who authorized the code to be stopped. Paramedic #1 returned to Resident #1 where he and Emergency Medical Technicians (EMT) #1 and #2 initiated CPR. The resident's airway was patent and clear, breathing and pulses were absent and there was a long capillary refill time. The resident's skin was warm, pale and pupils were non reactive. Extremities were flaccid. Resident #1 was transported to the emergency room via ambulance. Interview with the Director of Nursing (DON), on [DATE] at 12:00 PM, revealed she was not present during the event but RN #1 and RN #2 had said it was an irreversible death. The DON described neglect as Knowingly not providing a need someone has. Interview with the Administrator, conducted on [DATE] at 1:25 PM, revealed RN #1 and RN #2 did not initiate chest compressions and rescue ventilations because they determined there was an indication of irreversible death and they pronounced Resident #1 dead. The Administrator stated she spoke with Paramedic #1 after the event, when she was looking into what had happened. She stated RN #1 told Paramedic #1 the resident was a full code, and when Paramedic #1 asked why no CPR was being performed, RN #1 stated because there was no pulse. RN #1 was not current in CPR certification; however, RN #2 was current in CPR certification. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (76 of 76) by a licensed nurse and/or the Director of Social Services on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical POA wishes. No concerns were identified. 2. All resident care plans (76 of 76) were audited by a licensed nurse or Social Service Director (SSD) on [DATE] and [DATE] to determine that resident code status was on the resident's plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. The facility's policy revealed that CPR certified staff would be on duty at all times. Beginning on [DATE] and ending on [DATE], all facility staff personnel files (82 of 82) were reviewed by the Payroll Benefits Coordinator to identify and track who held a current CPR certification as indicated by a current CPR card. Contract staff including housekeeping, laundry and therapy were not considered to meet this requirement. Corrective action included contacting the employee to determined if he/she had a current CPR certification with proof to be provided and placed in the certification book. The Payroll Benefits Coordinator, Center Nurse Executive (CNE), Center Executive Director (CED), Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE) or Receptionist will obtain a copy of the employee's CPR card to verify active dates and place in the certification book and/or personnel file. Beginning on [DATE] and completed on [DATE], the facility's schedule was reviewed for the past thirty (30) days by the Payroll Benefits Coordinator to validate that at least one (1) CPR certified staff member was on duty at all times. All CPR certified staff was listed and placed in the staffing book at each nurse's station. The master nursing schedule is highlighted by the Payroll Benefits Coordinator to ensure CPR certified staff will be on duty at all times per facility policy. The Charge Nurse will review daily to validate CPR certified staff are scheduled with corrective action upon discovery. Facility staff obtained CPR certification independently of the facility through approved programs. The facility requires CPR certified staff to obtain CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessments. 4. Two (2) of the two (2) emergency crash carts were reviewed on [DATE] by a licensed nurse on the front nurses' station; and, on [DATE] by the Clinical Reimbursement Coordinator on the back nurses's station to validate all items on the emergency cart daily check list form were available and in working order. No concerns were identified. 5. A Code Blue drill was conducted on [DATE] by the ADON for the 7:00 AM to 3:00 PM shift; and, on [DATE] for the 11:00 PM to 7:00 AM, and 3:00 PM to 11:00 PM shifts. The facility's Executive Nurse, ADON, Nurse Practice Educator (NPE) or Regional RN support staff will continue drills weekly for four (4) weeks to include weekends using different scenarios to audit individual critical thinking skills and validate that Cardiac and/or Respiratory arrest procedures are followed. Any issues identified will be immediately addressed. Audits will continue monthly for five (5) months, then as determined by the Quality Improvement Committee. 6. On [DATE], all alert and oriented residents (31 of 72) with a BIMS score of eight (8) or greater were interviewed by the Director of Social Services to determine if the resident felt abused and/or neglected. The interviews included questions regarding: concerns related to care provided by any caregiver, concerns with not receiving care and services needed and who to report to if they felt abused or neglected. No concerns specifically regarding abuse or neglect were identified. Any other concerns were addressed through a formal grievance process by the Director of Social Services immediately upon discovery. 7. On [DATE], residents with a BIMS score lower than eight (8) or who declined to participate in the interview process (39 of 72) received a body audit performed by the licensed nurse to identify any physical signs of abuse or neglect including a change in mood or behavior. No concerns were identified. On [DATE], residents who were admitted to the facility that day (2 of 72) received a baseline body audit performed by a licensed nurse. The Center Executive Director or the Center Nurse Executive met with each resident and informed him/her of who to contact if they felt abused or neglected during their stay. 8. The Center Nurse Executive, ADON, Nurse Practice Educator (NPE) or Licensed Nurse reviewed all current resident Progress Notes from [DATE] for timeliness and accuracy. No concerns were identified. 9. Education was provided for all staff on two (2) separate occasions, defined in the following timeline: On [DATE], the Manager of Clinical Operations provided re-education to the Center Executive Director, Center Nurse Executive and ADON; then the Center Executive Director provided re-education to the Health Information Director, Admissions, Maintenance Director, Director of Recreation, Payroll/Benefits Coordinator, Director of Rehab and Housekeeping/Laundry Supervisor on [DATE]. A post-test with a required score of 100% was included which was graded by the Center Executive Director. The Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive, or Center Executive Director provided re-education to all non-licensed staff on [DATE] through [DATE]. A post-test with a required score of 100% was included which was graded by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive or Center Executive Director (57 of 59). All staff not available for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * How to quickly locate a resident's code status. * Procedure for identifying a resident unresponsive. * Policy NSG102 Care plans including development, communication & implementation. * Death pronouncement and Certification by State. 10. The Nurse Practice Educator (NPE), Center Nurse Executive, ADON or Registered Nurse provided re-education to the licensed staff (RNs & LPNs) from [DATE] to [DATE]. All licensed staff completed a post-test with a required score of 100% which was graded by the Nurse Practice Educator, Center Nurse Executive, ADON, Center Executive Director or Registered Nurse (22 of 23). All staff not available for re-education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * Policy NSG107 and procedure for Emergency Medical Response. * Policy NSG 208 and procedure for Cardiac and/or Respiratory Arrest. * Specific instruction will be provided to include evaluation of signs of irreversible death. * Policy NSG 102 Care Plans including development, communication & implementation. * Death pronouncement and certification by State. 11. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all non-licensed staff to include contract employees (31 of 59). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All staff not available for re-education will be provided the education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse and Neglect Prohibition - State of Kentucky. 12. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all licensed staff (18 of 23). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All licensed staff not available for re-education will be provided the re-education prior to initiating work assignments and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse & Neglect Prohibition - State of Kentucky. * Policy NSG4.20 Charting Errors and/or Omissions including late entries. 13. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), Center Nurse Executive, ADON, RN MDS Coordinator or RN provided education to all licensed staff (6 of 23). All licensed staff not available for education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: In the event there is not a Registered Nurse (RN) available to pronounce death, the Licensed Practical Nurse (LPN) must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. 14. Beginning [DATE], the Health Information Manager, Center Nurse Executive, ADON, RN, LPN, Certified Nursing Executive, Executive, Admissions Director, Payroll Benefits Coordinator and/or Social Services Director will interview at least five (5) non-licensed staff and/or CNAs daily, across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Where a resident's code status can be quickly located * Response steps for a non-licensed staff. * Articulate the purpose of a resident care plan/care card. * Articulate the definition of neglect and appropriate * Reporting steps. Following the initial fourteen (14) days, five (5) non-licensed staff and/or CNAs will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the Quality Improvement (QI) Committee with corrective action upon discovery. 15. Beginning [DATE], the Center Executive Director, Center Nurse Executive, Nurse Practice Educator (NPE), ADON and/or Licensed Nurse will interview at least three (3) licensed staff (RN or LPN), across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Expected medical response to an emergency. * Process steps expected in response to a Cardiac and/or Respiratory Arrest. * Signs of irreversible death. * Where a resident's code status can be quickly located. * Kentucky requirements related to death pronouncement. * Articulate the definition of neglect and appropriate reporting steps. * Definition of a complete medical record. Beginning [DATE], the interview tool will include validation of understanding that in the event an RN is not available to pronounce death, the LPN must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. Following the initial fourteen (14) days, three (3) licensed staff will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 16. Beginning [DATE], the Center Nurse Executive, ADON, Nurse Practice Educator (NPE), or Licensed Nurse will audit all nursing progress notes associated with unplanned transfers and associated care plans daily for fourteen (14) days to include weekends to validate: * Advanced Directives are honored according to the care plan. * Goods and services provided as necessary to avoid mental anguish and physical harm according to the Advanced Directive in the event that CPR is indicated. Following the initial fourteen (14) days, unplanned transfers will be audited three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 17. Audit results will be brought to the QI Committee by the Center Nurse Executive, Center Executive Director, or Licensed Nurse until the issue is resolved and ongoing thereafter. The QI Committee consists of at least the Medical Director, Center Nurse Executive, Center Executive Director, Social Service Director, Maintenance Director, Health Information Manager, ADON, Business Office Manager, and the Nurse Practice Educator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of an audit log, dated [DATE], revealed the Social Service Director (SSD) and an LPN reviewed all residents' records related to Advanced Directives to ensure clear documentation related to Advanced Directives. 2. All care plans were also audited by SSD and check off sheets were verified to ensure residents' code status were on the care plan. Interviews, on [DATE] with the SSD at 11:15 AM, and LPN #1 at 2:55 PM, revealed all resident records related to Advanced Directives were reviewed on [DATE] to verify documentation and care plans were also audited to ensure code status was addressed. 3. Review of the log book that was implemented to verify which licensed staff was current revealed all current CPR certified staff was verified by the Payroll Benefits Coordinator on [DATE]. The log book was tabbed by month to indicate when certifications will expire. Observation on [DATE], revealed a current CPR certification list was located on each of the two (2) nursing stations. Interview conducted with the Center Nurse Executive (CNE), on [DATE] at 9:00 AM revealed CPR status was verified by the Payroll Benefits Coordinator on [DATE] and a log book was implemented to maintain current CPR certification of staff and when certifications will expire. A system to address and ensure coverage of CPR certified staff on duty was implemented. 4. Crash carts were reviewed by LPN #1 on [DATE]. The check list was updated and will be validated daily on the 11:00 PM to 7:00 AM shift. Review of the check list on [DATE] revealed daily signatures by licensed staff on the 11:00 PM to 7:00 AM shift. Interview with LPN #1, on [DATE] at 2:55 PM, verified she had inspected the crash carts on [DATE]. She revealed the carts will be inspected daily by the night shift nurse and documented on the check list. 5. Review of the Code Blue Drill audit revealed a drill was completed, on [DATE], by the ADON on all shifts and weekly drills are being completed through [DATE]. Monthly drills are scheduled to start [DATE] and will be completed by [DATE]. Interview with the ADON, on [DATE] at 9:45 AM, revealed a Code Blue drill was conducted by her on [DATE] and drills are being done weekly on varied shifts by the ADON, the Nurse Practice Educator (NPE) and Center Nurse Executive (CNE). 6. Documented interviews of interviewable residents were reviewed and determined to have been completed by the Social Service Director. There were thirty-one (31) interviewable residents with two (2) refusing to participate. The interviews were directed to care by care givers, not receiving care, whom to report to if they were feeling abused/neglected. No concerns were identified. Concerns identified not related to abuse neglect were resolved through the grievance process. Interview with the SSD, on [DATE] at 11:15 AM, revealed she conducted interviews with all interviewable residents on [DATE] and no concerns were identified related to abuse or neglect. She did resolve some grievance issues about other things that came from the interviews. 7. Review of body audits of non interviewable residents were completed by licensed nurses on [DATE]; and, there were no concerns identified. Two (2) new residents received base line audits and met with the Center Nurse Executive (CNE). Interview, on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE) revealed the skin assessments were divided and completed on [DATE] and two (2) new admissions were included. 8. Resident Progress Notes from [DATE] through [DATE], were reviewed for time and accuracy by the Center Nurse Executive (CNE). Review of the list of Progress Notes audited revealed no concerns. Interview with the Center Nurse Executive (CNE), on [DATE] starting at 9:00 AM, revealed she had completed the audit of Progress Notes with no concern identified. 9. The Manager of Clinical Operations educated the Center Executive Director (CED), and the Center Nurse Executive (CNE), then the Center Executive Director provided education to the Admissions Director, Director of Recreation, Payroll Benefits Coordinator, Director of Rehabilitation, and the Housekeeping/Laundry Supervisor on [DATE]. Post tests were given. The education included resident code status, the unresponsive resident, care plans and death pronouncement. Review of the tests revealed 100% passed with a 100%;

Based on interview, record review, review of facility policies, and review of the Emergency Medical System (EMS) records and hospital records, it was determined the facility failed to honor the explicit Advance Directive wishes of one (1) of twelve (12) sampled residents (Resident #1). Resident #1 had an Advanced Directive which specified he/she desired to be provided Cardio [MEDICAL CONDITION] Resuscitation (CPR) if cardiac or respiratory arrest occurred. However, on [DATE], Registered Nurse (RN) #1 and RN #2 failed to provide CPR for Resident #1 when he/she was found unresponsive and a Code Blue was called. 911 was called and the Emergency Medical Service (EMS) arrived to Resident #1's room at 6:16 PM finding the resident alone, unresponsive and no staff present. Paramedic #1 located RN #1 at the nursing station and requested the resident's code status and RN #1 revealed Resident #1 was a full code. CPR was initiated and the resident was transferred to the hospital. Resident #1 was pronounced dead at the hospital. The facility's failure to ensure residents' Advance Directives were honored has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE], and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE], as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Cardiac and/or Respiratory Arrest, last revised [DATE], revealed the facility supports the right of every resident to accept or decline cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. The Center will perform CPR on all residents, except in certain limited circumstances, unless there is a written physician's orders [REDACTED]. The policy also stated if a resident does not have a DNR order, CPR/Automated External Defibrillator (AED) certified staff will initiate CPR/AED and emergency medical services will be activated. The purpose of the policy was to ensure residents' wishes were followed in the event of [MEDICAL CONDITION]. Review of the facility's policy titled, Cardiac and/or Respiratory Arrest, last revised [DATE], revealed an un-witnessed arrest for residents without a DNR (Do Not Resuscitate), if there are no conclusive signs of death, to initiate actions for witnessed arrest which include: CPR/AED certified staff will initiate CPR/AED application. Call 911 and notify the primary physician. Designate an individual to record events on the CPR/AED Flow sheet. Continue CPR until one of the following occurs: Restoration of effective, spontaneous circulation; Care is transferred to a team providing advanced life support (EMS); The rescuer is unable to continue because of exhaustion, the presence of dangerous environmental hazards, or because continuation of the resuscitation efforts places others in jeopardy; or if State regulation allows licensed nurse to pronounce/certify death, for reliable and valid criteria indicating irreversible death are met, criteria of obvious death are identified, or criteria for termination of resuscitation are met; When EMS personnel arrive, they assume responsibility. Treatment will be directed by EMS personnel; Notify the family/health care decision maker of the patient's status. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 with severe cognitive impairment and required total assistance with all activities of daily living. Further review of the record revealed there was no Advanced Directive in the record. However, the resident's record had a green sticker that indicated the resident was a full code and review of the Comprehensive Care Plan, dated [DATE], revealed the resident desired to be a full code (perform CPR and and activate 911) in the event respiratory or [MEDICAL CONDITION] occurred. The intervention was Activate resident's Advanced Directive as indicated. Review of Nurses' Notes, dated [DATE] at 6:01 PM, and interviews with Registered Nurse (RN) #1 on [DATE] at 1:50 PM, RN #2 on [DATE] at 10:12 AM, Certified Nurse Aide (CNA) #1 on [DATE] at 3:00 PM, and CNA #2 on [DATE] at 10:50 AM, revealed on [DATE] at approximately 6:01 PM, CNA #1 and #2 found Resident #1 unresponsive. The CNAs called RN #1 who initiated a Code Blue by announcing Code Blue on the intercom and calling 911 (Emergency Medical System) at 6:06 PM, for an ambulance. RN #1 returned to Resident #1's room where RN #2 had arrived to respond to the code. RN #1 and RN #2 discussed Resident #1's full code status, but felt the resident had expired and they (Registered Nurses) did not initiate rescue ventilations or chest compressions. RN #2 then returned to her workstation located by the ,[DATE] Hall and RN #1 went to the 100 Hall nursing station to make notifications. Interview with Paramedic #1, on [DATE] at 11:55 AM, and review of the EMS run report, dated [DATE], revealed EMS arrived to the resident's room at 6:16 PM finding the resident alone, unresponsive, not breathing, and there was no staff present. Paramedic #1 located RN #1 at the nursing station and requested the resident's code status. RN #1 informed the EMS the resident was a full code. Paramedic #1 asked why CPR was not being performed on the resident and RN #1 replied the code was stopped due to the resident not having a pulse. RN #1 walked away from Paramedic #1 without response when he asked who authorized the code to be stopped. Paramedic #1 returned to Resident #1 where he and Emergency Medical Technicians (EMT) #1 and #2 initiated CPR. The resident's airway was patent and clear, breathing and pulses were absent and there was a long capillary refill time. The resident's skin was warm, pale and pupils were non reactive. Extremities were flaccid. Resident #1 was transported to the emergency room via ambulance. EMS staff initiated Intravenous (IV) treatment enroute to the emergency room ; and [MEDICATION NAME] (for cardiac stimulation) was administered three (3) times. Sodium [MEDICATION NAME] (alkalinizing agent used for [MEDICAL CONDITION]) was administered one (1) time prior to arrival to the hospital. Review of hospital records, dated [DATE], revealed Resident #1 was admitted to the Emergency Department (ER) on [DATE] at 6:48 PM. The ER record revealed CPR continued with an additional [MEDICATION NAME] injection given at 6:48 PM, and noted the resident's pacemaker was firing at a rate of 110 beats per minute, however, the resident was pronounced dead at 6:51 PM. Further interview with RN #1, on [DATE] at 1:50 PM, revealed when she entered Resident #1's room, Resident #1's tongue was to the side, pupils were big and in her heart she knew Resident #1 was dead. She stated after calling the code and 911, she returned to the room and RN #2 stated, Do you really want to do this to (him/her)? (meaning CPR). RN #1 stated she picked up the resident's hand and it was dark and discolored with no capillary refill so she and RN #2 looked at their watches and agreed the time of death was 6:08 PM. RN #1 stated when EMS arrived the Paramedic asked why CPR was not being done on the resident and stated she did not think she answered because there was no pulse, but thinks that is what the Paramedic said she said. RN #1 stated the Paramedic asked a second time why the CPR was stopped and she didn't have an answer for him. RN #1 stated, I regret walking out of the room, I know in my mind if I brought (him/her) back, (he/she) would have nothing in (his/her) mind. Interview with RN #2, on [DATE] at 10:12 AM, revealed the resident was blue around the mouth and felt cold when she touched the resident's chest when she checked for breathing. She stated when RN #1 returned from calling 911 and checking to see if the resident was a full code, she and RN #1 discussed CPR. RN #2 stated she asked RN #1, Are we doing this because (he/she) is gone. RN #2 stated there was nothing they could do. She stated RN #1 said No, let (him/her) be. She (RN #2) stated, You have to make a decision about the quality of (his/her) life. RN #2 stated Resident #1 had no respirations, no pulse, was cyanotic around the mouth, and was stiff with rigor when they rolled him/her to place him/her on the back board, and the resident rolled all together like a log. Interview with CNA #1, on [DATE] at 3:00 PM, revealed RN #1 and RN #2 discussed the resident's code status and RN #2 asked RN #1 Do you really want to crack the ribs? It's obvious (he/she) is dead. She stated RN #1 and RN #2 did not start rescue ventilations or chest compressions. Interview with CNA #2, on [DATE] at 10:50 AM, revealed she opened Resident #1's eyes and they were not moving and the pupils were big. She stated Resident #1's skin was warm and she told RN #1 to call a Code Blue. CNA #2 stated RN #2 asked RN #1 who was going to do compressions and they discussed CPR and one of the RNs said Let's agree that we did the CPR and be done with it. CNA #2 stated she had touched Resident #1's chest and it felt warm and the resident's tongue was not sticking out and the resident was slobbering. Further review with Paramedic #1, on [DATE] at 11:55 AM, revealed Resident #1 was not cold. The resident was warm and pale and he did not see any cyanosis. He stated there was no rigor in the resident and no lividity (bluish discoloration). Interview with the Administrator, conducted on [DATE] at 1:25 PM, revealed RN #1 and RN #2 did not initiate chest compressions or rescue ventilations because they determined there was an indication of irreversible death and they pronounced Resident #1 dead. She stated RN #1 worked the 100 Hall where Resident #1 resided and was not current in CPR certification. RN #2 worked the ,[DATE] Hall on the opposite side of the building, and was current in CPR certification. The Administrator felt the nurses did not provide CPR because they felt there were signs of irreversible death and RN #1 had documented pupils dilated, fixed, tongue displaced and skin cool to touch and hands mottled (discolored). The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (76 of 76) by a licensed nurse and/or the Director of Social Services on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical POA wishes. No concerns were identified. 2. All resident care plans (76 of 76) were audited by a licensed nurse or Social Service Director (SSD) on [DATE] and [DATE] to determine that resident code status was on the resident's plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. The facility's policy revealed that CPR certified staff would be on duty at all times. Beginning on [DATE] and ending on [DATE], all facility staff personnel files (82 of 82) were reviewed by the Payroll Benefits Coordinator to identify and track who held a current CPR certification as indicated by a current CPR card. Contract staff including housekeeping, laundry and therapy were not considered to meet this requirement. Corrective action included contacting the employee to determined if he/she had a current CPR certification with proof to be provided and placed in the certification book. The Payroll Benefits Coordinator, Center Nurse Executive (CNE), Center Executive Director (CED), Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE) or Receptionist will obtain a copy of the employee's CPR card to verify active dates and place in the certification book and/or personnel file. Beginning on [DATE] and completed on [DATE], the facility's schedule was reviewed for the past thirty (30) days by the Payroll Benefits Coordinator to validate that at least one (1) CPR certified staff member was on duty at all times. All CPR certified staff was listed and placed in the staffing book at each nurse's station. The master nursing schedule is highlighted by the Payroll Benefits Coordinator to ensure CPR certified staff will be on duty at all times per facility policy. The Charge Nurse will review daily to validate CPR certified staff are scheduled with corrective action upon discovery. Facility staff obtained CPR certification independently of the facility through approved programs. The facility requires CPR certified staff to obtain CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessments. 4. Two (2) of the two (2) emergency crash carts were reviewed on [DATE] by a licensed nurse on the front nurses' station; and, on [DATE] by the Clinical Reimbursement Coordinator on the back nurses's station to validate all items on the emergency cart daily check list form were available and in working order. No concerns were identified. 5. A Code Blue drill was conducted on [DATE] by the ADON for the 7:00 AM to 3:00 PM shift; and, on [DATE] for the 11:00 PM to 7:00 AM, and 3:00 PM to 11:00 PM shifts. The facility's Executive Nurse, ADON, Nurse Practice Educator (NPE) or Regional RN support staff will continue drills weekly for four (4) weeks to include weekends using different scenarios to audit individual critical thinking skills and validate that Cardiac and/or Respiratory arrest procedures are followed. Any issues identified will be immediately addressed. Audits will continue monthly for five (5) months, then as determined by the Quality Improvement Committee. 6. On [DATE], all alert and oriented residents (31 of 72) with a BIMS score of eight (8) or greater were interviewed by the Director of Social Services to determine if the resident felt abused and/or neglected. The interviews included questions regarding: concerns related to care provided by any caregiver, concerns with not receiving care and services needed and who to report to if they felt abused or neglected. No concerns specifically regarding abuse or neglect were identified. Any other concerns were addressed through a formal grievance process by the Director of Social Services immediately upon discovery. 7. On [DATE], residents with a BIMS score lower than eight (8) or who declined to participate in the interview process (39 of 72) received a body audit performed by the licensed nurse to identify any physical signs of abuse or neglect including a change in mood or behavior. No concerns were identified. On [DATE], residents who were admitted to the facility that day (2 of 72) received a baseline body audit performed by a licensed nurse. The Center Executive Director or the Center Nurse Executive met with each resident and informed him/her of who to contact if they felt abused or neglected during their stay. 8. The Center Nurse Executive, ADON, Nurse Practice Educator (NPE) or Licensed Nurse reviewed all current resident Progress Notes from [DATE] for timeliness and accuracy. No concerns were identified. 9. Education was provided for all staff on two (2) separate occasions, defined in the following timeline: On [DATE], the Manager of Clinical Operations provided re-education to the Center Executive Director, Center Nurse Executive and ADON; then the Center Executive Director provided re-education to the Health Information Director, Admissions, Maintenance Director, Director of Recreation, Payroll/Benefits Coordinator, Director of Rehab and Housekeeping/Laundry Supervisor on [DATE]. A post-test with a required score of 100% was included which was graded by the Center Executive Director. The Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive, or Center Executive Director provided re-education to all non-licensed staff on [DATE] through [DATE]. A post-test with a required score of 100% was included which was graded by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive or Center Executive Director (57 of 59). All staff not available for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * How to quickly locate a resident's code status. * Procedure for identifying a resident unresponsive. * Policy NSG102 Care plans including development, communication & implementation. * Death pronouncement and Certification by State. 10. The Nurse Practice Educator (NPE), Center Nurse Executive, ADON or Registered Nurse provided re-education to the licensed staff (RNs & LPNs) from [DATE] to [DATE]. All licensed staff completed a post-test with a required score of 100% which was graded by the Nurse Practice Educator, Center Nurse Executive, ADON, Center Executive Director or Registered Nurse (22 of 23). All staff not available for re-education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: * Policy NSG107 and procedure for Emergency Medical Response. * Policy NSG 208 and procedure for Cardiac and/or Respiratory Arrest. * Specific instruction will be provided to include evaluation of signs of irreversible death. * Policy NSG 102 Care Plans including development, communication & implementation. * Death pronouncement and certification by State. 11. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all non-licensed staff to include contract employees (31 of 59). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All staff not available for re-education will be provided the education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse and Neglect Prohibition - State of Kentucky. 12. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), ADON or Center Nurse Executive provided re-education to all licensed staff (18 of 23). A post-test with a required score of 100% was included which was graded by the Nurse Practice Educator (NPE). All licensed staff not available for re-education will be provided the re-education prior to initiating work assignments and new staff will be educated during his/her orientation process. The education included: * Policy NSG102 Care Plans including development, communication & implementation and following the care plan for Advanced Directives. * Policy OPS310 Abuse & Neglect Prohibition - State of Kentucky. * Policy NSG4.20 Charting Errors and/or Omissions including late entries. 13. Beginning on [DATE] through [DATE], the Nurse Practice Educator (NPE), Center Nurse Executive, ADON, RN MDS Coordinator or RN provided education to all licensed staff (6 of 23). All licensed staff not available for education will be provided education prior to initiating work assignment and new staff will be educated during his/her orientation process. The education included: In the event there is not a Registered Nurse (RN) available to pronounce death, the Licensed Practical Nurse (LPN) must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. 14. Beginning [DATE], the Health Information Manager, Center Nurse Executive, ADON, RN, LPN, Certified Nursing Executive, Executive, Admissions Director, Payroll Benefits Coordinator and/or Social Services Director will interview at least five (5) non-licensed staff and/or CNAs daily, across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Where a resident's code status can be quickly located * Response steps for a non-licensed staff. * Articulate the purpose of a resident care plan/care card. * Articulate the definition of neglect and appropriate * Reporting steps. Following the initial fourteen (14) days, five (5) non-licensed staff and/or CNAs will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the Quality Improvement (QI) Committee with corrective action upon discovery. 15. Beginning [DATE], the Center Executive Director, Center Nurse Executive, Nurse Practice Educator (NPE), ADON and/or Licensed Nurse will interview at least three (3) licensed staff (RN or LPN), across all shifts for fourteen (14) days to include weekends to validate that he/she can state the following: * Expected medical response to an emergency. * Process steps expected in response to a Cardiac and/or Respiratory Arrest. * Signs of irreversible death. * Where a resident's code status can be quickly located. * Kentucky requirements related to death pronouncement. * Articulate the definition of neglect and appropriate reporting steps. * Definition of a complete medical record. Beginning [DATE], the interview tool will include validation of understanding that in the event an RN is not available to pronounce death, the LPN must notify an RN or Physician to come to the facility to pronounce and sign the KY Provisional Report of Death form in the Facility Note section before the body can be released to the Funeral Home. Following the initial fourteen (14) days, three (3) licensed staff will be interviewed three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 16. Beginning [DATE], the Center Nurse Executive, ADON, Nurse Practice Educator (NPE), or Licensed Nurse will audit all nursing progress notes associated with unplanned transfers and associated care plans daily for fourteen (14) days to include weekends to validate: * Advanced Directives are honored according to the care plan. * Goods and services provided as necessary to avoid mental anguish and physical harm according to the Advanced Directive in the event that CPR is indicated. Following the initial fourteen (14) days, unplanned transfers will be audited three (3) times per week for four (4) weeks, then weekly for four (4) weeks, then monthly for four (4) months then as determined by the QI Committee with corrective action upon discovery. 17. Audit results will be brought to the QI Committee by the Center Nurse Executive, Center Executive Director, or Licensed Nurse until the issue is resolved and ongoing thereafter. The QI Committee consists of at least the Medical Director, Center Nurse Executive, Center Executive Director, Social Service Director, Maintenance Director, Health Information Manager, ADON, Business Office Manager, and the Nurse Practice Educator. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of an audit log, dated [DATE], revealed the Social Service Director (SSD) and an LPN reviewed all residents' records related to Advanced Directives to ensure clear documentation related to Advanced Directives. 2. All care plans were also audited by SSD and check off sheets were verified to ensure residents' code status were on the care plan. Interviews, on [DATE] with the SSD at 11:15 AM, and LPN #1 at 2:55 PM, revealed all resident records related to Advanced Directives were reviewed on [DATE] to verify documentation and care plans were also audited to ensure code status was addressed. 3. Review of the log book that was implemented to verify which licensed staff was current revealed all current CPR certified staff was verified by the Payroll Benefits Coordinator on [DATE]. The log book was tabbed by month to indicate when certifications will expire. Observation on [DATE], revealed a current CPR certification list was located on each of the two (2) nursing stations. Interview conducted with the Center Nurse Executive (CNE), on [DATE] at 9:00 AM revealed CPR status was verified by the Payroll Benefits Coordinator on [DATE] and a log book was implemented to maintain current CPR certification of staff and when certifications will expire. A system to address and ensure coverage of CPR certified staff on duty was implemented. 4. Crash carts were reviewed by LPN #1 on [DATE]. The check list was updated and will be validated daily on the 11:00 PM to 7:00 AM shift. Review of the check list on [DATE] revealed daily signatures by licensed staff on the 11:00 PM to 7:00 AM shift. Interview with LPN #1, on [DATE] at 2:55 PM, verified she had inspected the crash carts on [DATE]. She revealed the carts will be inspected daily by the night shift nurse and documented on the check list. 5. Review of the Code Blue Drill audit revealed a drill was completed, on [DATE], by the ADON on all shifts and weekly drills are being completed through [DATE]. Monthly drills are scheduled to start [DATE] and will be completed by [DATE]. Interview with the ADON, on [DATE] at 9:45 AM, revealed a Code Blue drill was conducted by her on [DATE] and drills are being done weekly on varied shifts by the ADON, the Nurse Practice Educator (NPE) and Center Nurse Executive (CNE). 6. Documented interviews of interviewable residents were reviewed and determined to have been completed by the Social Service Director. There were thirty-one (31) interviewable residents with two (2) refusing to participate. The interviews were directed to care by care givers, not receiving care, whom to report to if they were feeling abused/neglected. No concerns were identified. Concerns identified not related to abuse neglect were resolved through the grievance process. Interview with the SSD, on [DATE] at 11:15 AM, revealed she conducted interviews with all interviewable residents on [DATE] and no concerns were identified related to abuse or neglect. She did resolve some grievance issues about other things that came from the interviews. 7. Review of body audits of non interviewable residents were completed by licensed nurses on [DATE]; and, there were no concerns identified. Two (2) new residents received base line audits and met with the Center Nurse Executive (CNE). Interview, on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE) revealed the skin assessments were divided and completed on [DATE] and two (2) new admissions were included. 8. Resident Progress Notes from [DATE] through [DATE], were reviewed for time and accuracy by the Center Nurse Executive (CNE). Review of the list of Progress Notes audited revealed no concerns. Interview with the Center Nurse Executive (CNE), on [DATE] starting at 9:00 AM, revealed she had completed the audit of Progress Notes with no concern identified. 9. The Manager of Clinical Operations educated the Center Executive Director (CED), and the Center Nurse Executive (CNE), then the Center Executive Director provided education to the Admissions Director, Director of Recreation, Payroll Benefits Coordinator, Director of Rehabilitation, and the Housekeeping/Laundry Supervisor on [DATE]. Post tests were given. The education included resident code status, the unresponsive resident, care plans and death pronouncement. Review of the tests revealed 100% passed with a 100%; the test was graded by the Executive Director. Interview, conducted on [DATE] at 9:00 AM, with the Center Nurse Executive (CNE), revealed she received education from the Manager of Clinical Operations on [DATE] and passed a post test with 100%. Interviews, on [DATE] at 11:03 AM with the Admissions Director, 10:01 AM with the Housekeeping/Laundry Supervisor, and the Nurse Practice Educator (NPE), revealed they had received the education and it was about locating a resident's code status, identifying an unresponsive resident, care plans and death pronouncement. Review of education that was provided to non-licensed staff by the Admissions Director, Recreation Director, Housekeeping/Laundry Supervisor, Center Nurse Executive (CNE) and Executive Director on [DATE] through [DATE]. The post test required 100% and was graded by the Admissions Director. Two (2) staff, the Dietary Manager and Activity staff were the only remaining staff not provided the training and will receive the training prior to initiating any assignment on return to work. That education included how to locate code status, procedure for identifying a resident unresponsive, Policy NSG102 Care Plans and Death Pronouncement and Certification by State. Review of the POS [REDACTED]. Interviews on [DATE] with the Admissions Director at 11:03 AM, Restorative Aide #1 at 10:29 AM, CNA #5 at 10:24 AM, Dietary Aide #1 at 10:19 AM, the Housekeeping/Laundry Supervisor at 10:01 AM, and CNA #4 at 9:40 AM, revealed they had received education related to a resident's code status and where to find that information, related to unresponsive resident and what to do, care plans and death pronouncement by the RN. 10. Review of documented education and post tests, on [DATE], revealed 22 of 23 RNs and LPNs were educated by the Nurse Practice Educator (NPE), Center Nurse Executive (CNE), and ADON on [DATE] through [DATE]. All had post test with 100% pass rate graded by the Nurse Practice Educator (NPE), CNA, and ADON. One (1) licensed staff remains to be re-educated. The Scheduling Supervisor is to ensure that education is completed when that staff returns. Review of the education revealed it included Policy NSG 107 related to the procedure for Emergency Medical Response, Policy NSG 208 for cardiac and/or respiratory arrest, specific instructions which included evaluation of irreversible death and care plans policy NSG 102 related to care plan development, implementation and communication and death pronouncement. Interviews on [DATE] with RN #2 at 10:36 AM, LPN #3 at 10:13 AM, LPN #2 at 9:48 AM, RN #3 at 9:02 AM, and the Clinical Reimbursement Coordinator (CRC) at 10:50 AM, revealed they had education related to emergency medical response, cardiac and respiratory arrest, irreversible death and care plans. They were required to pass a post test with 100%. 11. Review on [DATE] of education and post tests of non-licensed staff and contract employees revealed 31 of 59 had completed the education. All staff not available for re-education will be provided that education prior to initiating work assignment and new staff will be educated during orientation. Review of the education revealed Policy NSG 102 related to care plans for Advanced Directives, Policy OS310 related to abuse/neglect was provided by the Nurse Practice Educator (NPE), ADON, Center Nurse Executive (CNE). Review of the POS [REDACTED]

Based on interview, record review, and facility policy review, it was determined the facility failed to provide appropriate treatment and services to identify complications of an indwelling urinary catheter related to a Urinary Tract Infection [MEDICAL CONDITION] for one (1) of fourteen (14) sampled residents (Resident #3). On 07/04/15, Resident #3 was hollering and complaining of pain related to an indwelling catheter most of the day. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to assess the resident's catheter and catheter pain. They failed to assess the resident's urine output, the amount, color, consistency and odor of urine. At 9:00 PM, RN #3 assessed the resident and identified the resident had no urine output, his/her bladder was distended and was complaining of pain due to the catheter. RN #3 removed water from the catheter bulb, the catheter popped out and the resident had a brown, bloody drainage. RN #3 sent the resident to the emergency room and the resident was identified as having a UTI. The facility's failure to provide appropriate treatment and services to identify complications of an indwelling urinary catheter has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 09/08/15 and determined to exist on 07/04/15. The facility was notified of the Immediate Jeopardy on 09/08/15. An acceptable Allegation of Compliance (AoC) was received on 09/17/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/18/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Catheter: Indwelling Urinary - Care of, last revised 01/02/14, revealed that any abnormal findings should be reported to the nurse or physician/mid-level provider. Documentation should include any abnormal findings and physician/mid-level provider notification, if indicated. Review of the facility's policy titled, Assessment: Nursing, dated 01/02/14, revealed routine and focused assessments should be performed on an ongoing basis, as needed. The purpose of the assessment is to determine a resident's condition and clinical needs. Record review revealed the facility admitted Resident #3 on 04/29/15 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set Assessment, dated 07/28/15, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. The resident had an indwelling urinary catheter. Review of the Comprehensive Care Plan for the indwelling catheter, dated 05/07/15, revealed interventions for staff to record output; monitor for signs and symptoms of infection and report to physician; and monitor output for odor, color, consistency and amount. Interview with Resident #3, on 08/04/15 at 9:10 AM, revealed he/she had been in pain all day on 07/04/15 related to his/her catheter. The resident stated he/she told LPN #1 and the LPN stated he/she had been medicated already. The resident said when the night nurse (RN #3) came in that night, she called the ambulance and the resident was transported to the emergency room . Review of Nurses Notes, dated 07/04/15, revealed there was no documented evidence RN #1 and/or LPN #1 assessed Resident #3's indwelling urinary catheter related to the catheter pain. Review of the July 2015 Treatment Administration Record (TAR) for Resident #3 revealed staff was to monitor the resident's urinary output every shift for retention. There was documentation noted for 07/01/15, but the remainder of the empty boxes had a line drawn through with a note to, See ADL Book. There was no documented evidence of a catheter assessment every shift. Review of the Intake and Output document, dated July 2015, revealed documentation that Resident #3 had 400 milliliter (ml) output on 07/03-04/15, on the 11:00 PM-7:00 AM shift; I/C (indwelling catheter) documented with no amount indicated on 07/04/15, 7:00 AM-3:00 PM; and, 400 ml output on 07/04/15, 3:00 PM-11:00 PM shift. Review of a Nursing Note, dated 07/04/15 at 9:54 PM and 10:00 PM, revealed Resident #3 complained of pain with urination, with the presence of a indwelling urinary catheter to bedside drainage. RN #3 observed that the resident's skin was cool and clammy and his/her face was red. The resident continued to yell stating it hurts down there and the resident clarified that it hurt, Where I pee. The nurse took a syringe to check for proper placement of the catheter and the resident yelled louder with pain and stated, take out. The bulb was deflated, the resident yelled and the catheter came out of the urethra. The resident continued to yell and voided thick, brownish urine. The resident then voided bright red blood. RN #3 was unable to contact the physician so she called the Assistant Director of Nursing (ADON) and the resident was sent to the emergency room . Review of the Admission History and Physical , dated 07/05/15, revealed Resident #3 presented to the emergency room with a chief complaint of hematuria (blood in urine). Laboratory studies revealed a urinalysis with White Blood Cells (WBC's) too numerous to count (TNTC) (normal: Negative), Red Blood Cells TNTC (normal: Negative), four plus (4+) bacteria (normal: Negative), turbid, positive [MEDICATION NAME] (normal: Negative) and large leukocyte esterase (normal: Negative). The Complete Blood Count revealed an elevated reading of 11.39 (normal: 3.5 to 10.5 billion cells per liter). The resident was admitted from the emergency room with a [DIAGNOSES REDACTED]. Review of the Discharge Summary, dated 07/08/15, revealed Resident #3 was discharged to return to the facility on [DATE]. The resident would continue to receive intramuscular doses of [MEDICATION NAME] one (1) Gram every twenty-four (24) hours with the final dose to be administered at 9:00 PM on 07/14/15. Interview with State Registered Nurse Aide (SRNA) #3, on 08/04/15 at 11:40 AM, revealed she worked 7:00 AM to 3:00 PM on 07/04/15. She stated Resident #3 was complaining of pain where the catheter goes in. She said RN #1 was made aware of the resident's complaints of pain and the RN checked the catheter and the drainage bag and said the resident was fine, maybe a UTI . The SRNA stated she was giving the resident a bath and the resident continued to yell that he/she was hurting and burning in the penis area. The SRNA stated she checked everything, the tubing was clear and the resident requested to stay in bed. Further interview (Post Survey) with CNA #3, on 08/14/15 at 2:40 PM, revealed she looks for signs of irritation, discoloration in the urine and if there was urine in the drainage bag. She revealed catheters were emptied and the amount recorded at the end of the shift. She stated she emptied Resident #3's catheter bag around 2:00 PM on 07/04/15, but she did not recall how much urine was in the bag. She said she recorded IC on the flow sheet because they used to write the amount of urine output on a piece of paper and give it to the nurse so it could be recorded on the TAR. She stated she was not aware at the time she was supposed to document the amount of urine emptied from the bag. Interview with SRNA #1, on 08/04/15 at 5:10 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 07/04/15. She stated when she came into work that day, Resident #3 was in a wheelchair in the lobby area with other residents and was irritated and yelling out. SRNA #1 stated RN #1 and LPN #1 reported the resident had been yelling all day. The SRNA stated the resident was screaming as if in pain and his/her face was red. SRNA #1 said when she asked the resident where the pain was, the resident pointed downward to his/her private area and said pee pee. She stated the resident requested medication for pain and she made LPN #1 aware, but the LPN told her the resident had already been medicated and that the resident was just trying to go out to the hospital. The SRNA stated the resident was sweating while being transferred by lift, to the bed. She stated LPN #1 kept telling the resident, You are not going to the hospital. The SRNA revealed when she entered the resident's room around 9:00 PM, RN #3 pulled the resident's covers back and there was urine on the bed sheets and when the catheter came out, the urine kept coming out. The SRNA stated RN #3 sent the resident to the hospital. Attempts at interviewing LPN #1, on 08/05/15 at 12:48 PM and on 08/06/15 at 12:08 PM, were unsuccessful. Interview with RN #1, on 08/04/15 at 3:15 PM, revealed Resident #3 was hollering so she and LPN #1 placed the resident back to bed. RN #1 stated the resident did not complain of pain and/or request to go to the hospital. She stated the SRNA never reported the resident was in pain and/or wanted to go to the hospital due to the resident's catheter. RN #1 revealed licensed staff should assess catheters each shift and as needed and document it on the TAR; however, further review of the July 2015 TAR revealed there was no documentation on the TAR that indicated Licensed staff had assessed Resident #3's catheter on 07/04/15. Interview, on 08/04/15 at 5:40 PM, with SRNA #2, who worked the 3:00 PM to 11:00 PM shift on 07/04/15, revealed RN #3 called him into the room around 9:00 PM and Resident #3 was complaining of hurting and was hollering loudly. SRNA #2 stated when RN #3 took the catheter out, there was blood, urine and gooey pus and a lot of blood and the resident said that he/she wanted to go to the hospital. SRNA #2 said the resident's skin was very clammy and cold to touch. Interview with RN #3, on 08/04/15 at 2:35 PM, revealed she had worked on 07/04/15 on the 7:00 PM-7:00 AM shift. She stated RN #1 reported to her that Resident #3 had complained all day long of having pain on urination and was told by the nurse that he had a catheter and shouldn't be hurting. RN #3 revealed she entered Resident #3's room and Resident #3 kept telling her that he/she was in severe pain and kept grabbing the catheter saying that he/she couldn't pee. RN #3 stated the resident's catheter drainage bag was empty and his/her bladder was distended so she secured a syringe to flush the catheter. She stated she let out a little of the water from the bulb and the resident screamed in pain and the catheter shot out. She revealed there was a brown, thick, substance coming out of the resident's urethra and then the resident voided straight blood. She stated at that time the resident was begging to be sent to the hospital so the nurse attempted to reach the on call physician but was unable to reach him so she phoned the Assistant Director of Nursing (ADON) and got permission to send the resident to the hospital. She stated she learned later in the evening the resident was being admitted for a Urinary Tract Infection [MEDICAL CONDITION]. Interview with the former Assistant Director of Nursing (ADON), on 08/05/15 at 9:20 AM, revealed RN #3 phoned saying she wanted to send Resident #3 to the emergency room . She stated RN #3 stated the resident had no output, the balloon was deflated and the resident had relief; however, the resident continued to ask RN #3 to go to the hospital and she was unable to contact the physician. The ADON said he told RN #3 to send the resident to the emergency room . The ADON reported he was not sure why LPN #1 didn't do a more thorough assessment of Resident #3, but thanked RN #3 for assessing the resident and putting his/her safety first. The ADON revealed he would expect the staff to assess the resident for pain/catheter. Interview with the Director of Nursing (DON), on 08/06/15 at 2:39 PM, revealed she would expect staff to assess the residents for pain and to attempt to find the root cause for the pain. The staff would also need to notify the physician of any concerns identified. Interview with the Physician/Medical Director of the facility, on 08/07/15 at 8:21 AM, revealed he would expect the facility staff to assess residents for pain and take the appropriate action. If staff was unable to reach the physician, it would be appropriate to send the resident to the emergency room . The physician reported that complications from not assessing the resident could be increased pain from a distended bladder. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was transferred to the hospital on [DATE] at 10:15 PM by RN #3 immediately upon assessment of the catheter in order to address Resident #3's complaints of pain. 2. Resident #1 was readmitted to the facility on [DATE] at 5:12 PM with no orders to remove the speaking valve. Resident #3 continued to have a urinary catheter due to [MEDICAL CONDITION] bladder as assessed by the Physician related to a stroke on 04/30/15. 3. Resident #3's [MEDICAL CONDITION] was removed on 08/24/15 by the Respiratory Therapist. 4. Resident #3's urinary catheter was discontinued by the physician on 08/10/15 and removed by the licensed nurse on that date. 5. As of 08/27/15, there were no residents in the center with a [MEDICAL CONDITION]; therefore, no potential exists for issues relating to tracheostomies at this time. 6. On 08/25/15, the center had three (3) of seventy-eight (78) residents who utilized a catheter. The DON assessed these three (3) residents on 08/25/15 for signs/symptoms of a urinary tract infection and assessed for pain. One (1) resident with a catheter was identified as having pain. The physician was notified and new orders were obtained for a urinalysis (UA) and culture and sensitivity (CNS) and antibiotic treatment was based on the preliminary analysis. The antibiotic therapy was completed on 08/31/15. 7. On 08/21/15, the three (3) residents utilizing catheters were reviewed by a RN to validate physician's orders [REDACTED]. No concerns were identified. 8. On 08/21/15, a RN reviewed all resident records (79 of 79) (census fluctuated) to validate the MAR and/or Treatment Administration Record (TAR) reflected daily pain monitoring, which included a care plan review. No concerns were identified. 9. On 08/27/15, all resident records (78 of 78) (census fluctuated) were reviewed by the Director of Health Information Management to validate a PRN (as needed) Pain Management Flow Sheet was present for each resident which included a care plan review; no concerns were identified. 10. On 08/28/15, a RN reviewed residents listed on a change of condition report for the period between 08/07/15-08/28/15. Twenty-two (22) of seventy-seven (77) (census fluctuated) residents were reviewed to determine if residents were assessed for the presence of pain; and, if pain interventions were initiated upon the identified change of condition, which included a care plan review; no concerns were identified. 11. Beginning on 08/28/15 through 09/03/15, an RN reviewed all residents receiving PRN pain medication to validate accuracy of the physician's orders [REDACTED]. Order clarification needs were identified as requiring the specification of mild, moderate, or severe indications. These identified clarification needs were reviewed with the Physician with corrective action initiated upon discovery. 12. The Administrator and DON participated in Corporate sponsored mandated reeducation via independent computer training. The Administrator completed training on 07/07/15 and the DON completed training on 09/02/15. This education was on the Code of Conduct related to meeting professional standards, complying with regulatory guidance, and exercise of good judgement regarding how best to uphold ethical behavior every day. In addition, the code included measuring clinical outcomes and resident satisfaction to confirm quality goals are met and focus and discipline on improving quality of care. Creativity and innovation to develop effective solutions. 13. All facility staff including Food Service Director, Cooks, and Cook Aides, SRNAs, LPNs, RNs, Social Services, Business Office Manager, Receptionist, Activities Director, Admissions Director, Medical Records, Payroll, Maintenance and Maintenance Assistant, Therapy Program Director, and Therapists participated in Corporate mandated Code of Conduct Training with a completion date of 09/17/15 (76 out of 110). On 09/17/15, this training will be completed with the contracted Housekeeping Supervisor and Housekeepers. Staff not available on 09/17/15 will be provided reeducation including competency and post-test by the Nurse Practice Educator (NPE) or RN with a pass rate of 100% prior to returning to work. In addition on 09/08/15, all were re-educated by the NPE on identification of all forms of abuse, including neglect, when to report suspicions of abuse, and reporting of suspicions of abuse, to include the chain of command, and the abuse prevention coordinator. This was completed on 09/14/15. Staff not available during this time frame (33 of 110) will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The NPE and DON were reeducated by the Manager of Clinical Operations on 08/26/15 and then the NPE, Consulting Respiratory Therapist or Regional Risk Manager, who was also an RN began reeducation on 08/26/15 through 09/04/15 with all licensed nurses which included RN #1 and RN #3, were provided with all reeducation. Twenty-three (23) of twenty-seven (27) RNs and LPNs were provided with the reeducation. RNs and LPNs not available during this timeframe will be provided the re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The above re-education included the following: A. Abuse and Neglect Policy which covered removing a Passey Muir speaking valve with return demonstration. All nurses educated verbalized and signed that they understood the removal of the valve to prevent a resident to speak is considered abuse. B. [MEDICAL CONDITION] policy and procedure. C. Timely review, revision and implementation of care plans and care cards to reflect response to care and changing needs and goals; a post test was used to validate learning. D. Pain assessment and administering mediation and treatments as prescribed by the physician and/or Nurse Practitioner, and/or per the care plan. Monitoring effectiveness, side effects, and non-verbal signs/symptoms of pain. Completion of pain assessment regarding PRN pain medication administration when receiving communication from another staff member who suspects a resident may be in pain. Learning was validated with a post-test. E. Ensuring assessment initiated for appropriate treatment and services to identify complications of an indwelling catheter related to UTI to include signs and symptoms of pain, assessing for discoloration and urine flow in the tubing and an attempt to find the root cause for the pain and take appropriate action. Learning was validated with post-test. On 09/17/15, all SRNA's will be provided with re-education on recognizing symptoms of any pain but specifically related to tracheostomies or urinary catheters, observations for discoloration of urine in urinary catheter or changes in urinary output related to catheters who to report these observations, when to report these observations, and what action to take if their concerns were not addressed. Learning will be validated via post-test graded by the NPE, DON, or RN with a 100% pass rate. SRNAs not available during this timeframe will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. 13. The DON, NPE, or Licensed Nurse will observe licensed nurse providing all aspects of [MEDICAL CONDITION] care including observing for sign/symptoms of pain or discomfort during the care or if resident with a [MEDICAL CONDITION] enters into the facility. This will include speaking valve treatment and orders, abuse related to removing it when not specifically ordered to do so and following the plan of care. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 14. The DON, NPE, or Licensed Nurse will observe for signs and symptoms of pain associated with indwelling urinary catheters and following the care plan related to urinary catheter use. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 15. The DON, NPE, or RN Supervisor or Charge Nurse will review residents with a change of condition and audit by head to toe assessment that the change of condition is accurately documented and followed up on timely daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 16. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview five (5) residents across all shifts to determine if they feel if a staff member abused them, to include all forms of abuse or neglect, of if they have witnessed any other resident being abused daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 17. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview three (3) staff members across all shifts to determine if they know or suspect any resident being abused that they have not reported daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 18. Beginning on 09/17/15, the Administrator, DON, NPE, RN Supervisor or Licensed Nurse will observe staff interaction including care of five (5) residents to visually determine that the care plan is being followed daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. On 09/18/15, review of Resident #3's Nurse's Notes revealed the resident was transported to the emergency roiagnom on [DATE] at 10:15 PM via ambulance. The resident was admitted with a [DIAGNOSES REDACTED]. 2. On 09/18/15, review of Resident #3's readmission orders [REDACTED]. There was no order written to remove the speaking valve. 3. On 09/18/15, review of Resident #3's physician's orders [REDACTED].#3's [MEDICAL CONDITION] was removed on 08/24/15. 4. On 09/18/15, review of Resident #3's physician's orders [REDACTED]. 5. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed as of 08/25/15 there were no other [MEDICAL CONDITION] residents. However, the facility reviewed their [MEDICAL CONDITION] care policy and procedures, including following physician's orders [REDACTED]. 6. On 09/18/15, review of documentation by the DON revealed the DON identified three (3) residents with an indwelling urinary catheter in the facility. She assessed the residents for signs and symptoms of an UTI and pain. She identified one of the residents had symptoms of a UTI . The Physician was notified and orders were received for a Urinalysis and C&S with antibiotic ordered. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE on 1:09 PM, revealed three (3) residents were assessed for Urinary Tract Infection symptoms and one (1) resident was started on an antibiotic which has since been completed. 7. On 09/18/15, review of documentation by the DON revealed on 08/21/15 an RN reviewed three (3) residents with indwelling catheters to validate the physician's orders [REDACTED]. The MAR contained instructions to assess every shift for the presence of pain. A Care Plan review was also completed. All with no concerns noted. 8. On 09/18/15, review of check sheets on 09/18/15 revealed the DON reviewed all seventy-nine (79) (census fluctuated) residents medical records to ensure the MAR and TAR reflected daily pain management. The Manager of Clinical Operations assisted with this and it was completed on 08/21/15. Interviews on 09/18/15 with the DON, at 12:52 PM and the Manager of Clinical Operations at 1:09 PM revealed they reviewed all seventy-nine (79) (census fluctuated) residents' records and ensured the MAR/TAR and care plan reflected daily pain management. 9. On 09/18/15, review of a check sheet and interview with the Director of Health Information at 1:09 PM revealed the Director of Health Information validated all resident records were complete with a pain management sheet on 08/27/15. 10. On 09/18/15, review of documentation revealed the Regional Risk Manager (who is an RN) and the DON reviewed all resident records for a change of condition on 08/28/15. A total of twenty-five (25) change of conditions were identified, none had a concern that was identified. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed audits for change of condition were completed and if there was a change of condition, a head to toe assessment was completed. 11. On 09/18/15, review of an Order Listing Report, revealed all PRN (as needed) pain medications were reviewed to validate the order accuracy and the Care Plan was reviewed on 09/03/15. In addition, MILD, MODERATE or SEVERE was included on the order to print on the MAR. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed orders were reviewed for accuracy. No concerns were identified. 12. On 09/18/15, review of the Code Of Conduct Signature Sheets verified that mandated education via computer independent training was completed on 07/07/15 by the Administrator and by the DON on 09/02/15. The training included Code of Conduct, how it related to staff positions, all were expected to meet Professional Standards, comply with Regulatory guidance and exercise judgement on how to best uphold ethical behavior every day. The Code also included measuring clinical outcomes, patient satisfaction to confirm goals are met. Additionally, it included focused discipline on improving the Quality of Care, creativity and innovation to develop effective solutions. Interviews on 09/18/15 with the DON at 12:52 PM and the Administrator at 12:04 PM verified they received this training. On 09/18/15, review of the acknowledgement signature forms revealed facility staff except housekeeping, (who is contract) completed the Code of Conduct computer training on 09/17/15, except for ten (10) staff that have not completed the training and those staff will complete the training before returning to work. All housekeeping staff completed the inservices manually on 09/17/15 and signed acknowledgement forms. Further review of signature validation sheets and post tests revealed all facility staff received education by the NPE on the facility's Abuse/Neglect policy and procedure to include the forms of abuse and neglect, when to report, and including following the chain of command from 09/08/15-09/14/15. On 09/14/15, there were thirty-three (33) staff remaining to be educated and they will complete the training before being allowed to care for residents. On 09/18/15, review of signature validation sheets and post tests validated the NPE and the DON were re-educated by the Manager of Clinical Operations on 08/26/15. Further review of the signature validation sheets revealed the NPE, Consulting Respiratory Therapist or Regional Risk Manager also reeducated all licensed nurses on 09/02/15 related to the Passey-Muir speaking valve, the Abuse/Neglect policy, [MEDICAL CONDITION] care policies and procedures, following MD orders, timely review of revision of Care Plan implementation and care cards, pain assessments and medication, treatments, and assessments related to complications of indwelling urinary catheters. Post-tests and return demonstrations were completed by staff to ensure understanding. Twenty-three (23) of twenty-seven (27) licensed staff received the education with the remaining to complete on return to work. Interview with the DON, on 09/18/15 at 12:52 PM, revealed all nurses were educated regarding Abuse and Neglect, [MEDICAL CONDITION], the speaking valve,[MEDICAL CONDITION], care plans and care cards and all training was completed by 09/17/15. On 09/18/15, review of signature validation sheets and post tests revealed SRNAs were educated by the NPE and DON on 09/17/15 on recognizing the signs and symptoms of any kind of pain, especially related to residents who have a [MEDICAL CONDITION] or indwelling urinary catheter. Twenty-nine (29) out of thirty (30) SRNAs were education with the one (1) remaining to complete the training upon return to work. Interview with the NPE, on 09/18/15 at 1:09 PM, revealed there was a Code of Conduct training presented by Corporate Staff and the NPE assisted with training of facility staff. She stated the Respiratory Therapist provided education to her and she then provided education to the facility staff which included a return demonstration. She stated the education covered the revision of Care Plans, care cards, signs and symptoms and non-verbal indicators of pain, pain assessment, PRN pain medications, indwelling catheter care, recognizing pain symptoms for SRNAs and who they should report it to. She stated post tests were completed by all and were graded by the Regional Risk Manager and the NPE. Abuse and Neglect education to include reporting was completed on 09/14/15. She stated she was responsible to make sure that all staff received education before they returned to work. Interviews on 09/18/15 with RN #5 at 1:41 PM, RN #6 at 2:26 PM, LPN #2 at 2:41 PM, LPN #4 at 1:25 PM, LPN #5 at 1:33 PM, LPN #6 at 1:39 PM, revealed they received recent training on [MEDICAL CONDITION], speaking valves and the care of the valve, Care Plan revisions and implementation, pain assessment and the administration of pain medications, communication, catheters, UTI signs and symptoms, abuse and neglect and Code of Conduct, accuracy of orders, and pain to be identified as mild, moderate or severe. They

Based on interview, record review and facility policy review, it was determined the facility failed to carry out interventions in accordance to the written plan of care for two (2) of fourteen (14) sampled residents (Resident #1 and Resident #3). Resident #3 was care planned for staff to record urinary output; monitor output for odor, color, consistency and amount; monitor for signs and symptoms of infection and report to physician; medicate the resident as ordered for pain; monitor for effectiveness and monitor for side effects; report to physician as indicated and monitor for non-verbal signs/symptoms of pain and medicate as ordered. On 07/04/15, Resident #3 was hollering and complaining of pain related to a catheter most the day. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to administer pain medication, and monitor the resident's urinary output which included the odor, color, consistency and amount according to the care plan after the resident expressed catheter pain and discomfort. At 9:00 PM, RN #3 assessed the resident and identified the resident was complaining of severe pain, his/her bladder was distended and there had been no output in the catheter bag. RN #3 removed water from the catheter bulb, the catheter popped out and the resident had brown, bloody drainage. RN #3 sent the resident to the emergency room and the diagnosed with [REDACTED]. In addition, on 07/21/15 at approximately 8:50 PM, Resident #2 was rummaging in Resident #1's personal belongings; however, when Resident #1 yelled out for help and pushed the call light, the staff failed to respond. Resident #1 called the nurses' station via the public telephone line and reported to the staff that Resident #2 had been in his/her room for approximately thirty (30) minutes and somebody needed to come get him/her out. State Registered Nurse Aide (SRNA) #7 entered Resident #1's room, and observed Resident #2 was in the room in his/her wheelchair and she removed Resident #2 from the room. The facility's failure to provide services in accordance with each resident's written plan of care has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 09/08/15 and determined to exist on 07/04/15. The facility was notified of the Immediate Jeopardy on 09/08/15. An acceptable Allegation of Compliance (AoC) was received on 09/17/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/18/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Care Plans, dated 01/02/14, revealed a comprehensive, individualized care plan should be developed by the interdisciplinary team for each resident. The care plan should include measurable objectives to meet resident needs and goals as identified by the assessment process. The purpose of the Care Plan was to provide necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. Record review revealed the facility admitted Resident #3 on 04/29/15 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set Assessment, dated 07/28/15, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable and did not have pain. Review of the Comprehensive Care Plan for alteration in comfort, dated 05/05/15, revealed interventions for staff to medicate the resident as ordered for pain; monitor for effectiveness and monitor for side effects; report to physician as indicated and also to monitor for non-verbal signs/symptoms of pain and medicate as ordered. Interview with Resident #3, on 08/04/15 at 9:10 AM, on 08/05/15 at 11:50 AM, and on 08/06/15 at 9:30 AM, revealed he/she had been in pain all day on 07/04/15 and LPN #1 told him/her, he/she had been medicated for pain already. Resident #3 stated he/she told staff he/she was hurting down at the urinary catheter and staff would not send him/her to the hospital. Resident #3 stated when the night nurse (RN #3) came in that night, she called the ambulance and he/she was transported to the emergency room . Interview on 08/04/15 at 11:40 AM, with State Registered Nurse Aide (SRNA) #3 who worked 7:00 AM-3:00 PM on 07/04/15; revealed Resident #3 complained of pain in the catheter area and was hollering out most of the day. SRNA #3 stated she made RN #1 aware of the resident's complaints of pain and the RN looked at the catheter and the drainage bag and said the resident was fine, maybe a UTI. Interview with SRNA #1 who worked the 3:00 PM to 11:00 PM shift on 07/04/15, on 08/04/15 at 5:10 PM, revealed Resident #3 complained of pain in the catheter area and was hollering out most of the day. SRNA #1 said she also made LPN #1 aware the resident was complaining of pain and requesting pain medication on her shift and the LPN told her the resident had already been medicated. Review of the July 2015 Physician order [REDACTED]. However, review of the July 2015 Medication Administration Record (MAR) and Nursing Notes for 07/04/15 revealed there was no documented evidence the resident received Tylenol for pain on 07/04/15, as he/she should have, as per the care plan. Review of the Comprehensive Care Plan for the indwelling catheter, dated 05/07/15, revealed interventions for staff to record output; monitor for signs and symptoms of infection and report to the physician; monitor output for odor, color, consistency and amount. Review of the July 2015 Treatment Administration Record (TAR) for Resident #3 revealed staff was to monitor the resident's urinary output every shift for retention. Further review revealed no documentation noted for 07/01/15, but the remainder of the boxes had a line drawn through with a note stating, See ADL Book. Review of the Intake and Output document that was kept in the ADL Book, dated July 2015, revealed documentation that Resident #3 had 400 milliliter (ml) output on 07/03-04/15, on the 11:00 PM-7:00 AM shift; I/C (indwelling catheter) was documented with no amount on 07/04/15, 7:00 AM-3:00 PM; and 400 ml output on 07/04/15, 3:00 PM-11:00 PM shift. Interview (Post Survey), on 08/14/15 at 2:40 PM, with SRNA #3, who had documented I/C for output on 7:00 AM-3:00 PM shift on 07/04/15, revealed she looked for signs of irritation, discoloration in the urine and if there was urine in the drainage bag. She stated the catheters bags were emptied and the amount recorded at the end of the shift. SRNA #3 stated she emptied Resident #3's catheter bag around 2:00 PM on 07/04/15, but she did not recall how much urine was in the bag or what the urine looked like. She said she recorded IC on the flow sheet because they used to write the amount of urine output on a piece of paper and give it to the nurse so it could be recorded on the TAR. She stated she was not aware at the time she was supposed to document the amount of urine emptied from the bag. Interview with LPN #1, on 08/05/15 at 12:48 PM, revealed she was unable to talk at that time and she would return the call to the surveyor. An attempt was made to reach LPN #1, on 08/06/15 at 12:08 PM, but there was no answer and the surveyor left a message requesting a return call. Interview with RN #1, on 08/04/15 at 3:15 PM, revealed Resident #3 was hollering so she and LPN #1 placed the resident back to bed. RN #1 stated the licensed staff should assess catheters each shift and document the findings on the TAR. She stated pain assessments should be completed on a resident receiving an as needed dose of pain medication one (1) hour after the administration of the medication and documented on the MAR. She also stated residents were assessed for pain every shift. However, review of the MAR revealed no documented evidence the resident received pain medication on 07/04/15. Review of a Nursing Note, dated 07/04/15 at 9:54 PM and 10:00 PM, and interview on 08/04/15 at 2:35 PM, with RN #3, who worked 7:00 PM to 7:AM on 07/04/15, revealed Resident #3 complained of pain with urination. RN #3 stated the resident's skin was cool and clammy and his/her face was red. The resident continued to yell stating it hurts down there and the resident clarified that it hurt, where I pee. RN #3 stated she took a syringe to check for proper placement of the catheter and the resident yelled louder with pain and stated, take out. The bulb was deflated, the resident yelled and the catheter came out of the urethra. The resident continued to yell and voided thick, brownish urine. The resident then voided bright red blood. RN #3 was unable to contact the physician so she called the Assistant Director of Nursing (ADON) and the resident was sent to the emergency room . Review of the hospital History and Physical, dated 07/05/15 at 2:32 AM, revealed Resident #3 was admitted to the hospital with [REDACTED]. Plan on admission included the antibiotic [MEDICATION NAME] and intravenous (IV) hydration. Interview with the Director of Nursing, on 08/06/15 at 2:39 PM, revealed she would expect staff to implement the care plan and assess the resident's pain and attempt to find the root cause for the pain. She stated the staff would also need to notify the physician of any concerns identified. She stated the SRNAs were responsible for monitoring urinary output when emptying drainage bags and should alert the nurse of any concerns with the urinary output. Interview (Post Survey) with the Director of Nursing (DON), on 08/14/15 at 8:15 AM, revealed the SRNAs were responsible to enter output amounts on the flow sheet. She stated they should also notify the nurse in charge on the hall of any changes noted in color, consistency and change in output amounts. She stated licensed staff chart by exception and were required to document when there had been a change in condition for the resident. She stated she would have expected LPN #1 to have charted the care she provided for Resident #3 on 07/04/15, and licensed staff should assess catheters when providing care, and as needed per the plan of care. 2. Record review revealed the facility admitted Resident #1 on 11/24/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 06/26/15, revealed the facility assessed Resident #1's cognition as intact with a BIMS' score of fifteen (15) which indicated the resident was interviewable. Resident #1 required total assist with transfers, utilized a mechanical lift and required assistance with all Activities of Daily Living (ADLs). Review of Resident #1's Comprehensive Care Plan for falls revealed an intervention that was initiated on 04/15/15, to place the resident's call light within reach at all times. Review of a Progress Note, dated 07/21/15 at 8:15 PM (Change in Condition) revealed the resident had called, via telephone for someone to get a resident (Resident #2) out of his/her room and an aide had been sent to get the resident out of the room. Interview with Resident #1, on 08/03/15 at 11:45 AM, revealed on 07/21/15 he/she was in bed asleep around 9:00 PM and woke up to Resident #2 at the foot of the bed. He/she stated he/she turned on the call light and was repeatedly yelling for help but there wasn't anyone anywhere. Resident #1 stated Resident #2 kept getting into his/her stuff and had gotten stuck by the bed and the over the bed table and they were wrestling for the table. Resident #1 further stated Resident #2 had been in the room about twenty (20) minutes, so he/she (Resident #1) finally got on the telephone and told the person that answered that Resident #2 had been in his/her room and somebody needed to come get him/her. Interview (phone) conducted on 08/03/15 at 7:25 PM with RN #4 revealed she had answered the telephone on the evening of 07/21/15 and it was Resident #1. She stated Resident #1 was saying Resident #2 had been in his/her room for twenty (20) minutes so she called the other nurse and then paged for someone to go to Resident #1's room immediately. Interview with State Registered Nurse Aide (SRNA) #7, on 08/03/15 at 9:20 AM, revealed she worked 07/21/15 on the 3:00 PM to 11:00 PM shift. She stated she was sitting in the dining room with another resident and heard an over head page for someone to go to Resident #1's room. She stated she responded and found Resident #2 in Resident #1's room. She stated she pushed Resident #2 into the hall in his/her wheelchair. SRNA #7 stated when she came out of the dining room to answer the page, Resident #1's and another resident's call light were blinking which meant the lights had been on for a few minutes. Interview with the Administrator, on 08/03/15 at 7:10 AM, revealed staff was expected to answer call lights timely. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was transferred to the hospital on [DATE] at 10:15 PM by RN #3 immediately upon assessment of the catheter in order to address Resident #3's complaints of pain. 2. Resident #1 was readmitted to the facility on [DATE] at 5:12 PM with no orders to remove the speaking valve. Resident #3 continued to have a urinary catheter due to [MEDICAL CONDITION] bladder as assessed by the Physician related to a stroke on 04/30/15. 3. Resident #3's [MEDICAL CONDITION] was removed on 08/24/15 by the Respiratory Therapist. 4. Resident #3's urinary catheter was discontinued by the physician on 08/10/15 and removed by the licensed nurse on that date. 5. As of 08/27/15, there were no residents in the center with a [MEDICAL CONDITION]; therefore, no potential exists for issues relating to tracheostomies at this time. 6. On 08/25/15, the center had three (3) of seventy-eight (78) residents who utilized a catheter. The DON assessed these three (3) residents on 08/25/15 for signs/symptoms of a urinary tract infection and assessed for pain. One (1) resident with a catheter was identified as having pain. The physician was notified and new orders were obtained for a urinalysis (UA) and culture and sensitivity (CNS) and antibiotic treatment was based on the preliminary analysis. The antibiotic therapy was completed on 08/31/15. 7. On 08/21/15, the three (3) residents utilizing catheters were reviewed by a RN to validate physician's orders [REDACTED]. No concerns were identified. 8. On 08/21/15, a RN reviewed all resident records (79 of 79) (census fluctuated) to validate the MAR and/or Treatment Administration Record (TAR) reflected daily pain monitoring, which included a care plan review. No concerns were identified. 9. On 08/27/15, all resident records (78 of 78) (census fluctuated) were reviewed by the Director of Health Information Management to validate a PRN (as needed) Pain Management Flow Sheet was present for each resident which included a care plan review; no concerns were identified. 10. On 08/28/15, a RN reviewed residents listed on a change of condition report for the period between 08/07/15-08/28/15. Twenty-two (22) of seventy-seven (77) (census fluctuated) residents were reviewed to determine if residents were assessed for the presence of pain; and, if pain interventions were initiated upon the identified change of condition, which included a care plan review; no concerns were identified. 11. Beginning on 08/28/15 through 09/03/15, an RN reviewed all residents receiving PRN pain medication to validate accuracy of the physician's orders [REDACTED]. Order clarification needs were identified as requiring the specification of mild, moderate, or severe indications. These identified clarification needs were reviewed with the Physician with corrective action initiated upon discovery. 12. The Administrator and DON participated in Corporate sponsored mandated reeducation via independent computer training. The Administrator completed training on 07/07/15 and the DON completed training on 09/02/15. This education was on the Code of Conduct related to meeting professional standards, complying with regulatory guidance, and exercise of good judgement regarding how best to uphold ethical behavior every day. In addition, the code included measuring clinical outcomes and resident satisfaction to confirm quality goals are met and focus and discipline on improving quality of care. Creativity and innovation to develop effective solutions. 13. All facility staff including Food Service Director, Cooks, and Cook Aides, SRNAs, LPNs, RNs, Social Services, Business Office Manager, Receptionist, Activities Director, Admissions Director, Medical Records, Payroll, Maintenance and Maintenance Assistant, Therapy Program Director, and Therapists participated in Corporate mandated Code of Conduct Training with a completion date of 09/17/15 (76 out of 110). On 09/17/15, this training will be completed with the contracted Housekeeping Supervisor and Housekeepers. Staff not available on 09/17/15 will be provided reeducation including competency and post-test by the Nurse Practice Educator (NPE) or RN with a pass rate of 100% prior to returning to work. In addition on 09/08/15, all were re-educated by the NPE on identification of all forms of abuse, including neglect, when to report suspicions of abuse, and reporting of suspicions of abuse, to include the chain of command, and the abuse prevention coordinator. This was completed on 09/14/15. Staff not available during this time frame (33 of 110) will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The NPE and DON were reeducated by the Manager of Clinical Operations on 08/26/15 and then the NPE, Consulting Respiratory Therapist or Regional Risk Manager, who was also an RN began reeducation on 08/26/15 through 09/04/15 with all licensed nurses which included RN #1 and RN #3, were provided with all reeducation. Twenty-three (23) of twenty-seven (27) RNs and LPNs were provided with the reeducation. RNs and LPNs not available during this timeframe will be provided the re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The above re-education included the following: A. Abuse and Neglect Policy which covered removing a Passey Muir speaking valve with return demonstration. All nurses educated verbalized and signed that they understood the removal of the valve to prevent a resident to speak is considered abuse. B. [MEDICAL CONDITION] policy and procedure. C. Timely review, revision and implementation of care plans and care cards to reflect response to care and changing needs and goals; a post test was used to validate learning. D. Pain assessment and administering mediation and treatments as prescribed by the physician and/or Nurse Practitioner, and/or per the care plan. Monitoring effectiveness, side effects, and non-verbal signs/symptoms of pain. Completion of pain assessment regarding PRN pain medication administration when receiving communication from another staff member who suspects a resident may be in pain. Learning was validated with a post-test. E. Ensuring assessment initiated for appropriate treatment and services to identify complications of an indwelling catheter related to UTI to include signs and symptoms of pain, assessing for discoloration and urine flow in the tubing and an attempt to find the root cause for the pain and take appropriate action. Learning was validated with post-test. On 09/17/15, all SRNA's will be provided with re-education on recognizing symptoms of any pain but specifically related to tracheostomies or urinary catheters, observations for discoloration of urine in urinary catheter or changes in urinary output related to catheters who to report these observations, when to report these observations, and what action to take if their concerns were not addressed. Learning will be validated via post-test graded by the NPE, DON, or RN with a 100% pass rate. SRNAs not available during this timeframe will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. 13. The DON, NPE, or Licensed Nurse will observe licensed nurse providing all aspects of [MEDICAL CONDITION] care including observing for sign/symptoms of pain or discomfort during the care or if resident with a [MEDICAL CONDITION] enters into the facility. This will include speaking valve treatment and orders, abuse related to removing it when not specifically ordered to do so and following the plan of care. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 14. The DON, NPE, or Licensed Nurse will observe for signs and symptoms of pain associated with indwelling urinary catheters and following the care plan related to urinary catheter use. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 15. The DON, NPE, or RN Supervisor or Charge Nurse will review residents with a change of condition and audit by head to toe assessment that the change of condition is accurately documented and followed up on timely daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 16. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview five (5) residents across all shifts to determine if they feel if a staff member abused them, to include all forms of abuse or neglect, of if they have witnessed any other resident being abused daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 17. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview three (3) staff members across all shifts to determine if they know or suspect any resident being abused that they have not reported daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 18. Beginning on 09/17/15, the Administrator, DON, NPE, RN Supervisor or Licensed Nurse will observe staff interaction including care of five (5) residents to visually determine that the care plan is being followed daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. On 09/18/15, review of Resident #3's Nurse's Notes revealed the resident was transported to the emergency roiagnom on [DATE] at 10:15 PM via ambulance. The resident was admitted with a [DIAGNOSES REDACTED]. 2. On 09/18/15, review of Resident #3's readmission orders [REDACTED]. There was no order written to remove the speaking valve. 3. On 09/18/15, review of Resident #3's physician's orders [REDACTED].#3's [MEDICAL CONDITION] was removed on 08/24/15. 4. On 09/18/15, review of Resident #3's physician's orders [REDACTED]. 5. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed as of 08/25/15 there were no other [MEDICAL CONDITION] residents. However, the facility reviewed their [MEDICAL CONDITION] care policy and procedures, including following physician's orders [REDACTED]. 6. On 09/18/15, review of documentation by the DON revealed the DON identified three (3) residents with an indwelling urinary catheter in the facility. She assessed the residents for signs and symptoms of an UTI and pain. She identified one of the residents had symptoms of a UTI . The Physician was notified and orders were received for a Urinalysis and C&S with antibiotic ordered. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE on 1:09 PM, revealed three (3) residents were assessed for Urinary Tract Infection symptoms and one (1) resident was started on an antibiotic which has since been completed. 7. On 09/18/15, review of documentation by the DON revealed on 08/21/15 an RN reviewed three (3) residents with indwelling catheters to validate the physician's orders [REDACTED]. The MAR contained instructions to assess every shift for the presence of pain. A Care Plan review was also completed. All with no concerns noted. 8. On 09/18/15, review of check sheets on 09/18/15 revealed the DON reviewed all seventy-nine (79) (census fluctuated) residents medical records to ensure the MAR and TAR reflected daily pain management. The Manager of Clinical Operations assisted with this and it was completed on 08/21/15. Interviews on 09/18/15 with the DON, at 12:52 PM and the Manager of Clinical Operations at 1:09 PM revealed they reviewed all seventy-nine (79) (census fluctuated) residents' records and ensured the MAR/TAR and care plan reflected daily pain management. 9. On 09/18/15, review of a check sheet and interview with the Director of Health Information at 1:09 PM revealed the Director of Health Information validated all resident records were complete with a pain management sheet on 08/27/15. 10. On 09/18/15, review of documentation revealed the Regional Risk Manager (who is an RN) and the DON reviewed all resident records for a change of condition on 08/28/15. A total of twenty-five (25) change of conditions were identified, none had a concern that was identified. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed audits for change of condition were completed and if there was a change of condition, a head to toe assessment was completed. 11. On 09/18/15, review of an Order Listing Report, revealed all PRN (as needed) pain medications were reviewed to validate the order accuracy and the Care Plan was reviewed on 09/03/15. In addition, MILD, MODERATE or SEVERE was included on the order to print on the MAR. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed orders were reviewed for accuracy. No concerns were identified. 12. On 09/18/15, review of the Code Of Conduct Signature Sheets verified that mandated education via computer independent training was completed on 07/07/15 by the Administrator and by the DON on 09/02/15. The training included Code of Conduct, how it related to staff positions, all were expected to meet Professional Standards, comply with Regulatory guidance and exercise judgement on how to best uphold ethical behavior every day. The Code also included measuring clinical outcomes, patient satisfaction to confirm goals are met. Additionally, it included focused discipline on improving the Quality of Care, creativity and innovation to develop effective solutions. Interviews on 09/18/15 with the DON at 12:52 PM and the Administrator at 12:04 PM verified they received this training. On 09/18/15, review of the acknowledgement signature forms revealed facility staff except housekeeping, (who is contract) completed the Code of Conduct computer training on 09/17/15, except for ten (10) staff that have not completed the training and those staff will complete the training before returning to work. All housekeeping staff completed the inservices manually on 09/17/15 and signed acknowledgement forms. Further review of signature validation sheets and post tests revealed all facility staff received education by the NPE on the facility's Abuse/Neglect policy and procedure to include the forms of abuse and neglect, when to report, and including following the chain of command from 09/08/15-09/14/15. On 09/14/15, there were thirty-three (33) staff remaining to be educated and they will complete the training before being allowed to care for residents. On 09/18/15, review of signature validation sheets and post tests validated the NPE and the DON were re-educated by the Manager of Clinical Operations on 08/26/15. Further review of the signature validation sheets revealed the NPE, Consulting Respiratory Therapist or Regional Risk Manager also reeducated all licensed nurses on 09/02/15 related to the Passey-Muir speaking valve, the Abuse/Neglect policy, [MEDICAL CONDITION] care policies and procedures, following MD orders, timely review of revision of Care Plan implementation and care cards, pain assessments and medication, treatments, and assessments related to complications of indwelling urinary catheters. Post-tests and return demonstrations were completed by staff to ensure understanding. Twenty-three (23) of twenty-seven (27) licensed staff received the education with the remaining to complete on return to work. Interview with the DON, on 09/18/15 at 12:52 PM, revealed all nurses were educated regarding Abuse and Neglect, [MEDICAL CONDITION], the speaking valve,[MEDICAL CONDITION], care plans and care cards and all training was completed by 09/17/15. On 09/18/15, review of signature validation sheets and post tests revealed SRNAs were educated by the NPE and DON on 09/17/15 on recognizing the signs and symptoms of any kind of pain, especially related to residents who have a [MEDICAL CONDITION] or indwelling urinary catheter. Twenty-nine (29) out of thirty (30) SRNAs were education with the one (1) remaining to complete the training upon return to work. Interview with the NPE, on 09/18/15 at 1:09 PM, revealed there was a Code of Conduct training presented by Corporate Staff and the NPE assisted with training of facility staff. She stated the Respiratory Therapist provided education to her and she then provided education to the facility staff which included a return demonstration. She stated the education covered the revision of Care Plans, care cards, signs and symptoms and non-verbal indicators of pain, pain assessment, PRN pain medications, indwelling catheter care, recognizing pain symptoms for SRNAs and who th

Based on interview, record review, and policy review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (1) of fourteen (14) sampled residents (Resident #3). On 07/04/15, Resident #3 was hollering and complaining of pain related to a catheter. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to assess Resident #1's pain and administer pain medication. RN #1 and LPN #1 failed to determine what was causing the resident's pain to determine if further action was needed. At approximately 9:00 PM, RN #3 assessed the resident and identified the resident was in pain, bladder was distended, had no urine in the catheter bag and was requesting to go to the hospital. RN #3 removed water from the catheter bulb, the catheter popped out and the resident had a brown, bloody drainage. RN #3 sent the resident to the emergency room and admitted to the hospital. The resident was diagnosed as having a urinary tract infection. The facility's failure to to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 09/08/15 and determined to exist on 07/04/15. The facility was notified of the Immediate Jeopardy on 09/08/15. An acceptable Allegation of Compliance (AoC) was received on 09/17/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/18/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Pain Management, last revised 01/02/15, revealed residents should be evaluated as part of the nursing assessment process for the presence of pain upon admission/re-admission, quarterly, with change in condition or change in pain status. The purpose is to maintain the highest possible level of comfort for residents by providing a system to identify, assess, treat and evaluate pain. In addition, the purpose is to design a plan of care to achieve an optimal balance between pain relief and preservation of function, in accordance with the resident's directed goals. At a minimum of daily, residents should be evaluated for the presence of pain by making an inquiry of the resident or by observing for signs of pain. Documentation will be completed using the Pain Presence Monitor documentation tool. The Center's staff will report any observation or communication of pain to the nurse responsible for that resident. Review of the facility's policy titled, Assessment: Nursing, dated 01/02/14, revealed routine and focused assessments should be performed on an ongoing basis as needed. The purpose of the assessment is to determine a resident's condition and clinical needs. Record review revealed the facility admitted Resident #3 on 04/29/15 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set Assessment, dated 07/28/15, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable and did not have pain. Review of the Comprehensive Care Plan for alteration in comfort, dated 05/05/15, revealed interventions for staff to medicate the resident as ordered for pain and monitor for effectiveness and monitor for side effects, and report to the physician, as indicated. Staff should also monitor for non-verbal signs/symptoms of pain and medicate as ordered. Interview with Resident #3, on 08/04/15 at 9:10 AM, revealed he/she had been in pain all day on 07/04/15 and LPN #1 would not give him/her anything for pain stating he/she had already been medicated. Review of Nursing Notes, dated 07/04/15, revealed there was no documented evidence by Registered Nurse (RN) #1 or Licensed Practical Nurse (LPN) #1 that Resident #3 had any complaints of pain or was assessed for pain from 7:00 AM through 7:00 PM. In addition, review of the Pain Presence Monitor form revealed there was no pain assessment documented on the tool for 07/04/15 per the facility policy, as the space was blank. Review of the July 2015 Physician order [REDACTED].#3 was administered Tylenol for pain on 07/04/15. Review of a Nursing Note by RN #3, dated 07/04/15 at 9:54 PM, revealed Resident #3 complained of pain with the presence of an indwelling urinary catheter to the bedside drainage and no urine in the drainage bag. RN #3 documented the resident's skin was noted to have been cool and clammy and his/her face was red. The resident vital signs were documented as a temperature of 96.0 degrees Fahrenheit orally (normal: 97.5) and was 98.6 degrees Fahrenheit under the arm. The resident's blood sugar was documented to be 144 (normal: 80- 120 mg/dL), pulse was 78 (normal: 85), respirations were 20 (normal: 19) and blood pressure was 128/84 (normal range: 135/85). Further review of the Nursing Note revealed when RN #3 pulled the covers back it was noted that there was urine on the sheets. RN #3 documented the resident continued to yell stating it hurts down there where I pee. The nurse documented she took a syringe to check for proper placement of the catheter and the resident yelled louder with pain and stated, take out. She documented she deflated the bulb, the resident yelled and the catheter came out of the urethra. RN #3 documented the resident continued to yell, voided thick, brownish urine, once again expressed the desire to go to the hospital and then voided bright red blood. RN #3 documented she left the room to attempt to contact the physician and the family without success. Review of a Nursing Note, dated 07/04/15 at 10:00 PM, revealed RN #3 was unable to contact the physician and family of Resident #3. A phone call was placed to the Assistant Director of Nursing (ADON) in which she reported the situation to him and RN #3 was told to send the resident to the emergency room if he/she wanted to go. Emergency Medical Services (EMS) was notified regarding the need for transport to the emergency room . Review of the Hospital History and Physical, dated 07/05/15 at 2:32 AM, revealed Resident #3 was admitted to the hospital with [REDACTED]. The plan on admission included the antibiotic [MEDICATION NAME] and intravenous (IV) hydration. Interview, on 08/04/15 at 11:40 AM, with State Registered Nurse Aide (SRNA) #3 who worked 7:00 AM-3:00 PM on 07/04/15, revealed Resident #3 complained of pain in the catheter area and was hollering out most of the day. She said RN #1 was made aware of the resident's complaints of pain and the RN looked at the catheter and the drainage bag and said the resident was fine, maybe a UTI. Interview with SRNA #1, on 08/04/15 at 5:10 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 07/04/15. She stated when she came into work that day, Resident #3 was in a wheelchair in the lobby area with other residents and was irritated and yelling out. SRNA #1 stated RN #1 and LPN #1, reported the resident had been yelling all day. The SRNA stated the resident was screaming as if in pain and his/her face was red. SRNA #1 said when she asked the resident where the pain was, the resident pointed downward to his/her private area and said pee pee. She stated the resident requested medication for pain and LPN #1 was made aware by the SRNA and the LPN told her the resident had already been medicated. Interview with LPN #1, on 08/05/15 at 12:48 PM, revealed she was unable to talk at that time and stated she would return the call. An attempt was made to reach LPN #1, on 08/06/15 at 12:08 PM, but there was no answer and the Surveyor left a message requesting a return call. Interview with RN #1, on 08/04/15 at 3:15 PM, revealed Resident #3 was hollering so she and LPN #1 placed the resident back to bed. RN #1 stated the resident did not complain of pain and did not request to go to the hospital. In addition, she said the SRNA never reported the resident was in pain and/or wanted to go to the hospital. Interview with RN #3, on 08/04/15 at 2:35 PM, revealed she had worked on 07/04/15 on the 7:00 PM-7:00 AM shift. She stated RN #1 reported to her in report that Resident #3 had complained all day long of having pain on urination and was told by the nurse that he had a catheter and shouldn't be hurting. RN #3 said RN #1 told her they had taken Resident #3's speaking valve off because he/she was yelling too much and the resident's roommate was removed from the room as well. RN #3 stated when she entered Resident #3's room, she noted the voice valve was on the table on the resident's left side and the resident would normally refuse to have the valve removed. RN #3 revealed Resident #3 kept telling her that he/she was in severe pain and kept grabbing the catheter saying that he/she couldn't urinate. RN #3 stated the resident's catheter drainage bag was empty so she secured a syringe to flush the catheter. She stated she let out a little of the water from the bulb and the resident screamed in pain and the catheter shot out. She revealed there was a brown, thick, substance coming out of the resident's urethra. The nurse stated she could tell the resident's bladder was distended and then the resident voided straight blood. She stated at that time the resident was begging to be sent to the hospital so the nurse attempted to reach the on call physician, but she was unable to reach him so she phoned the Assistant Director of Nursing (ADON) and got permission to send the resident to the hospital. She stated she learned later in the evening the resident was being admitted for a Urinary Tract Infection [MEDICAL CONDITION]. Interview, on 08/04/15 at 5:40 PM, with SRNA #2, who worked the 3:00 PM to 11:00 PM shift on 07/04/15, revealed RN #3 called him into the room and Resident #3 was complaining of hurting and was hollering loudly. SRNA #2 stated when RN #3 took the catheter out, there was blood, urine and gooey pus and a lot of blood and the resident said that he/she wanted to go to the hospital. SRNA #2 said the resident's skin was very clammy and cold to touch. Interview with the former ADON, on 08/05/15 at 9:20 AM, revealed RN #3 phoned saying she wanted to send Resident #3 to the emergency room because the resident was in pain, and had no urinary output and the resident was requesting to go to the hospital. The ADON stated she told RN #3 to send the resident to the hospital, He revealed that he would expect the staff to assess the resident for pain, administer medications as ordered and if not helpful to contact the physician. Further interview (Post Survey) with the former ADON, on 08/14/15 at 10:35 AM, revealed pain assessments should be completed daily and as needed; should be documented on the MAR; and should be conducted by licensed nurses. Interview with the Physician/Medical Director of the facility, on 08/07/15 at 8:21 AM, revealed he would expect the facility staff to assess residents for pain and take the appropriate action. If staff were unable to reach the physician, it would be appropriate to send the resident to the emergency room . The Physician reported that complications from not assessing the resident could be increased pain from a distended bladder. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #3 was transferred to the hospital on [DATE] at 10:15 PM by RN #3 immediately upon assessment of the catheter in order to address Resident #3's complaints of pain. 2. Resident #3 was readmitted to the facility on [DATE] at 5:12 PM with no orders to remove the speaking valve. Resident #3 continued to have a urinary catheter due to [MEDICAL CONDITION] bladder as assessed by the Physician related to a stroke on 04/30/15. 3. Resident #3's [MEDICAL CONDITION] was removed on 08/24/15 by the Respiratory Therapist. 4. Resident #3's urinary catheter was discontinued by the physician on 08/10/15 and removed by the licensed nurse on that date. 5. As of 08/27/15, there were no residents in the center with a [MEDICAL CONDITION]; therefore, no potential exists for issues relating to tracheostomies at this time. 6. On 08/25/15, the center had three (3) of seventy-eight (78) residents who utilized a catheter. The DON assessed these three (3) residents on 08/25/15 for signs/symptoms of a urinary tract infection and assessed for pain. One (1) resident with a catheter was identified as having pain. The physician was notified and new orders were obtained for a urinalysis (UA) and culture and sensitivity (CNS) and antibiotic treatment was based on the preliminary analysis. The antibiotic therapy was completed on 08/31/15. 7. On 08/21/15, the three (3) residents utilizing catheters were reviewed by a RN to validate physician's orders [REDACTED]. No concerns were identified. 8. On 08/21/15, a RN reviewed all resident records (79 of 79) (census fluctuated) to validate the MAR and/or Treatment Administration Record (TAR) reflected daily pain monitoring, which included a care plan review. No concerns were identified. 9. On 08/27/15, all resident records (78 of 78) (census fluctuated) were reviewed by the Director of Health Information Management to validate a PRN (as needed) Pain Management Flow Sheet was present for each resident which included a care plan review; no concerns were identified. 10. On 08/28/15, a RN reviewed residents listed on a change of condition report for the period between 08/07/15-08/28/15. Twenty-two (22) of seventy-seven (77) (census fluctuated) residents were reviewed to determine if residents were assessed for the presence of pain; and, if pain interventions were initiated upon the identified change of condition, which included a care plan review; no concerns were identified. 11. Beginning on 08/28/15 through 09/03/15, an RN reviewed all residents receiving PRN pain medication to validate accuracy of the physician's orders [REDACTED]. Order clarification needs were identified as requiring the specification of mild, moderate, or severe indications. These identified clarification needs were reviewed with the Physician with corrective action initiated upon discovery. 12. The Administrator and DON participated in Corporate sponsored mandated reeducation via independent computer training. The Administrator completed training on 07/07/15 and the DON completed training on 09/02/15. This education was on the Code of Conduct related to meeting professional standards, complying with regulatory guidance, and exercise of good judgement regarding how best to uphold ethical behavior every day. In addition, the code included measuring clinical outcomes and resident satisfaction to confirm quality goals are met and focus and discipline on improving quality of care. Creativity and innovation to develop effective solutions. 13. All facility staff including Food Service Director, Cooks, and Cook Aides, SRNAs, LPNs, RNs, Social Services, Business Office Manager, Receptionist, Activities Director, Admissions Director, Medical Records, Payroll, Maintenance and Maintenance Assistant, Therapy Program Director, and Therapists participated in Corporate mandated Code of Conduct Training with a completion date of 09/17/15 (76 out of 110). On 09/17/15, this training will be completed with the contracted Housekeeping Supervisor and Housekeepers. Staff not available on 09/17/15 will be provided reeducation including competency and post-test by the Nurse Practice Educator (NPE) or RN with a pass rate of 100% prior to returning to work. In addition on 09/08/15, all were re-educated by the NPE on identification of all forms of abuse, including neglect, when to report suspicions of abuse, and reporting of suspicions of abuse, to include the chain of command, and the abuse prevention coordinator. This was completed on 09/14/15. Staff not available during this time frame (33 of 110) will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The NPE and DON were reeducated by the Manager of Clinical Operations on 08/26/15 and then the NPE, Consulting Respiratory Therapist or Regional Risk Manager, who was also an RN began reeducation on 08/26/15 through 09/04/15 with all licensed nurses which included RN #1 and RN #3, were provided with all reeducation. Twenty-three (23) of twenty-seven (27) RNs and LPNs were provided with the reeducation. RNs and LPNs not available during this timeframe will be provided the re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The above re-education included the following: A. Abuse and Neglect Policy which covered removing a Passey Muir speaking valve with return demonstration. All nurses educated verbalized and signed that they understood the removal of the valve to prevent a resident to speak is considered abuse. B. [MEDICAL CONDITION] policy and procedure. C. Timely review, revision and implementation of care plans and care cards to reflect response to care and changing needs and goals; a post test was used to validate learning. D. Pain assessment and administering mediation and treatments as prescribed by the physician and/or Nurse Practitioner, and/or per the care plan. Monitoring effectiveness, side effects, and non-verbal signs/symptoms of pain. Completion of pain assessment regarding PRN pain medication administration when receiving communication from another staff member who suspects a resident may be in pain. Learning was validated with a post-test. E. Ensuring assessment initiated for appropriate treatment and services to identify complications of an indwelling catheter related to UTI to include signs and symptoms of pain, assessing for discoloration and urine flow in the tubing and an attempt to find the root cause for the pain and take appropriate action. Learning was validated with post-test. On 09/17/15, all SRNA's will be provided with re-education on recognizing symptoms of any pain but specifically related to tracheostomies or urinary catheters, observations for discoloration of urine in urinary catheter or changes in urinary output related to catheters who to report these observations, when to report these observations, and what action to take if their concerns were not addressed. Learning will be validated via post-test graded by the NPE, DON, or RN with a 100% pass rate. SRNAs not available during this timeframe will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. 13. The DON, NPE, or Licensed Nurse will observe licensed nurse providing all aspects of [MEDICAL CONDITION] care including observing for sign/symptoms of pain or discomfort during the care or if resident with a [MEDICAL CONDITION] enters into the facility. This will include speaking valve treatment and orders, abuse related to removing it when not specifically ordered to do so and following the plan of care. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 14. The DON, NPE, or Licensed Nurse will observe for signs and symptoms of pain associated with indwelling urinary catheters and following the care plan related to urinary catheter use. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 15. The DON, NPE, or RN Supervisor or Charge Nurse will review residents with a change of condition and audit by head to toe assessment that the change of condition is accurately documented and followed up on timely daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 16. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview five (5) residents across all shifts to determine if they feel if a staff member abused them, to include all forms of abuse or neglect, of if they have witnessed any other resident being abused daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 17. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview three (3) staff members across all shifts to determine if they know or suspect any resident being abused that they have not reported daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 18. Beginning on 09/17/15, the Administrator, DON, NPE, RN Supervisor or Licensed Nurse will observe staff interaction including care of five (5) residents to visually determine that the care plan is being followed daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. On 09/18/15, review of Resident #3's Nurse's Notes revealed the resident was transported to the emergency roiagnom on [DATE] at 10:15 PM via ambulance. The resident was admitted with a [DIAGNOSES REDACTED]. 2. On 09/18/15, review of Resident #3's readmission orders [REDACTED]. There was no order written to remove the speaking valve. 3. On 09/18/15, review of Resident #3's physician's orders [REDACTED].#3's [MEDICAL CONDITION] was removed on 08/24/15. 4. On 09/18/15, review of Resident #3's physician's orders [REDACTED]. 5. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed as of 08/25/15 there were no other [MEDICAL CONDITION] residents. However, the facility reviewed their [MEDICAL CONDITION] care policy and procedures, including following physician's orders [REDACTED]. 6. On 09/18/15, review of documentation by the DON revealed the DON identified three (3) residents with an indwelling urinary catheter in the facility. She assessed the residents for signs and symptoms of an UTI and pain. She identified one of the residents had symptoms of a UTI . The Physician was notified and orders were received for a Urinalysis and C&S with antibiotic ordered. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE on 1:09 PM, revealed three (3) residents were assessed for Urinary Tract Infection symptoms and one (1) resident was started on an antibiotic which has since been completed. 7. On 09/18/15, review of documentation by the DON revealed on 08/21/15 an RN reviewed three (3) residents with indwelling catheters to validate the physician's orders [REDACTED]. The MAR contained instructions to assess every shift for the presence of pain. A Care Plan review was also completed. All with no concerns noted. 8. On 09/18/15, review of check sheets on 09/18/15 revealed the DON reviewed all seventy-nine (79) (census fluctuated) residents medical records to ensure the MAR and TAR reflected daily pain management. The Manager of Clinical Operations assisted with this and it was completed on 08/21/15. Interviews on 09/18/15 with the DON, at 12:52 PM and the Manager of Clinical Operations at 1:09 PM revealed they reviewed all seventy-nine (79) (census fluctuated) residents' records and ensured the MAR/TAR and care plan reflected daily pain management. 9. On 09/18/15, review of a check sheet and interview with the Director of Health Information at 1:09 PM revealed the Director of Health Information validated all resident records were complete with a pain management sheet on 08/27/15. 10. On 09/18/15, review of documentation revealed the Regional Risk Manager (who is an RN) and the DON reviewed all resident records for a change of condition on 08/28/15. A total of twenty-five (25) change of conditions were identified, none had a concern that was identified. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed audits for change of condition were completed and if there was a change of condition, a head to toe assessment was completed. 11. On 09/18/15, review of an Order Listing Report, revealed all PRN (as needed) pain medications were reviewed to validate the order accuracy and the Care Plan was reviewed on 09/03/15. In addition, MILD, MODERATE or SEVERE was included on the order to print on the MAR. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed orders were reviewed for accuracy. No concerns were identified. 12. On 09/18/15, review of the Code Of Conduct Signature Sheets verified that mandated education via computer independent training was completed on 07/07/15 by the Administrator and by the DON on 09/02/15. The training included Code of Conduct, how it related to staff positions, all were expected to meet Professional Standards, comply with Regulatory guidance and exercise judgement on how to best uphold ethical behavior every day. The Code also included measuring clinical outcomes, patient satisfaction to confirm goals are met. Additionally, it included focused discipline on improving the Quality of Care, creativity and innovation to develop effective solutions. Interviews on 09/18/15 with the DON at 12:52 PM and the Administrator at 12:04 PM verified they received this training. On 09/18/15, review of the acknowledgement signature forms revealed facility staff except housekeeping, (who is contract) completed the Code of Conduct computer training on 09/17/15, except for ten (10) staff that have not completed the training and those staff will complete the training before returning to work. All housekeeping staff completed the inservices manually on 09/17/15 and signed acknowledgement forms. Further review of signature validation sheets and post tests revealed all facility staff received education by the NPE on the facility's Abuse/Neglect policy and procedure to include the forms of abuse and neglect, when to report, and including following the chain of command from 09/08/15-09/14/15. On 09/14/15, there were thirty-three (33) staff remaining to be educated and they will complete the training before being allowed to care for residents. On 09/18/15, review of signature validation sheets and post tests validated the NPE and the DON were re-educated by the Manager of Clinical Operations on 08/26/15. Further review of the signature validation sheets revealed the NPE, Consulting Respiratory Therapist or Regional Risk Manager also reeducated all licensed nurses on 09/02/15 related to the Passey-Muir speaking valve, the Abuse/Neglect policy, [MEDICAL CONDITION] care policies and procedures, following MD orders, timely review of revision of Care Plan implementation and care cards, pain assessments and medication, treatments, and assessments related to complications of indwelling urinary catheters. Post-tests and return demonstrations were completed by staff to ensure understanding. Twenty-three (23) of twenty-seven (27) licensed staff received the education with the remaining to complete on return to work. Interview with the DON, on 09/18/15 at 12:52 PM, revealed all nurses were educated regarding Abuse and Neglect, [MEDICAL CONDITION], the speaking valve,[MEDICAL CONDITION], care plans and care cards and all training was completed by 09/17/15. On 09/18/15, review of signature validation sheets and post tests revealed SRNAs were educated by the NPE and DON on 09/17/15 on recognizing the signs and symptoms of any kind of pain, especially related to residents who have a [MEDICAL CONDITION] or indwelling urinary catheter. Twenty-nine (29) out of thirty (30) SRNAs were education with the one (1) remaining to complete the training upon return to work. Interview with the NPE, on 09/18/15 at 1:09 PM, revealed there was a Code of Conduct training presented by Corporate Staff and the NPE assisted with training of facility staff. She stated the Respiratory Therapist provided education to her and she then provided education to the facility staff which included a return demonstration. She stated the education covered the revision of Care Plans, care cards, signs and symptoms and non-verbal indicators of pain, pain assessment, PRN pain medications, indwelling catheter care, recognizing pain symptoms for SRNAs and who they should report it to. She stated post tests were completed by all and were graded by the Regional Risk Manager and the NPE. Abuse and Neglect education to include reporting was completed on 09/14/15. She stated she was responsible to make sure that all staff received education before they returned to work. Interviews on 09/18/15 with RN #5 at 1:41 PM, RN #6 at 2:26 PM, LPN #2 at 2:41 PM, LPN #4 at 1:25 PM, LPN #5 at 1:33 PM, LPN #6 at 1:39 PM, revealed they received recent training on [MEDICAL CONDITION], speaking valves and the care of the valve, Care Plan revisions and implementation, pain assessment and the administration of pain medications, communication, catheters, UTI signs and symptoms, abuse and neglect and Code of Conduct, accuracy of orders, and pain to be identified as mild, moderate or severe. They stated staff was required to complete post tests. Interviews on 09/18/15 with SRNA #14 at 1:56 PM, SRNA #15 at 1:58 PM, SRNA #16 at 2:01 PM, SRNA #17 at 2:03 PM, SRNA #18 at 2:06 PM, SRNA #21 at 2:09 PM, SRNA #22 at 2:12 PM, SRNA #23 at 2:14 PM, SRNA #20 at 1:52 PM, SRNA #19 at 2:38 PM, Certified Occupational Therapy Assistant (COTA) #1 at 1:54 PM, COTA #2 at 2:30 PM, Physical Therapy Assistant (PTA) #1 at 2:32 PM, and PTA #2 at 2:33 PM revealed they had received inservice training by the NPE on Abuse/Neglect, catheters, reporting of pain, care cards, and reporting of concerns to the DON. They stated post tests were provided after the training. Interviews on 09/18/15 with the Activities Director at 1:46 PM, the Dietary Director a

Based on interview, record review, facility policy review, review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, and review of the Hospital History and Physical, it was determined the facility failed to provide services, in accordance with acceptable standards of practice, for one (1) of fourteen (14) sampled residents (Resident #3). On 07/04/15, Resident #3 was hollering and complaining of pain related to an indwelling urinary catheter most of the day. Licensed Practical Nurse (LPN) #1 and Registered Nurse (RN) #1 failed to follow the physician's orders [REDACTED]. At 9:00 PM, Registered Nurse #3 assessed the resident and identified the resident had a distended bladder and no urine output was in the catheter bag. When RN #3 deflated (removed water) the catheter bulb, the catheter popped out and the resident had brown, bloody drainage. RN #3 sent the resident to the emergency room . The resident was admitted to the hospital and was identified as having a urinary tract infection, resulting in intravenous (IV) antibiotic therapy and hydration therapy. The facility's failure to provide services in accordance with acceptable standards of practice has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 09/08/15 and determined to exist on 07/04/15. The facility was notified of the Immediate Jeopardy on 09/08/15. An acceptable Allegation of Compliance (AoC) was received on 09/17/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/18/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the KBN AOS #14, Patient Care Orders, last revised 10/2010, revealed licensed nurses were responsible for administering medication and treatments as prescribed by the Physician or Advanced Practice Registered Nurse (APRN). Record review revealed the facility admitted Resident #3 on 04/29/15 with [DIAGNOSES REDACTED]. The resident also had [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 07/28/15, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. Interviews with Resident #3, on 08/04/15 at 9:10 AM, revealed he/she complained most of the day of pain on 07/04/15. Resident #3 stated he/she told staff he/she was hurting down at the urinary catheter and staff would not send him/her to the hospital. Resident #3 stated when the night nurse (RN #3) came in that night, she called the ambulance and he/she was transported to the emergency room . Review of the July 2015 physician's orders [REDACTED]. However, review of the July 2015 Medication Administration Record (MAR) revealed there was no documented evidence the resident received Tylenol for pain on 07/04/15. Review of Nursing Notes, dated 07/04/15, revealed there was no documented evidence by Registered Nurse (RN) #1 or Licensed Practical Nurse (LPN) #1 that Resident #3 had any complaints of pain or was administered pain medication from 7:00 AM through 7:00 PM. However, interviews with State Registered Nurse Aide (SRNA) #3 who worked 7:00 AM-3:00 PM on 07/04/15, on 08/04/15 at 11:40 AM; and, SRNA #1 who worked 3:00 PM to 11:00 PM shift on 07/04/15, on 08/04/15 at 5:10 PM; revealed Resident #3 complained of catheter pain most of the day on 07/04/15. SRNA #1 said she made LPN #1 aware the resident was complaining of pain and requesting pain medication on her shift and the LPN told her the resident had already been medicated. Interview with LPN #1, on 08/05/15 at 12:48 PM, revealed she was unable to talk at that time; she stated she would return the call to the surveyor. An attempt was made to reach LPN #1, on 08/06/15 at 12:08 PM, but there was no answer, a message was left requesting a return call. Interview with RN #1, on 08/04/15 at 3:15 PM, revealed Resident #3 was hollering so she and LPN #1 placed the resident back to bed. RN #1 stated the resident did not state he/she was in pain and/or wanted to go to the hospital and the SRNA never reported the resident was in pain and wanted to go to the hospital. However, interview with SRNA #3, who worked 7:00 AM-3:00 PM on 07/04/15, on 08/04/15 at 11:40 AM, revealed she told RN #1 that Resident #3 was in pain and she stated the resident was fine, maybe a UTI. Review of a Nursing Note, dated 07/04/15 at 9:54 PM and 10:00 PM, and interview on 08/04/15 at 2:35 PM, with RN #3 who worked 7:00 PM to 7:AM on 07/04/15, revealed Resident #3 complained of pain with urination related to his/her indwelling urinary catheter. RN #3 stated she observed the resident's skin was cool and clammy and his/her face was red. The resident continued to yell stating it hurts down there and when asked to clarify, the resident stated that it hurt, Where I pee. RN #3 stated she took a syringe to check for proper placement of the catheter and the resident yelled louder with pain and stated, Take out. When the urinary catheter bulb deflated, the resident yelled and the catheter came out of the urethra. The resident continued to yell and voided thick, brownish urine. The resident then voided bright red blood. RN #3 was unable to contact the physician so she called the Assistant Director of Nursing (ADON) and the resident was sent to the emergency room . Review of the Hospital History and Physical, dated 07/05/15 at 2:32 AM, revealed Resident #3 was admitted to the hospital with [REDACTED]. The plan on admission to the hospital included the antibiotic [MEDICATION NAME] and intravenous (IV) hydration. Interview with the former ADON, on 08/05/15 at 9:20 AM, revealed he expected the licensed staff to assess the resident's pain, administer medications as ordered and if that was not helpful to contact the physician. Interview with the Director of Nursing (DON), on 08/06/15 at 2:39 PM, revealed her expectation was that licensed staff should administer medications according to the physician's orders [REDACTED]. Interview with the Physician/Medical Director , on 08/07/15 at 8:21 AM, revealed he expected the facility staff to provide pain medication according to the physician's orders [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was transferred to the hospital on [DATE] at 10:15 PM by RN #3 immediately upon assessment of the catheter in order to address Resident #3's complaints of pain. 2. Resident #1 was readmitted to the facility on [DATE] at 5:12 PM with no orders to remove the speaking valve. Resident #3 continued to have a urinary catheter due to [MEDICAL CONDITION] bladder as assessed by the Physician related to a stroke on 04/30/15. 3. Resident #3's [MEDICAL CONDITION] was removed on 08/24/15 by the Respiratory Therapist. 4. Resident #3's urinary catheter was discontinued by the physician on 08/10/15 and removed by the licensed nurse on that date. 5. As of 08/27/15, there were no residents in the center with a [MEDICAL CONDITION]; therefore, no potential exists for issues relating to tracheostomies at this time. 6. On 08/25/15, the center had three (3) of seventy-eight (78) residents who utilized a catheter. The DON assessed these three (3) residents on 08/25/15 for signs/symptoms of a urinary tract infection and assessed for pain. One (1) resident with a catheter was identified as having pain. The physician was notified and new orders were obtained for a urinalysis (UA) and culture and sensitivity (CNS) and antibiotic treatment was based on the preliminary analysis. The antibiotic therapy was completed on 08/31/15. 7. On 08/21/15, the three (3) residents utilizing catheters were reviewed by a RN to validate physician's orders [REDACTED]. No concerns were identified. 8. On 08/21/15, a RN reviewed all resident records (79 of 79) (census fluctuated) to validate the MAR and/or Treatment Administration Record (TAR) reflected daily pain monitoring, which included a care plan review. No concerns were identified. 9. On 08/27/15, all resident records (78 of 78) (census fluctuated) were reviewed by the Director of Health Information Management to validate a PRN (as needed) Pain Management Flow Sheet was present for each resident which included a care plan review; no concerns were identified. 10. On 08/28/15, a RN reviewed residents listed on a change of condition report for the period between 08/07/15-08/28/15. Twenty-two (22) of seventy-seven (77) (census fluctuated) residents were reviewed to determine if residents were assessed for the presence of pain; and, if pain interventions were initiated upon the identified change of condition, which included a care plan review; no concerns were identified. 11. Beginning on 08/28/15 through 09/03/15, an RN reviewed all residents receiving PRN pain medication to validate accuracy of the physician's orders [REDACTED]. Order clarification needs were identified as requiring the specification of mild, moderate, or severe indications. These identified clarification needs were reviewed with the Physician with corrective action initiated upon discovery. 12. The Administrator and DON participated in Corporate sponsored mandated reeducation via independent computer training. The Administrator completed training on 07/07/15 and the DON completed training on 09/02/15. This education was on the Code of Conduct related to meeting professional standards, complying with regulatory guidance, and exercise of good judgement regarding how best to uphold ethical behavior every day. In addition, the code included measuring clinical outcomes and resident satisfaction to confirm quality goals are met and focus and discipline on improving quality of care. Creativity and innovation to develop effective solutions. 13. All facility staff including Food Service Director, Cooks, and Cook Aides, SRNAs, LPNs, RNs, Social Services, Business Office Manager, Receptionist, Activities Director, Admissions Director, Medical Records, Payroll, Maintenance and Maintenance Assistant, Therapy Program Director, and Therapists participated in Corporate mandated Code of Conduct Training with a completion date of 09/17/15 (76 out of 110). On 09/17/15, this training will be completed with the contracted Housekeeping Supervisor and Housekeepers. Staff not available on 09/17/15 will be provided reeducation including competency and post-test by the Nurse Practice Educator (NPE) or RN with a pass rate of 100% prior to returning to work. In addition on 09/08/15, all were re-educated by the NPE on identification of all forms of abuse, including neglect, when to report suspicions of abuse, and reporting of suspicions of abuse, to include the chain of command, and the abuse prevention coordinator. This was completed on 09/14/15. Staff not available during this time frame (33 of 110) will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The NPE and DON were reeducated by the Manager of Clinical Operations on 08/26/15 and then the NPE, Consulting Respiratory Therapist or Regional Risk Manager, who was also an RN began reeducation on 08/26/15 through 09/04/15 with all licensed nurses which included RN #1 and RN #3, were provided with all reeducation. Twenty-three (23) of twenty-seven (27) RNs and LPNs were provided with the reeducation. RNs and LPNs not available during this timeframe will be provided the re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The above re-education included the following: A. Abuse and Neglect Policy which covered removing a Passey Muir speaking valve with return demonstration. All nurses educated verbalized and signed that they understood the removal of the valve to prevent a resident to speak is considered abuse. B. [MEDICAL CONDITION] policy and procedure. C. Timely review, revision and implementation of care plans and care cards to reflect response to care and changing needs and goals; a post test was used to validate learning. D. Pain assessment and administering mediation and treatments as prescribed by the physician and/or Nurse Practitioner, and/or per the care plan. Monitoring effectiveness, side effects, and non-verbal signs/symptoms of pain. Completion of pain assessment regarding PRN pain medication administration when receiving communication from another staff member who suspects a resident may be in pain. Learning was validated with a post-test. E. Ensuring assessment initiated for appropriate treatment and services to identify complications of an indwelling catheter related to UTI to include signs and symptoms of pain, assessing for discoloration and urine flow in the tubing and an attempt to find the root cause for the pain and take appropriate action. Learning was validated with post-test. On 09/17/15, all SRNA's will be provided with re-education on recognizing symptoms of any pain but specifically related to tracheostomies or urinary catheters, observations for discoloration of urine in urinary catheter or changes in urinary output related to catheters who to report these observations, when to report these observations, and what action to take if their concerns were not addressed. Learning will be validated via post-test graded by the NPE, DON, or RN with a 100% pass rate. SRNAs not available during this timeframe will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100 % prior to returning to work. 13. The DON, NPE, or Licensed Nurse will observe licensed nurse providing all aspects of [MEDICAL CONDITION] care including observing for sign/symptoms of pain or discomfort during the care or if resident with a [MEDICAL CONDITION] enters into the facility. This will include speaking valve treatment and orders, abuse related to removing it when not specifically ordered to do so and following the plan of care. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 14. The DON, NPE, or Licensed Nurse will observe for signs and symptoms of pain associated with indwelling urinary catheters and following the care plan related to urinary catheter use. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 15. The DON, NPE, or RN Supervisor or Charge Nurse will review residents with a change of condition and audit by head to toe assessment that the change of condition is accurately documented and followed up on timely daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 16. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview five (5) residents across all shifts to determine if they feel if a staff member abused them, to include all forms of abuse or neglect, of if they have witnessed any other resident being abused daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 17. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview three (3) staff members across all shifts to determine if they know or suspect any resident being abused that they have not reported daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 18. Beginning on 09/17/15, the Administrator, DON, NPE, RN Supervisor or Licensed Nurse will observe staff interaction including care of five (5) residents to visually determine that the care plan is being followed daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. On 09/18/15, review of Resident #3's Nurse's Notes revealed the resident was transported to the emergency roiagnom on [DATE] at 10:15 PM via ambulance. The resident was admitted with a [DIAGNOSES REDACTED]. 2. On 09/18/15, review of Resident #3's readmission orders [REDACTED]. There was no order written to remove the speaking valve. 3. On 09/18/15, review of Resident #3's physician's orders [REDACTED].#3's [MEDICAL CONDITION] was removed on 08/24/15. 4. On 09/18/15, review of Resident #3's physician's orders [REDACTED]. 5. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed as of 08/25/15 there were no other [MEDICAL CONDITION] residents. However, the facility reviewed their [MEDICAL CONDITION] care policy and procedures, including following physician's orders [REDACTED]. 6. On 09/18/15, review of documentation by the DON revealed the DON identified three (3) residents with an indwelling urinary catheter in the facility. She assessed the residents for signs and symptoms of an UTI and pain. She identified one of the residents had symptoms of a UTI . The Physician was notified and orders were received for a Urinalysis and C&S with antibiotic ordered. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE on 1:09 PM, revealed three (3) residents were assessed for Urinary Tract Infection symptoms and one (1) resident was started on an antibiotic which has since been completed. 7. On 09/18/15, review of documentation by the DON revealed on 08/21/15 an RN reviewed three (3) residents with indwelling catheters to validate the physician's orders [REDACTED]. The MAR contained instructions to assess every shift for the presence of pain. A Care Plan review was also completed. All with no concerns noted. 8. On 09/18/15, review of check sheets on 09/18/15 revealed the DON reviewed all seventy-nine (79) (census fluctuated) residents medical records to ensure the MAR and TAR reflected daily pain management. The Manager of Clinical Operations assisted with this and it was completed on 08/21/15. Interviews on 09/18/15 with the DON, at 12:52 PM and the Manager of Clinical Operations at 1:09 PM revealed they reviewed all seventy-nine (79) (census fluctuated) residents' records and ensured the MAR/TAR and care plan reflected daily pain management. 9. On 09/18/15, review of a check sheet and interview with the Director of Health Information at 1:09 PM revealed the Director of Health Information validated all resident records were complete with a pain management sheet on 08/27/15. 10. On 09/18/15, review of documentation revealed the Regional Risk Manager (who is an RN) and the DON reviewed all resident records for a change of condition on 08/28/15. A total of twenty-five (25) change of conditions were identified, none had a concern that was identified. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed audits for change of condition were completed and if there was a change of condition, a head to toe assessment was completed. 11. On 09/18/15, review of an Order Listing Report, revealed all PRN (as needed) pain medications were reviewed to validate the order accuracy and the Care Plan was reviewed on 09/03/15. In addition, MILD, MODERATE or SEVERE was included on the order to print on the MAR. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed orders were reviewed for accuracy. No concerns were identified. 12. On 09/18/15, review of the Code Of Conduct Signature Sheets verified that mandated education via computer independent training was completed on 07/07/15 by the Administrator and by the DON on 09/02/15. The training included Code of Conduct, how it related to staff positions, all were expected to meet Professional Standards, comply with Regulatory guidance and exercise judgement on how to best uphold ethical behavior every day. The Code also included measuring clinical outcomes, patient satisfaction to confirm goals are met. Additionally, it included focused discipline on improving the Quality of Care, creativity and innovation to develop effective solutions. Interviews on 09/18/15 with the DON at 12:52 PM and the Administrator at 12:04 PM verified they received this training. On 09/18/15, review of the acknowledgement signature forms revealed facility staff except housekeeping, (who is contract) completed the Code of Conduct computer training on 09/17/15, except for ten (10) staff that have not completed the training and those staff will complete the training before returning to work. All housekeeping staff completed the inservices manually on 09/17/15 and signed acknowledgement forms. Further review of signature validation sheets and post tests revealed all facility staff received education by the NPE on the facility's Abuse/Neglect policy and procedure to include the forms of abuse and neglect, when to report, and including following the chain of command from 09/08/15-09/14/15. On 09/14/15, there were thirty-three (33) staff remaining to be educated and they will complete the training before being allowed to care for residents. On 09/18/15, review of signature validation sheets and post tests validated the NPE and the DON were re-educated by the Manager of Clinical Operations on 08/26/15. Further review of the signature validation sheets revealed the NPE, Consulting Respiratory Therapist or Regional Risk Manager also reeducated all licensed nurses on 09/02/15 related to the Passey-Muir speaking valve, the Abuse/Neglect policy, [MEDICAL CONDITION] care policies and procedures, following MD orders, timely review of revision of Care Plan implementation and care cards, pain assessments and medication, treatments, and assessments related to complications of indwelling urinary catheters. Post-tests and return demonstrations were completed by staff to ensure understanding. Twenty-three (23) of twenty-seven (27) licensed staff received the education with the remaining to complete on return to work. Interview with the DON, on 09/18/15 at 12:52 PM, revealed all nurses were educated regarding Abuse and Neglect, [MEDICAL CONDITION], the speaking valve,[MEDICAL CONDITION], care plans and care cards and all training was completed by 09/17/15. On 09/18/15, review of signature validation sheets and post tests revealed SRNAs were educated by the NPE and DON on 09/17/15 on recognizing the signs and symptoms of any kind of pain, especially related to residents who have a [MEDICAL CONDITION] or indwelling urinary catheter. Twenty-nine (29) out of thirty (30) SRNAs were education with the one (1) remaining to complete the training upon return to work. Interview with the NPE, on 09/18/15 at 1:09 PM, revealed there was a Code of Conduct training presented by Corporate Staff and the NPE assisted with training of facility staff. She stated the Respiratory Therapist provided education to her and she then provided education to the facility staff which included a return demonstration. She stated the education covered the revision of Care Plans, care cards, signs and symptoms and non-verbal indicators of pain, pain assessment, PRN pain medications, indwelling catheter care, recognizing pain symptoms for SRNAs and who they should report it to. She stated post tests were completed by all and were graded by the Regional Risk Manager and the NPE. Abuse and Neglect education to include reporting was completed on 09/14/15. She stated she was responsible to make sure that all staff received education before they returned to work. Interviews on 09/18/15 with RN #5 at 1:41 PM, RN #6 at 2:26 PM, LPN #2 at 2:41 PM, LPN #4 at 1:25 PM, LPN #5 at 1:33 PM, LPN #6 at 1:39 PM, revealed they received recent training on [MEDICAL CONDITION], speaking valves and the care of the valve, Care Plan revisions and implementation, pain assessment and the administration of pain medications, communication, catheters, UTI signs and symptoms, abuse and neglect and Code of Conduct, accuracy of orders, and pain to be identified as mild, moderate or severe. They stated staff was required to complete post tests. Interviews on 09/18/15 with SRNA #14 at 1:56 PM, SRNA #15 at 1:58 PM, SRNA #16 at 2:01 PM, SRNA #17 at 2:03 PM, SRNA #18 at 2:06 PM, SRNA #21 at 2:09 PM, SRNA #22 at 2:12 PM, SRNA #23 at 2:14 PM, SRNA #20 at 1:52 PM, SRNA #19 at 2:38 PM, Certified Occupational Therapy Assistant (COTA) #1 at 1:54 PM, COTA #2 at 2:30 PM, Physical Therapy Assistant (PTA) #1 at 2:32 PM, and PTA #2 at 2:33 PM revealed they had received inservice training by the NPE on Abuse/Neglect, catheters, reporting of pain, care cards, and reporting of concerns to the DON. They stated post tests were provided after the training. Interviews on 09/18/15 with the Activities Director at 1:46 PM, the Dietary Director at 1:48 PM, the Social Services Director at 1:49 PM, the Maintenance Man at 2:15 PM, the Health Information Coordinator at 1:36 PM, the Payroll and Benefits Coordinator at 1:43 PM, the Business Office Manager at 2:23 PM, the Admissions/Marketing Director at 2:18 PM, a Receptionist at 2:05 PM, the Hairdresser at 2:21 PM, Housekeeper #2 at 2:35 PM revealed inservice training was provided by the NPE regarding the abuse/neglect policy and the types of abuse as well as the signs and symptoms and reporting. They also received education on the chain of command and the reporting of pain. They were required to take a test after completion. 13. Review of the Roster Sample Matrix revealed as of 09/18/15, revealed there were no residents with a [MEDICAL CONDITION] in the building. 14. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM revealed they were observing residents with indwelling catheters daily for signs of pain and ensuring staff was following the Plan of Correction. 15. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM revealed they were completing head to toe skin assessments and documenting daily on any resident identified as having a change of condition daily. 16. Interview with the DON, on 09/18/15 at 12:52 PM, revealed five (5)residents were being interviewed daily regarding Abuse/Neglect. 17. Interview with the DON, on 09/18/15 at 12:52 PM, revealed three (3) staff members were being interviewed daily regarding Abuse/Neglect and the proper procedures to follow. 18. Interview with the DON, on 09/18/15 at 12:52 PM, revealed Administration and various staff were watching interactions between staff and residents daily.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of fourteen (14) sampled residents was free from mistreatment and neglect (Resident #3). On 07/04/15, Resident #3 was hollering and complaining of pain related to a urinary indwelling catheter. Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to assess the resident; and failed to provide care to address the resident's catheter pain. RN #1 removed the resident's [MEDICAL CONDITION] voice valve for an unknown length of time to prevent the resident from hollering and voicing pain. At approximately 9:00 PM, RN #3 assessed the resident and identified the resident's voice valve had been removed; his/her bladder was distended; and, the resident had no urinary output in the catheter bag. RN #3 replaced the resident's voice valve and the resident immediately complained of pain and started hollering. RN #3 removed water from the catheter bulb, the catheter popped out and the resident had brown, bloody drainage. RN #3 sent the resident to the emergency room and the resident was identified as having a urinary tract infection. In addition, RN #1 and LPN #1 failed to provide necessary care and services when they neglected to assess the resident's catheter pain; failed to ensure treatment was provided; and when they removed the resident's [MEDICAL CONDITION] voice valve, depriving him/her of the means to communicate his/her needs. The facility's failure to ensure residents were free from mistreatment or neglect has caused or is likely to cause serious injury, harm, or impairment to a resident. Immediate Jeopardy was identified on 09/08/15 and determined to exist on 07/04/15. The facility was notified of the Immediate Jeopardy on 09/08/15. An acceptable Allegation of Compliance (AoC) was received on 09/17/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 09/18/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Abuse Prohibition, dated 07/01/13, revealed the definition of abuse as the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services which are necessary to maintain physical or mental health. The policy further defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Record review revealed the facility admitted Resident #3 on 04/29/15 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set Assessment, dated 07/28/15, revealed the facility assessed Resident #3's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. The facility coded the MDS as functional limitation on one side, upper and lower related to a [MEDICAL CONDITION]. Review of the facility's Complaint Investigation Initial Report, dated 07/09/15, revealed Resident #3 alleged Licensed Practical Nurse (LPN) #1 neglected him/her when she refused to send the resident to the hospital when he/she was in pain on 07/04/15. Interview with Resident #3, on 08/04/15 at 9:10 AM; on 08/05/15 at 11:50 AM; and, on 08/06/15 at 9:30 AM, revealed he/she had been in pain all day on 07/04/15 and LPN #1 told him/her, that he/she had been medicated for pain already. Resident #3 stated he/she told staff he/she was hurting related to the catheter and staff would not send him/her to the hospital. During further interview, Resident #3 stated when the night nurse (RN #3) came in that night, she called the ambulance and the resident was transported to the emergency room . Resident #3 stated he/she was unable to insert or remove his/her speaking valve by himself/herself. Review of the July 2015 Medication Administration Record (MAR) revealed on 07/04/15, Resident #3 received [MEDICATION NAME] (anti-anxiety) 0.5 milligrams (mg) via feeding tube at 1:45 PM. However, there was no documented evidence the resident received any medication for pain. Review of the Nursing Notes, dated 07/04/15, revealed there was no documented evidence staff addressed Resident #3's pain until 9:00 PM. Interview with State Registered Nurse Aide (SRNA) #3, on 08/04/15 at 11:40 AM, revealed she worked 7:00 AM to 3:00 PM on 07/04/15. She stated Resident #3 yells all the time and on this particular day he/she was complaining of pain where the catheter goes in. She said RN #1 was made aware of the resident's complaints of pain and the RN checked the catheter and the drainage bag and said the resident was fine, maybe a UTI. The SRNA stated she was giving the resident a bath and the resident continued to yell that he/she was hurting and burning in the penis area. SRNA #3 stated she checked the resident's catheter tubing and it was clear. She stated the resident stated he/she wanted to stay in the bed. Interview with SRNA #1, on 08/04/15 at 5:10 PM, revealed she worked the 3:00 PM to 11:00 PM shift on 07/04/15. She stated when she came into work that day, Resident #3 was in a wheelchair in the lobby area with other residents. She stated the resident was irritated and yelling out. SRNA #1 stated RN #1 and LPN #1, reported that the resident had been yelling all day. The SRNA stated the resident was screaming as if he/she was in pain and his/her face was red. SRNA #1 said when she asked the resident where the pain was, the resident pointed downward to his/her private area and said pee pee. She stated the resident requested medication for pain and LPN #1 was made aware by her. Further interview revealed LPN #1 told her the resident had already been medicated and the resident was just trying to go out to the hospital. The SRNA stated she told LPN #1 she felt like the resident needed to be put to bed, and LPN #1 spun around and headed down the hallway with the resident before she (SRNA #1) could even secure the lift. She stated the nurse acted as if she was irritated. The SRNA stated the resident was sweating while being transferred to the bed using the lift, and LPN #1 kept telling the resident, You are not going to the hospital. SRNA #1 stated when she entered the resident's room around 9:00 PM, the resident looked as if he/she was screaming but nothing was coming out. The SRNA stated she told RN #3 and the RN picked up the voice box valve and inserted it and the resident went back to screaming. SRNA #1 stated when the resident's covers were pulled back, there was urine on the bed sheets and when the catheter came out, the urine kept coming out. The SRNA stated RN #3 sent the resident to the hospital. Interview, on 08/04/15 at 5:40 PM, with SRNA #2, who worked the 3:00 PM to 11:00 PM shift on 07/04/15, revealed when RN #3 called him into the room, Resident #3 was complaining of hurting and was hollering loudly. SRNA #2 stated when RN #3 took the resident's catheter out, there was blood, urine and gooey pus and a lot of blood. SRNA stated the resident said that he/she wanted to go to the hospital. The SRNA stated the resident's skin was very clammy and cold to touch. SRNA #2 stated he did not know anything about the speaking valve, as the resident was speaking while he was in the room. Telephone interview with LPN #1, on 08/05/15 at 12:48 PM, revealed she was unable to talk at that time. LPN #1 stated she would return the call to the surveyor. An attempt was made to reach LPN #1, on 08/06/15 at 12:08 PM, but there was no answer. A message was left requesting a return call. Interview, on 08/04/15 at 3:15 PM, with RN #1, who worked the 7:00 AM to 7:00 PM shift on 07/04/15, revealed Resident #3 was hollering so she and LPN #1 placed the resident back to bed. RN #1 stated the resident did not complain of pain and/or request to go to the hospital and the SRNA never reported the resident wanted to go to the hospital. RN #1 said she provided [MEDICAL CONDITION] care and removed the speaking valve and put it down within the resident's reach just before shift change at 7:00 PM. However, interview with RN #3, on 08/04/15 at 2:35 PM, revealed when she entered the room at approximately 9:00 PM, she noted the voice valve was on the table on the resident's left side (the [MEDICAL CONDITION]) and out of the resident's reach. Review of a Nursing Note written by RN #3, dated 07/04/15 at 9:54 PM, revealed Resident #3 complained of pain with the presence of a indwelling urinary catheter to a bedside drainage. RN #3 documented there was no urine in the drainage bag and the resident's skin was noted to be cool and clammy and his/her face was red. The RN wrote when she pulled the covers back it was noted that there was urine on the sheets and the resident continued to yell stating it hurts down there where I pee. Further review of the Note revealed the nurse took a syringe to check for proper placement of the catheter and the resident yelled louder with pain and stated, take out. The nurse documented she deflated the bulb, the resident yelled, the catheter came out of the urethra and the resident voided thick, brownish urine. RN #3 documented once again the resident expressed the desire to go to the hospital and then voided bright red blood. RN #3 documented she left the room to attempt to contact the physician and the family without success. Interview with RN #3, on 08/04/15 at 2:35 PM, revealed she had worked on 07/04/15 on the 7:00 PM-7:00 AM shift. She stated RN #1 reported to her that Resident #3 had complained all day long of having pain on urination and was told by the nurse that he/she had a catheter and shouldn't be hurting. RN #3 said RN #1 told her they had taken Resident #3's speaking valve off because he/she was yelling too much and the resident's roommate was removed from the room as well. RN #3 stated when she entered Resident #3's room, she noted the voice valve was on the table on the resident's left side ([MEDICAL CONDITION] side). RN #3 stated the resident would normally refuse to have the valve removed. She stated Resident #3 kept telling her that he/she was in severe pain and kept grabbing the catheter saying that he/she couldn't pee. RN #3 stated the resident's catheter drainage bag was empty so she secured a syringe to flush the catheter. She stated she let out a little of the water from the bulb and the resident screamed in pain and the catheter shot out. RN #3 stated there was a brown, thick, substance coming out of the resident's urethra. She stated she could tell the resident's bladder was distended and then the resident voided straight blood. The RN stated at that time the resident was begging to be sent to the hospital so she attempted to reach the On Call Physician, but she was unable to reach him so she phoned the Assistant Director of Nursing (ADON) and got permission to send the resident to the hospital. She stated she learned later in the evening the resident was being admitted to the hospital for a Urinary Tract Infection [MEDICAL CONDITION]. Review of the Hospital History and Physical, dated 07/05/15 at 2:32 AM, revealed Resident #3 was admitted to the hospital with [REDACTED]. The Plan of Care on admission to the hospital included the antibiotic [MEDICATION NAME] and intravenous (IV) hydration. Review of the Hospital Discharge Summary revealed the resident was discharged back to the facility on [DATE]. Interview with the former ADON, on 08/05/15 at 9:20 AM, revealed RN #3 phoned her saying she wanted to send Resident #3 to the emergency room because Resident #3 had no urine output. RN #3 stated the balloon had been deflated and the resident had some relief. The ADON stated RN #3 reported the resident wanted to go to the hospital and she told RN #3 to send the resident to the emergency room . Further interview with the ADON revealed RN #3 reported she had found the resident's speaking valve on the bedside table when she entered the room. Further interview with the ADON revealed the resident was able to take the valve out and put it back in. She stated she thought the other nurses had left the valve out intentionally related to the resident hollering all day long. The ADON reported he was not sure why LPN #1 didn't do a more thorough assessment of Resident #3. He stated he thanked RN #3 for assessing the resident and putting his/her safety first. The ADON stated that he would expect the staff to assess the resident for pain, administer medications as ordered and if these things didn't work, they should contact the physician. Interview (Post Survey) with the Director of Nursing, on 08/14/15 at 8:15 AM, revealed the facility's investigation did not determine there was any mistreatment/neglect of Resident #3. She stated the facility determined LPN #1 failed to follow clinical protocols for assessments and LPN #1 was terminated. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was transferred to the hospital on [DATE] at 10:15 PM by RN #3 immediately upon assessment of the catheter in order to address Resident #3's complaints of pain. 2. Resident #1 was readmitted to the facility on [DATE] at 5:12 PM with no orders to remove the speaking valve. Resident #3 continued to have a urinary catheter due to [MEDICAL CONDITION] bladder as assessed by the Physician related to a stroke on 04/30/15. 3. Resident #3's [MEDICAL CONDITION] was removed on 08/24/15 by the Respiratory Therapist. 4. Resident #3's urinary catheter was discontinued by the physician on 08/10/15 and removed by the licensed nurse on that date. 5. As of 08/27/15, there were no residents in the center with a [MEDICAL CONDITION]; therefore, no potential exists for issues relating to tracheostomies at this time. 6. On 08/25/15, the center had three (3) of seventy-eight (78) residents who utilized a catheter. The DON assessed these three (3) residents on 08/25/15 for signs/symptoms of a urinary tract infection and assessed for pain. One (1) resident with a catheter was identified as having pain. The physician was notified and new orders were obtained for a urinalysis (UA) and culture and sensitivity (CNS) and antibiotic treatment was based on the preliminary analysis. The antibiotic therapy was completed on 08/31/15. 7. On 08/21/15, the three (3) residents utilizing catheters were reviewed by a RN to validate physician's orders [REDACTED]. No concerns were identified. 8. On 08/21/15, a RN reviewed all resident records (79 of 79) (census fluctuated) to validate the MAR and/or Treatment Administration Record (TAR) reflected daily pain monitoring, which included a care plan review. No concerns were identified. 9. On 08/27/15, all resident records (78 of 78) (census fluctuated) were reviewed by the Director of Health Information Management to validate a PRN (as needed) Pain Management Flow Sheet was present for each resident which included a care plan review; no concerns were identified. 10. On 08/28/15, a RN reviewed residents listed on a change of condition report for the period between 08/07/15-08/28/15. Twenty-two (22) of seventy-seven (77) (census fluctuated) residents were reviewed to determine if residents were assessed for the presence of pain; and, if pain interventions were initiated upon the identified change of condition, which included a care plan review; no concerns were identified. 11. Beginning on 08/28/15 through 09/03/15, an RN reviewed all residents receiving PRN pain medication to validate accuracy of the physician's orders [REDACTED]. Order clarification needs were identified as requiring the specification of mild, moderate, or severe indications. These identified clarification needs were reviewed with the Physician with corrective action initiated upon discovery. 12. The Administrator and DON participated in Corporate sponsored mandated reeducation via independent computer training. The Administrator completed training on 07/07/15 and the DON completed training on 09/02/15. This education was on the Code of Conduct related to meeting professional standards, complying with regulatory guidance, and exercise of good judgement regarding how best to uphold ethical behavior every day. In addition, the code included measuring clinical outcomes and resident satisfaction to confirm quality goals are met and focus and discipline on improving quality of care. Creativity and innovation to develop effective solutions. 13. All facility staff including Food Service Director, Cooks, and Cook Aides, SRNAs, LPNs, RNs, Social Services, Business Office Manager, Receptionist, Activities Director, Admissions Director, Medical Records, Payroll, Maintenance and Maintenance Assistant, Therapy Program Director, and Therapists participated in Corporate mandated Code of Conduct Training with a completion date of 09/17/15 (76 out of 110). On 09/17/15, this training will be completed with the contracted Housekeeping Supervisor and Housekeepers. Staff not available on 09/17/15 will be provided reeducation including competency and post-test by the Nurse Practice Educator (NPE) or RN with a pass rate of 100% prior to returning to work. In addition on 09/08/15, all were re-educated by the NPE on identification of all forms of abuse, including neglect, when to report suspicions of abuse, and reporting of suspicions of abuse, to include the chain of command, and the abuse prevention coordinator. This was completed on 09/14/15. Staff not available during this time frame (33 of 110) will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The NPE and DON were reeducated by the Manager of Clinical Operations on 08/26/15 and then the NPE, Consulting Respiratory Therapist or Regional Risk Manager, who was also an RN began reeducation on 08/26/15 through 09/04/15 with all licensed nurses which included RN #1 and RN #3, were provided with all reeducation. Twenty-three (23) of twenty-seven (27) RNs and LPNs were provided with the reeducation. RNs and LPNs not available during this timeframe will be provided the re-education including competency and post-test by the NPE or RN with a pass rate of 100% prior to returning to work. The above re-education included the following: A. Abuse and Neglect Policy which covered removing a Passey Muir speaking valve with return demonstration. All nurses educated verbalized and signed that they understood the removal of the valve to prevent a resident to speak is considered abuse. B. [MEDICAL CONDITION] policy and procedure. C. Timely review, revision and implementation of care plans and care cards to reflect response to care and changing needs and goals; a post test was used to validate learning. D. Pain assessment and administering mediation and treatments as prescribed by the physician and/or Nurse Practitioner, and/or per the care plan. Monitoring effectiveness, side effects, and non-verbal signs/symptoms of pain. Completion of pain assessment regarding PRN pain medication administration when receiving communication from another staff member who suspects a resident may be in pain. Learning was validated with a post-test. E. Ensuring assessment initiated for appropriate treatment and services to identify complications of an indwelling catheter related to UTI to include signs and symptoms of pain, assessing for discoloration and urine flow in the tubing and an attempt to find the root cause for the pain and take appropriate action. Learning was validated with post-test. On 09/17/15, all SRNA's will be provided with re-education on recognizing symptoms of any pain but specifically related to tracheostomies or urinary catheters, observations for discoloration of urine in urinary catheter or changes in urinary output related to catheters who to report these observations, when to report these observations, and what action to take if their concerns were not addressed. Learning will be validated via post-test graded by the NPE, DON, or RN with a 100% pass rate. SRNAs not available during this timeframe will be provided re-education including competency and post-test by the NPE or RN with a pass rate of 100 % prior to returning to work. 13. The DON, NPE, or Licensed Nurse will observe licensed nurse providing all aspects of [MEDICAL CONDITION] care including observing for sign/symptoms of pain or discomfort during the care or if resident with a [MEDICAL CONDITION] enters into the facility. This will include speaking valve treatment and orders, abuse related to removing it when not specifically ordered to do so and following the plan of care. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 14. The DON, NPE, or Licensed Nurse will observe for signs and symptoms of pain associated with indwelling urinary catheters and following the care plan related to urinary catheter use. This will be completed across all shifts times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 15. The DON, NPE, or RN Supervisor or Charge Nurse will review residents with a change of condition and audit by head to toe assessment that the change of condition is accurately documented and followed up on timely daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 16. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview five (5) residents across all shifts to determine if they feel if a staff member abused them, to include all forms of abuse or neglect, of if they have witnessed any other resident being abused daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 17. Beginning 09/17/15, the Administrator, Social Service Director, Business Office Manager, Admission Director, Activities Director, Payroll, Receptionist, Food Service Director, DON, NPE, or Licensed Nurse will interview three (3) staff members across all shifts to determine if they know or suspect any resident being abused that they have not reported daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. 18. Beginning on 09/17/15, the Administrator, DON, NPE, RN Supervisor or Licensed Nurse will observe staff interaction including care of five (5) residents to visually determine that the care plan is being followed daily times fourteen (14) days to include weekends, then three (3) times per week times two (2) weeks then as determined by the Quality Improvement Committee with corrective action upon discovery. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. On 09/18/15, review of Resident #3's Nurse's Notes revealed the resident was transported to the emergency roiagnom on [DATE] at 10:15 PM via ambulance. The resident was admitted with a [DIAGNOSES REDACTED]. 2. On 09/18/15, review of Resident #3's readmission orders [REDACTED]. There was no order written to remove the speaking valve. 3. On 09/18/15, review of Resident #3's physician's orders [REDACTED].#3's [MEDICAL CONDITION] was removed on 08/24/15. 4. On 09/18/15, review of Resident #3's physician's orders [REDACTED]. 5. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed as of 08/25/15 there were no other [MEDICAL CONDITION] residents. However, the facility reviewed their [MEDICAL CONDITION] care policy and procedures, including following physician's orders [REDACTED]. 6. On 09/18/15, review of documentation by the DON revealed the DON identified three (3) residents with an indwelling urinary catheter in the facility. She assessed the residents for signs and symptoms of an UTI and pain. She identified one of the residents had symptoms of a UTI . The Physician was notified and orders were received for a Urinalysis and C&S with antibiotic ordered. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE on 1:09 PM, revealed three (3) residents were assessed for Urinary Tract Infection symptoms and one (1) resident was started on an antibiotic which has since been completed. 7. On 09/18/15, review of documentation by the DON revealed on 08/21/15 an RN reviewed three (3) residents with indwelling catheters to validate the physician's orders [REDACTED]. The MAR contained instructions to assess every shift for the presence of pain. A Care Plan review was also completed. All with no concerns noted. 8. On 09/18/15, review of check sheets on 09/18/15 revealed the DON reviewed all seventy-nine (79) (census fluctuated) residents medical records to ensure the MAR and TAR reflected daily pain management. The Manager of Clinical Operations assisted with this and it was completed on 08/21/15. Interviews on 09/18/15 with the DON, at 12:52 PM and the Manager of Clinical Operations at 1:09 PM revealed they reviewed all seventy-nine (79) (census fluctuated) residents' records and ensured the MAR/TAR and care plan reflected daily pain management. 9. On 09/18/15, review of a check sheet and interview with the Director of Health Information at 1:09 PM revealed the Director of Health Information validated all resident records were complete with a pain management sheet on 08/27/15. 10. On 09/18/15, review of documentation revealed the Regional Risk Manager (who is an RN) and the DON reviewed all resident records for a change of condition on 08/28/15. A total of twenty-five (25) change of conditions were identified, none had a concern that was identified. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed audits for change of condition were completed and if there was a change of condition, a head to toe assessment was completed. 11. On 09/18/15, review of an Order Listing Report, revealed all PRN (as needed) pain medications were reviewed to validate the order accuracy and the Care Plan was reviewed on 09/03/15. In addition, MILD, MODERATE or SEVERE was included on the order to print on the MAR. Interviews on 09/18/15 with the DON at 12:52 PM and the NPE at 1:09 PM, revealed orders were reviewed for accuracy. No concerns were identified. 12. On 09/18/15, review of the Code Of Conduct Signature Sheets verified that mandated education via computer independent training was completed on 07/07/15 by the Administrator and by the DON on 09/02/15. The training included Code of Conduct, how it related to staff positions, all were expected to meet Professional Standards, comply with Regulatory guidance and exercise judgement on how to best uphold ethical behavior every day. The Code also included measuring clinical outcomes, patient satisfaction to confirm goals are met. Additionally, it included focused discipline on improving the Quality of Care, creativity and innovation to develop effective solutions. Interviews on 09/18/15 with the DON at 12:52 PM and the Administrator at 12:04 PM verified they received this training. On 09/18/15, review of the acknowledgement signature forms revealed facility staff except housekeeping, (who is contract) completed the Code of Conduct computer training on 09/17/15, except for ten (10) staff that have not completed the training and those staff will complete the training before returning to work. All housekeeping staff completed the inservices manually on 09/17/15 and signed acknowledgement forms. Further review of signature validation sheets and post tests revealed all facility staff received education by the NPE on the facility's Abuse/Neglect policy and procedure to include the forms of abuse and neglect, when to report, and including following the chain of command from 09/08/15-09/14/15. On 09/14/15, there were thirty-three (33) staff remaining to be educated and they will complete the training before being allowed to care for residents. On 09/18/15, review of signature validation sheets and post tests validated the NPE and the DON were re-educated by the Manager of Clinical Operations on 08/26/15. Further review of the signature validation sheets revealed the NPE, Consulting Respiratory Therapist or Regional Risk Manager also reeducated all licensed nurses on 09/02/15 related to the Passey-Muir speaking valve, the Abuse/Neglect policy, [MEDICAL CONDITION] care policies and procedures, following MD orders, timely review of revision of Care Plan implementation and care cards, pain assessments and medication, treatments, and assessments related to complications of indwelling urinary catheters. Post-tests and return demonstrations were completed by staff to ensure understanding. Twenty-three (23) of twenty-seven (27) licensed staff received the education with the remaining to complete on return to work. Interview with the DON, on 09/18/15 at 12:52 PM, revealed all nurses were educated regarding Abuse and Neglect, [MEDICAL CONDITION], the speaking valve,[MEDICAL CONDITION], care plans and care cards and all training was completed by 09/17/15. On 09/18/15, review of signature validation sheets and post tests revealed SRNAs were educated by the NPE and DON on 09/17/15 on recognizing the signs and symptoms of any kind of pain, especially related to residents who have a [MEDICAL CONDITION] or indwelling urinary catheter. Twenty-nine (29) out of thirty (30) SRNAs were education with the one (1) remaining to complete the training upon return to work. Interview with the NPE, on 09/18/15 at 1:09 PM, revealed there was a Code of Conduct training presented by Corporate Staff and the NPE assisted with training of facility staff. She stated the Respiratory Therapist provided education to her and she then provided education to the facility staff which included a return demonstration. She stated the education covered the revision of Care Plans, care cards, signs and symptoms and non-verbal indicators of pain, pain assessment, PRN pain medications, indwelling catheter care, recognizing pain symptoms for SRNAs and who they should report it to. She stated post tests were completed by all and were graded by the Regional Risk Manager and the NPE. Abuse and Neglect education to include reporting was completed on 09/14/15. She stated she was responsible to make sure that all staff received education before they retu

Based on interview, record review, review of the Administrator's job description, and review of the facility's policy and procedures, and the Allegation of Compliance (A0C) and Plan of Correction (PoC) for the 12/11/14 Immediate Jeopardy Abbreviated Survey, it was determined the facility failed to have an effective system to ensure staff was knowledgeable related to the facility's elopement policy and procedures to ensure the residents' safety. This failure affected one (1) of six (6) sampled residents (Resident #1). On 11/21/14, a resident exited the facility without staff's knowledge, unsupervised which resulted in the facility being cited Immediate Jeopardy. The facility educated staff on the facility's policy and procedures related to how to respond to an alarm; the different sounds and the types of alarms. However, the facility failed to ensure the staff followed the policy and procedures, in order to keep Resident #1 safe. Resident #1 exited the facility without staff's knowledge approximately six (6) weeks later, after the first Immediate Jeopardy. On 01/04/15 at approximately 6:15 AM-6:30 AM, a door alarm sounded and Registered Nurse (RN) #1 turned off the alarm; however, the RN failed to conduct a head count and search outside the door for a resident per the facility's policy and procedures, which were included in the AOC and POC. In addition, the nurse failed to identify that the alarm that was sounding was a wanderguard alarm. At approximately 6:40 AM, after the resident's roommate informed staff the resident had gone for a walk, Certified Nurse Aide (CNA) #2 identified that Resident #1 was not in the facility. Resident #1 had exited the facility without staff's knowledge and was discovered outside on a main road at approximately 6:45 AM. The Administrator failed to ensure the education provided to staff was effective. (Refer to F323) The facility's failure to be administered in a manner that enabled it to use its resources effectively and efficiently has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility's job description for the Administrator, last revised 08/01/12, revealed, "The Administrator was responsible for planning and was accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs and coordinates all activities of the Center to assure the highest degree of quality of care is consistently provided to residents; and concerns his/herself with the safety of all Nursing Center residents in order to minimize the potential for fire and accidents." Review of the facility's policy and procedures titled, "Elopement of Patient", last revised 05/15/14, revealed residents should be evaluated for elopement risk upon admission, readmission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk should receive appropriate interventions to reduce risk and minimize injury. For residents identified at risk, an interdisciplinary elopement prevention care plan should be developed with family and resident participation. Individual risk factors and patterns will be identified and addressed within the care plan. Further review of the policy revealed for unwitnessed elopements staff should search room to room and all areas of the Center: resident rooms, closets, under beds, shower rooms, utility rooms, offices, dining rooms, stairwells, laundry, kitchen (including walk-in refrigerators and freezers), bathrooms, dayrooms/lounges, courtyards, and employee lounges; and outside perimeter and grounds. Interview and record review revealed the facility assessed Resident #1 and care planned him/her as an elopement risk. According to the 12/11/14 Abbreviated Survey's AOC and POC the Administrator and Administrative staff educated staff on the facility's Elopement Prevention and Management Policy and a Post Test was given to determine staff competency. The education included the "... Expected employee response to a door alarm" and, the different sounds of the door alarms. Review of the POS [REDACTED]. However, on 01/04/15 at approximately 6:15 AM-6:30 AM, the exit door alarm sounded by the Therapy Department. RN #1 turned the alarm off but failed to identify that the alarm was the wanderguard alarm; she failed to search for the resident outside the door; and, failed to conduct a head count to ensure all residents were accounted for per the facility's AoC and PoC. At approximately 6:30 AM, CNA #2 was told by another resident that Resident #1 had gone for a walk. Resident #1 was found standing outside the facility on a main road at approximately 6:45 AM. Further review of the AoC and PoC revealed elopement drills were conducted on each shift monthly (December 2014 and January 2015) but the facility did not identify any concerns. Review of the elopement Drill Documentation Audit Form revealed the Audit addressed identifying if staff responded to the announcement of a Code Yellow on the intercom system; however, the form did not address if the appropriate action was taken when a wanderguard alarm sounded and if staff was able to identify the alarm as a wanderguard alarm. Further review of the AOC and the POC revealed elopements drills were conducted on 11/21/14, 11/22/14, 11/23/14, 11/24/14, 01/04/15 and 01/10/15. These drills ensured that staff was able to hear the alarm sounding at the door or at the Nurse's Station. However, the drills did not address or ensure that staff could distinguish the different alarms. Interview with RN #1 revealed the alarm sounded different but she did not recognize it as the wanderguard alarm. Interview with RN #1, on 01/12/15 at 2:56 PM and on 01/14/15 at 9:22 AM, revealed when the alarm sounded she turned off the alarm with the key and the code at the door because CNA #1 stated the alarm was sounding related to another resident reentering the facility. RN #1 stated she did not conduct a head count and search outside the door, as per the AOC and POC. RN #1 stated she was not sure of the elopement procedures; however, review of a post test, conducted at the end of an inservice, after the 12/11/14 Immediate Jeopardy, addressing the facility's elopement policy and procedures revealed she scored 100%. The post test included fill in the blank questions: "If a door alarm sounds, what are the three (3) immediate steps?" The RN's written responses were "1. check the alarm, 2. thoroughly check the area, and 3. validate that no resident is missing." Interview on 01/13/15 at 12:17 PM with CNA #5 revealed CNA #2 asked if Resident #1 had been seen on the hall around 6:00 AM on 01/04/15. CNA #5 stated she was confused because no code had been called and no one had announced or done anything according to the policy. CNA #5 further revealed the policy was not followed even after she informed her nurse that a resident could not be found. CNA #5 stated the facility's protocol was not initiated, and the staff did not do what they were suppose to do. CNA #1 revealed he did not know how Resident #1 got out of the facility and the last alarm he heard was around 4:00 AM and 5:00 AM. He stated RN #1 told him to continue his bed checks and she would get the alarm. Interview on 01/11/15 at 4:59 PM; and, on 01/14/15 at 12:11 PM with Licensed Practical Nurse (LPN) #1, revealed she was in another resident's room when she heard an alarm. She stated she did not hear anything on the intercom system, but she was informed by CNA #5 that a resident had gotten out of the facility. LPN #1 stated she continued with her work, and did not know if the resident had been found or not. During the interview, LPN #1 stated when an alarm goes off, staff are to go to the desk and see where the alarm is and tell everyone to start looking for a resident, do a head count, and start looking at the door and around where the alarm went off. She stated if no one is found and the head count is correct, then it is called off. LPN #1 revealed this was not done on the day Resident #1 eloped and she did not know if the resident had gone out or not. LPN #1 revealed she had been trained on elopement and the wanderguard policy and procedure. Even though the LPN had been trained, she failed to follow the facility's elopement policy. Interview with the Administrator, on 01/12/15 at 4:20 PM, on 01/21/15 at 4:15 PM and on 01/30/15 at 6:00 PM, revealed the root cause of the incident was that the nurse walked away and shut off the wanderguard alarm. The Administrator stated the RN should have recognized it was a wanderguard alarm and validated whether there was a resident outside instead of just turning the alarm off. The Administrator stated the RN should not have assumed all was all right because she knew the alarms sounded differently. Further interview revealed she expected the staff to know the sounds of the alarms, search inside and outside when an alarm sounded and do a visual census check. However, she stated they focused the education more on what not to do, such as not silencing the alarm and walking away without knowing what was happening. The Administrator revealed staff was educated and was able to verbalize the sound of the routine alarm which had a high pitched and fast sound, like a siren; and the wanderguard alarm which had a high pitched, slow, chirping sound (two beats). If the staff was unable to verbalize, she would reeducate immediately. However, interview with staff revealed they were confused and didn't follow the facility's policy. RN #1 stated she could not tell that the alarm was for the wandergard. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated "I'm fine; I was just going for a walk." Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's "use by" date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a "sister" facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the "Elopement Drill Documentation Form" on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a "pass" being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Maintenance Supervisor revealed he checked the functionality of the doors, and wander guard alarms. He stated the wander guard alarm would still go off at the doors even with the door releasing after being pushed on for fifteen (15) seconds. Interview on 01/29/15 at 5:14 PM with LPN #6 revealed the residents' wanderguards were tested every shift by the nurse with the transmitter and documented on the Treatment Administration Records (TARs). Review of the January TARs for residents at risk for elopement (13 of 13) revealed daily shift audits of the functionality of each resident's wanderguard. Interview on 01/29/15 at 11:31 AM with the Maintenance Helper revealed nurses checked the residents' wander guards with the transmitters. 14. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed a weekly testing of wanderguard transmitter testers was done and would be in the system. The Maintenance Supervisor provided a copy of the weekly testing of the wanderguard transmitter testers (3 of 3) with one being a spare; which revealed weekly checks were documented on 01/12/15, 01/20/15, and 01/26/15. 15. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed the batteries were changed in the wanderguard transmitter tester in September 2014, November 2014, and on 01/19/15; with the expiration date of the batteries placed on the documentation starting in January. Review of the Wanderguard Tester Battery Replacement Form provided by the Maintenance Supervisor revealed the batteries in the wanderguard transmitter tester were changed on 09/22/14, 11/20/14, and 01/19/15; with the start of documentation of battery expiration date beginning on 01/19/15. 16. Interviews on 01/29/15 at 5:14 PM with LPN #6; on 01/09/15 at 2:45 PM with LPN #4; on 01/15/15 at 1:25 PM with RN #8; and, on 01/09/15 at 2:59 PM with RN #6 revealed residents' wanderguards were tested every shift by the nurse with the transmitter and it was documented on the Treatment Administration Records (TARs). Review of TARs for residents at risk for elopement revealed daily shift audits of the functionality of each resident wander guard. 17. Review of the facility's investigation revealed in an interview conducted on 01/05/15 with CNA #21, who was providing 1:1 supervision of Resident #1, she commented to the resident the door was locked; and Resident #1 made a statement about the door sign saying "push" and the door will open in fifteen (15) seconds. Interview on 01/21/15 at 4:15 PM with the Administrator revealed Resident #1 was on 1:1 with CNA #21 when she had tried to open the door and CNA #21 commenting to the resident the door was locked. 18. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she had turned off the alarm at the door when CNA #1 asked her to, because it was alarming, and the alarm had sounded different to her. RN #1 further revealed she had signed an elopement paper during orientation on 11/25/14, and she had been terminated after this incident. Review of the POS [REDACTED]. Interview on 01/18/15 at 1:13 PM with CRM revealed two (2) staff members were suspended with RN #2 being terminated after the incident. Interview on 01/13/15 at 12:40 PM with the acting DON at the time of the incident revealed RN #1 did not follow the facility's policy and had received the training and testing on elopement to include the sounds of alarms. 19. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed entrance and exit codes were not the same, and if a visitor activated the alarm a staff member would have to silence it. The Maintenance Supervisor stated the exit codes had been changed at least once monthly since November 2014. Review of the Log of Code Changes provided by the Maintenance Supervisor and Administrator revealed exit codes had been changed four (4) times on November 11/21/14, twice (2) on 11/28/14, twice (2) on 11/29/14, twice (2) on 12/26/14, twice (2) on 01/03/15, and once (1) on 01/10/15. Interviews with the CRC on 01/14/15 at 4:05 PM, the SSD on 01/16/15 at 12:45 PM, LPN #1 on 01/11/15 at 4:59 PM, LPN #3 on 01/15/15 at 1:35 AM, LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 at 01/12/15 at 1:01 PM, CNA #22 at 01/29/15 at 12:06 PM revealed when alarms go off staff respond to the alarm. Interviews with LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #11 on 01/13/15 at 8:25 AM, CNA #15 at 01/16/15 at 12:55 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 on 01/12/15 at 1:01 PM, and CNA #22 on 01/29/15 at 12:06 PM revealed the cod

An Abbreviated Survey (KY # ) was conducted on 05/26/15 through 05/28/15. KY # was substantiated with deficient practice identified at the highest scope and severity of a "D". Resident #1 was assessed and care planned to be at risk for elopement due to behaviors of exit seeking. The resident was care planned for staff to redirect the resident when the security system sounded and/or a resident attempted to leave the building; stay with the resident and provide support and supervision until they (staff) are able to redirect the resident; provide 1:1 interactions and support as needed; and, in the event of an elopement, staff should follow the search and reporting protocols. On 01/03/15 and 01/04/15, Resident #1 was up all night wanting to go home and he/she had packed a suitcase and was sitting in the lobby. Staff failed to redirect the resident or stay with the resident to provide support and supervision until the resident was redirected, as stated in the care plan. On 01/04/15 at approximately 6:15 AM, a door alarm sounded and Registered Nurse (RN) #1 turned off the alarm. However, the facility failed to follow the resident's care plan, as the RN failed to follow the facility's search and reporting protocols to conduct a head count and search outside to ensure a resident had not exited the building. Resident #1's roommate informed staff that the resident had gone for a walk. At approximately 6:40 AM, Certified Nurse Aide (CNA) #2 identified Resident #1 was not in the facility. The resident was discovered outside on the main road at 6:45 AM. The facility's failure to implement the care plan caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, "Elopement of Patient", last revised 05/15/14, revealed "Residents should be evaluated for elopement risk upon admission, readmission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. For patients identified as at risk, an interdisciplinary elopement prevention care plan will be developed with family and patient participation. Individual risk factors and patterns will be identified and addressed within the care plan." Review of the facility's policy and procedures titled, "Care Plans", last revised 01/02/14 revealed a comprehensive, individualized care plan should be developed by the interdisciplinary team for each resident. The care plan should include measurable objectives to meet resident needs and goals as identified by the assessment process. The purpose of the care plan was to provide the necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Record review revealed the facility admitted Resident #1 on 12/22/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable; however, the resident was diagnosed with [REDACTED]. The resident was assessed as requiring extensive assistance of two (2) staff with Activities of Daily Living (ADLs), and supervision while walking in the halls, on the unit and off the unit (locomotion). Review of Resident #1's Comprehensive Care Plan for Elopement related to Dementia, Cognitive Loss and Delusional [MEDICAL CONDITION], last revised 12/31/14, revealed staff should redirect the resident when the security system sounds and/or he/she attempts to leave the building. Stay with the resident and provide support and supervision until they (staff) are able to redirect the resident. Further review revealed in the event of an elopement, staff should follow the search and reporting protocols. Review of Resident #1's Comprehensive Care Plan, last revised 12/31/14, revealed the resident had a history of [REDACTED]. Interventions included to maintain a safe environment, identify behavior triggers and reduce exposures to triggers, and provide 1:1 interactions and support as needed. Interview, on 01/14/15 at 12:28 PM with Certified Nurse Aide (CNA) #4, revealed Resident #1 had come out of his/her room at 10:00 PM on 01/03/15 and stated he/she wanted a new room. The resident tried to open a locked office door on the wing; and the resident sat in the lobby when the door would not open. CNA #4 stated she told RN #1 that Resident #1 was stating he/she was going to pack a bag; but the resident had not packed his/her bag while she (CNA #4) was there. Interview, on 01/14/15 at 8:43 AM with CNA #2, revealed when she arrived at work on 01/03/15 at 11:00 PM, Resident #1 was sitting in the lobby and had a suitcase and a "bear" with him/her. Interview, on 01/14/15 at 8:44 AM with CNA #1, revealed when he came on shift at 11:00 PM on 01/03/15, Resident #1 had his/her clothes packed in a suitcase and was sitting in the lobby all night wanting to go home. CNA #1 stated he and CNA #2 took Resident #1 to his/her room and unpacked the suitcase after talking with the resident. Interviews, on 01/12/15 at 2:56 PM; and, on 01/14/15 at 9:22 AM with RN #1, revealed Resident #1 had been up all night and was wanting to go home on 01/03/15-01/04/15. RN #1 stated the resident had his/her bags packed and was sitting in the lobby telling staff he/she was going to "Metropolis". RN #1 revealed the resident laid down one time but it was not for long. RN #1 stated she did not call anyone about the resident's exit-seeking behaviors because she had been told that was normal for the resident. RN #1 stated staff had stayed with Resident #1 some, but they could not stay with the resident all night. She stated she did not increase the supervision of the resident. Review of the facility's Investigation Summary, dated 01/09/15, revealed the exit door alarm sounded by the Therapy Department at approximately 6:15 AM-6:30 AM. When RN #1 responded to the alarm, CNA #1 told RN #1 the alarm was sounding because another resident, who goes outside to smoke, had reentered the facility. Review of RN #1's written statement revealed the alarm sound was different and she glanced out the window but she did not visualize anyone, so she assumed the alarm was sounding due to another resident entering the building, as CNA #1 had reported to her. RN #1 disengaged the alarm by keying it off and using the code. However, the RN failed to follow the facility's search and reporting protocols, per the care plan, to conduct a head count and search outside to ensure a resident had not exited the building. Interview with RN #1, on 01/12/15 at 2:56 PM, revealed the door alarm and wanderguard alarms sound different. The alarm that sounded when Resident #1 exited the building sounded different than the alarm that had sounded a number of times previously that night. Further review of the facility's Investigation Summary revealed CNA #2 last visualized Resident #1 a little after 6:00 AM. Resident #1's roommate told CNA #2 that around 6:30 AM that Resident #1 had gone walking. CNA #2 searched for the resident and informed RN #1 of Resident #1 missing. Resident #1 was found by RN #1 outside on the main road about two (2) car lengths from the parking lot coming from the direction of a church. Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation. Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility. Interview on 01/20/15 at 12:50 PM with Registered Nurse (RN) #2; on 01/20/15 at 1:38 PM with RN #7; on 01/20/15 at 1:39 PM with LPN #2; and, on 01/24/15 at 4:35 PM with LPN #9 revealed staff did not follow the Resident #1's care plan. Further interview revealed they should have followed the care plan related to the resident's behaviors and increased his/her supervision. Interview on 01/09/15 at 4:05 PM, on 01/12/15 at 11:45 AM, and 01/13/15 at 3:47 PM with the Director of Nursing (DON) revealed she expected all staff to follow the care plans. Interviews, on 01/21/15 at 4:15 PM; and, on 01/30/15 at 8:01 PM with the Administrator, revealed interventions were implemented to anticipate and to mitigate to the best of staff's ability something from happening that was identified as a risk. She stated staff should have followed the care plan when there was a change in condition of the resident. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated "I'm fine; I was just going for a walk." Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's "use by" date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a "sister" facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the "Elopement Drill Documentation Form" on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a "pass" being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Maintenance Supervisor revealed he checked the functionality of the doors, and wander guard alarms. He stated the wander guard alarm would still go off at the doors even with the door releasing after being pushed on for fifteen (15) seconds. Interview on 01/29/15 at 5:14 PM with LPN #6 revealed the residents' wanderguards were tested every shift by the nurse with the transmitter and documented on the Treatment Administration Records (TARs). Review of the January TARs for residents at risk for elopement (13 of 13) revealed daily shift audits of the functionality of each resident's wanderguard. Interview on 01/29/15 at 11:31 AM with the Maintenance Helper revealed nurses checked the residents' wander guards with the transmitters. 14. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed a weekly testing of wanderguard transmitter testers was done and would be in the system. The Maintenance Supervisor provided a copy of the weekly testing of the wanderguard transmitter testers (3 of 3) with one being a spare; which revealed weekly checks were documented on 01/12/15, 01/20/15, and 01/26/15. 15. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed the batteries were changed in the wanderguard transmitter tester in September 2014, November 2014, and on 01/19/15; with the expiration date of the batteries placed on the documentation starting in January. Review of the Wanderguard Tester Battery Replacement Form provided by the Maintenance Supervisor revealed the batteries in the wanderguard transmitter tester were changed on 09/22/14, 11/20/14, and 01/19/15; with the start of documentation of battery expiration date beginning on 01/19/15. 16. Interviews on 01/29/15 at 5:14 PM with LPN #6; on 01/09/15 at 2:45 PM with LPN #4; on 01/15/15 at 1:25 PM with RN #8; and, on 01/09/15 at 2:59 PM with RN #6 revealed residents' wanderguards were tested every shift by the nurse with the transmitter and it was documented on the Treatment Administration Records (TARs). Review of TARs for residents at risk for elopement revealed daily shift audits of the functionality of each resident wander guard. 17. Review of the facility's investigation revealed in an interview conducted on 01/05/15 with CNA #21, who was providing 1:1 supervision of Resident #1, she commented to the resident the door was locked; and Resident #1 made a statement about the door sign saying "push" and the door will open in fifteen (15) seconds. Interview on 01/21/15 at 4:15 PM with the Administrator revealed Resident #1 was on 1:1 with CNA #21 when she had tried to open the door and CNA #21 commenting to the resident the door was locked. 18. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she had turned off the alarm at the door when CNA #1 asked her to, because it was alarming, and the alarm had sounded different to her. RN #1 further revealed she had signed an elopement paper during orientation on 11/25/14, and she had been terminated after this incident. Review of the POS [REDACTED]. Interview on 01/18/15 at 1:13 PM with CRM revealed two (2) staff members were suspended with RN #2 being terminated after the incident. Interview on 01/13/15 at 12:40 PM with the acting DON at the time of the incident revealed RN #1 did not follow the facility's policy and had received the training and testing on elopement to include the sounds of alarms. 19. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed entrance and exit codes were not the same, and if a visitor activated the alarm a staff member would have to silence it. The Maintenance Supervisor stated the exit codes had been changed at least once monthly since November 2014. Review of the Log of Code Changes provided by the Maintenance Supervisor and Administrator revealed exit codes had been changed four (4) times on November 11/21/14, twice (2) on 11/28/14, twice (2) on 11/29/14, twice (2) on 12/26/14, twice (2) on 01/03/15, and once (1) on 01/10/15. Interviews with the CRC on 01/14/15 at 4:05 PM, the SSD on 01/16/15 at 12:45 PM, LPN #1 on 01/11/15 at 4:59 PM, LPN #3 on 01/15/15 at 1:35 AM, LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 at 01/12/15 at 1:01 PM, CNA #22 at 01/29/15 at 12:06 PM revealed when alarms go off staff respond to the alarm. Interviews with LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #11 on 01/13/15 at 8:25 AM, CNA #15 at 01/16/15 at 12:55 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 on 01/12/15 at 1:01 PM, and CNA #22 on 01/29/15 at 12:06 PM revealed the codes to let visitors out was only provided to staff and no one else was to be given the code. 20. Interview on 01/14/15 at 4:05 PM with the RN/MDS Coordinator revealed she had come in on 01/04/15 and reassessed all of the elopement risk residents (13 of 13) after the elopement. Review of the Elopement Care Plan Evaluations revealed (13 of 13) residents were reassessed on 01/04/15. Review of the AOC binder revealed review of residents identified as at risk for elopement by RN MDS Coordinator with a date of 01/04/15. 21. Review of the AOC binder revealed education of the Administrator, the acting DON, and a sister facility's DON at the time of the elopement. This education was provided by the RVP and RMCO regarding regulations and requirements for F490 and F52

Based on interview, record review, review of the facility's policy and procedures, and review of the facility's Allegation of Compliance (AoC) and Plan of Correction (PoC) for the 12/11/14 Immediate Jeopardy Abbreviated Survey it was determined the facility failed to provide adequate supervision to prevent an elopement for one (1) of six (6) sampled residents (Resident #1). The facility assessed and care planned Resident #1 to be an elopement risk; however, on 01/04/15 Resident #1 exited the facility without staff's knowledge. During the night of 01/03/15 and the morning of 01/04/15, Resident #1 packed a bag, sat in the lobby of the facility and was wanting to go home. Registered Nurse (RN) #1 failed to take any action to address this behavior or increase the resident's supervision. A door alarm sounded at approximately 6:15 AM and RN #1 turned off the alarm. RN #1 failed to identify that the alarm was the wanderguard alarm, and failed to conduct a head count and search outside the door for a resident. Review of the AoC and PoC for the 12/11/14 Immediate Jeopardy Abbreviated Survey revealed RN #1 was administered a Post Test after education was provided. Review of RN #1's post test revealed she scored 100%. Facility staff was not aware of the Resident #1's whereabouts, Resident 1's roommate informed staff that the resident had gone for a walk. At that time, at approximately 6:40 AM, Certified Nurse Aide (CNA) #2 began searching and identified Resident #1 was not in the facility. The resident was discovered outside on the main road at 6:45 AM, unsupervised. The facility's failure to provide adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedures titled, "Elopement of Patient", last revised 05/15/14, revealed residents should be evaluated for elopement risk upon admission, readmission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk should receive appropriate interventions to reduce risk and minimize injury. For residents identified at risk, an interdisciplinary elopement prevention care plan should be developed with family and resident participation. Individual risk factors and patterns will be identified and addressed within the care plan. Further review of the policy revealed for Unwitnessed Elopements staff should search room to room and all areas of the Center: resident rooms, closets, under beds, shower rooms, utility rooms, offices, dining rooms, stairwells, laundry, kitchen (including walk-in refrigerators and freezers), bathrooms, dayrooms/lounges, courtyards, and employee lounges; and outside perimeter and grounds. Review of the facility's Wander Guard Transmitter Policy and Procedure, dated 02/24/14, revealed the system must be tested daily by the facility for proper operation, and the system was not a substitute for careful identification and monitoring of residents by professional staff. Further review revealed the system had been designed to augment a facility's reasonable procedures for protecting residents; however, the was no system or combination of procedures and equipment that could eliminate all risk or assure complete security. The system was not intended as a substitute for the careful identification and monitoring of residents by a facility's professional staff. Record review revealed the facility admitted Resident #1 on 12/22/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #1 as requiring supervision while walking in the halls, on the unit and off the unit (locomotion). Resident #1 was assessed as having a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated moderate impairment; however, the resident was diagnosed with [REDACTED]. Review of Resident #1's Elopement Evaluation, dated 12/22/14, revealed the facility had assessed Resident #1 to be at risk for elopement due to the resident having a past history of wandering that placed the resident at significant risk of getting to a potentially dangerous place; a sleep pattern disturbance that caused increased confusion; resident had expressed a desire to leave, and the resident was unable to locate significant landmarks. Further review of the Evaluation revealed the resident also triggered for the following behaviors such as shadowing staff/other residents, hovering near exits, hyperactivity (restless walking patterns), and restlessness and/or agitation. Review of Resident #1's Device Evaluation for a wanderguard, completed on 12/23/14, revealed Resident #1 was identified as an elopement risk and had impaired safety awareness. Review of the Nursing Assessment, dated 12/22/14, revealed under, "Mood and Behavior" that Resident #1 triggered for exit-seeking/wandering behaviors. Review of the Comprehensive Care Plan for Elopement related to Dementia, Cognitive Loss and Delusion Psychosis, last revised 12/31/14, revealed interventions to redirect the resident when the security system sounded and/or resident attempted to leave the facility; if unable to redirect the resident, stay with the resident and provide support and supervision until able to redirect; and in the event of an elopement, follow search and reporting protocols. Review of the Comprehensive Care Plan for Delusional Psychosis and Early Dementia, last revised 12/30/14, revealed the resident had behaviors of physical aggression, wandering (into other rooms, exit seeking), resists care, and verbal aggression as evidenced by yelling at staff. The interventions were to maintain a safe environment, identify behavior triggers and reduce exposures to triggers, and to provide 1:1 interactions and support as needed. Review of the facility's Investigation Summary which included interviews, dated 01/09/15, revealed the exit door alarm sounded by the Therapy Department at approximately 6:15 AM-6:30 AM. RN #1 responded to the alarm. CNA #1 told RN #1 the alarm was sounding because another resident, who goes outside to smoke, had reentered the facility. Review of RN #1's written statement revealed the alarm sound was different; she glanced out the window, but did not visualize anyone, so she assumed the alarm was sounding due to another resident entering the building per CNA #1's report. RN #1 disengaged the alarm by keying it off and using the code. Further review of the investigation summary, revealed CNA #2 last visualized Resident #1 a little after 6:00 AM, and was told by Resident #1's roommate around 6:30 AM that Resident #1 had gone for a walk. CNA #2 searched for the resident and informed RN #1 that Resident #1 was missing. Resident #1 was found by RN #1 outside on the main road about two (2) car lengths from the parking lot coming from the direction of a church. Interview and observation, on 01/09/15 at 4:10 PM with the Maintenance Director, revealed a creek was located in front of the facility along the parking lot. There was an eight (8) to ten (10) foot drop into the creek bed. Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation. Review of a Nursing Note, dated 01/04/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility. Interview on 01/12/15 at 2:56 PM with RN #1 revealed Resident #1's right foot was wetter than the left one, and the shoe looked like he/she had been in the mud. RN #1 stated she did not know where the resident had been to get into mud. Interview, on 01/12/15 at 2:56 PM; and, on 01/14/15 at 9:22 AM with Registered Nurse (RN) #1, revealed Resident #1 did not sleep the night of 01/03/15-01/04/15. RN #1 stated Resident #1 had been up all night; his/her bags were packed and the resident stated he/she was going to "Metropolis". RN #1 stated she did not call anyone about the resident's exit-seeking behaviors because she had been told the resident had those behaviors. RN #1 revealed staff stayed with Resident #1 at times but they could not stay with the resident all night. She stated no action was taken to increase the resident's supervision due to the resident's behaviors. RN #1 stated when the door alarm sounded she turned off the alarm with the key and the code at the door when CNA #1 asked her to because the CNA had told her a resident had reentered the building after smoking causing it to alarm. RN #1 failed to conduct a head count, search for a resident outside and recognize the alarm was a Wanderguard alarm. RN #1 stated she was not sure of the elopement procedures because it was new to her. However, review of the Allegation of Compliance and the Plan of Correction for the 12/11/14 Immediate Jeopardy revealed a Post Test was administered after education was provided to staff. The Post Test administered after the education revealed the door alarm was described as high pitched and fast like a siren and a wander guard alarm was a high-pitched, slow, chirping sound. Review of RN #1's post test revealed she scored 100% and she had documented the answer to the question when staff respond to an alarm what should they do, staff should: "1. check the alarm, 2. thoroughly check the area, and 3. validate that no resident is missing." Interview, on 01/13/15 at 9:20 AM; and, on 01/14/15 at 8:44 AM and 8:55 AM with CNA #1, revealed Resident #1 had his/her clothes packed in his/her suitcase when he came on shift at 11:00 PM. He stated the resident sat in the lobby all night wanting to go home. CNA #1 stated he was informed of the disappearance of Resident #1 around 6:30 AM on 01/04/15 and he did not know if the other Wing was told of the elopement; but, no staff from the Wing had responded. According to the AOC and POC for the 12/11/14 Abbreviated Survey and facility protocols, the facility staff should have called a Code Yellow when they identified the resident was missing. CNA #1 revealed he did not know how Resident #1 got out of the facility and the last alarm he heard was around 4:00 AM and 5:00 AM. He stated RN #1 told him to continue his bed checks and she would get the alarm. Interview on 01/13/15 at 6:08 AM; and, on 01/14/15 at 8:43 AM with CNA #2 revealed when she arrived at the facility on 01/03/14 at 11:00 PM, Resident #1 had a suitcase and a bear with him/her and was sitting in the lobby. She stated she last saw Resident #1 at approximately 6:10 AM sitting in the lobby on the 300/400 Wing. CNA #2 stated at approximately 6:30 AM, Resident #1's roommate told her Resident #1 had gone walking. CNA #2 revealed she was unable to find the resident so she notified RN #1. She stated when an alarm sounds staff are supposed to respond to the alarm, let the nurse know, do a head count of the residents and, if a resident was unaccounted for, this was supposed to be paged overhead to let everyone know. CNA #2 stated this was not done. Interview on 01/13/15 at 12:17 PM with CNA #5 revealed CNA #2 asked if Resident #1 had been seen on the hall around 6:00 AM on 01/04/15. CNA #5 stated she was confused because no code had been called and no one had announced or done anything according to the policy. CNA #5 further revealed the policy was not followed even after she informed her nurse that a resident could not be found. CNA #5 stated the facility's protocol was not initiated, and the staff did not do what they were suppose to do. Interview on 01/11/15 at 4:59 PM; and, on 01/14/15 at 12:11 PM with Licensed Practical Nurse (LPN) #1, revealed she was in a room with another resident when she heard an alarm and it shut off before she could see the location. She stated she did not hear anything on the intercom system. She stated she was informed by CNA #5 that a resident had gotten out of the facility but she continued with her work, and did not know if the resident had been found or not. LPN #1 revealed when an alarm goes off, staff are to go to the desk and see where the alarm is and tell everyone to start looking for a resident, do a head count, and start looking at the door and around where the alarm went off. She stated if no one is found and the head count is correct, then it is called off. LPN #1 revealed this was not done on the day Resident #1 eloped and she did not know if the resident had gone out or not. LPN #1 revealed she had been trained on elopement and the wanderguard policy and procedure. She stated she was trained on elopement and wanderguards several times; however, no dates were provided. Review of In-service Sign-in Sheets/Elopement Drill revealed she was trained and participated in elopement drills on the following dates: 11/21/14, 11/22/14, 11/23/14, 01/04/15, and 01/05/15. She provided no reason why she did not follow the POC/AOC. Interview, on 01/13/15 at 9:20 AM with the Nurse Practice Educator (NPE), revealed if an alarm sounded, staff should respond to the door, check outside the door, tell the nurse, and start the elopement process which includes a head count. Interview on 01/21/15 at 3:23 PM with the Director of Nursing (DON) revealed if a wanderguard triggers an alarm staff should look outside, do a head count, and make sure all staff are notified of the elopement by calling a code yellow. Interview on 01/13/15 at 12:13 PM; and, on 01/20/15 at 4:20 PM with the acting DON at the time of the elopement, revealed she expected when staff were inserviced and trained they carry out the policy and procedures as they were trained. She stated if alarms were going off staff should respond in the appropriate way based on the alarm sound. If it's the wanderguard alarm staff should treat it as an actual elopement and follow policy and procedure, and in this case it was not followed but should have been. Interview on 01/21/15 at 4:15 PM; and, on 01/30/15 at 8:01 PM with the Administrator, revealed care plans should be implemented when there is a change in condition of a resident. The Administrator stated RN #1 was fired because she failed to follow the system policy and procedure that was in place. The Administrator revealed they had conducted drills and re-educated to validate that staff understood the severity of the situation and the facility's expectations. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated "I'm fine; I was just going for a walk." Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's "use by" date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a "sister" facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the "Elopement Drill Documentation Form" on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a "pass" being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Main

Based on interview, record review, review of the Administrator's job description, and review of the facility's policy and procedures, and the Allegation of Compliance (A0C) and Plan of Correction (PoC) for the 12/11/14 Immediate Jeopardy Abbreviated Survey, it was determined the facility failed to have an effective system to ensure staff was knowledgeable related to the facility's elopement policy and procedures to ensure the residents' safety. This failure affected one (1) of six (6) sampled residents (Resident #1). On 11/21/14, a resident exited the facility without staff's knowledge, unsupervised which resulted in the facility being cited Immediate Jeopardy. The facility educated staff on the facility's policy and procedures related to how to respond to an alarm; the different sounds and the types of alarms. However, the facility failed to ensure the staff followed the policy and procedures, in order to keep Resident #1 safe. Resident #1 exited the facility without staff's knowledge approximately six (6) weeks later, after the first Immediate Jeopardy. On 01/04/15 at approximately 6:15 AM-6:30 AM, a door alarm sounded and Registered Nurse (RN) #1 turned off the alarm; however, the RN failed to conduct a head count and search outside the door for a resident per the facility's policy and procedures, which were included in the AOC and POC. In addition, the nurse failed to identify that the alarm that was sounding was a wanderguard alarm. At approximately 6:40 AM, after the resident's roommate informed staff the resident had gone for a walk, Certified Nurse Aide (CNA) #2 identified that Resident #1 was not in the facility. Resident #1 had exited the facility without staff's knowledge and was discovered outside on a main road at approximately 6:45 AM. The Administrator failed to ensure the education provided to staff was effective. (Refer to F323) The facility's failure to be administered in a manner that enabled it to use its resources effectively and efficiently has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility's job description for the Administrator, last revised 08/01/12, revealed, "The Administrator was responsible for planning and was accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs and coordinates all activities of the Center to assure the highest degree of quality of care is consistently provided to residents; and concerns his/herself with the safety of all Nursing Center residents in order to minimize the potential for fire and accidents." Review of the facility's policy and procedures titled, "Elopement of Patient", last revised 05/15/14, revealed residents should be evaluated for elopement risk upon admission, readmission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk should receive appropriate interventions to reduce risk and minimize injury. For residents identified at risk, an interdisciplinary elopement prevention care plan should be developed with family and resident participation. Individual risk factors and patterns will be identified and addressed within the care plan. Further review of the policy revealed for unwitnessed elopements staff should search room to room and all areas of the Center: resident rooms, closets, under beds, shower rooms, utility rooms, offices, dining rooms, stairwells, laundry, kitchen (including walk-in refrigerators and freezers), bathrooms, dayrooms/lounges, courtyards, and employee lounges; and outside perimeter and grounds. Interview and record review revealed the facility assessed Resident #1 and care planned him/her as an elopement risk. According to the 12/11/14 Abbreviated Survey's AOC and POC the Administrator and Administrative staff educated staff on the facility's Elopement Prevention and Management Policy and a Post Test was given to determine staff competency. The education included the "... Expected employee response to a door alarm" and, the different sounds of the door alarms. Review of the POS [REDACTED]. However, on 01/04/15 at approximately 6:15 AM-6:30 AM, the exit door alarm sounded by the Therapy Department. RN #1 turned the alarm off but failed to identify that the alarm was the wanderguard alarm; she failed to search for the resident outside the door; and, failed to conduct a head count to ensure all residents were accounted for per the facility's AoC and PoC. At approximately 6:30 AM, CNA #2 was told by another resident that Resident #1 had gone for a walk. Resident #1 was found standing outside the facility on a main road at approximately 6:45 AM. Further review of the AoC and PoC revealed elopement drills were conducted on each shift monthly (December 2014 and January 2015) but the facility did not identify any concerns. Review of the elopement Drill Documentation Audit Form revealed the Audit addressed identifying if staff responded to the announcement of a Code Yellow on the intercom system; however, the form did not address if the appropriate action was taken when a wanderguard alarm sounded and if staff was able to identify the alarm as a wanderguard alarm. Further review of the AOC and the POC revealed elopements drills were conducted on 11/21/14, 11/22/14, 11/23/14, 11/24/14, 01/04/15 and 01/10/15. These drills ensured that staff was able to hear the alarm sounding at the door or at the Nurse's Station. However, the drills did not address or ensure that staff could distinguish the different alarms. Interview with RN #1 revealed the alarm sounded different but she did not recognize it as the wanderguard alarm. Interview with RN #1, on 01/12/15 at 2:56 PM and on 01/14/15 at 9:22 AM, revealed when the alarm sounded she turned off the alarm with the key and the code at the door because CNA #1 stated the alarm was sounding related to another resident reentering the facility. RN #1 stated she did not conduct a head count and search outside the door, as per the AOC and POC. RN #1 stated she was not sure of the elopement procedures; however, review of a post test, conducted at the end of an inservice, after the 12/11/14 Immediate Jeopardy, addressing the facility's elopement policy and procedures revealed she scored 100%. The post test included fill in the blank questions: "If a door alarm sounds, what are the three (3) immediate steps?" The RN's written responses were "1. check the alarm, 2. thoroughly check the area, and 3. validate that no resident is missing." Interview on 01/13/15 at 12:17 PM with CNA #5 revealed CNA #2 asked if Resident #1 had been seen on the hall around 6:00 AM on 01/04/15. CNA #5 stated she was confused because no code had been called and no one had announced or done anything according to the policy. CNA #5 further revealed the policy was not followed even after she informed her nurse that a resident could not be found. CNA #5 stated the facility's protocol was not initiated, and the staff did not do what they were suppose to do. CNA #1 revealed he did not know how Resident #1 got out of the facility and the last alarm he heard was around 4:00 AM and 5:00 AM. He stated RN #1 told him to continue his bed checks and she would get the alarm. Interview on 01/11/15 at 4:59 PM; and, on 01/14/15 at 12:11 PM with Licensed Practical Nurse (LPN) #1, revealed she was in another resident's room when she heard an alarm. She stated she did not hear anything on the intercom system, but she was informed by CNA #5 that a resident had gotten out of the facility. LPN #1 stated she continued with her work, and did not know if the resident had been found or not. During the interview, LPN #1 stated when an alarm goes off, staff are to go to the desk and see where the alarm is and tell everyone to start looking for a resident, do a head count, and start looking at the door and around where the alarm went off. She stated if no one is found and the head count is correct, then it is called off. LPN #1 revealed this was not done on the day Resident #1 eloped and she did not know if the resident had gone out or not. LPN #1 revealed she had been trained on elopement and the wanderguard policy and procedure. Even though the LPN had been trained, she failed to follow the facility's elopement policy. Interview with the Administrator, on 01/12/15 at 4:20 PM, on 01/21/15 at 4:15 PM and on 01/30/15 at 6:00 PM, revealed the root cause of the incident was that the nurse walked away and shut off the wanderguard alarm. The Administrator stated the RN should have recognized it was a wanderguard alarm and validated whether there was a resident outside instead of just turning the alarm off. The Administrator stated the RN should not have assumed all was all right because she knew the alarms sounded differently. Further interview revealed she expected the staff to know the sounds of the alarms, search inside and outside when an alarm sounded and do a visual census check. However, she stated they focused the education more on what not to do, such as not silencing the alarm and walking away without knowing what was happening. The Administrator revealed staff was educated and was able to verbalize the sound of the routine alarm which had a high pitched and fast sound, like a siren; and the wanderguard alarm which had a high pitched, slow, chirping sound (two beats). If the staff was unable to verbalize, she would reeducate immediately. However, interview with staff revealed they were confused and didn't follow the facility's policy. RN #1 stated she could not tell that the alarm was for the wandergard. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated "I'm fine; I was just going for a walk." Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's "use by" date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a "sister" facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the "Elopement Drill Documentation Form" on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a "pass" being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Maintenance Supervisor revealed he checked the functionality of the doors, and wander guard alarms. He stated the wander guard alarm would still go off at the doors even with the door releasing after being pushed on for fifteen (15) seconds. Interview on 01/29/15 at 5:14 PM with LPN #6 revealed the residents' wanderguards were tested every shift by the nurse with the transmitter and documented on the Treatment Administration Records (TARs). Review of the January TARs for residents at risk for elopement (13 of 13) revealed daily shift audits of the functionality of each resident's wanderguard. Interview on 01/29/15 at 11:31 AM with the Maintenance Helper revealed nurses checked the residents' wander guards with the transmitters. 14. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed a weekly testing of wanderguard transmitter testers was done and would be in the system. The Maintenance Supervisor provided a copy of the weekly testing of the wanderguard transmitter testers (3 of 3) with one being a spare; which revealed weekly checks were documented on 01/12/15, 01/20/15, and 01/26/15. 15. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed the batteries were changed in the wanderguard transmitter tester in September 2014, November 2014, and on 01/19/15; with the expiration date of the batteries placed on the documentation starting in January. Review of the Wanderguard Tester Battery Replacement Form provided by the Maintenance Supervisor revealed the batteries in the wanderguard transmitter tester were changed on 09/22/14, 11/20/14, and 01/19/15; with the start of documentation of battery expiration date beginning on 01/19/15. 16. Interviews on 01/29/15 at 5:14 PM with LPN #6; on 01/09/15 at 2:45 PM with LPN #4; on 01/15/15 at 1:25 PM with RN #8; and, on 01/09/15 at 2:59 PM with RN #6 revealed residents' wanderguards were tested every shift by the nurse with the transmitter and it was documented on the Treatment Administration Records (TARs). Review of TARs for residents at risk for elopement revealed daily shift audits of the functionality of each resident wander guard. 17. Review of the facility's investigation revealed in an interview conducted on 01/05/15 with CNA #21, who was providing 1:1 supervision of Resident #1, she commented to the resident the door was locked; and Resident #1 made a statement about the door sign saying "push" and the door will open in fifteen (15) seconds. Interview on 01/21/15 at 4:15 PM with the Administrator revealed Resident #1 was on 1:1 with CNA #21 when she had tried to open the door and CNA #21 commenting to the resident the door was locked. 18. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she had turned off the alarm at the door when CNA #1 asked her to, because it was alarming, and the alarm had sounded different to her. RN #1 further revealed she had signed an elopement paper during orientation on 11/25/14, and she had been terminated after this incident. Review of the POS [REDACTED]. Interview on 01/18/15 at 1:13 PM with CRM revealed two (2) staff members were suspended with RN #2 being terminated after the incident. Interview on 01/13/15 at 12:40 PM with the acting DON at the time of the incident revealed RN #1 did not follow the facility's policy and had received the training and testing on elopement to include the sounds of alarms. 19. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed entrance and exit codes were not the same, and if a visitor activated the alarm a staff member would have to silence it. The Maintenance Supervisor stated the exit codes had been changed at least once monthly since November 2014. Review of the Log of Code Changes provided by the Maintenance Supervisor and Administrator revealed exit codes had been changed four (4) times on November 11/21/14, twice (2) on 11/28/14, twice (2) on 11/29/14, twice (2) on 12/26/14, twice (2) on 01/03/15, and once (1) on 01/10/15. Interviews with the CRC on 01/14/15 at 4:05 PM, the SSD on 01/16/15 at 12:45 PM, LPN #1 on 01/11/15 at 4:59 PM, LPN #3 on 01/15/15 at 1:35 AM, LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 at 01/12/15 at 1:01 PM, CNA #22 at 01/29/15 at 12:06 PM revealed when alarms go off staff respond to the alarm. Interviews with LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #11 on 01/13/15 at 8:25 AM, CNA #15 at 01/16/15 at 12:55 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 on 01/12/15 at 1:01 PM, and CNA #22 on 01/29/15 at 12:06 PM revealed the cod

Based on interview and record review, review of the facility's Allegation of Compliance (AoC) and Plan of Correction (PoC) for the Immediate Jeopardy Abbreviated Survey on 12/11/14, and review of the facility's Quality Assurance (QA) Policy, it was determined the Quality Assessment and Assurance Committee failed to have an effective system to ensure appropriate action plans for quality deficiencies were developed and implemented to prevent reoccurrence related to elopement. This failure affected one (1) of six (6) sampled residents (Resident #1). The facility was cited Immediate Jeopardy related to an incident that occurred on 11/21/14 when a resident exited the building without staff's knowledge. Approximately six (6) weeks later, on 01/04/15 Resident #1 was able to exit the building without staff's knowledge. On 01/04/15 at approximately 6:15 AM-6:30 AM, a door alarm sounded and Registered Nurse (RN) #1 turned off the alarm. The RN failed to follow the AOC and POC. She failed to identify that the alarm sounding was a wanderguard alarm; conduct a head count; and, search outside the door for a resident. At approximately 6:40 AM, Certified Nurse Aide (CNA) #2 identified Resident #1 was not in the facility. Resident #1 exited the facility and was discovered outside on a main road at approximately 6:45 AM. The facility's failure to have an effective QA program to prevent the reoccurrence of quality deficiencies related to elopement has caused or is likely to cause serious injury, harm or impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy/procedure titled, "Center Quality Improvement Process", last revised 04/01/03, revealed the Quality processes were to provide a framework for structuring and implementing data-driven quality improvement and to establish and maintain a quality improvement process that would satisfy internal standards of excellence and regulatory excellence. A door alarm sounded on 01/04/15 at approximately 6:15 AM-6:30 AM, and Registered Nurse (RN) #1 turned off the alarm. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she turned off the door alarm after CNA #1 told her the alarm had sounded due to a resident re-entering the building after going out to smoke. RN #1 failed to identify the alarm was a wanderguard alarm; conduct a head count; and search outside the door for a resident, per the facility's policy, AOC and POC. Review of the facility's AoC and PoC developed after another resident's elopement on the 11/21/14 revealed all staff was educated on the Center's policies on elopement prevention and management, the expected employee response to a door alarm, and the different sounds of door alarms. Further review revealed the facility's monitoring included elopement drills conducted on each shift monthly to ensure the education was effective. However, review of the Elopement Drill audit form revealed the drill documentation form addressed identifying if staff took the appropriate actions after the announcement of a Code Yellow on the intercom system but, it did not address how staff should respond to the wanderguard alarm prior to the Code Yellow being called. Further review revealed the Elopement Drills were conducted on each shift monthly (December 2014 and January 2015) but the facility did not identify any concerns. Interviews with CNA #1, CNA #2, CNA #5, LPN #1 and RN #1 revealed they did not follow the facility's policy and they were confused related to the policy. RN #1 stated she could not distinguish the difference between the alarms. Review of the AOC and the POC revealed elopements drills were conducted on 11/21/14, 11/22/14, 11/23/14, 11/24/14, 01/04/15 and 01/10/15. These drills ensured that staff was able to hear the alarm sounding at the door or at the Nurse's Station. However, the drills did not address or ensure that staff could distinguish the different alarm sounds. Interview with RN #1 revealed the alarm sounded different but she did not recognize it as the wanderguard alarm. Interview, on 01/13/15 at 11:35 AM with the Director of Nursing (DON), revealed she felt they had an effective plan in place; however, the problem occurred when the staff did not follow the policy and procedure. She further stated if a wanderguard alarm went off, she expected the staff to follow the protocol. Interview, on 01/13/15 at 2:40 PM and on 01/21/15 at 4:01 PM with the Medical Director, revealed he expected staff to follow the policy and procedures of the facility, and resident safety was number one . The Medical Director stated the facility's Plan of Correction obviously did not stop the elopement and something had broken down in the process but he did not know where the system failed. Interview, on 01/21/15 at 4:15 PM and on 01/30/15 at 6:00 PM with the Administrator, revealed she felt QA was monitoring the effectiveness of the elopement plan through the drills, the audits and communication with staff. The Administrator stated she expected staff to respond to the alarms, ensure the residents were safe, and validate the reason the alarm was sounding. She further stated RN #1 did not see or know what had occurred, did not validate, and did not realize what had happened until after the CNA told her that they could not locate Resident #1 in the facility. The Administrator stated the RN knew what to do, but she had made a mistake by silencing the alarm and not checking it. Further interview with the Administrator revealed staff was provided education, and had to take a post test and pass the test related to the 12/11/14 elopement. Additionally, an elopement drill was added to ensure staff had a complete understanding of the education that was provided. She stated this was completed on each shift, beginning 01/04/15. The Administrator stated the education was more focused on what not to do, such as do not silence the alarm and not walk away without first knowing what was going on in that situation. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated "I'm fine; I was just going for a walk." Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's "use by" date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a "sister" facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the "Elopement Drill Documentation Form" on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a "pass" being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Maintenance Supervisor revealed he checked the functionality of the doors, and wander guard alarms. He stated the wander guard alarm would still go off at the doors even with the door releasing after being pushed on for fifteen (15) seconds. Interview on 01/29/15 at 5:14 PM with LPN #6 revealed the residents' wanderguards were tested every shift by the nurse with the transmitter and documented on the Treatment Administration Records (TARs). Review of the January TARs for residents at risk for elopement (13 of 13) revealed daily shift audits of the functionality of each resident's wanderguard. Interview on 01/29/15 at 11:31 AM with the Maintenance Helper revealed nurses checked the residents' wander guards with the transmitters. 14. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed a weekly testing of wanderguard transmitter testers was done and would be in the system. The Maintenance Supervisor provided a copy of the weekly testing of the wanderguard transmitter testers (3 of 3) with one being a spare; which revealed weekly checks were documented on 01/12/15, 01/20/15, and 01/26/15. 15. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed the batteries were changed in the wanderguard transmitter tester in September 2014, November 2014, and on 01/19/15; with the expiration date of the batteries placed on the documentation starting in January. Review of the Wanderguard Tester Battery Replacement Form provided by the Maintenance Supervisor revealed the batteries in the wanderguard transmitter tester were changed on 09/22/14, 11/20/14, and 01/19/15; with the start of documentation of battery expiration date beginning on 01/19/15. 16. Interviews on 01/29/15 at 5:14 PM with LPN #6; on 01/09/15 at 2:45 PM with LPN #4; on 01/15/15 at 1:25 PM with RN #8; and, on 01/09/15 at 2:59 PM with RN #6 revealed residents' wanderguards were tested every shift by the nurse with the transmitter and it was documented on the Treatment Administration Records (TARs). Review of TARs for residents at risk for elopement revealed daily shift audits of the functionality of each resident wander guard. 17. Review of the facility's investigation revealed in an interview conducted on 01/05/15 with CNA #21, who was providing 1:1 supervision of Resident #1, she commented to the resident the door was locked; and Resident #1 made a statement about the door sign saying "push" and the door will open in fifteen (15) seconds. Interview on 01/21/15 at 4:15 PM with the Administrator revealed Resident #1 was on 1:1 with CNA #21 when she had tried to open the door and CNA #21 commenting to the resident the door was locked. 18. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she had turned off the alarm at the door when CNA #1 asked her to, because it was alarming, and the alarm had sounded different to her. RN #1 further revealed she had signed an elopement paper during orientation on 11/25/14, and she had been terminated after this incident. Review of the POS [REDACTED]. Interview on 01/18/15 at 1:13 PM with CRM revealed two (2) staff members were suspended with RN #2 being terminated after the incident. Interview on 01/13/15 at 12:40 PM with the acting DON at the time of the incident revealed RN #1 did not follow the facility's policy and had received the training and testing on elopement to include the sounds of alarms. 19. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed entrance and exit codes were not the same, and if a visitor activated the alarm a staff member would have to silence it. The Maintenance Supervisor stated the exit codes had been changed at least once monthly since November 2014. Review of the Log of Code Changes provided by the Maintenance Supervisor and Administrator revealed exit codes had been changed four (4) times on November 11/21/14, twice (2) on 11/28/14, twice (2) on 11/29/14, twice (2) on 12/26/14, twice (2) on 01/03/15, and once (1) on 01/10/15. Interviews with the CRC on 01/14/15 at 4:05 PM, the SSD on 01/16/15 at 12:45 PM, LPN #1 on 01/11/15 at 4:59 PM, LPN #3 on 01/15/15 at 1:35 AM, LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 at 01/12/15 at 1:01 PM, CNA #22 at 01/29/15 at 12:06 PM revealed when alarms go off staff respond to the alarm. Interviews with LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #11 on 01/13/15 at 8:25 AM, CNA #15 at 01/16/15 at 12:55 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 on 01/12/15 at 1:01 PM, and CNA #22 on 01/29/15 at 12:06 PM revealed the codes to let visitors out was only provided to staff and no one else was to be given the code. 20. Interview on 01/14/15 at 4:05 PM with the RN/MDS Coordinator revealed she had come in on 01/04/15 and reassessed all of the elopement risk residents (13 of 13) after the elopement. Review of the Elopement Care Plan Evaluations revealed (13 of 13) residents were reassessed on 01/04/15. Review of the AOC binder revealed review of residents identified as at risk for elopement by RN MDS Coordinator with a date of 01/04/15. 21. Review of the AOC binder revealed education of the Administrator, the acting DON, and a sister facility's DON at the time of the elopement. This education was provided by the RVP and RMCO regarding regulations and requirements for F490 and F520 with Performance Improvement/Quality Improvement (PI/QI) being key to validation of the systems and key to enhancing quality of life for residents and staff at the Center. The education further stated, if/when there was a deviation of the facility's policy or standard of practice identified, it was the responsibility of the PI Committee to conduct a root cause analysis and determine applicable steps based on the analysis. A re-education document was signed by the Administrator and Acting DON on 01/04/15. A Post-test was given to the Administrator on subject matter by the RVP with 100% pass rate on 01/04/15. A post-test was given to the acting DON by RMCO on 01/04/15 with passing score of 100%. Review of the AOC binder revealed Administrative education with the acting DON at time of the elopement, incoming DON, and Administrator as well as their job description and post-test with a passing score. 22. Review of the re-education post-test for the Nurse Practice Educator (NPE) entitled, "Resident Safety and Elopement", dated 01/04/15, revealed the RMCO completed the post-test with a passing score of 100%. 23. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed the RVPO and RMCO educated the Administrator, Interim Director of Nursing (DON), and "assisting" Director of Nursing. She revealed the RMCO educated the Administrative staff on the post tests, then they educated the Department Heads, who then trained the facility staff related to the material on the post tests. The Administrator further revealed she, the interim DON, and the assisting DON were the only ones who received education specific to Administration and Quality Assurance. The education difference from the first IJ to the second IJ was focused more on what not to do, what the expectations were, and to not silence the alarm and walk away without knowing what was going on in that situation. The Administrator stated this would be a part of the facility's standard orientation. 24. Review of the AOC binder revealed re-education to the Therapy Program Manager, RN MDS Coordinator, Payroll Coordinator and Admissions Director on the elopement policy and procedure, the sound of emergency exit alarms, sound of the wander guard alarm, and updating care plans for change in behaviors with post-test score of 100%. Interview on 01/29/15 at 4:50 PM with the Dietary Supervisor revealed she had been re-educated on: the elopement process; which involved the difference in the sound of the alarms, if staff notice an alarm going off, the staff is to check it, make sure no one has gone out, do a head count to see if residents are in the facility, and if not, search everywhere. A code yellow is called over the intercom and everybody in the facility is involved in the search. The Dietary Manager revealed she had received training on them and was involved in the morning meeting when they were discussed for revision related to any new behaviors residents may exhibit. She stated staff should not turn an alarm off until staff had discovered if a resident was missing and a code yellow has been called. 25. Review of the AOC binder revealed re-education, listing of staff per shift and date of education and passin

Based on interview and record review, review of the facility's Allegation of Compliance (AoC) and Plan of Correction (PoC) for the Immediate Jeopardy Abbreviated Survey on 12/11/14, and review of the facility's Quality Assurance (QA) Policy, it was determined the Quality Assessment and Assurance Committee failed to have an effective system to ensure appropriate action plans for quality deficiencies were developed and implemented to prevent reoccurrence related to elopement. This failure affected one (1) of six (6) sampled residents (Resident #1). The facility was cited Immediate Jeopardy related to an incident that occurred on 11/21/14 when a resident exited the building without staff's knowledge. Approximately six (6) weeks later, on 01/04/15 Resident #1 was able to exit the building without staff's knowledge. On 01/04/15 at approximately 6:15 AM-6:30 AM, a door alarm sounded and Registered Nurse (RN) #1 turned off the alarm. The RN failed to follow the AOC and POC. She failed to identify that the alarm sounding was a wanderguard alarm; conduct a head count; and, search outside the door for a resident. At approximately 6:40 AM, Certified Nurse Aide (CNA) #2 identified Resident #1 was not in the facility. Resident #1 exited the facility and was discovered outside on a main road at approximately 6:45 AM. The facility's failure to have an effective QA program to prevent the reoccurrence of quality deficiencies related to elopement has caused or is likely to cause serious injury, harm or impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy/procedure titled, "Center Quality Improvement Process", last revised 04/01/03, revealed the Quality processes were to provide a framework for structuring and implementing data-driven quality improvement and to establish and maintain a quality improvement process that would satisfy internal standards of excellence and regulatory excellence. A door alarm sounded on 01/04/15 at approximately 6:15 AM-6:30 AM, and Registered Nurse (RN) #1 turned off the alarm. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she turned off the door alarm after CNA #1 told her the alarm had sounded due to a resident re-entering the building after going out to smoke. RN #1 failed to identify the alarm was a wanderguard alarm; conduct a head count; and search outside the door for a resident, per the facility's policy, AOC and POC. Review of the facility's AoC and PoC developed after another resident's elopement on the 11/21/14 revealed all staff was educated on the Center's policies on elopement prevention and management, the expected employee response to a door alarm, and the different sounds of door alarms. Further review revealed the facility's monitoring included elopement drills conducted on each shift monthly to ensure the education was effective. However, review of the Elopement Drill audit form revealed the drill documentation form addressed identifying if staff took the appropriate actions after the announcement of a Code Yellow on the intercom system but, it did not address how staff should respond to the wanderguard alarm prior to the Code Yellow being called. Further review revealed the Elopement Drills were conducted on each shift monthly (December 2014 and January 2015) but the facility did not identify any concerns. Interviews with CNA #1, CNA #2, CNA #5, LPN #1 and RN #1 revealed they did not follow the facility's policy and they were confused related to the policy. RN #1 stated she could not distinguish the difference between the alarms. Review of the AOC and the POC revealed elopements drills were conducted on 11/21/14, 11/22/14, 11/23/14, 11/24/14, 01/04/15 and 01/10/15. These drills ensured that staff was able to hear the alarm sounding at the door or at the Nurse's Station. However, the drills did not address or ensure that staff could distinguish the different alarm sounds. Interview with RN #1 revealed the alarm sounded different but she did not recognize it as the wanderguard alarm. Interview, on 01/13/15 at 11:35 AM with the Director of Nursing (DON), revealed she felt they had an effective plan in place; however, the problem occurred when the staff did not follow the policy and procedure. She further stated if a wanderguard alarm went off, she expected the staff to follow the protocol. Interview, on 01/13/15 at 2:40 PM and on 01/21/15 at 4:01 PM with the Medical Director, revealed he expected staff to follow the policy and procedures of the facility, and resident safety was number one . The Medical Director stated the facility's Plan of Correction obviously did not stop the elopement and something had broken down in the process but he did not know where the system failed. Interview, on 01/21/15 at 4:15 PM and on 01/30/15 at 6:00 PM with the Administrator, revealed she felt QA was monitoring the effectiveness of the elopement plan through the drills, the audits and communication with staff. The Administrator stated she expected staff to respond to the alarms, ensure the residents were safe, and validate the reason the alarm was sounding. She further stated RN #1 did not see or know what had occurred, did not validate, and did not realize what had happened until after the CNA told her that they could not locate Resident #1 in the facility. The Administrator stated the RN knew what to do, but she had made a mistake by silencing the alarm and not checking it. Further interview with the Administrator revealed staff was provided education, and had to take a post test and pass the test related to the 12/11/14 elopement. Additionally, an elopement drill was added to ensure staff had a complete understanding of the education that was provided. She stated this was completed on each shift, beginning 01/04/15. The Administrator stated the education was more focused on what not to do, such as do not silence the alarm and not walk away without first knowing what was going on in that situation. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated "I'm fine; I was just going for a walk." Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's "use by" date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a "sister" facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the "Elopement Drill Documentation Form" on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a "pass" being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Maintenance Supervisor revealed he checked the functionality of the doors, and wander guard alarms. He stated the wander guard alarm would still go off at the doors even with the door releasing after being pushed on for fifteen (15) seconds. Interview on 01/29/15 at 5:14 PM with LPN #6 revealed the residents' wanderguards were tested every shift by the nurse with the transmitter and documented on the Treatment Administration Records (TARs). Review of the January TARs for residents at risk for elopement (13 of 13) revealed daily shift audits of the functionality of each resident's wanderguard. Interview on 01/29/15 at 11:31 AM with the Maintenance Helper revealed nurses checked the residents' wander guards with the transmitters. 14. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed a weekly testing of wanderguard transmitter testers was done and would be in the system. The Maintenance Supervisor provided a copy of the weekly testing of the wanderguard transmitter testers (3 of 3) with one being a spare; which revealed weekly checks were documented on 01/12/15, 01/20/15, and 01/26/15. 15. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed the batteries were changed in the wanderguard transmitter tester in September 2014, November 2014, and on 01/19/15; with the expiration date of the batteries placed on the documentation starting in January. Review of the Wanderguard Tester Battery Replacement Form provided by the Maintenance Supervisor revealed the batteries in the wanderguard transmitter tester were changed on 09/22/14, 11/20/14, and 01/19/15; with the start of documentation of battery expiration date beginning on 01/19/15. 16. Interviews on 01/29/15 at 5:14 PM with LPN #6; on 01/09/15 at 2:45 PM with LPN #4; on 01/15/15 at 1:25 PM with RN #8; and, on 01/09/15 at 2:59 PM with RN #6 revealed residents' wanderguards were tested every shift by the nurse with the transmitter and it was documented on the Treatment Administration Records (TARs). Review of TARs for residents at risk for elopement revealed daily shift audits of the functionality of each resident wander guard. 17. Review of the facility's investigation revealed in an interview conducted on 01/05/15 with CNA #21, who was providing 1:1 supervision of Resident #1, she commented to the resident the door was locked; and Resident #1 made a statement about the door sign saying "push" and the door will open in fifteen (15) seconds. Interview on 01/21/15 at 4:15 PM with the Administrator revealed Resident #1 was on 1:1 with CNA #21 when she had tried to open the door and CNA #21 commenting to the resident the door was locked. 18. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she had turned off the alarm at the door when CNA #1 asked her to, because it was alarming, and the alarm had sounded different to her. RN #1 further revealed she had signed an elopement paper during orientation on 11/25/14, and she had been terminated after this incident. Review of the POS [REDACTED]. Interview on 01/18/15 at 1:13 PM with CRM revealed two (2) staff members were suspended with RN #2 being terminated after the incident. Interview on 01/13/15 at 12:40 PM with the acting DON at the time of the incident revealed RN #1 did not follow the facility's policy and had received the training and testing on elopement to include the sounds of alarms. 19. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed entrance and exit codes were not the same, and if a visitor activated the alarm a staff member would have to silence it. The Maintenance Supervisor stated the exit codes had been changed at least once monthly since November 2014. Review of the Log of Code Changes provided by the Maintenance Supervisor and Administrator revealed exit codes had been changed four (4) times on November 11/21/14, twice (2) on 11/28/14, twice (2) on 11/29/14, twice (2) on 12/26/14, twice (2) on 01/03/15, and once (1) on 01/10/15. Interviews with the CRC on 01/14/15 at 4:05 PM, the SSD on 01/16/15 at 12:45 PM, LPN #1 on 01/11/15 at 4:59 PM, LPN #3 on 01/15/15 at 1:35 AM, LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 at 01/12/15 at 1:01 PM, CNA #22 at 01/29/15 at 12:06 PM revealed when alarms go off staff respond to the alarm. Interviews with LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #11 on 01/13/15 at 8:25 AM, CNA #15 at 01/16/15 at 12:55 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 on 01/12/15 at 1:01 PM, and CNA #22 on 01/29/15 at 12:06 PM revealed the codes to let visitors out was only provided to staff and no one else was to be given the code. 20. Interview on 01/14/15 at 4:05 PM with the RN/MDS Coordinator revealed she had come in on 01/04/15 and reassessed all of the elopement risk residents (13 of 13) after the elopement. Review of the Elopement Care Plan Evaluations revealed (13 of 13) residents were reassessed on 01/04/15. Review of the AOC binder revealed review of residents identified as at risk for elopement by RN MDS Coordinator with a date of 01/04/15. 21. Review of the AOC binder revealed education of the Administrator, the acting DON, and a sister facility's DON at the time of the elopement. This education was provided by the RVP and RMCO regarding regulations and requirements for F490 and F520 with Performance Improvement/Quality Improvement (PI/QI) being key to validation of the systems and key to enhancing quality of life for residents and staff at the Center. The education further stated, if/when there was a deviation of the facility's policy or standard of practice identified, it was the responsibility of the PI Committee to conduct a root cause analysis and determine applicable steps based on the analysis. A re-education document was signed by the Administrator and Acting DON on 01/04/15. A Post-test was given to the Administrator on subject matter by the RVP with 100% pass rate on 01/04/15. A post-test was given to the acting DON by RMCO on 01/04/15 with passing score of 100%. Review of the AOC binder revealed Administrative education with the acting DON at time of the elopement, incoming DON, and Administrator as well as their job description and post-test with a passing score. 22. Review of the re-education post-test for the Nurse Practice Educator (NPE) entitled, "Resident Safety and Elopement", dated 01/04/15, revealed the RMCO completed the post-test with a passing score of 100%. 23. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed the RVPO and RMCO educated the Administrator, Interim Director of Nursing (DON), and "assisting" Director of Nursing. She revealed the RMCO educated the Administrative staff on the post tests, then they educated the Department Heads, who then trained the facility staff related to the material on the post tests. The Administrator further revealed she, the interim DON, and the assisting DON were the only ones who received education specific to Administration and Quality Assurance. The education difference from the first IJ to the second IJ was focused more on what not to do, what the expectations were, and to not silence the alarm and walk away without knowing what was going on in that situation. The Administrator stated this would be a part of the facility's standard orientation. 24. Review of the AOC binder revealed re-education to the Therapy Program Manager, RN MDS Coordinator, Payroll Coordinator and Admissions Director on the elopement policy and procedure, the sound of emergency exit alarms, sound of the wander guard alarm, and updating care plans for change in behaviors with post-test score of 100%. Interview on 01/29/15 at 4:50 PM with the Dietary Supervisor revealed she had been re-educated on: the elopement process; which involved the difference in the sound of the alarms, if staff notice an alarm going off, the staff is to check it, make sure no one has gone out, do a head count to see if residents are in the facility, and if not, search everywhere. A code yellow is called over the intercom and everybody in the facility is involved in the search. The Dietary Manager revealed she had received training on them and was involved in the morning meeting when they were discussed for revision related to any new behaviors residents may exhibit. She stated staff should not turn an alarm off until staff had discovered if a resident was missing and a code yellow has been called. 25. Review of the AOC binder revealed re-education, listing of staff per shift and date of education and pas

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to revise the Plan of Care for one (1) of four (4) sampled residents (Resident #4). Staff used a mechanical lift to transfer Resident #4; however, there was no intervention on the resident's care plan for a lift for transfers. The findings include: Review of the facility's policy titled, "Care Plans", last revised 01/02/14, revealed a comprehensive, individualized care plan will be developed by the interdisciplinary team for each resident. The care plan will include measurable objectives to meet resident needs and goals as identified by the assessment process; to provide necessary care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The comprehensive care plan is based on nursing assessment, subsequent assessments/evaluations, care area assessments and other observations; communicated to appropriate staff and reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. The care plan must be customized to each individual resident's care plan. Review of a notation by the Administrator attached on 12/01/14 to the care plan policy revealed the Interdisciplinary Team (IDT) develops and revises the care plans along with the licensed nurses. Record review revealed the facility admitted Resident #4 on 02/27/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/14/14 , revealed the facility assessed Resident #4's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of "0" which indicated the resident was not interviewable. The facility also assessed the resident as requiring total assistance with activities of daily living. Review of the Nursing Notes, dated, 09/10/14 and 11/20/14 revealed Resident #4 was transferred with the use of a mechanical lift. Review of the Comprehensive Care Plan, last revised 11/17/14, revealed there was no intervention for the use of a mechanical lift for transfers for Resident #4. Review of the Certified Nursing Aide (CNA) Care Plan, dated 11/2014, revealed there was no documentation for the use of a mechanical lift for transfers. Interviews on 11/26/14 with CNA #2 at 10:15 AM, CNA #11 at 10:01 AM, and CNA #12 at 12:18 PM, revealed Resident #4 was transferred with a mechanical lift. The CNAs stated they were unaware if the use of a lift was on the resident's plan of care. Interview with CNA #14, on 11/25/14 at 11:20 AM revealed staff used a mechanical lift to transfer Resident #4. CNA #14 stated she completed the revisions to CNA care plans by looking at the Comprehensive Care Plans and the information from the MDS. CNA #14 revealed the mechanical lift should have been on the CNA care plan. Interview with LPN #4, on 11/25/14 at 10:10 AM, revealed the mechanical lift should be on the CNA care plan and Comprehensive Care Plan. Interview with Registered Nurse (RN) #2, on 11/25/14 at 11:50 AM and on 12/03/14 at 11:26 AM revealed nurses were to place the interventions on the Plan of Care daily and the MDS staff updates the care plans quarterly. RN #1 stated staff transfer Resident #4 with a mechanical lift. Interview with Minimum Data Set (MDS) Coordinator, on 11/25/14 at 3:24 PM, revealed Resident #4 was not assessed for the use of the mechanical lift until 11/25/14 although the staff were using the lift for transfers. Interview with the Director of Nursing (DON), on 11/26/14 at 11:15 AM, revealed he would expect the mechanical lift to be on the care plan.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure the services provided met professional standards of care for one (1) of four (4) sampled residents (Resident #1) related to elopement. Resident #1 was care planned for a wanderguard on 11/21/14 in order to alert staff of the resident's unsupervised attempts to exit the facility. However, later that same day (on 11/21/14) at approximately 4:45 PM staff was not alerted when Resident #1 exited the building, unattended. In addition, the facility was unable to determine which door the resident had exited. The facility's failure to provide care according to the Plan of Care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/03/14 and determined to exist on 11/21/14. The facility was notified of the Immediate Jeopardy on 12/03/14. An acceptable Allegation of Compliance (AoC) was received on 12/10/14 alleging removal of the Immediate Jeopardy on 12/10/14; however, the State Survey Agency validated the Immediate Jeopardy was not removed until 12/11/14. The scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Corrections (POC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy, entitled "Care Plans", last revised 01/02/14 revealed "A comprehensive, individualized care plan would be developed by the interdisciplinary team for each resident. The care plan will include measurable objectives to meet resident needs and goals as identified by the assessment process. The comprehensive care plan is based on nursing assessment, subsequent assessments/evaluations, care area assessments and other observations; communicated to appropriate staff and reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. The care plan must be customized to each individual patient's care plan." Notation by Administrator attached on 12/01/14 to care plan policy revealed Interdisciplinary Team (IDT) develops and revises the care plans along with the licensed nurses. Review of the facility's policy and procedure entitled, "Nursing Care:Provision", last revised 10/01/12, revealed nursing services will be provided with nursing supervision twenty-four (24) hours a day, seven (7) days a week. Record review revealed the facility admitted Resident #1 on 11/19/14 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 12/02/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of "11", which indicated the resident was interviewable. The resident required the assistance of one (1) for Activities of Daily Living with functional limitation in Range of Motion (ROM); and, impairment to one (1) side of upper and lower extremities. The resident utilized a cane and wheelchair for mobility. Review of a Change of Condition Note, dated 11/21/14 at 11:00 AM, revealed Registered Nurse (RN) #1 placed a wanderguard on Resident #1 after he/she was heard making statements such as, "I'm not supposed to be here" and "I want to go home." Review of the Comprehensive Care Plan for "Exhibits behavior that is disruptive/demanding", dated 11/21/14, revealed Resident #1 was at risk for elopement. Further review revealed an intervention for the resident to wear a wanderguard to alert staff to unassisted attempts to exit the facility. However, on 11/25/14 at approximately 4:45 PM, Resident #1 was seen outside in the facility's parking lot, unsupervised. Staff did not heard the wanderguard alarm sound when the resident exited the building, as they should have, per the resident's care plan. Interview with Resident #1, on 12/03/14 at 9:52 AM, revealed he/she did not remember going outside on 11/21/14. Interview with Physical Therapy Assistant (PTA) #1, on 11/25/14 at 9:10 AM, revealed Resident #1 was observed through the glass door of the Therapy Department outside in the front parking lot on 11/21/14 at 4:45 PM. PTA #1 stated there were two (2) other staff members in the Therapy Department at the time and no one heard any alarm, prior to seeing Resident #1 outside. PTA #1 revealed Resident#1 would walk back and forth a lot, and the Physical Therapy staff would redirect him/her. Review of the November 2014 Medication Administration Record [REDACTED]. Interview on 11/26/14 at 8:15 AM with Licensed Practical Nurse (LPN) #1, revealed she administered Resident #1's [MEDICATION NAME] (bowel stimulator) at 4:40 PM on 11/21/14 in his/her room. LPN #1 further stated she was responsible for checking Resident #4's wanderguard, however she failed to to do so the day of the elopement, she was also responsible for the supervision of the resident as she was the nurse on duty for 200 hall where the resident resided. Interview on 11/25/14 at 3:15 PM with Certified Nursing Assistant(CNA) #1, revealed she was passing liquids in the dining room and she had been told not to leave the dining room and to watch the residents. She stated between 4:30 PM and 5:00 PM, Licensed Practical Nurse (LPN) #1, came and told her Resident #1 had gone outside and she needed her to watch the resident, while she went to figure out what had happened and how the resident had got outside. She stated she had not heard any alarms sound. Interview with LPN #1, on 11/25/14 at 3:20 PM and on 11/26/14 at 8:50 AM, revealed she was passing her medications, when someone from the Physical Therapy Department came and told her one of the residents was outside about 4:45 PM. LPN #1 stated she had not heard any alarm go off. Interview with Registered Nurse (RN) #1 on 11/26/14 at 8:30 AM, CNA #2 on 11/25/14 at 4:10 PM, and CNA #3 on 12/02/14 at 5:55 PM, revealed they were working at the facility on 11/21/14 at approximately 4:45 PM and they did not hear a wanderguard alarm sound. Interview with Director of Nursing (DON), on 12/02/14 at 9:20 AM revealed they were unable to determine what door Resident #1 exited through and did not know why no one heard an alarm when he/she exited the building. The facility implemented the following actions to remove the Immediate Jeopardy: 1. 1:1 observation was initiated immediately following elopement on 11/21/14 through 12/05/14, the day the resident was discharged . A physician's orders [REDACTED]. Change in Condition document which included vital signs was completed after the elopement on 11/21/14. 2. Resident #1's Physician/Medical Director of the facility was notified of the elopement on 11/21/14 and an order for [REDACTED]. 3. The Elopement Evaluation and Device Evaluation was updated by the LPN on 11/21/14. 4. The Maintenance Director checked the egress doors for function, on 11/21/14. Maintenance Director reset all of the mag lock exit codes, on 11/22/14. 5. The residents residing in the Center were reviewed for elopement risk on 11/22/14 by the RNs and LPNs. Care Plans and Care Card were reviewed and updated as indicated by the licensed nurses. 6. Re-education of staff related to elopement prevention and management; expected response of staff during an elopement; the different sounds of alarms; door codes not to be released to any visitor or vendor, and Care Plans and CNA Care Plans showing safety of residents; with implementation of post-test showing comprehension of material was conducted on 11/22/14 through 11/24/14 by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE) or Administrator. Employees not available during this timeframe were contacted via telephone. 7. All new employees will have elopement education provided during orientation. Employees not available were contacted via telephone by supervisor and made aware of education and will have to take a post test prior to their next scheduled shift. 8. Care Plan education was initiated on 12/03/14 and sixty (60) of eighty- nine (89) active employees competed re-education and post testing between 12/03/14-12/08/14. Employees not available were contacted via telephone by a supervisor and made aware of education and post test prior to working their next scheduled shift. 9. Written education of alarm significance was placed at the Nurse's Stations on 11/22/14. 10. Signs documented with "Please be mindful that no resident of the facility is exiting with you.", were placed on all exit doors by the DON on 11/21/14. 11. A letter from the Administrator was mailed on 11/22/14 to vendors (such as EMS, PATS Public Transportation, Mobilex, Gamma Labs, Respiratory Health Services) identified as potentially having the code to the doors informing the codes would no longer be released and asking for attention to security when entering and exiting the facility. 12. Elopement drills were completed with staff on all shifts by licensed staff on 11/22/14 through 11/24/14. 13. Functionality of the door alarms was checked by the Maintenance Supervisor or Assistant five (5) days per week through 12/08/14. 14. Care Plan audits will be done on five (5) residents across random shifts times fourteen (14) days, then five (5) times per week times sixty (60) days, then no less than three (3) times a week for an additional thirty (30) days beginning 12/09/14 by the DON, ADON, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy of elopement risk. 15. A meeting of the Interdisciplinary Team (IDT), which included the Administrator, DON, Social Service Director, Admissions Director, Nurse Practice Educator (NPE), and Medical Director, to review the elopement event and Performance Improvement (PI) plan with Medical Director attending via telephone on 11/22/14. **The State Survey Agency validated the corrective action taken by the facility on 12/11/12-12/12/14 as follows: 1. Review of telephone physician's orders [REDACTED].#1 until he/she was discharged . Interviews on 12/12/14 at 11:00 AM with Certified Nursing Aide (CNA) #15 revealed she had sat 1:1 with Resident #1 after the elopement. Interview on 12/02/14 at 5:37 PM with RN #4 revealed she had relieved staff for 1:1 supervision for Resident #1 after the elopement. 2. Review of Change of Condition document dated 11/21/14 revealed the physician was informed of the elopement by LPN #1. 3. Record review revealed Resident #1's elopement evaluation and device evaluation were updated on 11/21/14 by RN #1. 4. Interview on 12/11/14 at 3:30 PM with the Maintenance Director revealed all doors were found to be functioning on 11/21/14 and the codes to the doors being reset on 11/22/14. Review of AOC binder revealed Maintenance checked the doors on 11//21/14 and reset the mag lock exit codes on 11/22/14. 5. Review of the facility's audit sheet for elopement risk revealed all seventy-four (74) residents elopement evaluations were reviewed by licensed staff on 11/22/14 and one resident was identified as needing a wanderguard. Additionally the audit sheet reflected revision of Care Plans and care cards for all seventy-four (74) residents to include revision for the resident who was identified as needing a wander guard. 6. Review of the re-education information on 11/22/14-11/24/14; and, on 12/03/14 -12/08/14 revealed staff was inserviced by the Administrator and NPE on policies of elopement prevention and management, expected response of staff, the different sounds of alarms, door codes not to be released to any visitor or vendor, and care plans and CNA care plans showing safety of residents; with staff passing post -test showing comprehension of material. Interviews on 12/11/14 at 1:25 PM with RN #5, at 2:15 PM with RN #1, at 2:35 PM with the MDS Coordinator; and, at 6:28 PM with CNA #18 revealed they had been re-educated on the facility's elopement and care plan policies. 7. Interview on 12/02/14 at 11:55 AM and 12/12/11/14 at 2:22 PM with the NPE revealed she was involved in the re-education of staff related to the elopement process and identifying elopement risk residents, and would be doing education for present and future employees. Interviews on 12/11/14 at 1:00 PM with Certified Nursing Assistant (CNA) #4, at 1:05 PM with CNA #15 and CNA #16, at 1:10 PM with the Speech Language Pathologist, Therapy Program Manager, Occupational Therapy Assistant (COTA) #1 and COTA #2, at 1:38 PM with the Housekeeping Supervisor, at 1:40 PM with the Housekeeping Aide, at 1:25 PM with Registered Nurse (RN) #5, at 2:28 PM with Licensed Practical Nurse (LPN) #4, at 4:09 PM with LPN #1, at 2:35 PM with the Minimum Data Set (MDS) Coordinator #2 and at 2:45 PM with the Social Service Director, revealed they had received elopement education to include the sound of the wanderguard alarm, documentation and signage on the exit doors to alert visitors to be mindful that no resident of the facility exits with you. 8. Interviews on 12/11/14 at 1:25 PM with Registered Nurse (RN) #5, at 2:28 PM with Licensed Practical Nurse (LPN) #4, at 2:35 PM with MDS Coordinator #2, at 2:45 PM with the Social Service Director, at 1:00 PM with CNA #4, at 1:05 PM with CNA #15 and CNA #16, revealed they had been inserviced on the facility's care plan policy. Employees not available were contacted via telephone by supervisor or NPE and made aware of education and post testing prior to next scheduled shift. 9. Review of an Elopement binder at the Nurse's Station revealed it contained written education of alarm significance. 10. Observation of the egress doors revealed signage stating, "Please be mindful that no resident of the facility is exiting with you.", this was placed by the DON on 11/21/14. Interview on 12/02/14 at 9: 10 AM with Licensed Practical Nurse (LPN) #3, at 9:25 AM with LPN #2 at 9:12 AM with the Occupations Therapy Assistant (OTA) and at 9:18 AM with the Director of Recreation revealed signs were on the exit doors, to remind individuals not to let anyone follow them out. 11. Review of documented letters revealed the letters were sent on 11/22/14 to responsible parties and venders related to the door alarm code not being given out. 12. Review of the Inservice Sign In Sheets revealed elopement drills were conducted on all shifts from 11/21/14-11/24/14. Interview on 12/02/14 at 11:15 AM with LPN # 3 revealed she had an elopement drill during her shift. 13. Review of logbook documentation from the Maintenance Director revealed the functionality of the door alarms and wanderguards were checked by the Maintenance Director and for functionality from 11/16/14-12/08/14. 14. Review of the Risk for Elopement Audit Sheet revealed five (5) residents' elopement evaluation were reviewed on random shifts by the Director of Nursing (DON), Assistant, Director of Nursing (ADON), Nurse Practice Educator (NPE) and Administrator. 15. Review of Meeting Notes, dated 11/22/14 revealed the Interdisciplinary Team (IDT), which included the Administrator, DON, SSD, AD, NPE and Medical Director, met to review the elopement event and Performance Improvement Plan with the Medical Director attending via telephone. Interview on 12/11/14 at 5:05 PM with the Medical Director revealed he had participated in the PI meeting related to the elopement event.

Based on interview, record review and review of the facility's policy and procedures, it was determined the facility failed to ensure one (1) of three (4) sampled residents (Resident #1) received adequate supervision to prevent accidents. The facility failed to ensure the resident was supervised, after being assessed and care planned as an elopement risk. On 11/21/14 at 4:45 PM, Resident #1 was observed in the facility's parking lot, unsupervised by staff. Resident #1 had exited the building without staff's knowledge. Physical Therapy Assistant (PTA) #1, witnessed the resident unsupervised in the parking lot on 11/21/14 at 4:45 PM.. The facility's failure to provide adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/03/14 and determined to exist on 11/21/14. The facility was notified of the Immediate Jeopardy on 12/03/14. An acceptable Allegation of Compliance (AoC) was received on 12/10/14 alleging removal of the Immediate Jeopardy on 12/10/14; however, the State Survey Agency validated the Immediate Jeopardy was not removed until 12/11/14. The Scope and Severity was lowered to a "D" while the facility develops and implements the Plan of Corrections (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy entitled "Elopement of Patient", last revised 05/15/14, revealed residents where to be evaluated for elopement risk upon admission, re-admission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk were to receive appropriate interventions to reduce risk and minimize injury. Record review revealed the facility admitted Resident #1 on 11/19/14 with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) score was noted to be eleven (11), which indicated the resident was interviewable. Review of a Elopement Evaluation, dated 11/21/14, revealed the facility reassessed Resident #1 after the resident voiced that he/she wanted to leave the facility; the facility assessed the resident to be at risk for elopement. Review of the Device Assessment, dated 11/21/14, revealed a wanderguard (a device placed on the person that alarms when he/she gets near an exit) was placed on the resident to alert staff of unassisted attempts to exit the facility. Review of the Comprehensive Care Plan for "Exhibits behavior that is disruptive/demanding", dated 11/21/14, revealed Resident #1 was at risk for elopement. Interventions included the resident was to wear a wanderguard to alert staff to unassisted attempts to exit the facility. Other interventions noted on the residents Care Plan were to encourage engagement in activities and conversation. Interview with Physical Therapy Assistant (PTA) #1, on 11/25/14 at 9:10 AM, revealed at approximately 4:45 PM on 11/21/14, she observed Resident #1 in the facility parking lot, at the front of the building. PTA #1 stated she did not hear an alarm, prior to observing Resident #1 outside. PTA #1 revealed she had seen Resident #1, walking back and forth in the parking lot, at approximately 4:30 PM. She stated the resident had earlier asked her the location of the front desk. Review of the November 2014 Medication Administration Record (MAR), revealed Resident #1 was last seen at 4:40 PM when he/she was administered Miralax (bowel stimulator). Interview on 11/26/14 at 8:15 AM with Licensed Practical Nurse (LPN) #1, revealed she administered Resident #1's Miralax (bowel stimulator) at 4:40 PM on 11/21/14 in his/her room. LPN #1 further stated she was responsible for checking Resident #4's wanderguard, however she failed to to do so the day of the elopement, she was also responsible for the supervision of the resident as she was the nurse on duty for 200 hall where the resident resided. Interview with Licensed Practical Nurse (LPN) #1, on 11/25/14 at 3:20 PM and on 11/26/14 at 8:15 AM, revealed she went outside and assisted the resident back in the facility. She stated the resident had on a coat, long sleeve shirt, long pants, and house shoes. LPN #1 stated the alarm sounded when the resident was brought back into the building; however, she did not hear an alarm when the resident exited the facility. Interviews on 11/25/14 with Certified Nurse Aide (CNA) #1 at 3:15 PM and CNA #2 at 4:10 PM, revealed they were not aware Resident #1 had exited the building and did not hear a wanderguard alarm sound on the day Resident #1 was found outside the building. Interview with Registered Nurse #1, on 11/26/14 at 8:30 AM, revealed licensed staff were responsible for checking the wanderguard each shift, to make sure they were in place and working. RN #1 stated Resident #1's wanderguard was working when he put it on the resident earlier that day. Interview with LPN #2, on 12/03/14 at 2:18 PM, revealed the wanderguards were checked for proper functioning with a with Code Alert Transmitter Tester. She stated if the wanderguard was functioning correctly, it would make a constant beeping sound. If it was not functioning, no sound would be heard when the transmitter was held close to the wanderguard bracelet. She stated each resident's wanderguard bracelet was checked by licensed staff for proper placement and functioning each shift. Interview with the Maintenance Supervisor, on 12/03/14 at 2:10 PM, revealed he checked the doors daily when he arrived at the facility. He stated the wander guard alarm would sound if the resident was within five (5) feet of the door and the door would remain locked. He stated the wander guard alarm would alarm even if the door code was punched in to disengage the main door alarm and would continue to alarm if the resident followed someone out the door. He stated he thought the only way Resident #1 could have exited the building was if someone had reset the alarm and did not bother to look outside. However, staff interviews revealed no one heard an alarm. Interview with the Director of Nursing (DON), on 12/02/14 at 9:20 AM and on 12/03/14 at 2:20 PM, revealed maintenance checked the doors daily and the battery on the wander guard bracelet was changed every month on the fifteenth (15th). He stated the wander guard alarm would sound if a resident with a wander guard bracelet was close to the door and if the resident followed someone out the door. The DON stated he was unable to determine how Resident #1 exited the building without staff's knowledge. Interview with the Administrator, on 12/05/14 at 10:55 AM, revealed an investigation of the elopement was conducted and she was unable to determine how Resident #1 was able to exit the building without staff's knowledge. The facility implemented the following actions to remove the Immediate Jeopardy: 1. 1:1 observation was initiated immediately following elopement on 11/21/14 through 12/05/14, the day the resident was discharged . A physician's orders [REDACTED]. Change in Condition document which included vital signs was completed after the elopement on 11/21/14. 2. Resident #1's Physician/Medical Director of the facility was notified of the elopement on 11/21/14 and an order for [REDACTED]. Licensed staff notified the Resident's Responsible Party on 11/21/14 of the elopement. 3. The Elopement Evaluation and Device Evaluation was updated by the LPN on 11/21/14. 4. The Maintenance Director checked the egress doors for function, on 11/21/14. Maintenance Director reset all of the mag lock exit codes, on 11/22/14. 5. The residents residing in the Center were reviewed for elopement risk on 11/22/14 by the RNs and LPNs. Care Plans and Care Card were reviewed and updated as indicated by the licensed nurses. 6. Re-education of staff related to elopement prevention and management; expected response of staff during an elopement; the different sounds of alarms; door codes not to be released to any visitor or vendor, and Care Plans and CNA Care Plans showing safety of residents; with implementation of post-test showing comprehension of material was conducted on 11/22/14 through 11/24/14 by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE) or Administrator. Employees not available during this timeframe were contacted via telephone. 7. All new employees will have elopement education provided during orientation. Employees not available were contacted via telephone by supervisor and made aware of education and will have to take a post test prior to their next scheduled shift. 8. Care Plan education was initiated on 12/03/14 and sixty (60) of eighty- nine (89) active employees competed re-education and post testing between 12/03/14-12/08/14. Employees not available were contacted via telephone by a supervisor and made aware of education and post test prior to working their next scheduled shift. 9. Written education of alarm significance was placed at the Nurse's Stations on 11/22/14. 10. Signs documented with "Please be mindful that no resident of the facility is exiting with you.", were placed on all exit doors by the DON on 11/21/14. 11. A letter from the Administrator was mailed on 11/22/14 to vendors (such as EMS, PATS Public Transportation, Mobilex, Gamma Labs, Respiratory Health Services) identified as potentially having the code to the doors informing the codes would no longer be released and asking for attention to security when entering and exiting the facility. 12. Elopement drills were completed with staff on all shifts by licensed staff on 11/22/14 through 11/24/14. 13. Functionality of the door alarms was checked by the Maintenance Supervisor or Assistant five (5) days per week through 12/08/14. 14. Care Plan audits will be done on five (5) residents across random shifts times fourteen (14) days, then five (5) times per week times sixty (60) days, then no less than three (3) times a week for an additional thirty (30) days beginning 12/09/14 by the DON, ADON, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy of elopement risk. 15. A meeting of the Interdisciplinary Team (IDT), which included the Administrator, DON, Social Service Director, Admissions Director, Nurse Practice Educator (NPE), and Medical Director, to review the elopement event and Performance Improvement (PI) plan with Medical Director attending via telephone on 11/22/14. **The State Survey Agency validated the corrective action taken by the facility on 12/11/12-12/12/14 as follows: 1. Review of telephone physician's orders [REDACTED].#1 until he/she was discharged . Interviews on 12/12/14 at 11:00 AM with Certified Nursing Aide (CNA) #15 revealed she had sat 1:1 with Resident #1 after the elopement. Interview on 12/02/14 at 5:37 PM with RN #4 revealed she had relieved staff for 1:1 supervision for Resident #1 after the elopement. 2. Review of Change of Condition document dated 11/21/14 revealed the physician was informed of the elopement by LPN #1. 3. Record review revealed Resident #1's elopement evaluation and device evaluation were updated on 11/21/14 by RN #1. 4. Interview on 12/11/14 at 3:30 PM with the Maintenance Director revealed all doors were found to be functioning on 11/21/14 and the codes to the doors being reset on 11/22/14. Review of AOC binder revealed Maintenance checked the doors on 11//21/14 and reset the mag lock exit codes on 11/22/14. 5. Review of the facility's audit sheet for elopemnet risk revealed all seventy-four (74) residents elopement evaluations were reviewed by licensed staff on 11/22/14 and one resident was identified as needing a wanderguard. Additionally the audit sheet reflected revision of Care Plans and care cards for all seventy-four (74) residents to include revision for the resident who was identified as needing a wander guard. 6. Review of the re-education information on 11/22/14-11/24/14; and, on 12/03/14 -12/08/14 revealed staff was inserviced by the Administrator and NPE on policies of elopement prevention and management, expected response of staff, the different sounds of alarms, door codes not to be released to any visitor or vendor, and care plans and CNA care plans showing safety of residents; with staff passing post -test showing comprehension of material. Interviews on 12/11/14 at 1:25 PM with RN #5, at 2:15 PM with RN #1, at 2:35 PM with the MDS Coordinator; and, at 6:28 PM with CNA #18 revealed they had been re-educated on the facility's elopement and care plan policies. 7. Interview on 12/02/14 at 11:55 AM and 12/12/11/14 at 2:22 PM with the NPE revealed she was involved in the re-education of staff related to the elopement process and identifying elopement risk residents, and would be doing education for present and future employees. Interviews on 12/11/14 at 1:00 PM with Certified Nursing Assistant (CNA) #4, at 1:05 PM with CNA #15 and CNA #16, at 1:10 PM with the Speech Language Pathologist, Therapy Program Manager, Occupational Therapy Assistant (COTA) #1 and COTA #2, at 1:38 PM with the Housekeeping Supervisor, at 1:40 PM with the Housekeeping Aide, at 1:25 PM with Registered Nurse (RN) #5, at 2:28 PM with Licensed Practical Nurse (LPN) #4, at 4:09 PM with LPN #1, at 2:35 PM with the Minimum Data Set (MDS) Coordinator #2 and at 2:45 PM with the Social Service Director, revealed they had received elopement education to include the sound of the wanderguard alarm, documentation and signage on the exit doors to alert visitors to be mindful that no resident of the facility exits with you. 8. Interviews on 12/11/14 at 1:25 PM with Registered Nurse (RN) #5, at 2:28 PM with Licensed Practical Nurse (LPN) #4, at 2:35 PM with MDS Coordinator #2, at 2:45 PM with the Social Service Director, at 1:00 PM with CNA #4, at 1:05 PM with CNA #15 and CNA #16, revealed they had been inserviced on the facility's care plan policy. Employees not available were contacted via telephone by supervisor or NPE and made aware of education and post testing prior to next scheduled shift. 9. Review of an Elopement binder at the Nurse's Station revealed it contained written education of alarm significance. 10. Observation of the egress doors revealed signage stating, "Please be mindful that no resident of the facility is exiting with you.", this was placed by the DON on 11/21/14. Interview on 12/02/14 at 9: 10 AM with Licensed Practical Nurse (LPN) #3, at 9:25 AM with LPN #2 at 9:12 AM with the Occupations Therapy Assistant (OTA) and at 9:18 AM with the Director of Recreation revealed signs were on the exit doors, to remind individuals not to let anyone follow them out. 11. Review of documented letters revealed the letters were sent on 11/22/14 to responsible parties and venders related to the door alarm code not being given out. 12. Review of the Inservice Sign In Sheets revealed elopement drills were conducted on all shifts from 11/21/14-11/24/14. Interview on 12/02/14 at 11:15 AM with LPN # 3 revealed she had an elopement drill during her shift. 13. Review of logbook documentation from the Maintenance Director revealed the functionality of the door alarms and wanderguards were checked by the Maintenance Director and for functionality from 11/16/14-12/08/14. 14. Review of the Risk for Elopement Audit Sheet revealed five (5) residents' elopement evaluation were reviewed on random shifts by the Director of Nursing (DON), Assistant, Director of Nursing (ADON), Nurse Practice Educator (NPE) and Administrator. 15. Review of Meeting Notes, dated 11/22/14 revealed the Interdisciplinary Team (IDT), which included the Administrator, DON, SSD, AD, NPE and Medical Director, met to review the elopement event and Performance Improvement Plan with the Medical Director attending via telephone. Interview on 12/11/14 at 5:05 PM with the Medical Director revealed he had participated in the PI meeting related to the elopement event.

2 Based on interview, record review, review of the Administrator's job description, and review of the facility's policy and procedures, and the Allegation of Compliance (A0C) and Plan of Correction (PoC) for the 12/11/14 Immediate Jeopardy Abbreviated Survey, it was determined the facility failed to have an effective system to ensure staff was knowledgeable related to the facility's elopement policy and procedures to ensure the residents' safety. This failure affected one (1) of six (6) sampled residents (Resident #1). On 11/21/14, a resident exited the facility without staff's knowledge, unsupervised which resulted in the facility being cited Immediate Jeopardy. The facility educated staff on the facility's policy and procedures related to how to respond to an alarm; the different sounds and the types of alarms. However, the facility failed to ensure the staff followed the policy and procedures, in order to keep Resident #1 safe. Resident #1 exited the facility without staff's knowledge approximately six (6) weeks later, after the first Immediate Jeopardy. On 01/04/15 at approximately 6:15 AM-6:30 AM, a door alarm sounded and Registered Nurse (RN) #1 turned off the alarm; however, the RN failed to conduct a head count and search outside the door for a resident per the facility's policy and procedures, which were included in the AOC and POC. In addition, the nurse failed to identify that the alarm that was sounding was a wanderguard alarm. At approximately 6:40 AM, after the resident's roommate informed staff the resident had gone for a walk, Certified Nurse Aide (CNA) #2 identified that Resident #1 was not in the facility. Resident #1 had exited the facility without staff's knowledge and was discovered outside on a main road at approximately 6:45 AM. The Administrator failed to ensure the education provided to staff was effective. (Refer to F323) The facility's failure to be administered in a manner that enabled it to use its resources effectively and efficiently has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15 and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility's job description for the Administrator, last revised 08/01/12, revealed, The Administrator was responsible for planning and was accountable for all activities and departments of the Center subject to rules and regulations promulgated by government agencies to ensure proper health care services to residents. The Administrator administers, directs and coordinates all activities of the Center to assure the highest degree of quality of care is consistently provided to residents; and concerns his/herself with the safety of all Nursing Center residents in order to minimize the potential for fire and accidents. Review of the facility's policy and procedures titled, Elopement of Patient, last revised 05/15/14, revealed residents should be evaluated for elopement risk upon admission, readmission, quarterly and with a change in condition as part of the nursing assessment process. Those determined to be at risk should receive appropriate interventions to reduce risk and minimize injury. For residents identified at risk, an interdisciplinary elopement prevention care plan should be developed with family and resident participation. Individual risk factors and patterns will be identified and addressed within the care plan. Further review of the policy revealed for unwitnessed elopements staff should search room to room and all areas of the Center: resident rooms, closets, under beds, shower rooms, utility rooms, offices, dining rooms, stairwells, laundry, kitchen (including walk-in refrigerators and freezers), bathrooms, dayrooms/lounges, courtyards, and employee lounges; and outside perimeter and grounds. Interview and record review revealed the facility assessed Resident #1 and care planned him/her as an elopement risk. According to the 12/11/14 Abbreviated Survey's AOC and POC the Administrator and Administrative staff educated staff on the facility's Elopement Prevention and Management Policy and a Post Test was given to determine staff competency. The education included the . Expected employee response to a door alarm and, the different sounds of the door alarms. Review of the POS [REDACTED]. However, on 01/04/15 at approximately 6:15 AM-6:30 AM, the exit door alarm sounded by the Therapy Department. RN #1 turned the alarm off but failed to identify that the alarm was the wanderguard alarm; she failed to search for the resident outside the door; and, failed to conduct a head count to ensure all residents were accounted for per the facility's AoC and PoC. At approximately 6:30 AM, CNA #2 was told by another resident that Resident #1 had gone for a walk. Resident #1 was found standing outside the facility on a main road at approximately 6:45 AM. Further review of the AoC and PoC revealed elopement drills were conducted on each shift monthly (December 2014 and January 2015) but the facility did not identify any concerns. Review of the elopement Drill Documentation Audit Form revealed the Audit addressed identifying if staff responded to the announcement of a Code Yellow on the intercom system; however, the form did not address if the appropriate action was taken when a wanderguard alarm sounded and if staff was able to identify the alarm as a wanderguard alarm. Further review of the AOC and the POC revealed elopements drills were conducted on 11/21/14, 11/22/14, 11/23/14, 11/24/14, 01/04/15 and 01/10/15. These drills ensured that staff was able to hear the alarm sounding at the door or at the Nurse's Station. However, the drills did not address or ensure that staff could distinguish the different alarms. Interview with RN #1 revealed the alarm sounded different but she did not recognize it as the wanderguard alarm. Interview with RN #1, on 01/12/15 at 2:56 PM and on 01/14/15 at 9:22 AM, revealed when the alarm sounded she turned off the alarm with the key and the code at the door because CNA #1 stated the alarm was sounding related to another resident reentering the facility. RN #1 stated she did not conduct a head count and search outside the door, as per the AOC and POC. RN #1 stated she was not sure of the elopement procedures; however, review of a post test, conducted at the end of an inservice, after the 12/11/14 Immediate Jeopardy, addressing the facility's elopement policy and procedures revealed she scored 100%. The post test included fill in the blank questions: If a door alarm sounds, what are the three (3) immediate steps? The RN's written responses were 1. check the alarm, 2. thoroughly check the area, and 3. validate that no resident is missing. Interview on 01/13/15 at 12:17 PM with CNA #5 revealed CNA #2 asked if Resident #1 had been seen on the hall around 6:00 AM on 01/04/15. CNA #5 stated she was confused because no code had been called and no one had announced or done anything according to the policy. CNA #5 further revealed the policy was not followed even after she informed her nurse that a resident could not be found. CNA #5 stated the facility's protocol was not initiated, and the staff did not do what they were suppose to do. CNA #1 revealed he did not know how Resident #1 got out of the facility and the last alarm he heard was around 4:00 AM and 5:00 AM. He stated RN #1 told him to continue his bed checks and she would get the alarm. Interview on 01/11/15 at 4:59 PM; and, on 01/14/15 at 12:11 PM with Licensed Practical Nurse (LPN) #1, revealed she was in another resident's room when she heard an alarm. She stated she did not hear anything on the intercom system, but she was informed by CNA #5 that a resident had gotten out of the facility. LPN #1 stated she continued with her work, and did not know if the resident had been found or not. During the interview, LPN #1 stated when an alarm goes off, staff are to go to the desk and see where the alarm is and tell everyone to start looking for a resident, do a head count, and start looking at the door and around where the alarm went off. She stated if no one is found and the head count is correct, then it is called off. LPN #1 revealed this was not done on the day Resident #1 eloped and she did not know if the resident had gone out or not. LPN #1 revealed she had been trained on elopement and the wanderguard policy and procedure. Even though the LPN had been trained, she failed to follow the facility's elopement policy. Interview with the Administrator, on 01/12/15 at 4:20 PM, on 01/21/15 at 4:15 PM and on 01/30/15 at 6:00 PM, revealed the root cause of the incident was that the nurse walked away and shut off the wanderguard alarm. The Administrator stated the RN should have recognized it was a wanderguard alarm and validated whether there was a resident outside instead of just turning the alarm off. The Administrator stated the RN should not have assumed all was all right because she knew the alarms sounded differently. Further interview revealed she expected the staff to know the sounds of the alarms, search inside and outside when an alarm sounded and do a visual census check. However, she stated they focused the education more on what not to do, such as not silencing the alarm and walking away without knowing what was happening. The Administrator revealed staff was educated and was able to verbalize the sound of the routine alarm which had a high pitched and fast sound, like a siren; and the wanderguard alarm which had a high pitched, slow, chirping sound (two beats). If the staff was unable to verbalize, she would reeducate immediately. However, interview with staff revealed they were confused and didn't follow the facility's policy. RN #1 stated she could not tell that the alarm was for the wandergard. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated I'm fine; I was just going for a walk. Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's use by date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a sister facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the Elopement Drill Documentation Form on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a pass being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Maintenance Supervisor revealed he checked the functionality of the doors, and wander guard alarms. He stated the wander guard alarm would still go off at the doors even with the door releasing after being pushed on for fifteen (15) seconds. Interview on 01/29/15 at 5:14 PM with LPN #6 revealed the residents' wanderguards were tested every shift by the nurse with the transmitter and documented on the Treatment Administration Records (TARs). Review of the January TARs for residents at risk for elopement (13 of 13) revealed daily shift audits of the functionality of each resident's wanderguard. Interview on 01/29/15 at 11:31 AM with the Maintenance Helper revealed nurses checked the residents' wander guards with the transmitters. 14. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed a weekly testing of wanderguard transmitter testers was done and would be in the system. The Maintenance Supervisor provided a copy of the weekly testing of the wanderguard transmitter testers (3 of 3) with one being a spare; which revealed weekly checks were documented on 01/12/15, 01/20/15, and 01/26/15. 15. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed the batteries were changed in the wanderguard transmitter tester in September 2014, November 2014, and on 01/19/15; with the expiration date of the batteries placed on the documentation starting in January. Review of the Wanderguard Tester Battery Replacement Form provided by the Maintenance Supervisor revealed the batteries in the wanderguard transmitter tester were changed on 09/22/14, 11/20/14, and 01/19/15; with the start of documentation of battery expiration date beginning on 01/19/15. 16. Interviews on 01/29/15 at 5:14 PM with LPN #6; on 01/09/15 at 2:45 PM with LPN #4; on 01/15/15 at 1:25 PM with RN #8; and, on 01/09/15 at 2:59 PM with RN #6 revealed residents' wanderguards were tested every shift by the nurse with the transmitter and it was documented on the Treatment Administration Records (TARs). Review of TARs for residents at risk for elopement revealed daily shift audits of the functionality of each resident wander guard. 17. Review of the facility's investigation revealed in an interview conducted on 01/05/15 with CNA #21, who was providing 1:1 supervision of Resident #1, she commented to the resident the door was locked; and Resident #1 made a statement about the door sign saying push and the door will open in fifteen (15) seconds. Interview on 01/21/15 at 4:15 PM with the Administrator revealed Resident #1 was on 1:1 with CNA #21 when she had tried to open the door and CNA #21 commenting to the resident the door was locked. 18. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she had turned off the alarm at the door when CNA #1 asked her to, because it was alarming, and the alarm had sounded different to her. RN #1 further revealed she had signed an elopement paper during orientation on 11/25/14, and she had been terminated after this incident. Review of the POS [REDACTED]. Interview on 01/18/15 at 1:13 PM with CRM revealed two (2) staff members were suspended with RN #2 being terminated after the incident. Interview on 01/13/15 at 12:40 PM with the acting DON at the time of the incident revealed RN #1 did not follow the facility's policy and had received the training and testing on elopement to include the sounds of alarms. 19. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed entrance and exit codes were not the same, and if a visitor activated the alarm a staff member would have to silence it. The Maintenance Supervisor stated the exit codes had been changed at least once monthly since November 2014. Review of the Log of Code Changes provided by the Maintenance Supervisor and Administrator revealed exit codes had been changed four (4) times on November 11/21/14, twice (2) on 11/28/14, twice (2) on 11/29/14, twice (2) on 12/26/14, twice (2) on 01/03/15, and once (1) on 01/10/15. Interviews with the CRC on 01/14/15 at 4:05 PM, the SSD on 01/16/15 at 12:45 PM, LPN #1 on 01/11/15 at 4:59 PM, LPN #3 on 01/15/15 at 1:35 AM, LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 a

2 Based on interview and record review, review of the facility's Allegation of Compliance (AoC) and Plan of Correction (PoC) for the Immediate Jeopardy Abbreviated Survey on 12/11/14, and review of the facility's Quality Assurance (QA) Policy, it was determined the Quality Assessment and Assurance Committee failed to have an effective system to ensure appropriate action plans for quality deficiencies were developed and implemented to prevent reoccurrence related to elopement. This failure affected one (1) of six (6) sampled residents (Resident #1). The facility was cited Immediate Jeopardy related to an incident that occurred on 11/21/14 when a resident exited the building without staff's knowledge. Approximately six (6) weeks later, on 01/04/15 Resident #1 was able to exit the building without staff's knowledge. On 01/04/15 at approximately 6:15 AM-6:30 AM, a door alarm sounded and Registered Nurse (RN) #1 turned off the alarm. The RN failed to follow the AOC and POC. She failed to identify that the alarm sounding was a wanderguard alarm; conduct a head count; and, search outside the door for a resident. At approximately 6:40 AM, Certified Nurse Aide (CNA) #2 identified Resident #1 was not in the facility. Resident #1 exited the facility and was discovered outside on a main road at approximately 6:45 AM. The facility's failure to have an effective QA program to prevent the reoccurrence of quality deficiencies related to elopement has caused or is likely to cause serious injury, harm or impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 01/16/15 and determined to exist on 01/04/15. The facility was notified of the Immediate Jeopardy on 01/16/15. An acceptable Allegation of Compliance (AoC) was received on 01/26/15, and the State Survey Agency validated the Immediate Jeopardy was removed on 01/13/15, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy/procedure titled, Center Quality Improvement Process, last revised 04/01/03, revealed the Quality processes were to provide a framework for structuring and implementing data-driven quality improvement and to establish and maintain a quality improvement process that would satisfy internal standards of excellence and regulatory excellence. A door alarm sounded on 01/04/15 at approximately 6:15 AM-6:30 AM, and Registered Nurse (RN) #1 turned off the alarm. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she turned off the door alarm after CNA #1 told her the alarm had sounded due to a resident re-entering the building after going out to smoke. RN #1 failed to identify the alarm was a wanderguard alarm; conduct a head count; and search outside the door for a resident, per the facility's policy, AOC and POC. Review of the facility's AoC and PoC developed after another resident's elopement on the 11/21/14 revealed all staff was educated on the Center's policies on elopement prevention and management, the expected employee response to a door alarm, and the different sounds of door alarms. Further review revealed the facility's monitoring included elopement drills conducted on each shift monthly to ensure the education was effective. However, review of the Elopement Drill audit form revealed the drill documentation form addressed identifying if staff took the appropriate actions after the announcement of a Code Yellow on the intercom system but, it did not address how staff should respond to the wanderguard alarm prior to the Code Yellow being called. Further review revealed the Elopement Drills were conducted on each shift monthly (December 2014 and January 2015) but the facility did not identify any concerns. Interviews with CNA #1, CNA #2, CNA #5, LPN #1 and RN #1 revealed they did not follow the facility's policy and they were confused related to the policy. RN #1 stated she could not distinguish the difference between the alarms. Review of the AOC and the POC revealed elopements drills were conducted on 11/21/14, 11/22/14, 11/23/14, 11/24/14, 01/04/15 and 01/10/15. These drills ensured that staff was able to hear the alarm sounding at the door or at the Nurse's Station. However, the drills did not address or ensure that staff could distinguish the different alarm sounds. Interview with RN #1 revealed the alarm sounded different but she did not recognize it as the wanderguard alarm. Interview, on 01/13/15 at 11:35 AM with the Director of Nursing (DON), revealed she felt they had an effective plan in place; however, the problem occurred when the staff did not follow the policy and procedure. She further stated if a wanderguard alarm went off, she expected the staff to follow the protocol. Interview, on 01/13/15 at 2:40 PM and on 01/21/15 at 4:01 PM with the Medical Director, revealed he expected staff to follow the policy and procedures of the facility, and resident safety was number one . The Medical Director stated the facility's Plan of Correction obviously did not stop the elopement and something had broken down in the process but he did not know where the system failed. Interview, on 01/21/15 at 4:15 PM and on 01/30/15 at 6:00 PM with the Administrator, revealed she felt QA was monitoring the effectiveness of the elopement plan through the drills, the audits and communication with staff. The Administrator stated she expected staff to respond to the alarms, ensure the residents were safe, and validate the reason the alarm was sounding. She further stated RN #1 did not see or know what had occurred, did not validate, and did not realize what had happened until after the CNA told her that they could not locate Resident #1 in the facility. The Administrator stated the RN knew what to do, but she had made a mistake by silencing the alarm and not checking it. Further interview with the Administrator revealed staff was provided education, and had to take a post test and pass the test related to the 12/11/14 elopement. Additionally, an elopement drill was added to ensure staff had a complete understanding of the education that was provided. She stated this was completed on each shift, beginning 01/04/15. The Administrator stated the education was more focused on what not to do, such as do not silence the alarm and not walk away without first knowing what was going on in that situation. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/04/15 between 6:30 AM-6:45 AM, CNA #2 notified RN #1 that Resident #1 was not in the facility. Based on the report, RN #1 began the search for Resident #1 outside the facility while CNA #2 continued the search inside. Resident #1 was found on 01/04/15 at approximately 6:45 AM outside the facility, unsupervised. He/She was assisted back into the facility by RN #1. (Review of the weather history for 01/04/15 at 6:53 AM revealed the temperature was 44.1 degrees Fahrenheit (F) with a wind chill temperature of 37.0 degrees F and no precipitation.) CNA #2 removed Resident #1's shoes and socks, replacing them with non-skid socks, and escorted him/her back to his/her room at approximately 6:50 AM. The resident's clothes were reported to be dry by CNA #2. RN #1 documented the resident's wanderguard sounded upon re-entry to the facility. (Review of a Nursing Note, dated 01/14/15 at 7:15 AM, revealed Resident #1 was wearing a pink jogging suit and his/her shoes were wet and slightly soiled when found outside the facility). 2. Upon return of Resident #1 to his/her room at approximately 6:50 AM, a head to toe assessment was conducted by RN #1 with no injury noted related to the event. RN #1 completed an assessment and vital signs of Resident #1 and documented the findings on the Change of Condition Form, and in the Nursing Notes. 3. The Administrator and DON were notified on 01/04/15 at approximately 7:01 AM by LPN #8 of Resident #1's elopement. 4. The resident's BIMS score revealed Resident #1 was interviewable with confusion at times Resident #1 was interviewed by RN #1 on 01/04/15 and the resident stated I'm fine; I was just going for a walk. Review of the Admission Minimum Data Set assessment, dated 12/29/14, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable (however, the resident was diagnosed with [REDACTED]. 5. Upon return to the facility Resident #1 was placed on 1:1 observation at approximately 7:00 AM. The resident will remain on 1:1 supervision until alternative placement could be found or an RN assessed Resident #1 to no longer be at risk for elopement. Resident #1 remained on 1:1 supervision until discharged on [DATE] to a secured assisted living facility in another state. 6. A visual census check was conducted by RN #5 on the 300/400 Wing after Resident #1 was back in the facility; and the 100/200 Wing was checked by CNA #3, CNA #19, and CNA #20 validating all residents were in the facility. Upon notification of the elopement, RN and LPN Charge Nurses immediately completed a visual validation to ensure all residents (73 of 74) were present in the facility. 7. The attending physician, was notified in person of the elopement of Resident #1 by RN #1 on 01/04/15 at 7:00 AM. The Physician assessed Resident #1 with no new orders noted. 8. The responsible party was called twice at 7:00 AM with no answer and two (2) more attempts were made at 8:00 AM with no answer. The responsible party was notified by RN #5 upon entering the building, and by the Administrator at 1:00 PM. 9. The RN/MDS Coordinator completed an updated Elopement Evaluation for Resident #1 on 01/04/15. Resident #1's care plan was updated on 01/04/15 by the RN/MDS Coordinator to include an updated elopement evaluation and one to one observation. 10. At approximately 7:00 AM on 01/04/15, the Maintenance Supervisor was contacted by the Administrator via phone to come to the facility to participate in the investigation. Upon arrival at approximately 8:00 AM, the Maintenance Supervisor checked all egress doors for function of the alarms and magnetic locks. 11. At approximately 7:45 AM, a second interview with Resident #1 was conducted by the Administrator, with Resident #1 stating he/she went outside when the door was opened by an unidentified male who came into the facility with a dog. Resident #1 could not give a description of the male and stated he/she had exited to go to the bank. 12. A search of the 300/400 Hall and interviews with residents and and staff on the 300/400 Hall conducted by the Social Services Director at approximately 8:00 AM verified that no male visitors and no dogs were identified in the Center between the hours of 6:00 AM and 8:00 AM. 13. Door alarm and magnetic lock function audits were completed on 01/04/15 by the Maintenance Supervisor. All door locking mechanisms and alarms were found to be working properly during the audits. It was validated that with a wander guard present, the door would release in fifteen (15) seconds sounding an emergency exit alarm. When the wander guard passed through the doorway, the alarm sound changed from the emergency exit alarm sound to the wander guard alarm sound. 14. The Maintenance Supervisor or Assistant Maintenance Director conducts a weekly tests on the transmitter tester (202) on a wander guard bracelet to validate it is in working order. 15. The nine (9) volt battery powering the transmitter tester is changed at least every sixty (60) days by the Maintenance Supervisor or the Assistant Maintenance Director and replaced with a new battery (2 of 2). The manufacturer's use by date, printed on the battery, is checked and recorded to ensure the battery is in proper working order at the time the battery is changed. 16. Wander guards audits were completed on 01/04/15 every shift by Licensed Nurses (RN/LPN) and documented on the TARs. Thirteen of thirteen (13 of 13) wander guard bracelets were found to be working properly during the audits. The RN/LPNs tested the function of each wander guard transmitter using the transmitter tester and validated the bracelets were functioning, placement on the resident was checked each shift and, documented on the TARs. 17. Through the investigative process, it was determined that Resident #1 held the exit door near the beauty shop for fifteen (15) seconds to release the door at an undetermined time and traveled through the door sounding the wander guard alarm. 18. It was determined that RN #1 heard the wander guard alarm, but failed to respond by initiating a search. RN #1 turned the alarm off and reset the alarm system, by her own admission. Subsequently RN #1 was put on suspension, and it was determined RN #1 had received education and passed a post-test on 11/25/14 , prior to this event, concerning response to any door alarm sounding in the facility and a resident search should be conducted both inside and outside the center. 19. Entrance Codes for all exit egress doors (6 of 6) cannot be used to silence the alarms, and are not the same as exit codes. If an alarm should sound upon entrance of a visitor to the facility a staff member must respond to it to silence the alarm; visitors are not provided exit codes, they are only known by staff, and changed at least monthly by maintenance personnel. 20. Thirteen of thirteen (13 of 13) residents residing in the facility that were identified as an elopement risks were reviewed by the RN/MDS Coordinator on 01/04/15. The Elopement Risk Evaluations, care plans and care cards were reviewed and updated, with the thirteen (13) residents at risk for elopement utilizing a wander guard bracelet. Fifty-nine (59) of sixty (60) Skill Nursing Facility (SNF) residents not currently identified as at risk for elopements were reviewed by the RN/ MDS Coordinator on 01/04/15. Care plan implementation for residents identified to be at risk for elopement will be initiated upon identification of the risk for elopement as determined by the elopement risk assessment by a licensed practical nurse or registered nurse. These care plans will be reviewed through the morning clinical process. 21. On 01/04/15, the Administrator, DON, and ADON from a sister facility were re-educated by the Regional Vice President of Operations (RVPO) and Regional Manager of Clinical Operations (RMCO) regarding their job descriptions, the Center's policies on care plans, resident safety, quality assurance and administration requirements and the CMS guide for developing Purpose, Guiding Principles, and Scope for QAPI was reviewed. Post tests were conducted with the Administrator, DON, and ADON on 01/04/15 by RMCO with 100% pass rating to validate learning of material. 22. On 01/04/15, re-education was provided to the Nurse Practice Educator (NPE) by the RMCO on the elopement policy and procedure and updating resident care plans for change in behaviors. A post-test was given to validate understanding of the elopement policy and care plan policy by the RMCO with a 100% passing rate. 23. The facility's Administrator is responsible for implementation and adherence to the facility's policies and procedures. Facility oversight is provided by the Administrator, DON, ADON, and the Charge Nurses daily. Additional support has been and will be provided by RVPO, RMCO, and the Regional Clinical Educator (RCE). 24. On 01/04/15, re-education was provided to the Therapy Program Manager, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, and Admissions Director by the Administrator and NPE on the facility's elopement policy and procedure, the sound of an emergency exit alarm and the sound of the wander guard alarm and updating resident care plans for change in behaviors; with a post-test given on 01/04/15 by the NPE validating understanding of the content by 100% pass rating. 25. Facility employees and contract employees' re-education was initiated by the NPE and Administrator beginning on 01/04/15. This reeducation was continued by the Therapy Program Manager, ADON, RN/MDS Coordinator, Payroll Coordinator, Nutrition Director, Admissions Director or Administrator and was completed on 01/12/15. Ninety-one (91) of one-hundred and twelve (112) active employees and also contract employees scheduled to work completed the re-education and post-testing on 01/04/15. The remaining employees and/or contract employees (21 of 112), who were unavailable on 01/04/15 due to being on leave, out of town, or not scheduled will have or had education/re-education prior to returning or beginning work. They were educated and/or re-educated by the Administrator, NPE, DON, ADON, Dietary Supervisor, or Rehabilitation Program Manager, RN or LPN. Re-education of staff included the facility's policies on elopement prevention and management; the sound of an emergency exit alarm and the sound of the wander guard alarm; the facility policy for updating a resident' care plan for a change in behavior; which includes implementation of the care plan. Each employee completed a post-test to validate learning of the education which was conducted prior to the conclusion of the training by the NPE, Therapy Program Manager, ADON, RN MDS Coordinator, Payroll Coordinator, Admissions Director, Administrator, RN or LPN. Post-test results were 100% pass rate prior to employees being released from training. 26. An Ad Hoc PI meeting with the Administrator, DON, ADON, Admissions Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, and Medical Director was held on 01/04/15. 27. Beginning on the day shift of 01/04/15, NPE or Licensed Nurses completed an elopement drill on each shift through 11:59 PM to audit training compliance. No concerns with these audits were identified. Charge Nurses (RN and/or LPNs), Department Managers or NPE will complete two (2) elopement drills, utilizing the Elopement Drill Documentation Form on each shift monthly for three (3) months (January 2015, February 2015, and March 2015), then two (2) quarterly for six (6) months; with corrective action at point of discovery of identified concerns. Findings will be reviewed by the Performance Improvement Committee (PIC) which meets at least ten (10) times annually. The PIC consists of: Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director and will make recommendations for additional audits based on audit outcomes. 28. Beginning 01/04/15 Care Plan audits for diversional activities for those residents identified to be at risk for elopement will be audited by a RN or LPN, NPE, ADON, RN/MDS Coordinator, DON or Administrator. The audits will be completed on five (5) residents daily for fourteen (14) days, then five (5) residents weekly for eight (8) weeks, and then five (5 ) residents monthly for two (2) months. In addition, Elopement Risk care plans for five (5) residents identified at risk for elopement will be audited by DNS, ADNS, NPE, CRC, MDS Coordinator or Administrator for implementation and accuracy daily across random shifts times fourteen (14) days, then five (5) times per week time 60 days, then no less than three (3) times a week for an additional 30 days beginning 12/09/14, including visual validation that the elopement care plan is being followed. Additional audits will be determined by the monthly QI/PI committee which consists of Administrator, DON, ADON, Admissions Director, Activities Director, SSD, RN MDS Coordinator, Maintenance Supervisor, NPE, Nutritional Services Director and Medical Director. Corrective Action and/or reeducation will be provided at point of discovery. 29. Beginning 01/04/15 PIC minutes will be reviewed by the RVPO or RMCO for the next three (3) months. The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she was notified of Resident #1 missing from the facility on 01/04/15 at 6:43 AM by CNA #2. RN #1 stated when she was told that Resident #1 was missing she went outside and located the resident. Review of Nursing Notes, dated 01/04/15 at 6:55 AM and 7:15 AM, revealed Resident #1 was found outside the building and brought back into the facility. CNA #2 changed the resident's socks and shoes due to moisture and muddiness and placed slipper socks on the resident. The resident's wander guard was verified for placement and function. 2. Review of a Nursing Note, dated 01/04/15 at 6:55 AM, revealed a head to toe assessment was completed by RN #1 with no noted injuries. Review of a Change of Condition form, dated 01/04/15 revealed vital signs were taken and a visual assessment was completed with no notable injuries. 3. Interview on 01/30/15 at 12:03 PM with LPN #8 revealed she had informed the Administrator and acting DON of the elopement of Resident #1 on 01/04/15, at approximately 7:00 AM. 4. Review of the 12/29/14 Admission Minimum Data Set (MDS) assessment revealed Resident #1 was assessed as having a BIMS score of nine (9), which indicated the resident had moderate impairment and was interviewable. Review of a Nursing Note, dated 01/04/15 at 7:15 AM revealed Resident #1 complained of being cold but said he/she was fine, he/she went for a walk. 5. Review of the facility's investigation revealed Resident #1 was placed on 1:1 supervision on 01/04/15. Review of 1:1 documentation revealed the resident was on 1:1 supervision until he/she was discharged on [DATE]. 6. Review of the AOC binder revealed attestation of the visual census verification of residents on all wings by RN # 5, CNA #2, CNA #3, CNA #19, and CNA #20. 7. Review of Nursing Notes by RN #1, dated 01/04/15 at 7:15 AM, revealed she notified the physician of the elopement. Interview on 01/13/15 at 2:40 PM with Resident #1's physician, who was also the Medical Director, revealed he was notified of the elopement of Resident #1 and had been at the facility that day and assessed Resident #1 with no noted issues. 8. Review of Nursing Notes and the Change of Condition form dated 01/04/15 revealed attempts to notify the resident's family three (3) times at 7:15 AM with a fourth (4th) attempt being made at 8:00 AM. Notification was made to the family member upon arrival to facility. 9. Review of Resident #1's Elopement Evaluation and Care Plan revealed the evaluation and care plan were updated on 01/04/15 by the MDS Coordinator. 10. Interview on 01/29/15 at 3:34 PM; and, on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed he was called by the Administrator to come in on 01/04/15, at 8:02 AM and left at 4:35 PM, related to the elopement investigation. He checked the functionality of the doors. The Maintenance Supervisor further revealed he thought there was no failure on the part of the doors, alarms or locks. Review of the Maintenance Supervisor's timecard revealed he was present in the facility on 01/04/15 from 8:02 AM until 4:35 PM. Review of the logbook entitled, Total Equipment Lifecycle Systems (TELS), dated 01/04/15 revealed doors, locks, and alarms were checked with a pass being documented. 11. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed some of the residents were interviewed about a man coming into the facility with a dog; however, they were unable to verify this information. 12. Interview on 01/30/15 at 6:28 PM with Social Services Director (SSD) revealed she had interviewed residents about a male with a dog, and could not verify it. 13. Interview on 01/29/15 at 3:34 PM with the Maintenance Supervisor revealed he checked the functionality of the doors, and wander guard alarms. He stated the wander guard alarm would still go off at the doors even with the door releasing after being pushed on for fifteen (15) seconds. Interview on 01/29/15 at 5:14 PM with LPN #6 revealed the residents' wanderguards were tested every shift by the nurse with the transmitter and documented on the Treatment Administration Records (TARs). Review of the January TARs for residents at risk for elopement (13 of 13) revealed daily shift audits of the functionality of each resident's wanderguard. Interview on 01/29/15 at 11:31 AM with the Maintenance Helper revealed nurses checked the residents' wander guards with the transmitters. 14. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed a weekly testing of wanderguard transmitter testers was done and would be in the system. The Maintenance Supervisor provided a copy of the weekly testing of the wanderguard transmitter testers (3 of 3) with one being a spare; which revealed weekly checks were documented on 01/12/15, 01/20/15, and 01/26/15. 15. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed the batteries were changed in the wanderguard transmitter tester in September 2014, November 2014, and on 01/19/15; with the expiration date of the batteries placed on the documentation starting in January. Review of the Wanderguard Tester Battery Replacement Form provided by the Maintenance Supervisor revealed the batteries in the wanderguard transmitter tester were changed on 09/22/14, 11/20/14, and 01/19/15; with the start of documentation of battery expiration date beginning on 01/19/15. 16. Interviews on 01/29/15 at 5:14 PM with LPN #6; on 01/09/15 at 2:45 PM with LPN #4; on 01/15/15 at 1:25 PM with RN #8; and, on 01/09/15 at 2:59 PM with RN #6 revealed residents' wanderguards were tested every shift by the nurse with the transmitter and it was documented on the Treatment Administration Records (TARs). Review of TARs for residents at risk for elopement revealed daily shift audits of the functionality of each resident wander guard. 17. Review of the facility's investigation revealed in an interview conducted on 01/05/15 with CNA #21, who was providing 1:1 supervision of Resident #1, she commented to the resident the door was locked; and Resident #1 made a statement about the door sign saying push and the door will open in fifteen (15) seconds. Interview on 01/21/15 at 4:15 PM with the Administrator revealed Resident #1 was on 1:1 with CNA #21 when she had tried to open the door and CNA #21 commenting to the resident the door was locked. 18. Interview on 01/12/15 at 2:56 PM with RN #1 revealed she had turned off the alarm at the door when CNA #1 asked her to, because it was alarming, and the alarm had sounded different to her. RN #1 further revealed she had signed an elopement paper during orientation on 11/25/14, and she had been terminated after this incident. Review of the POS [REDACTED]. Interview on 01/18/15 at 1:13 PM with CRM revealed two (2) staff members were suspended with RN #2 being terminated after the incident. Interview on 01/13/15 at 12:40 PM with the acting DON at the time of the incident revealed RN #1 did not follow the facility's policy and had received the training and testing on elopement to include the sounds of alarms. 19. Interview on 01/30/15 at 4:42 PM with the Maintenance Supervisor revealed entrance and exit codes were not the same, and if a visitor activated the alarm a staff member would have to silence it. The Maintenance Supervisor stated the exit codes had been changed at least once monthly since November 2014. Review of the Log of Code Changes provided by the Maintenance Supervisor and Administrator revealed exit codes had been changed four (4) times on November 11/21/14, twice (2) on 11/28/14, twice (2) on 11/29/14, twice (2) on 12/26/14, twice (2) on 01/03/15, and once (1) on 01/10/15. Interviews with the CRC on 01/14/15 at 4:05 PM, the SSD on 01/16/15 at 12:45 PM, LPN #1 on 01/11/15 at 4:59 PM, LPN #3 on 01/15/15 at 1:35 AM, LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 at 01/12/15 at 1:01 PM, CNA #22 at 01/29/15 at 12:06 PM revealed when alarms go off staff respond to the alarm. Interviews with LPN #5 at 01/29/15 at 10:41 AM, LPN #6 at 01/29/15 at 5:14 PM, CNA #11 on 01/13/15 at 8:25 AM, CNA #15 at 01/16/15 at 12:55 PM, CNA #16 on 01/30/15 at 8:09 AM, CNA #21 on 01/12/15 at 1:01 PM, and CNA #22 on 01/29/15 at 12:06 PM revealed the codes to let visitors out was only provided to staff and no one else was to be given the code. 20. Interview on 01/14/15 at 4:05 PM with the RN/MDS Coordinator revealed she had come in on 01/04/15 and reassessed all of the elopement risk residents (13 of 13) after the elopement. Review of the Elopement Care Plan Evaluations revealed (13 of 13) residents were reassessed on 01/04/15. Review of the AOC binder revealed review of residents identified as at risk for elopement by RN MDS Coordinator with a date of 01/04/15. 21. Review of the AOC binder revealed education of the Administrator, the acting DON, and a sister facility's DON at the time of the elopement. This education was provided by the RVP and RMCO regarding regulations and requirements for F490 and F520 with Performance Improvement/Quality Improvement (PI/QI) being key to validation of the systems and key to enhancing quality of life for residents and staff at the Center. The education further stated, if/when there was a deviation of the facility's policy or standard of practice identified, it was the responsibility of the PI Committee to conduct a root cause analysis and determine applicable steps based on the analysis. A re-education document was signed by the Administrator and Acting DON on 01/04/15. A Post-test was given to the Administrator on subject matter by the RVP with 100% pass rate on 01/04/15. A post-test was given to the acting DON by RMCO on 01/04/15 with passing score of 100%. Review of the AOC binder revealed Administrative education with the acting DON at time of the elopement, incoming DON, and Administrator as well as their job description and post-test with a passing score. 22. Review of the re-education post-test for the Nurse Practice Educator (NPE) entitled, Resident Safety and Elopement, dated 01/04/15, revealed the RMCO completed the post-test with a passing score of 100%. 23. Interview with the Administrator, on 01/30/15 at 5:15 PM, revealed the RVPO and RMCO educated the Administrator, Interim Director of Nursing (DON), and assisting Director of Nursing. She revealed the RMCO educated the Administrative staff on the post tests, then they educated the Department Heads, who then trained the facility staff related to the material on the post tests. The Administrator further revealed she, the interim DON, and the assisting DON were the only ones who received education specific to Administration and Quality Assurance. The education difference from the first IJ to the second IJ was focused more on what not to do, what the expectations were, and to not silence the alarm and walk away without knowing what was going on in that situation. The Administrator stated this would be a part of the facility's standard orientation. 24. Review of the AOC binder revealed re-education to the Therapy Program Manager, RN MDS Coordinator, Payroll Coordinator and Admissions Director on the elopement policy and procedure, the sound of emergency exit alarms, sound of the wander guard alarm, and updating care plans for change in behaviors with post-test score of 100%. Interview on 01/29/15 at 4:50 PM with the Dietary Supervisor revealed she had been re-educated on: the elopement process; which involved the difference in the sound of the alarms, if staff notice an alarm going off, the staff is to check it, make sure no one has gone out, do a head count to see if residents are in the facility, and if not, search everywhere. A code yellow is called over the intercom and everybody in the facility is involved in the search. The Dietary Manager revealed she had r

Based on observation, interview, and record review it was determined the facility failed to provide dental services for one resident (#1) in the selected sample of 3 for emergency dental services. Resident #1 on 03/05/12 experienced a change in condition, to include mouth pain associated with a abscessed tooth. On 03/08/12 the residents condition continued to decline requiring a change in diet related to mouth pain. No emergency dental services were provided until 08/28/12. The facility's failure to secure emergency dental contract services resulted in Resident #1 experiencing pain and suffering and the need for a altered diet for over the course of 5 months. Findings include: A review of nurses notes, care plan, and change in condition report dated 03/05/12, revealed the facility assessed Resident #1 as experiencing severe pain to the right lower gumline and identified his/her pain as an 8 on a pain scale from one to ten. Exam by staff revealed the residents teeth were worn and inflammed, antibiotics were ordered on [DATE] by the attending physician to treat the resident's "broken and abscess tooth." Record review revealed on 03/08/12, the facility changed the resident's diet due to his/her dental condition continuing to deteriorate. On 03/12/12, a physician's orders [REDACTED]. There was no documented evidence that the facility was successful in attaining emergency dental services for Resident #1 in the month of March 2012. On 06/18/12 a change in condition report revealed the resident's dental condition continued to deteriorate. A physician's orders [REDACTED]. Further record review revealed no documented evidence that the facility was successful in attaining emergency or routine dental services for Resident #1. Further record review revealed the facility was successful in finding a dentist to address Resident #1's continued dental issues on 08/28/12. At which time, the dentist ordered the fourth round of antibiotics ([MEDICATION NAME]). After consult with an Oral Surgeon, on 10/05/12, the Resident had multiple teeth extracted and a diet change to a dysphagia diet. Interview with the Minimum Data Set (MDS) Coordinator (RN), on 10/31/12 at 3:13 PM, revealed that the facility began trying to locate a dentist on 03/05/12. She contacted the Medicaid office and went through the list to find that no one was accepting patients. Interview with the Activities Director (formerly the Social Services Director at the time), on 11/02/12 at 3:35 PM, revealed as far as she knew the facility had no emergency dental services available to contact. The facility had no previous issues with other residents requiring dental services. This is the first experience the facility had difficulty finding services to address Resident #1's concerns. Continued interview with the MDS Coordinator, 11/02/12 at 4:05 PM, I tried to find someone to take Resident #1's insurance for dental work. I was not aware we were required to have an agreement for emergency dental services. She; however, stated that she didn't consider the Resident's dental concerns as an emergency as she had not identified that the resident's quality of life could potentially affected. However, review of the medical record revealed Resident #1 had been assessed with [REDACTED]. She stated the Administrator was aware of the difficulty the facility was having in acquiring a dentist due to his/her insurance. Interview with the Administrator, on 10/31/12 at 3:23 PM, revealed that the facility had no contract with any dentists to provide services at the facility.

Based on interview, and record review, it was determined the facility failed to revise a resident's care plan to address the need for dental services for one resident (#1) in the selected sample of 3. The facility assessed Resident #1, on 03/05/12, as having a change in condition, to include mouth pain associated with a abscessed tooth. While the facility addressed the resident's pain, there was no care plan to address the resident's need for dental services and interventions to implement to address the resident's immediate dental needs. On 03/08/12, the resident's condition continued to decline requiring a change in diet related to mouth pain. No emergency dental services were provided until 08/28/12. The facility's failure to secure emergency dental contract services resulted in Resident #1 experiencing pain and the need for a altered diet for over the course of 5 months. Findings include: Review of Resident #1's nurses notes, care plan, and change in condition report, dated 03/05/12, revealed the facility assessed Resident #1 as experiencing severe pain to the right lower gumline and identified his/her pain as an 8 on a pain scale from one to ten. Exam by staff revealed the residents teeth were worn and inflammed, antibiotics were ordered on [DATE] by the attending physician to treat the resident's "broken and abscess tooth." Revies of the comprehensive care plan revealed the facility updated the resident's pain care plan to address the resident's dental issues and detailed an intervention fot follow up with an oral surgeon, initiated on 03/05/12. Further review of the care plan revealed no initiation or development of interventions to address the resident's dental needs. Record review revealed on 03/08/12, the facility changed the resident's diet due to his/her dental condition continuing to deteriorate. On 03/12/12, a physician's orders [REDACTED]. Review of the care plan for pain revealed the care plan was updated related to the diet order and the antibiotic therapy; however, there was no evidence that the facility had developed a care plan to address the resident's dental needs as of 03/12/12. On 06/18/12 a change in condition report revealed the resident's dental condition continued to deteriorate. A physician's orders [REDACTED]. Further review of the care plan revealed the facility updated the pain care plan; however, there was still no update to the plan to address the resident's dental needs. Further record review revealed the facility was successful in finding a dentist to address Resident #1's continued dental issues on 08/28/12. At which time, the dentist ordered the fourth round of antibiotics ([MEDICATION NAME]). After consult with an Oral Surgeon, on 10/05/12, the Resident had multiple teeth extracted and a diet change to a dysphagia diet. Review of the comprehensive care plan revealed that the facility did not develop a care plan regarding the resident dental concerns until 10/24/2012, 19 days after the resident had 8 teeth extracted and experienced dental concerns for more than seven months. Interview with the MDS Coordinator, 11/02/12 at 4:05 PM, revealed she didn't consider the Resident's dental concerns as an emergency as she had not identified that the resident's quality of life could potentially affected. However, review of the medical record revealed Resident #1 had been assessed with [REDACTED].

Based on interview, record review, and facility policy review, it was determined the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility administration failed to ensure that facility routine dental services and emergency dental services were provided or obtained to meet the needs of one resident out of a sample of three residents. The facility failed to ensure that Resident #1 received emergency dental services after experiencing two separate incidents of having abcessed teeth in March 2012 and July 2012. Due to the facilities failure to ensure emergency dental services was provided, the resident was treated multiple times with antibiotics prescribed by his/her primary physician to address the infection and the pain the resident experienced. The facility was unable to provide dental services to Resident #1 for five months after the onset of having abcessed teeth, not having a dental consult or check until 08/28/12, where it was identified that the resident required treatment by an Oral Surgeon. The Resident required multiple teeth extraction, completed on 10/05/12, seven months after the initial onset of the dental condition. The findings include: A review of nurses notes, care plan, and change in condition report dated 03/05/12, revealed the facility assessed Resident #1 as experiencing severe pain to the right lower gumline and identified his/her pain as an 8 on a pain scale from one to ten. Exam by staff revealed the residents teeth were worn and inflammed, antibiotics were ordered on [DATE] by the attending physician to treat the resident's "broken and abscess tooth." Record review revealed on 03/08/12, the facility changed the resident's diet due to his/her dental condition continuing to deteriorate. On 03/12/12, a physician's orders [REDACTED]. On 06/18/12 a change in condition report revealed the resident's dental condition continued to deteriorate. A physician's orders [REDACTED]. Further record review revealed no documented evidence that the facility was successful in attaining emergency or routine dental services for Resident #1 from March 2012 through August 27, 2012, after experiencing two incidents of having abcessed teeth requiring three rounds of antibiotic therapy. Subsequently, the facility was able to refer Resident #1 to a dentist on 08/28/12 where it was identified the resident required a fourth round of antibiotics and was referred to an oral surgeon for potential teeth extraction. Record review revealed that Resident #1 had multiple teeth extraction on 10/05/12, seven months after the initial onset of having an abcessed tooth. Interviews with the Minimum Data Set (MDS) Coordinator (RN), on 10/31/12 at 3:13 PM, and the Activities Director (formerly the Social Services Director at the time), on 11/02/12 at 3:35 PM, revealed they were unsuccessful in obtaining dental services for Resident #1 and the facility Administrator was aware of the issue. Interview with the Administrator, on 10/31/12 at 3:23 PM, revealed that the facility had no contract with any dentists to provide services at the facility. The Administrator stated that the resident's dental issues was being followed and infection was being treated by the resident's primary physician. She stated that she did not consider the dental problems as an emergency because it was an intermittent problem that did not affect the resident's routine. The Administrator could provide no evidence of a contract the facility had related to procuring dental services for routine or emergency situations. While the Administrator felt the dental concerns did not affect Resident #1's routine therefore not requiring emergency services, the facility assessed the resident as having pain of an 8 out of 10, requiring four rounds of antibiotic therapy to address abcessed teeth, pain medication administration and eventually resulting in the extraction of 8 teeth in October 2012, seven months after the onset of the dental problems.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for one resident (#8), in the selected sample of ten residents. Resident #8 was at high risk for impaired skin integrity related to his/her multiple clinical conditions. Resident #8 was re-admitted to the facility on [DATE], with excoriation to buttocks noted. The facility failed to complete an assessment which included a pressure risk assessment (Norton Plus Pressure Ulcer Scale) upon re-admission from the hospital on [DATE]. On 10/04/11, a recommendation was made by the Registered Dietician (RD) for a Multivitamin (MVI) to promote wound healing; however, there was no documented evidence the physician was notified regarding this recommendation. Record review revealed, on 10/09/11, Resident #8 sat in his/her wheelchair for an undetermined amount of time prior to the oncoming shift's arrival on 10/08/11 (which started at 7:00 PM), through 10/09/11 at 11:00 AM. On 10/11/11 a new pressure sore was identified on the resident's coccyx area, measuring 7.9 centimeters (cm) length by 4.1 cm width by 0.1 cm depth. There was no documented evidence the physician was notified of the new pressure sore or consulted to alter treatment. On 10/18/11, the facility identified the coccyx wound had increased in size, measuring 8.9 cm length by 4.8 cm width by 0.1 cm depth. The facility faxed the physician notification, on 10/18/11, of the wound worsening; however, there was no evidence the physician received the fax and no change in treatment was received. Treatment to the resident's coccyx was not changed until 10/26/11, 8 days later. (Refer to F157) In addition, on 10/25/11, Resident #8 was assessed to have a blister to the left and right heel with physician orders [REDACTED]. Further review of the medical record revealed no evidence Resident #8's plan of care was revised to reflect the changes in the resident's skin integrity and/or interventions. (Refer to F280) Resident #8 was transferred to another facility on 11/14/11. The findings include: A review of the facility's policy and procedure, "Assessment: Identifying Residents at Risk of Skin Breakdown," undated, revealed, "When a resident arrives, the licensed nurse reviews the pre-admission screen and completes a head-to-toe assessment, documenting findings on the Nursing Assessment. This process provides the team with an accurate description of the resident's actual skin condition at the time of admission. If the resident has a pressure ulcer or other wound at the time of admission, treatment begins promptly according to physician orders. The licensed nurse continues the evaluation process to determine the risk of additional skin breakdown, evaluates rehabilitation and nutritional needs, and prepares a plan of care for the existing condition and prevention of additional skin breakdown...After examining a resident's current skin condition, the licensed nurse next evaluates the resident's risk for skin breakdown using the Norton Plus Pressure Ulcer Scale...Regardless of any resident's total risk score; the licensed nurse and interdisciplinary care team are responsible for reviewing each risk factor and its potential causes and implementing preventive strategies, as applicable...Adequate nutrition and hydration are necessary for overall body function and skin health." A closed record review Resident #8 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to be cognitively independent, required total dependence for Activities for Daily Living (ADL's), had no identified behaviors, and no skin issues were identified. A review of the care plan "Potential for Skin Breakdown," dated 07/06/11, revealed to "Observe skin every shift for signs/symptoms of potential skin breakdown (e.g. redness/discoloration or open areas)." If breakdown was identified, the charge nurse should be alerted so the nurse could notify the physician if needed for treatment orders. A review of the nurse's notes, dated 09/30/11 at 12:45 PM, revealed Resident #8 was readmitted to the facility from the hospital with excoriation to the resident's groin and buttocks noted. There was no documented evidence a formal skin assessment was completed to detail the skin integrity, nor was a Norton Plus Pressure Ulcer Scale completed to determine the risk for skin integrity issues, per the facility's policy. There was no evidence the resident's care plan was revised to address the identified excoriation. Additionally, a new non-pressure wound documentation form was not completed to monitor the progress of the identified completed excoriation. An interview with Registered Nurse (RN) #4, on 01/19/12 at 10:14 AM, revealed she could not provide specific information regarding Resident #8's skin assessment upon re-admission to the facility on [DATE]. She stated she was not sure who would be responsible for initiation of skin interventions, such as wheelchair cushions or air mattresses. An interview with the Director of Nursing (DON) on 01/19/12 at 3:45 PM, revealed on admission, the admitting nurse should have completed a head-to-toe assessment along with a Norton Pressure Ulcer Scale and the resident's care plan should have been revised on 09/30/11 to address the excoriated areas. Additionally, a new non-pressure ulcer documentation form should have been initiated on 09/30/11, upon identification of the excoriated areas. Further review of the closed medical record revealed a physician's orders [REDACTED]." However, there was no documented evidence of an open area or a skin assessment completed at that time. A review of a Medical Nutrition Therapy Assessment, dated 10/04/11, revealed the resident's needs were increased to promote wound healing. A MVI was recommended to improve overall nutritional status and to aid in wound healing. However, there was no evidence the physician was notified of this dietary recommendation. An interview with the Registered Dietician (RD), on 01/20/12 at 10:15 AM, revealed copies of the recommendations were given to the DON, Assistant Director of Nursing (ADON), Dietary Manager, and the respective nursing station. If a resident was given a dietary recommendation, she expected the nurse to contact the physician for an order. She stated a MVI provided extra nutrients to aid in wound healing which the resident may not have received by po intake. Further interview with the DON on 01/19/12 at 3:45 PM, revealed when the multi-vitamin was not ordered, on 10/04/11, she expected the staff to contact the physician with dietary recommendations. A review of the Treatment Administration Record (TAR), dated October 2011, revealed a weekly skin assessment was completed on 10/07/11. However, there was no documented evidence of the findings of the skin assessment in either the nurse's notes or on a pressure wound documentation form, even though the physician had ordered a treatment on 10/02/11 for an open area to the resident's coccyx. A review of the nurses' notes, dated 10/09/11 at 6:30 AM, revealed the DON documented "Resident has been up all night, refusing to lay down, refusing medications. Educated resident on need to lay down to relieve pressure off his/her buttocks. Resident continues to refuse. Spoke with daughter this AM. States she and her husband may try to come up today." Further review of a nurses' note, dated 10/09/11 at 11:00 AM, revealed "Daughter here, helped resident back to bed....." An interview with the DON, on 01/19/12 at 3:45 PM, revealed she was the nurse who worked night shift on 10/09/11. She received report about Resident #8's refusal to lay down during day shift. She was unsure of the exact time the resident sat up in the wheelchair prior to her arrival. She stated she did not contact the daughter or the physician that evening because she felt she could convince the resident to go to bed. She stated she was aware of the resident's history of paranoid behavior, which she believed contributed to the resident's refusal to lay down. She stated she contacted the resident's daughter, for assistance, prior to the end of the shift. She stated she explained the risks of being up all night in the wheelchair and documented it. She further explained that being up in a wheelchair for the entire shift could contribute to the worsening of a pressure ulcer. She stated the resident had a pressure-relieving cushion in the wheelchair during this incident; however, there was no documented evidence of a cushion in place. A review of Resident #8's "Pressure Wound and Skin Documentation Form," completed on 10/11/11, revealed a new Stage II wound on the coccyx, measuring 7.9 centimeters (cm) length by 4.1 cm width, by 0.1 cm depth. However, there was no documented evidence the physician was notified of the new pressure sore or consulted to alter treatment. A review of Resident #8's significant change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #8 was cognitively independent, and required extensive assistance to total dependence for Activities of Daily Living (ADL's). Resident #8 was identified to be incontinent of bowel, with a urinary catheter. The facility assessed Resident #8 to have one Stage II pressure ulcer that was noted to be present upon admission/reentry. Review of Resident #8's skin assessment completed on 10/18/11, revealed the coccyx wound had increased in size, measuring 8.9 cm length by 4.8 cm width by 0.1 cm depth. The facility faxed the physician notification, on 10/18/11, of the wound worsening; however, there was no evidence the physician received the fax and no change in treatment was received. A review of the physician's progress notes, dated 10/19/11, revealed the Nurse Practitioner (NP) ordered a wound care consultation due to the nurse's concern that the wound on the resident's sacral area was not healing and that wound continued to grow in size and had developed a dark center. However, the wound care consultation was scheduled for 10/31/11, twelve days later. Record review revealed the NP did not change the treatment orders on 10/19/11 and the facility did not notify the physician for a change in treatment until seven days later, on 10/26/11. On 10/26/11, a physician's orders [REDACTED]. An interview with Licensed Practical Nurse (LPN) #2, on 01/20/12 at 2:39 PM, revealed she completed wound assessments on Resident #8 and if there was a change in the wound, such as worsening or odor, she contacted the physician by phone and/or fax. She was unable to recall specifics of the worsening of the wound from 10/11/11 through 10/18/11. Further record review revealed, on 11/01/11, a wound odor was identified by the DON; however, there was no documented evidence the physician was notified at that time. Per record review, the resident's treatment was not changed until 11/07/11, when the wound care center discontinued the Dakin's solution and ordered Santyl ([MEDICATION NAME]) 250 units/gram (gm) ointment topical (external) - on day shift and evening shift everyday: soap and water, wash wound to coccyx area, apply Santyl gel then saf-gel, cover with dry gauze and secure with [MEDICATION NAME] tape twice daily. An interview with Resident #8's physician, on 01/20/12 at 4:00 PM, revealed he expected the staff to contact him regarding dietary recommendations. Additionally, he expected the staff to intensify treatment if the wound deteriorated. He expected the staff to re-evaluate, adjust treatment according to the facility's protocol, and notify him if there was a change in wound status. Further review of Resident #8's medical record revealed in the nurses' notes, dated 10/09/11 at 6:30 AM, the DON documented "Daughter voiced concern over [MEDICAL CONDITION] and 'blisters' on peri-area and upper thighs." Further review revealed a change in condition form was faxed to the physician about the [MEDICAL CONDITION]; however, it did not include the daughter's concern regarding the blistered areas. There was no documented evidence that a care plan was revised to reflect the new "blisters," or a non-pressure wound documentation form was completed at this time. A review of Resident #8's comprehensive care plan, dated 10/14/11, revealed the facility identified a problem of, "Swelling to all extremities," with interventions to include medications as ordered, monitoring for new or worsened condition, and to notify the MD of any changes. There was no documented evidence an intervention was put into place to prevent altered skin integrity to the extremities. A review of the non-pressure wound and skin condition documentation form, dated 10/25/11 (sixteen days after the daughter expressed concern about blister areas), revealed a new blister was identified to the left heel that measured 4 cm length by 5 cm width, and a new blister to the right heel, that measured 5 cm length X 5 cm width. A physician's orders [REDACTED]." However, neither Resident #8's comprehensive care plan nor nursing aide care plan was revised to reflect the new interventions to elevate/float bilateral heels or to check every two hours. Further interview with the Director of Nursing (DON) on 01/19/12 at 3:45 PM, revealed when the swelling was identified to extremities, on 10/14/11, a care plan should have been initiated to protect the skin integrity. She could not provide an explanation as to why an intervention such as heel boots was not implemented to prevent alteration in skin integrity per the physician's orders [REDACTED].

Based on interview, record review and review of the facility policy/procedures, it was determined the facility failed to review and revise a comprehensive care plan for one resident (#8), in the selected sample of ten residents related to the revision of Resident #8's individual care plan upon re-admission to the facility on [DATE], after new skin integrity issues were identified and treatment was altered. On 10/11/11 a pressure sore was identified on the resident's coccyx area, measuring 7.9 centimeters (cm) length by 4.1 cm width by 0.1 cm depth. On 10/18/11, the facility identified the coccyx wound had increased in size, measuring 8.9 cm length by 4.8 cm width by 0.1 cm depth. However, the resident's care plan was not revised until 10/20/11. In addition, Resident #8's care plan was not revised after recommendations from the Registered Dietician (RD), on 10/04/11, for a multi-vitamin (MVI); on 10/09/11, to prevent altered skin integrity to the extremities when the resident's extremities were swollen and blisters were noted on the resident's peri-area and upper thighs; and, on 10/25/11 to reflect the new interventions to elevate/float the resident's bilateral heels and to check the resident every two hours after the identification of blisters to the resident's bilateral heels. The findings include: A review of the facility's policy/procedure, "Putting the Plan into Action," dated January 2008, revealed "Nursing assistants, licensed nurses, and the entire interdisciplinary team all play a role in reviewing the care plan's effectiveness." A record review Resident #8 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident was cognitively independent, required total dependence for Activities for Daily Living (ADL's), and had no identified behaviors or identified skin issues. A review of Resident #8's "Potential for Skin Breakdown," care plan, dated 07/06/11, revealed to "Observe skin every shift for signs/symptoms of potential skin breakdown (e.g. redness/discoloration or open areas)." If breakdown was identified, the charge nurse should be alerted so the nurse could notify the physician if needed for treatment orders. A review of the nurse's notes, dated 09/30/11 at 12:45 PM, revealed Resident #8 was readmitted to the facility from the hospital, with excoriation to the resident's groin and buttocks noted. There was no evidence that the resident's care plan was revised to address the identified excoriation. An interview with Registered Nurse (RN) #4, on 01/19/12 at 10:14 AM, revealed she could not provide specific information regarding Resident #8's skin assessment upon re-admission to the facility on [DATE]. She stated she was not sure who would be responsible for initiation of skin interventions, such as wheelchair cushions or air mattresses. A review of a "Medical Nutrition Therapy Assessment," dated 10/04/11, revealed the resident's needs were increased to promote wound healing. A MVI was recommended to improve overall nutritional status and to aid in wound healing. There was no evidence the care plan was revised to reflect this intervention. A review of the nurses' notes, dated 10/09/11 at 6:30 AM, revealed documentation by the Director of Nursing (DON) that the "Daughter......voiced concern over [MEDICAL CONDITION] and 'blisters' on peri-area and upper thighs." There was no documented evidence that the skin integrity care plan was revised to include the "blistered" areas to the peri area and upper thighs. A review of Resident #8's "Pressure Wound and Skin Documentation Form," revealed, on 10/11/11, a new Stage II wound was identified to the coccyx, measuring 7.9 centimeters (cm) length by 4.1 cm width by 0.1 cm depth, was identified by Licensed Practical Nurse (LPN) #2. There was no evidence the skin integrity was revised to address the new identified wound on 10/11/11. A review of Resident #8's significant change Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #8 as cognitively independent, and to require extensive assistance to total dependence for Activities of Daily Living (ADLs). Resident #8 was assessed to be incontinent of bowel and had a urinary catheter. A review of Resident #8's comprehensive care plan, dated 10/14/11, revealed a problem of swelling to all extremities, with interventions for medications as ordered, monitoring for new or worsened condition, and to notify the MD of any changes. No intervention was put into place to prevent altered skin integrity to the extremities. On 10/18/11, the facility identified the coccyx wound had increased in size, measuring 8.9 cm length by 4.8 cm width by 0.1 cm depth. However, Resident #8's care plan was not revised until two days later (10/20/11), to reflect the pressure ulcer. A review of the "Non-pressure Wound and Skin Condition Documentation Form," dated 10/25/11, revealed a new blister was identified on the left heel on 10/25/11, which measured 4 cm length X 5 cm width, and a new blister on the right heel, which measured 5 cm length X 5 cm width. A review of a physician's order, dated 10/26/11, revealed "elevate/float bilateral heels, check every two hours." However, neither Resident #8's comprehensive care plan nor nursing aide care plan was updated to reflect the new interventions. An interview with the DON, on 01/19/12 at 3:45 PM, revealed on admission, the admitting nurse performs a head-to-toe assessment along with a Norton Pressure Ulcer Scale. Resident #8's care plan should have been revised on 09/30/11 to address the excoriated areas. She stated, on 10/07/11, when the nurse documented that the skin was not intact, the care plan should have been revised to reflect the non-intact skin. On 10/14/11, when swelling was identified to the resident's extremities, Resident #8's skin integrity care plan should had been revised to protect the skin integrity. She could not provide an explanation as to why an intervention such as heel boots were not implemented to prevent alteration in skin integrity. Additionally, she stated any licensed staff member could implement and revise the care plan.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to consult/notify the resident's physician when there was a need to alter treatment significantly for one resident (#8), in the selected sample of ten residents. Resident #8 was re-admitted to the facility on [DATE], with excoriation to buttocks noted and treatment was ordered. On 10/11/11, a skin assessment identified a new pressure sore on the resident's coccyx area measuring 7.9 centimeters (cm) length by 4.1 cm width by 0.1 cm depth. There was no documented evidence the physician was notified of the new pressure sore or consulted to alter treatment. On 10/18/11, the facility assessed the coccyx wound had increased in size, measuring 8.9 cm length by 4.8 cm width by 0.1 cm depth. The facility faxed the physician notification, on 10/18/11, of the wound worsening; however, there was no evidence the physician received the fax and no change in treatment was received. Treatment to the resident's coccyx was not changed until 10/26/11, 8 days later. On 11/01/11, the wound was noted to exhibit an odor; however, there was no documented evidence the facility notified the physician. Additionally, a multivitamin (MVI) was recommended on 10/04/11 to promote wound healing. The facility failed to notify the physician of the dietician's recommendation. The findings include: A review of the facility's policy/procedure, "Change in Condition of a Resident," dated 01/08, revealed "It is the policy of the center to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident." A closed record review revealed Resident #8 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's "Potential for Skin Breakdown," care plan, dated 07/06/11, revealed to "observe skin every shift for signs/symptoms of potential skin breakdown (e.g. redness/discoloration or open areas)." Per the care plan, if breakdown was identified, the charge nurse should be alerted so the nurse could notify the physician if needed for treatment orders. A review of the nurse's notes, dated 09/30/11, revealed excoriation was noted to the buttocks and groin. There was no formal skin assessment completed upon re-admission. However, on 10/02/11, an order was received for border gauze to an open area on the coccyx and to change as needed. A review of a "Medical Nutrition Therapy Assessment," dated 10/04/11, revealed the resident's needs were increased to promote wound healing. A MVI was recommended for overall nutritional status and to aid in wound healing. There was no evidence the physician was ever notified of this dietary recommendation. An interview with the Registered Dietician (RD), on 01/20/12 at 10:15 AM, revealed copies of the recommendations were given to the Director of Nursing (DON), Assistant Director of Nursing (ADON), Dietary Manager, and to the respective nursing station. If a resident was given a dietary recommendation, she expected the nurse to contact the physician for an order. She stated a MVI provided extra nutrients to aid in wound healing which the resident may not have received by po intake. A review of Resident #8's "Pressure Wound and Skin Documentation Form," completed on 10/11/11, revealed a new Stage II wound to the coccyx, measuring 7.9 centimeters (cm) length by 4.1 cm width by 0.1 cm depth. There was no evidence the physician was notified of the new wound, or consulted to alter treatment of [REDACTED]. The physician was notified by fax on 10/18/11 by Licensed Practical Nurse (LPN) #2, but there was no evidence the physician received the fax and no change in treatment was received. An interview with LPN #2, on 01/20/12 at 2:39 PM, revealed if there was a change in wound status or presence of a wound odor, she was supposed to notify the physician. She was unable to recall the skin assessment on 10/11/11, and when she notified the physician of the worsening of the pressure ulcer on 10/18/11. A review of the physician's progress notes, dated 10/19/11, revealed the Nurse Practitioner (NP) ordered a wound care consultation due to the nurse's concern that the wound on the resident's sacral area was not healing. Per the NP's progress notes, the wound continued to grow in size and had developed a dark center. After receipt of the wound care consult order on 10/19/11, the facility scheduled the wound care consultation for 10/31/11. However, the NP did not give an order on 10/19/11 to alter treatment for [REDACTED]. There was no documented evidence the nurse practitioner or Resident #8's physician was notified of the time lapse of the initial wound care consult ordered on [DATE], and the resident's scheduled appointment on 10/31/11. Further record review revealed, on 11/01/11, a wound odor was identified by the DON during a skin assessment; however, review of Resident #8's physician orders [REDACTED]. An interview with the DON, on 01/19/12 at 3:45 PM, revealed if a nurse identified an area worsened or with an odor, she expected the staff to notify the physician by phone or fax. Additionally, she expected the staff to contact the physician with dietary recommendations. An interview with Resident #8's physician, on 01/20/12 at 4:00 PM, revealed he expected the staff to contact him regarding dietary recommendations. Additionally, he expected the staff to intensify treatment if the wound deteriorated. He expected the staff to re-evaluate, adjust treatment according to the facility's protocol, and notify him if there was a change in wound status.