Every finding on record at Sunrise Manor Nursing Home

Based on observation, interview, and review of facility policy the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 127 of the facility's 127 residents who consumed food from the kitchen.The findings include:Review of the facility policy titled, Food Storage: Dry Goods and Cold Foods, revised 09/2017, stated all foods will be appropriately stored in accordance with guidelines of the FDA Food Code. FDA Food Code states, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above; (2) At 5 C (41 F) or less. Additionally, the FDA Food Code stated, The manufacturer's use-by date is its recommendation for using the product while its quality is at its best. As well as do not use moldy or decomposed food. The facility's policy stated, All foods will be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.1a. Observation of the kitchen on 12/09/2025 at 9:40 AM revealed the single walk-in refrigerator had five watermelons with mold-like appearing spots, and were mushy to the touch, 36 Tomatoes with mold-like appearing areas, mushy to the touch, six cucumbers with mold-like appearing areas, mushy to the touch, one bottle of Imperial Dijon mustard, opened 10/19/2025, expired 11/19/2025, one bottle of Sysco Fat Free Italian dressing, opened 10/28/2025, expired 11/18/2025, one carton of Wholesome half and half opened, no written dates, two Grove prune juice containers received 9/17/2025, opened, no written dates, one container of Imperial sweetened tea flavor opened, no written dates, one container of Dannon creamy yogurt, expired 12/05/2025, two containers of Philadelphia cream cheese 3lbs, expired 11/09/2025, one container of Philadelphia cream cheese 3lbs, opened no written dates, five Sysco hash brown potatoes 10lb bags, expired 11/09/2025, four of coleslaw, 7lbs bulk containers, expired 12/04/2025, one large block of ham, wrapped in plastic wrap, no written dates, several prepped cottage cheese bowls, no written dates, 36 Zucchini that were mushy to touch with the appearance of mold-like areas and 32 squash that were mushy to the touch with the appearance of mold-like areas.Observation of the kitchen on 12/09/2025 at 10:10 AM revealed the dry food storage area had two packages of Sysco Reliance cake mix 5lbs each, expired 08/06/2025.1b. Observation of the lunchtime test tray on 12/10/2025 at 1:34 PM revealed potato wedges had an internal temperature of 104.4 degrees Fahrenheit, chicken fingers with an internal temperature of 100.4 degrees Fahrenheit, green beans had an internal temperature of 107.8 degrees Fahrenheit, gravy had an internal temperature of 111.2 degrees Fahrenheit, and drinking tea had in internal temperature of 58.3 degrees Fahrenheit. Multiple resident interviews during the survey process on 12/09/2025 revealed multiple complaints of food served cold for all meals. In an interview with the Dietary Manager on 12/11/2025 at 2:10 PM stated it was everyone's responsibility to check the storage areas for expired food items on Wednesdays when the food delivery truck arrived, but ultimately it was his responsibility. He continued that all food items prepped prior to meals should be labeled with the name of the food item and a date, as well as, food items that were opened, should be labeled with open and expiration dates. He stated there were mold appearing produce items and expired food items because it had been difficult to keep personnel hired in the kitchen; and he (the Dietary Manager) has been cooking, washing dishes and preparing desserts for meals. He stated his expectation was to not have expired items in the food storage areas as a potential outcome could be food poisoning. The dietary manager also stated there was a delay in getting the food trays to the residents after the kitchen delivered the food trays to the units as staff do not pass them out promptly. In an interview with Licensed Practical Nurse (LPN)5 on 12/10/2025 at 1:40 PM, she stated the delay in passing of the food trays to the residents after the kitchen dropped off the carts was the trays were in no order, and all the trays must be pulled out one at a time to see who it belonged to. She continued that typically the trays are correct, it has only been this week that this has happened. In an interview with the Director of Nursing of Special Projects (DNSP) on 12/12/2025 at 2:12 PM she stated her expectation of food storage in kitchen was to follow proper protocol. She further stated she expected moldy appearing food items, expired food items and unlabeled food items to be thrown away. The DNSP stated a potential outcome of serving expired food items to residents was food poisoning and other things. She continued she was unaware of resident complaints of cold food; but her expectation of food temperature was for the resident's preference.In an interview with the Administrator on 12/12/2025 at 2:30 PM she stated no concerns regarding complaints of cold food served to the residents had been brought to her attention. She continued that she had no knowledge of any delay of food getting from the kitchen to the residents. The Administrator stated her expectation of food storage in the kitchen was unlabeled and expired food items would not be served to the residents. She continued by saying a potential outcome of serving expired food items to residents is situational of what exactly is the food and who it is served to.

Based on observation, interview, record review, review of the facility's policy, and review of the facility's Plans of Correction (POC) submitted for the 01/24/2019 and 11/05/2019 surveys, it was determined the facility failed to have effective processes in place to address system failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. As a result, the facility failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. This was evidenced by deficient practice cited at F656, F657, F689, and F755, on the 01/24/2019 survey; and F610, and F656, which were cited on the 11/05/2019 survey. During the 04/14/2022 Recertification Survey, Immediate Jeopardy (IJ) was identified at 42 CFR 483.12 Freedom from Abuse (F602), at a scope and severity (S/S) of K; 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), at a S/S of J; 42 CFR 483.25 Quality of Care (F689), at a S/S of J; 42 CFR 483.45 Pharmacy Services (F755), at a S/S of K; 42 CFR 483.70 Administration (F835, F837), at the S/S of K; and 42 CFR 483.75 Quality Assurance Performance Improvement (F867), at the S/S of K. Refer to F602, F689, F656, F755, F835, F837, and F867. The facility's failure to an effective process in place to address system failures through QAPI has caused or is likely to cause serious injury, serious harm, or death to other residents in the facility. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 04/04/2022 and were determined to exist on 02/24/2021 in the area in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F602 Free from Misappropriation Exploitation at a scope and severity (S/S) of K; 42 CFR 483.21 Comprehensive Person-Centered Care Plans, F656 Comprehensive Resident Centered Care Plans at a S/S of J; 42 CFR 483.25 Quality of Care, F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedure/Pharmacist/ Record at a S/S of K; 42 CFR 483.70 Administration, F835 Administration and F837 Governing Body at a S/S of K; and at 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities at a S/S of K. The facility was notified of the IJ and SQC on 04/04/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 04/12/2022, with the facility alleging removal of the Immediate Jeopardy, on 04/09/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 04/09/2022, prior to exit on 04/14/2022. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 10/02/2019, revealed the purpose of the QAPI program was to provide a process that would enhance the care and experience for all residents, improve the work environment for employees, and quality of all services provided by the facility. Additionally, the facility would have an ongoing QAPI program to systemically monitor, evaluate and improve the quality and appropriateness of resident care. Per the facility's policy, QAPI supported the overall goals of the facility and examined outcomes and processes relevant to outcomes with the objective of improving the organization's overall performance. Continued review revealed the program would be a coordinated effort among all departments and services within the facility and would meet at least monthly and as needed. Further the QAPI committee was composed of but not limited to: the Administrator, the Director of Nursing (DON), the Medical Director, and Pharmacy. Continued review revealed the QAPI Committee would select some aspects of care for performance improvement based on problem areas/aspects of care which in the past produced a problem for staff or residents. Review of the facility's, Job Description for the Administrator, dated December 2018, revealed the Administrator was responsible for the Quality Assurance (QA) Program. Further review revealed the Administrator would identify and participate in process improvement initiatives that would improve the customer's experience, enhance workflow, and/or improve the work environment. Review of the Acceptable Plan of Correction (POC), for the Recertification Survey, dated 01/24/2019, revealed for the deficient practice which had been cited at F656, the facility had provided education to nursing staff regarding the facility's policy on Care Plans-Comprehensive to ensure development and implementation. Continued review of the POC revealed for the deficient practice cited at F689, the facility had provided education to nursing staff on the facility's policy, Accident and Incident-Investigating and Reporting Falls, to ensure accidents were investigated and residents' environments remained as free of accident hazards as possible. Additional review of the POC revealed for the deficient practice cited at F755, the facility had educated all licensed nurses on the importance of maintaining an accurate account for all controlled medications. Further review of the Plan of Correction (POC), for the survey, dated 01/24/2019, revealed at the QAPI meetings the audit results for F656, F689 and F755 would be reviewed by the Administrator and Committee, monthly until substantial compliance was achieved. Finally, review of the POC for the 09/30/2021 survey revealed compliance was the responsibility of the Administrator. Review of the Acceptable Plan of Correction (POC), for the Abbreviated Survey dated 11/05/2019, revealed for the deficient practice which had been cited at F610, the facility had provided education to the Administrator, the Interim DON, the reporting nurse, and all clinical staff (licensed nurses and aides) regarding abuse to ensure proper investigations. Further review of the POC revealed for the deficient practice cited at F656, the facility provided education to all clinical staff (licensed nurses) on updating the Care Plan with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Further review of the Plan of Correction (POC), for the survey dated 11/05/2019, revealed at the QAPI meetings the audit results for F610 and F656 would be reviewed by the Administrator and Committee, monthly until substantial compliance was achieved. Review of the facility's Quality Assurance (QA) Committee meeting documentation revealed meetings had been held on at least monthly and revealed attendees included but were not limited to the Administrator, the Medical Director, and the Director of Nursing (DON). Interview with the Medical Director, on 03/28/2022 at 10:02 AM, revealed he participated in the facility's QAPI/QA Committee. Additionally, the facility had discussed previous surveys (01/24/2019 and 11/05/2019) during QA meetings; however, he could not confirm, if the facility had ongoing audits for repeat deficiencies (F602, F610, F656, F657, F689, F755 and F880) identified during the 03/20/2022-04/14/2022 survey. Further, he had not been notified of any identified concerns with clinical systems in the facility. Interview with the Minimum Data Set (MDS) Nurse #2, on 03/28/2022 at 11:45 AM, revealed she attended monthly QAPI meetings and was an active participate of the QA Committee. Per interview, she recalled attending an Ad Hoc QAPI meeting on 02/26/2019 related to an allegation of drug diversion/misappropriation. She stated she was not aware of details of the investigation that was reviewed. Additionally, she could not recall details about the audits that were completed during the investigation. Further, she could not remember if the QA Committee discussed or developed an action plan related to pharmacy services to implement after the allegation. Interview with Director of Nursing (DON), on 03/28/2022 at 5:19 PM, revealed she had been in the role for one (1) year and was previously a Unit Manager for one (1) year at the facility. Per interview, she led the Clinical Morning Meetings Monday through Friday. She also conducted ongoing rounds in the facility to monitor for Quality Assurance and regulatory compliance for all nursing practices and protocols. Additionally, she worked closely with the Clinical Care Consultant for guidance and support related to clinical Quality Assurance. Continued interview revealed the 02/25/2019 incident of misappropriation and drug diversion was discussed by the QA Committee, on 02/26/2019. However, she did not recall if any action plan was discussed or implemented related to a different process for ensuring non-controlled medications were accounted for before they were sent back to the pharmacy. Per interview, she had not reviewed the 2019 survey results and was not aware of the POCs for the surveys (01/24/2019 and 11/05/2019). The survey results were discussed in QAPI meetings monthly and it was her understanding that all POC audits from previous surveys were ongoing. Further, she provided support to the facility and ensured the safety and well-being of residents as well as delegating responsibilities for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policy and procedures. Continued interview revealed he/she was responsible to assist with the revisions of clinical policies and procedures to ensure compliance with governmental regulations and current standards of practice within the facility, after the corporation made policy changes as needed. Per interview, the facility until recently, did not have a Staff Development Coordinator and she was responsible to ensure the staff received all necessary education/training. Interview revealed the QA Committee had not identified any repeat deficient practice previously cited on the 01/24/2019 or 11/05/2019 surveys through the ongoing POC audits or other quality assurance efforts in the facility. She had not identified any issues concerning abuse, care plans, falls, infection control, or pharmacy practices. Interview with the Administrator, on 03/28/2022 at 3:40 PM, revealed he was not aware of the audits for POCs dated 01/24/2019 and 11/05/2019 or if the QAPI Committee had identified any deficient practices through the POC audits. However, the QAPI Committee met monthly, and the Director of Nursing (DON) brought any clinical concerns to the QAPI Committee meetings. Further interview revealed he was not aware of any current concerns with the clinical practices within the facility. In addition, the Administrator revealed it was his responsibility to ensure all facility processes established by the Governing Body were maintained, including the facility's Quality Assessment and Assurance (QAA) and QAPI programs. Continued interview revealed, he had been made aware of the allegation of misappropriation which occurred in February 2019; however, the alleged misappropriation, on 02/25/2021 was strictly an intentional criminal act by LPN #7 and the facility did not identify any systemic issues with their process to account for medication in the facility. He stated the QAPI Committee discussed the identified issues and initiated audits in February 2019; however, the QAPI Committee did not develop a plan to follow the medication audits. Interview with the Regional Vice President of Operations (RVPO), on 03/28/2022 at 4:11 PM, revealed he had worked with the facility eleven (11) months. Per interview, he was unaware of any concerns which had been identified at the facility, prior to the State Survey Agency's (SSA) entrance related to abuse, care plans, falls, infection control or pharmacy services. However, he was aware of the 01/24/2019 and the 11/05/2019 survey results and the facility's POC. He stated the facility had implemented audits, per the POCs, and through the QA process, to ensure the deficient practice did not reoccur. Further, he had not been notified related to any concerns/issues with clinical care in the facility. Review of the IJ Removal Plan revealed the facility implemented the following: 1. The Clinical Reimbursement Specialist reviewed the past thirty (30) days of falls on current residents to ensure the root cause was identified, new interventions were put in place, the Care Plan was revised to include supervision if it applied for recent falls. This was completed on 04/05/2022. 2. Regional Social Services reviewed the last thirty (30) days of Progress Notes for root cause was identified, new interventions were put in place with supervision, if the resident required it. This was completed on 04/05/2022. 3. The Regional Clinical Reimbursement Nurse (RCRN), the ADON, and the DON completed observations of Care Plan interventions to ensure they were effective and were implemented. They also reviewed all At Risk for Falls Care Plan, to ensure they reflected the correct intervention, determined Root Cause of the fall and to put new interventions in place to include extra supervision for residents who required it. 4. The Pharmacy Consultant completed medication cart audits as compared to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed on 04/07/2022 and no concerns were found. 5. Two Regional Social Services Directors reviewed all current residents' Progress Notes, events, and grievances to ensure residents were free from misappropriation of property. This was completed by 04/05/2022. 6. Signature Care Consultant (SCC) collaborated with the Pharmacy Director on 04/06/2022 and put the following plan in place: the nurses will remove the medication from the carts and store them properly. The medications being sent back will be listed on a form and the driver or two (2) licensed nurses will sign the form once the driver picked up the medication and returned it to the pharmacy. 7. The Vice President of Regulatory Compliance educated the Administrator/Regional Vice President, Medical Director, the Regional Nurse Consultant and the DON on the CMS regulations F835 on 04/06/2022 and the CMS regulations for F755, F689, F602, and F656 on 04/06/2022. 8. The facility conducted Ad Hoc Quality Assurance meetings which started 04/05/2022 and an Immediate Jeopardy Plan was developed and implemented. On 04/06/2022, another Quality Assurance meeting was held to review the plan and make needed revisions to include further education. 9. Starting on 04/07/2022, QAPI meetings were held the first seven (7) days, then weekly for four (4) weeks. These meetings will continue until monthly for ongoing recommendations and follow-up. 10. The QA Committee will determine as to what frequency these meetings will continue. The Administrator has the oversight to ensure the effective plan was in place and was working to meet the resident's needs. The Regional Vice President of Operations will provide oversight daily until the removal of immediacy. The State Survey Agency validated the implementation of the IJ Removal Plan as follows: 1. Interview with the Clinical Reimbursement Consultant (CRC) on 04/14/2022 at 12:10 PM, revealed she audited the last thirty (30) days of event notes and interventions. She revealed she also looked at Root Causes for falls. The CRC revealed she went room-to-room and evaluated the equipment on hand, safety in the resident's room and the interventions being used. She revealed no concerns were found. 2. Interview with Social Service Director-Floaters (SSD) #1 and #2 on 04/14/2022 revealed they were called upon for special projects to review all clinical Progress Notes, events, and grievances for any concerns about misappropriation of resident property, to include medication. The look back period was for thirty (30) days. Both RSSD #1 and #2 reported no concerns were identified. Record review on 04/13/2022 at 11:30 AM, revealed audits were completed of all residents' Progress Notes for misappropriation of resident property to include medications. Concerns found were addressed. Grievances were audited for misappropriation complaints and no concerns were found. 3. Interview with the Clinical Reimbursement Specialist (CRS) on 04/14/2022 at 12:10 PM, revealed she completed audits on the last thirty (30) event notes for new interventions and Care Plan updates. She also revealed she looked at root causes to see if the facility determined the actual cause of a fall; if the root cause was not documented it was discussed with the SCC for the team to address the findings in QAPI. She completed room to room audits for safety, ensured required equipment was available and proper interventions were in place. 4. Observation completed by SSA on 04/13/2022 at 2:55 PM, revealed the pharmacy courier completed the new medication pick-up process. The courier scanned a list of medications which contained four (4) residents. Each resident had one (1) medication listed. The blue tote bag was secured with a pull tie and the pull tie had a number on it. Tag number five (#5) was written on the medication list. Once the medication was secured the courier met with the DON in the lobby and they reviewed the list. Medications remain locked up and were dropped off at the pharmacy. Interview with the Regional Pharmacy Consultant on 04/14/2022 at 1:30 PM, revealed each medication cart was audited and each resident's medications were reconciled with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy audits will be ongoing. Record review on 04/13/2022 at 11:30 AM, revealed six (6) medication carts were audited. Audit findings were sent to the facility. Medications for Residents #19, #30, #63 and #77 were reconciled and no concerns were found. 5. Interview with Social Service Director-Floaters (SSD) #1 and #2 on 04/14/2022 revealed they were called upon for special projects to review all clinical progress notes, events, and grievances for any concerns about misappropriation of resident property, to include medication. The look back period was for thirty (30) days. Both RSSD #1 and #2 reported no concerns were identified. Record review on 04/13/2022 at 11:30 AM, revealed audits were completed of all residents' Progress Notes for misappropriation of resident property to include medications. Concerns found were addressed. Grievances were audited for misappropriation complaints and no concerns were found. 6. Observation completed by SSA on 04/13/2022 at 2:55 PM, revealed the pharmacy courier completed the new medication pick-up process. The courier scanned a list of medications which contained four (4) residents. Each resident had one (1) medication listed. The blue tote bag was secured with a pull tie and the pull tie had a number on it (five). Tag number five (#5) was written on the medication list. Once the medication was secured the courier met with the DON in the lobby and they reviewed the list. Medications remain locked up and were dropped off at the pharmacy. Interview with the Pharmacy Director (PD) on 04/13/2022 at 10:27 AM, revealed he worked with the SCC and the RVPRC to develop a plan for discontinued medications and how they would be returned to the pharmacy. Pharmacy Services will continue to have consultants present in the facility, for ongoing audits. The PD also revealed pharmacy staff were educated on the new process and expectation. Record review on 04/13/2022 at 11:30 AM, revealed six (6) medication carts were audited. The audit findings were sent to the facility. Medications for Residents #19, #30, #63 and #77 were reconciled and no concerns were found. 7. Interview with the Medical Director, Regional Vice President of Operations, the SCC and the DON on 04/14/2022 at 4:30 PM, revealed they all received reeducation on the Federal Regulations for F835 on 04/06/2022 and F656, F602, F689 and F755. They revealed they were each present during the meetings and discussed concerns as they came up. Policies were also discussed and it was reported the focus was to get the facility trained and get the immediacy removed. No ongoing concerns were found. 8. Interview with the Medical Director on 04/14/2022 at 3:25 PM, revealed he was present via phone for all Ad Hoc meetings since Immediate Jeopardy was determined. He was involved in all discussions and ensured the audits were being completed as required. Through the meetings any concerns were addressed, and necessary changes were made. Interview with the Director of Nursing (DON) on 04/14/2022 at 3:35 PM, revealed she was present for the Ad Hoc meetings and all aspects of the IJs were discussed. 9. Interview with the Vice President of Operations (VPO) on 04/14/2022 at 2:45 PM, revealed he was present at the QAPI meetings to provide oversight via phone. The QAPI meetings were led by the Administrator and all questions and concerns were addressed. 10. Interview with the Regional Vice President of Regulatory Compliance on 04/14/2022 at 4:12 PM, revealed he will continue to monitor the IJ process and the QAPI meetings will continued as outlined in the plan. Any adjustments or concerns would be addressed as the arise.

Based on interview, record review, and review of the facility's policy, it was determined the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility. The Governing Body failed to ensure compliance in the areas of 42 CFR 482.12 Freedom from Abuse, F600, F602, and F610; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F655, F656, F657; 42 CFR 483.25 Quality of Care, F689; 42 CFR 483.45 Pharmacy Services, F755; CRF 42 483.60 Food and Nutrition Services, F812; 42 CFR 483.70 Administration, F835 and F837; 42 CFR 483.75 Quality Assurance and Performance, F867; and 42 CFR 483.80 Infection Prevention and Control, F880 during the Recertification Survey 03/20/2022 through 04/14/2022. Continued non-compliance was cited during this Survey at 42 CFR 482.12 Freedom from Abuse, F610; 42 CFR 483.20; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F656, F657; and 42 CFR 483.45 Pharmacy Services, F755. The facility failure to provide oversight to ensure compliance has caused or is likely to cause serious injury, serious harm, or death to other residents in the facility. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 04/04/2022 and were determined to exist on 02/24/2021 in the area in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F602 Free from Misappropriation Exploitation at a scope and severity (S/S) of K; 42 CFR 483.21 Comprehensive Person-Centered Care Plans, F656 Comprehensive Resident Centered Care Plans at a S/S of J; 42 CFR 483.25 Quality of Care, F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedure/Pharmacist/ Record at a S/S of K; 42 CFR 483.70 Administration, F835 Administration and F837 Governing Body at a S/S of K; and at 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities at a S/S of K. The facility was notified of the IJ and SQC on 04/04/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 04/12/2022, with the facility alleging removal of the Immediate Jeopardy on 04/09/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 04/09/2022, prior to exit on 04/14/2022. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Governing Body, dated 08/07/2019, revealed the Governing Body was responsible to establish and implement policy regarding the management and operation of the facility. The Administrator reported to the Governing Body and was responsible for management of the facility and was responsible and accountable for the Quality Assurance/Performance Improvement (QAPI) program at the facility. Additionally, the Governing Body was compromised of the Administrator, the Director of Nursing (DON), the Medical Director (MD), and an administrative services representative. Per policy, the Governing Body had authority and discretion for day-to-day operations of the facility. In addition, the review and approval of all policies and procedures established and implemented in the facility regarding management and operations of the facility; and the facility's QAPI program, review of clinical quality and care provided at the facility. Review of the facility's, Job Description for the Administrator, dated December 2018, revealed the Administrator led and directed the overall operations of the facility in accordance with customers' needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Additionally, the Administrator would identify and participate in process improvement initiatives to improve customer experiences, enhance workflow, and/or improve the work environment. Continued review revealed the Administrator was responsible for the Quality Assurance (QA) program. Further, the Administrator would maintain working knowledge of and confirm compliance with all governmental regulations. The Administrator would consult with department managers, concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of service. Review of the facility's, Job Description of the Director of Nursing (DON), dated December 2018, revealed the DON was responsible for the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations to maintain excellent care of all resident's needs. Additionally, the DON would identify and participate in process improvement initiatives to improve customer experiences, enhance workflow, and/or improve the work environment. Continued review revealed the DON would train, develop, coach and counsel department staff. In addition, the DON would monitor clinical care, collaborate with the pharmacy and medical director, and take appropriate actions were taken to maintain compliance. Further, the DON, would plan, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility. Continued review revealed the DON would inspect the facility and nursing practice for compliance with federal, state, and local standards and regulation. Review of the facility's policy, titled, Medical Director, last revised on 07/19/2018, revealed the MD coordinated medical care and provided clinical guidance and oversight in regard to implementation of resident medical care policies. The MD would collaborate with the facility's leadership, staff, practitioners, and consultants to help develop, implement, and evaluate resident care polices and procedures that reflect current standards of practice. Additionally, the MD would help the facility identify, evaluate, and address/resolve medical and clinical concerns that affected resident care, medical care, and quality of life. Continued review revealed the MD would be knowledgeable about current standards of practice in care for long-term care residents and how to coordinate and oversee related medical and clinical care providers. Further, the MD would participate in the implementation of resident care policies and procedures; integrated delivery of care and services, to include but not limited to medical, nursing, and pharmacy, which included clinical assessment and analysis of findings. Continued review revealed the MD would participate in Quality Assurance to include care and other health-related services and provide appropriate feedback. Review of the Statements of Deficiencies (SOD) for the Recertification Survey, dated 01/24/2019, revealed deficient practice was cited in the areas of 42 CFR 483.10 Resident Right (F550, F553) at s/s of E; 42 CFR 483.10 Resident Right (F584) at s/s of D; 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656, F657) at a s/s of D; 42 CFR 483.24 Quality of life (F677) at s/s of D; 42 CFR 483.25 Quality of Life (F689) at a s/s of G; 42 CFR 483.25 Quality of Life (F693) at a s/s of D; 42 CFR 483.35 Nursing Services (F725) at s/s of E; and 42 CFR 483.50 Pharmacy Services (F755, F61) at a s/s of E. Further, the review of the SOD for the Abbreviated Survey, dated 11/05/2019, revealed deficient practice was cited in the areas of 42 CFR 483.12 Freedom from Abuse (F610), at a s/s of D; and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656) at a s/s of D. However, the Governing Body failed to ensure compliance was maintained after the 09/30/2021 and 12/16/2021 surveys. During the 04/15/2022 Recertification Survey, repeat deficiencies were identified that were previously cited during the Recertification Survey, dated 01/24/2019 and the Abbreviated Survey, dated 11/05/2019. The areas included 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656, F657); 42 CFR 483.25 Quality of Life (F689); 42 CFR 483.50 Pharmacy Services (F755); and 42 CFR 483.12 Freedom from Abuse (F610). Further, review of the SOD for the Abbreviated Survey, dated 11/05/2019, revealed deficient practice was cited in the areas of 42 CFR 483.12 Freedom from Abuse (F610), at a s/s of D; and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656) at a s/s of D. However, the Governing Body failed to ensure compliance was maintained after the 09/30/2021 and 12/16/2021 surveys. Interview with the Medical Director, on 03/28/2022 at 10:02 AM, revealed he was part of the facility's Governing Body. Additionally, he states he collaborated with leadership in the facility to assist with care policies and procedures. Continued interview revealed the facility had discussed previous surveys (01/24/2019 and 11/05/2019) during QA meetings; however, he could not confirm, if the facility had ongoing audits for repeat deficient practice (F 602, F610, F656, F657, F689, F755 and F880) identified during the 03/20/2022-04/14/2022 survey. Further, he had not been notified of any identified concerns with clinical systems in the facility. Interview with the Director of Nursing (DON), on 03/28/2022 at 5:19 PM, revealed she had worked at the facility for one (1) year as the DON, and was previously a Unit Manager for one (1) year at the facility. Per the interview, she was part of the Governing Body, as per the facility's policy. Additionally, she audited clinical systems, Quality Indicators and reviewed the overall operational status of the nursing department. She stated she also provided Quality Assurance (QA) review reports to the Administrator and the QA Committee. Further, interview revealed she was not aware of the deficiencies cited during the last Recertification Survey dated 01/24/2019 or the last Abbreviated Survey dated 11/05/2019 or the POCs. Further, she had not identified clinical systemic issues identified by the State Survey Agency (SSA), that were currently occurring in the facility, infection control, pharmacy services, or abuse. Interview with the Administrator, on 03/28/2022 at 3:40 PM, revealed he had been in his role for nine (9) months. Per interview, the facility's Governing Body included the Administrator, the DON, and the MD. He stated it was his responsibility, as the Administrator, to ensure all processes established in the facility were maintained, to include the Quality Assurance and Assessment/Quality Assessment Performance Improvement (QAA/QAPI) Program. Continued interview revealed the Administrator was not aware of the previous Plans of Correction for the Recertification Survey dated 01/24/2019 or the Abbreviated Survey dated 11/05/2019. Further, he was not aware of any current clinical systemic issues at the facility or issues identified by the SSA during the 03/20/2022 through 04/14/2022 Recertification Survey. Interview with the Division Vice President of Operations (DVPO), on 03/28/2022 at 4:11 PM, revealed he had worked with the facility eleven (11) months. His current role was to provide support to the facility's Administrator. Continued interview revealed he was not aware of any care concerns in the facility which had been identified by the State Survey Agency (SSA) for the current survey. Per interview, he provided direct oversight of the facility and the Administrator. The DVPO revealed he was in contact with the Administrator at least weekly and made routine visits to the facility to provide support and resources. Additionally, he was aware of the 09/30/2021 and the 12/16/2021 survey results and the facility's POC. He revealed the facility had implemented audits, per the POCs, and through the QA process, to ensure the deficient practice did not reoccur. Continued interview revealed he had not been notified related to any concerns/issues with clinical care in the facility Review of the IJ Removal Plan revealed the facility implemented the following: 1. The Clinical Reimbursement Specialist reviewed the past thirty (30) days of falls on current residents to ensure the root cause was identified, new interventions were put in place, the Care Plan was revised to include supervision if it applied for recent falls. This was completed on 04/05/2022. 2. Regional Social Services reviewed the last thirty (30) days of progress notes for root cause was identified, new interventions were put in place with supervision if resident required it. This was completed on 04/05/2022. 3. The Regional Clinical Reimbursement Nurse (RCRN), the ADON, and the DON completed observations of Care Plan interventions to ensure they were effective and were implemented. They also reviewed all At Risk for Falls Care Plan, to ensure they reflected the correct intervention, determine Root Cause of the fall and to put new interventions in place to include extra supervision for residents who required it. 4. The Pharmacy Consultant completed medication cart audit as compared to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed on 04/07/2022 and no concerns were found. 5. Two Regional Social Services Directors reviewed all current residents' progress notes, events, and grievances to ensure residents were free from misappropriation of property. This was completed by 04/05/2022. 6. Signature Care Consultant (SCC) collaborated with the Pharmacy Director on 04/06/2022 and put the following plan in place: the nurses will remove the medication from the carts, store them properly. The medications being sent back would be listed on a form and the driver or two licensed nurses will sign the form once the driver picked up the medication and returned it to the pharmacy. 7. The Vice President of Regulatory Compliance educated the facility's Administrator/Regional Vice President, Medical Director, the Regional Nurse Consultant and the DON on the CMS regulations F835 on 04/06/2022; and, the CMS regulations for F755, F689, F602, and F656 on 04/06/2022. 8. The facility conducted Ad Hoc Quality Assurance meetings which started 04/05/2022 and an Immediate Jeopardy Plan was developed and implemented. On 04/06/2022, another Quality Assurance meeting was held to review the plan and to make needed revisions to include further education. 9. Starting on 04/07/2022, QAPI meetings were held the first seven (7) days, then weekly for four (4) weeks. These meetings will continue until monthly for ongoing recommendations and follow-up. 10. The QA Committee will determine as to what frequency these meetings will continue. The Administrator has the oversight to ensure the effective plan was in place and was working to meet the resident's needs. The Regional Vice President of Operations will provide oversight daily until the removal of immediacy. The State Survey Agency validated the implementation of the IJ Removal Plan as follows: 1. Interview with the Clinical Reimbursement Consultant (CRC) on 04/14/2022 at 12:10 PM, revealed she audited the last thirty (30) days of event notes and interventions. She revealed she also looked at Root Causes for falls. The CRC revealed she went room-to-room and evaluated the equipment on hand, safety in the resident's room and the interventions being used. She revealed no concerns were found. 2. Interview with Social Service Director-Floaters (SSD) #1 and #2 on 04/14/2022 revealed they were called upon for special projects to review all clinical progress notes, events, and grievances for any concerns about misappropriation of resident property, to include medication. The look back period was for thirty (30) days. RSSD #1 and #2 reported no concerns were identified. Record review on 04/13/2022 at 11:30 AM, revealed audits were completed of all resident's progress notes for misappropriation of resident property to include medications. Concerns found were addressed. Grievances were audited for misappropriation complaints and no concerns were found. 3. Interview with the Clinical Reimbursement Specialist (CRS) on 04/14/2022 at 12:10 PM, revealed she completed audits on the last thirty (30) on event notes for new interventions and Care Plan updates. She also revealed she looked at root causes to see if the facility determined the actual cause of a fall; if the root cause was not documented it was discussed with the SCC for the team to address the findings in QAPI. She completed room to room audits for safety, ensured required equipment was available and proper interventions were in place. 4. Observation completed by SSA on 04/13/2022 at 2:55 PM, revealed the pharmacy courier completed the new medication pick-up process. The courier scanned a list of medications which contained four (4) residents. Each resident had one (1) medication listed. The blue tote bag was secured with a pull tie and the pull tie had a number on it. Tag number five (#5) was written on the medication list. Once the medication is secured the courier meets with the DON in the lobby and they review the list. Medications remain locked up and are dropped off at the pharmacy. Interview with Regional Pharmacy Consultant on 04/14/2022 at 1:30 PM, revealed each medication cart was audited and each resident's medications were reconciled to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy audits will be ongoing. Record review on 04/13/2022 at 11:30 AM, revealed six (6) medication carts were audited. Audit findings were sent to the facility. Medications for Resident #19, #30, #63 and #77 were reconciled and no concerns were found. 5. Interview with Social Service Director-Floaters (SSD) #1 and #2 on 04/14/2022 revealed they were called upon for special project to review all clinical progress notes, events, and grievances for any concerns about misappropriation of resident property, to include medication. The look back period was for thirty (30) days. RSSD #1 and #2 reported no concerns were identified. Record review on 04/13/2022 at 11:30 AM, revealed audits were completed of all residents' progress notes for misappropriation of resident property to include medications. Concerns found were addressed. Grievances were audited for misappropriation complaints and no concerns were found. 6. Observation completed by SSA on 04/13/2022 at 2:55 PM, revealed the pharmacy courier completed the new medication pick-up process. The courier scanned a list of medications which contained four (4) residents. Each resident had one (1) medication listed. The blue tote bag was secured with a pull tie and the pull tie had a number on it (five). Tag number five (#5) was written on the medication list. Once the medication was secured the courier met with the DON in the lobby and they reviewed the list. Medications remained locked up and were dropped off at the pharmacy. Interview with the Pharmacy Director (PD) on 04/13/2022 at 10:27 AM, revealed he worked with the SCC and the RVPRC to develop a plan for discontinued medications and how they would be returned to the pharmacy. Pharmacy Services will continue to have consultants present in the facility, for ongoing audits. The PD also revealed pharmacy staff were educated on the new process and expectation. Record review on 04/13/2022 at 11:30 AM, revealed six (6) medication carts were audited. Audit findings were sent to the facility. Medications for Residents #19, #30, #63 and #77 were reconciled and no concerns were found. 7. Interview with the Medical Director, Regional Vice President of Operations, the SCC and the DON on 04/14/2022 at 4:30 PM, revealed they all received reeducation on the Federal Regulations for F835 on 04/06/2022 and F656, F602, F689 and F755. They revealed they were each present during the meetings and discussed concerns as they came up. Policies were also discussed and it was reported the focus was to get the facility trained and get the immediacy removed. No ongoing concerns were found. 8. Interview with the Medical Director on 04/14/2022 at 3:25 PM, revealed he was present via phone for all Ad Hoc meetings since Immediate Jeopardy was determined. He was involved in all discussions and ensured the audits were being completed as required. Through the meetings any concerns were addressed, and necessary changes were made. Interview with the Director of Nursing (DON) on 04/14/2022 at 3:35 PM, revealed she was present for the Ad Hoc meetings and all aspects of the IJs were discussed. 9. Interview with the Vice President of Operations (VPO) on 04/14/2022 at 2:45 PM, revealed he was present at the QAPI meetings to provide oversight via phone. The QAPI meetings were led by the Administrator and all questions and concerns were addressed. 10. Interview with the Regional Vice President of Regulatory Compliance on 04/14/2022 at 4:12 PM, revealed he will continue to monitor the IJ process and the QAPI meetings will continue as outlined in the plan. Any adjustments or concerns would be addressed as the arise.

Based on observation, interview, record review, and review of the facility policies, it was determined the facility failed to ensure residents were free from misappropriation of property (medication) for eight (8) of seventy-one (71) sampled residents (Residents #19, #30, #63, #77, #150, #151, #161, and #162). On 02/25/2021, State Registered Nurse Assistant (SRNA) #8 reported to the facility's previous Administrator, that Licensed Practical Nurse (LPN) #7 had taken medication from a resident at the facility. SRNA #8 provided to the previous Administrator a photograph of Resident #151's prescribed medication at LPN #7's home. The facility initiated an investigation and LPN #7 and SRNA #8 were suspended pending the investigation. On 02/25/2021, local law enforcement was notified by the facility's previous Administrator that LPN #7 had allegedly taken medications from the facility's residents. LPN #7 was implicated for the charge of Theft of a Legend Drug (a drug approved by the Food and Drug Administration {FDA} that can be dispensed to the public only with a prescription) 9 counts, Illegal Possession of a Legend Drug, Possession of Marijuana, and Drug Paraphernalia-Buy/Possess. On 03/01/2021, LPN #7 provided a verbal statement to the facility which revealed she took discontinued and extra medications from the residents at the facility. She stated she would bring the medications back to work and kept them in her backpack in her truck. LPN #7 stated she kept the medications for resident use in case the medication was not available or a different shape of the same medication would be easier on the resident to swallow. On 03/01/2021, the Police called the facility's previous Administrator and confirmed the medications found in LPN #7's possession were in fact medications belonging to residents of the facility. Despite this, the facility's investigation unsubstantiated the allegation of misappropriation, and the facility failed to implement corrective action consistent with the investigation's findings and failed to take steps to eliminate any ongoing danger to the resident(s). (See F610 and F755) Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/04/2022 and was determined to exist on 02/24/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation; F602 Free from Misappropriation Exploitation at a scope and severity (S/S) of K, and at 42 CFR 483.25 Quality of Care F 689 Free from Accidents/Hazards/Supervision/Devices at a S/S of J. Immediate Jeopardy was identified at 42 CFR 483.21 Comprehensive Person-Centered Care Plans F656 Comprehensive Resident Centered Care Plans at a S/S of J 42 CFR 483.45 Pharmacy Services F755 Pharmacy Services/Procedure /Pharmacist/Record at a S/S of K at 42 CFR 483.70 Administration F835 Administration and F837 Governing Body at a S/S of K at CFR 42 483.75 Quality Assurance and Performance Improvement F867 QAPI/QAA Improvement Activities at a S/S of K. The facility was notified of the Immediate Jeopardy on 04/05/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 04/12/2022, with the facility alleging removal of the Immediate Jeopardy, on 04/09/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 04/09/2022, prior to exit on 04/14/2022. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Abuse, Neglect, or Misappropriation of Resident Property, revised 05/08/2019, revealed the facility's intention was to prevent the occurrences of misappropriation of resident property and to assure all alleged violations of federal or state laws which involved misappropriation of resident property were investigated and reported immediately to agencies. Further, the Administrator made reasonable efforts to determine the root cause of the alleged violation and implemented corrective action consistent with the investigation findings and took steps to eliminate any ongoing danger to the resident(s). Continued review revealed the facility trained employees on hire and annual thereafter related to abuse, including misappropriation of resident property. Review of the facility's Employee File, for LPN #7, Screening Report/State Criminal background check, dated 12/06/2019, revealed a felony, misdemeanor and other offense. However, there was no documented evidence in the file related to the offense. The State Survey Agency (SSA) requested further information regarding the misdemeanor. Per interview with Clinical Care Consultant, on 03/25/2022 at 4:23 PM, LPN #7 was previously in the Kentucky Alternative Recovery Effort (KARE) (a program provided by the Kentucky Board of Nurses for nurses whose abilities to provide nursing care are compromised by a Substance Use Disorder, the program helps the nurses to return to work competent.). Additionally, the corporate hiring team reviewed the background checks and used a National Background Check Program to determine eligibility. Since the LPN's theft conviction was over seven (7) years old, she was eligible for employment. Further, information was provided to the SSA related to LPN #7 being charged with shoplifting on 03/22/2008, with a sentence of two (2) year conditional discharge and an Alternative Program. Continued review of LPN #7's Employee File/Kentucky Board of Nursing (KBN) Validation, dated 12/03/2019, revealed a valid/current licensure, with no investigations on the license. Additionally, the LPN's hire date was 12/16/2019. The LPN most recently received Abuse Education on 01/19/2021; 01/27/2021; and 02/14/2021. Continued review revealed a Suspension Form, dated 02/25/2021, which noted the LPN was suspended related to an investigation. Additional review revealed an Employee Termination Notice, dated 03/02/2021, which noted the LPN was terminated related to theft related to the 02/25/2021 investigation. Further review revealed a letter of receipt from the KBN, addressed to the facility, dated 03/09/2021, which noted acknowledgment of receipt of information submitted, in regard to nursing practice of LPN #7. 1. Review of Resident #151's closed medical record revealed the facility admitted the resident on 01/10/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #151, in a Quarterly Minimum Data Set (MDS) Assessment, dated 02/28/2021, as a one (1) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility discharged the resident on 03/12/2021. 2. Review of Resident #19's medical record revealed the resident was admitted by the facility, on 02/01/2016 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #19, in a Quarterly MDS Assessment, dated 01/05/2021, as a fourteen (14) of fifteen (15) on the BIMS assessment, indicating intact cognition. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #77's medical record revealed the facility admitted the resident on 12/28/2015 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #77, in a Significant Change MDS Assessment, dated 02/15/2021, as a fifteen (15) of fifteen (15) on the BIMS assessment, indicating intact cognition. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Review of Resident #30's medical record revealed the facility admitted the resident on 07/07/2017 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #30 in an Annual MDS Assessment, dated 02/01/2021, as a three (3) of fifteen (15) on the BIMS assessment, indicating severe cognitive impairment. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Review of Resident #63's closed medical record revealed the facility admitted the resident on 06/01/2019 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #63 in a Quarterly MDS Assessment, dated 12/09/2021, as a three (3) of fifteen (15) on the BIMS assessment, indicating severe cognitive impairment. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Review of Resident #161's closed medical record revealed the facility admitted the resident on 11/13/2013 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #161, in a Quarterly MDS Assessment, dated 01/15/2021, as short and long-term memory problems. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility discharged the resident on 08/24/2021. 7. Review of Resident #150's closed medical record revealed the facility admitted the resident on 02/12/2018 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #150, in a Quarterly MDS Assessment, dated 12/15/2020, as a fifteen (15) of fifteen (15) on the BIMS' assessment, indicating intact cognition. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility discharged the resident on 05/27/2021. 8. Review of Resident #162's closed medical record revealed the facility admitted the resident on 06/24/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no MDS data. The record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility discharged the resident on 02/22/2021. Review of SRNA #8's telephone Witness Statement, dated 02/25/2021, signed by the previous Administrator and the Director of Nursing (DON), revealed she was moving out of LPN #7's house on the night of 02/24/2021, and when she looked in a drawer, she saw Resident #151's prescription medication ([MEDICATION(S)]). Per statement, SRNA #8 took a picture of the medication showing the resident's name on it. Further, she believed LPN #7 took the medication from the facility. Review of the Long-Term Care Facility-Self-Reported Incident Form/Initial Report, dated 02/26/2021 at 3:31 PM, signed by the facility's previous Administrator, revealed an Allegation of Misappropriation of resident property occurred on 02/25/2021 involving Resident #151. Additional review revealed SRNA #8 reported to the Administrator that LPN #7 had medication at her house labeled with a resident's name. Per the Report, the facility was not able to validate the allegation based on record review which indicated the resident had not missed any doses of his/her medication. Further, the facility suspended LPN #7 and SRNA #8 immediately pending the investigation. Review of LPN #7's telephone Witness Statement, dated 03/01/2021, signed by the previous Administrator and Clinical Care Consultant, revealed the LPN stated she recently took both discontinued and extra medications from the medication rooms and kept them in her backpack in her truck. Additionally, her intention was to keep the medication for resident use in case the Emergency Drug Kit was out, or a different shape of the same medication would be easier on the resident to swallow. Further, she stated she knew it was stupid, illegal and against policy. Review of the Long-Term Care Facility-Self-Reported Incident form/Final Report, dated 03/03/2021, signed by the facility's previous Administrator, revealed an allegation of misappropriation of resident property occurred on 02/25/2021, which involved Resident #151. Additional review of the Final Report revealed other residents involved in the allegation of misappropriation were unknown at the time of the Final Report and staff involved in the incident was LPN #7. Per summary of the incident, the facility was not able to validate if the medication was prescribed to the resident at the time of the allegation or if the allegation was valid based on their investigation. However, continued review revealed, on 03/01/2021, the Police contacted the facility and informed them the medication found at the LPN's house was from the facility, but the Police did not discover medication for Resident #151. The Police stated they were unable to release the medication or residents' names while their investigation was ongoing. Further, the facility concluded through their investigation that current residents at the facility were never without prescription medication and no resident had an Activities of Daily Living (ADL)/Psychosocial decline because of the incident. Per the Final Report, LPN #7 was terminated, and the KBN was notified. The Final Report concluded that once the Police released their findings, if it was proven any medication came from the facility, residents would be reimbursed. However, review of KYIBRS (Kentucky Incident Based Reporting System) Report of incident 2021-1594, dated 02/25/2021 at 3:35 PM, revealed police were contacted by the facility's previous Administrator, who reported that LPN #7 allegedly took medication from residents at the facility. Continued review of the Police Report revealed the Administrator provided the picture taken by SRNA #8, at LPN #7's residence, which showed a blister card of medication with a resident's name and prescription for Resident #151's medication ([MEDICATION(S)] 150 mg). Additionally, the Administrator provided a written statement from SRNA #8, which stated the resident's medication was seen in the LPN's drawer at her home residence and SRNA #8 believed the LPN took the medication from the facility. The Police report revealed LPN #7's home residence was searched, and multiple prescription medications were found. Ninety-three (93) medications were found and identified as medication of current/former residents at the facility. Review of the documented evidence listed on the Police Report revealed the following resident medications were found at LPN #7's home: four (4) unit doses of [MEDICATION(S)] (anti-fungal medication), 150 milligrams (mg), Resident #151; seven (7) [MEDICATION(S)] 25 mg (antiemetic medication), Resident #19; twenty-five (25) [MEDICATION(S)] (muscle relaxer medication) 5 mg, Resident #77; eight (8) Acetaminophen Arthritis Extended Releases 650 mg (non-controlled pain medication), Resident #30; three (3) [MEDICATION(S)] 500 mg (antibiotic medication), Resident #63; two (2) [MEDICATION(S)] 20 mg (steroid medication), Resident #161; one (1) [MEDICATION(S)] 150 mg (anti-fungal medication), Resident #150; seven (7) [MEDICATION(S)] 25 mg (antiemetic medication), twenty-five (25) [MEDICATION(S)] 150 mg (antidepressant medication), and nine (9) Omeprazole 40 mg (decreases the amount of acid in the stomach), Resident #162. Further review of the Police Report revealed LPN #7 admitted she took the medications from the facility in her backpack. Per the report, a warrant of arrest was issued for LPN #7 for the charge of Theft of a Legend Drug (9 counts), Illegal Possession of a Legend Drug, Possession of Marijuana, and Drug Paraphernalia-Buy/Possess. The State Survey Agency (SSA) attempted to contact LPN #7, on 03/25/2022, at 9:24 AM; however, her voice mail box was full and the SSA was unable to leave a message for a return call. Interview with the Clinical Care Consultant, on 03/25/2022 at 2:15 PM, revealed she worked in her role for five (5) years; however, she had been assigned to other facilities since April 2021. Per interview, she submitted the Initial Report and assisted with the facility's investigation. Additionally, the facility's investigation could not prove that medications alleged at LPN #7's house came from facility; it was reported to the facility by the Police that they also could not validate that the medication at the LPN's house were the resident's or facility medications. Continued interview revealed even though LPN #7's written statement said she was taking extra and discontinued medication from the facility, the facility felt that they did not have sufficient evidence to say it was Resident #151's medication or medication from the facility without the Police corroborating the medications at the LPN's house were from the facility. Additional interview revealed it was her understanding the Police found medications at LPN #7's house that were not prescribed to her and she was charged. However, the Police could not release their Investigation. Per interview, she and the previous Administrator followed up on the Police Investigation routinely and tried to obtain a copy of the Police Report. However, the last time she contacted the Police related to the Investigation of the alleged drug diversion from residents at the facility was in April of 2021. Further, after April 2021, she was no longer assigned as a consultant for the facility and did not know the outcome of the investigation. On 03/03/2021, the facility's investigation concluded, no active medications were missing for any resident in the facility, and there were no outcomes to any resident, therefore, there was no misappropriation of resident property (medication). Telephone interview with SRNA #8, on 03/25/2022 at 3:47 PM, revealed she reported the medication misappropriation/drug diversion to the previous Administrator on 02/25/2021. Per interview, she was at LPN #7's house and was in the bathroom, opened a drawer and saw medication with Resident #151's name on it. Additionally, she took a picture and sent it to the previous Administrator. Further, she wrote a statement for the facility; however, she did not talk to the police because she wanted to be left out of it. SRNA #8 stated she had been harassed for a year over this incident and would not talk to the SSA anymore and ended the call. Interview with the Chief of Police, on 03/28/2022 at 10:53 AM, revealed he was familiar with the drug diversion incident on 02/25/2021 involving the residents at the facility and LPN #7. Additionally, he recalled the facility's previous Administrator telephoned and reported the allegation of drug diversion and provided LPN #7's address on 02/25/2021. Further, an officer went to LPN #7's house to conduct a knock and talk, and discovered the nurse had a collection of assorted medications from the facility at her house. Per interview, he reviewed the Police Report after the arrest and the previous Administrator was contacted on 03/01/2021 to confirm that all the prescription medications located at LPN #7's house belonged to current or discharged residents from the facility. Interview with the previous Administrator, on 03/26/2022 at 9:54 AM, revealed he was the Administrator at the facility from January 2021 until May 2021. Per interview, he recalled the misappropriation of residents' medications involving LPN #7 that occurred in February 2021. Continued interview revealed SRNA #8 reported to him, on 02/25/2021, that she saw medications in LPN #7's house that belonged to Resident #151. Additionally, the SRNA either showed or sent him a picture of the medications with Resident #151's name on it. He immediately started an investigation, reported the allegation, made timely notification to the local Police, and suspended the staff involved. Per interview, the police went to LPN #7's house and reported to the facility that they did find medications at her house that belonged to residents at the facility. Further interview revealed the police did not give the facility a list of what exactly they had found at the LPN's house or what specific residents' medications were found; but they did tell him there were medications labeled with facility resident's names at LPN #7's house. The facility completed a medication reconciliation for all residents and their active medication orders, and it was determined nothing was missing. Per interview, he was not aware the facility reconciled discontinued or extra medications during their investigation. Additionally, he understood that when discontinued medications were sent back to the pharmacy, the residents were credited for the remaining medications. Continued interview revealed he could not confirm if the facility implemented an action plan after this incident to ensure an incident of the same nature did not happen again. Further, based on the LPN's statement and what the Police reported to him, the facility terminated the LPN's employment and reported the incident to KBN. However, the previous Administrator stated in LPN #7's statement, she admitted she was taking the mediations from the residents, and the Police confirmed there were residents' medications at the LPN's house. LPN #7 was taking residents' medication, which was their personal property, and that was misappropriation. The residents could not be reimbursed for those medications she took because he was not aware of the specific residents involved in the incident and what medication was taken from the facility. Interview with Director of Nursing (DON), on 03/26/2022 at 11:09 AM, revealed she had been in the role for one (1) year and was previously a Unit Manager for one (1) year at the facility. Per interview, prior to the investigation dated 02/25/2021, the facility did not have a system in place to ensure non-controlled medications were accounted for/reconciled before destruction or returned to the Pharmacy. Continued interview revealed the process to review discontinued medications in the Clinical Meeting was implemented after the alleged misappropriation of medication incident, on 02/25/2021, involving LPN #7. The DON stated the nurse management attended the Clinical meetings, Monday through Friday, and reviewed discontinued orders. She stated they were responsible to ensure discontinued medications, previously discussed were removed from the medication carts and placed in medication rooms for pharmacy pick up. However, other than the discontinued order in the Electronic Medical Record (EMR), there was no documented evidence of a process on how non-controlled discontinued medications were reconciled, destroyed, or returned to Pharmacy. The DON stated the previous Administrator notified her on 02/25/2021 of the allegation of misappropriation of medication. During the investigation, she was responsible to audit medications in the medication carts compared to the active orders for each resident to ensure each active medication with an order was in the medication carts. However, the audit did not include discontinued medication or review of the process for discontinued medications. She stated she did not contact Pharmacy related to the possible drug diversion of discontinued medications. Further interview revealed the previous Administrator completed the investigation and made the conclusion because she (the DON) was busy on the floor; however, she probably was updated before it was all over by the previous Administrator. The DON stated she was not aware of what the facility's investigation concluded. After reviewing the investigation's conclusion, she stated the facility concluded no misappropriation. Per interview, it was important the facility ensured residents were free from misappropriation of property (medication). Interview with Unit Manager/RN #3, on 03/26/2022 at 12:00 PM, revealed she had been in the role for three (3) weeks and was previously a direct care nurse at the facility. Per interview, the facility held Clinical meetings Monday through Friday and attendees included the Minimum Data Set (MDS) Nurse, the Staff Development Nurse, the DON, the Assistant DON, and Unit Managers. In the meeting a print-out from the Electronic Medical Record (EMR), of all new orders from the last twenty-four (24) hours were reviewed. The print-out included discontinued medication orders. The team ensured the medication orders, the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, she documented any discontinued medications and the resident's name. After the meeting, they would take the paper and physically go to the medication carts, and remove the discontinued medication from the cart and place it in the pharmacy tote in the locked medication room. Continued interview revealed if there was a discontinued medication order, the nurse was supposed to remove it from the cart and place it in the medication room, in the pharmacy tote. However, there was no process in place to ensure discontinued medications were returned to the Pharmacy. Per interview, Pharmacy came to the facility Monday through Friday, twice daily and once per night on weekends, to pick up discontinued medications. Continued interview revealed the facility should make sure discontinued medications were returned to Pharmacy and there should be a system in place to reconcile the discontinued medication to ensure residents were reimbursed. Interview with the current Administrator, on 03/26/2022 at 11:35 AM, revealed he came to the facility on [DATE]. Per interview, he was not aware of any misappropriation/diversion of medications made prior to his arrival to the facility. Additionally, he stated he expected residents' discontinued medications to be returned to pharmacy so residents would be reimbursed. However, he did not expect the Nursing Department to have a system in place to reconcile discontinued medications to ensure they were returned to pharmacy for reconciliation and reimbursement; that was the responsibility of the Pharmacy. Further there was no way to guarantee a nurse would not take medications from the facility. He stated laws were in place to prevent nurses from taking medications; nurses could be convicted and jailed for up to five (5) years. Per interview, that was the preventive measure for nurses to not take medications. Continued interview revealed the alleged misappropriation, on 02/25/2021, was strictly an intentional criminal act by LPN #7. He stated residents should be free from abuse/misappropriation. Interview with the Medical Director (MD), on 03/28/2022 at 10:02 AM, revealed he was aware of the 02/25/2021 incident with LPN #7 related to misappropriation of medications. However, he was not aware of the specific details of what the nurse was doing with the medications per her statement or the facility's investigation. The Medical Director stated he could not recall an action plan the facility had implemented/changed to make improvement with the current practice to minimize diversion or misappropriation of medications. However, something should have been done to correct the issue. Additionally, he stated it was very important for the facility to have safeguards in place to ensure the incident did not occur again. Further, the facility had a fiduciary (act on behalf of ) duty to residents to treat medical conditions. The MD The facility was responsible for all care and well being for each resident. Telephone interview with the contracted Pharmacist and the Pharmacy Director, on 03/28/2022 at 2:20 PM, revealed the pharmacy was not contacted by the facility or made aware of the drug diversion/misappropriation of the ninety-three (93) medications, on 02/25/2021, involving LPN #7 and eight (8) residents at the facility. Per interview, the facility was responsible to have a process in place to ensure reconciliation of all medications. Further interview revealed not all medications were returned to the Pharmacy for reconciliation. Interview revealed controlled medications and multi dose medications that could not be re-used were destroyed at the facility and were considered non-creditable medications. The Pharmacy's process for reconciliation of discontinued medications relied on the facility to return medications that had been discontinued, for reimbursement. Per interview, the medication came back to the pharmacy in the same cards which they were dispensed from the pharmacy in. The card of medication went straight to the billing department, where the number of pills returned for a specific prescription was counted, which projected the reimbursement. Additionally, the Pharmacy expected the facility to communicate all diversion issues, due to the need to have medications available to residents and for necessary review of the policy and procedures; and, collaboration to ensure best practice. Continued interview revealed there should have been an audit immediately to ensure correct medications were on hand in the facility; and, a review of the process on how the facility handled discontinued medications. In addition, a review of policy and procedures with staff should have been completed after the incident as a safeguard to prevent it from occurring again in the future. After review of LPN #7's statement, related to her taking the extra and discontinued medication from the facility and keeping them in her book bag in her truck for intention of dispensing the medication to residents based on the shape or the medication or the medication not being available at the facility, raised great concern from the Pharmacy. Per interview, the LPN could grab any drug not prescribed to a resident and administer it without an order; it would also be theft/stealing prescription medication from residents, and medication was controlled by government. Further, the facility should have documentation of the actions implemented to ensure diversion of the same nature did not happen again. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Pharmacy Nurse Consultants completed a medication cart audit to ensure discontinued medication was removed. This was completed by 04/07/2022. 2. Two Regional Social Services Directors reviewed all current residents' Progress Notes, events, and grievances to ensure residents were free from misappropriation of property. This was completed by 04/05/2022. 3. Signature Care Consultant (SCC) collaborated with the Pharmacy Director on 04/06/2022 and put the following plan in place: the nurses will remove the medication from the carts, store them properly, the medications listed on the form will be sent back; the driver, and two (2) licensed nurses signed the form prior to the driver exiting the facility with the discontinued medications. 4. The SCC educated the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), Staff Development Coordinator (SDC), Medical Records Nurse and the Administrator on the Abuse Policy including misappropriation of residents' property which included medications. This was completed on 04/05/2022. 5. The DON, ADON, UM, SDC, Medical Records Nurse and the Administrator were assigned to reeducate current staff working in the facility, to include agency staff, in small groups. This was completed by 04/07/2022. Certified letters were mailed out to staff not currently on shifts and no staff was allowed to work until reeducation was provided. Reeducation included abuse, misappropriation of residents' property which included medications. 6. Audits of Progress Notes, events, and grievances for current residents began on 04/08/2022 by the DON, ADON, UM, SDC, MDS Nurse, and Restorative Nurse to look for any documentation of misappropriation of property. The State Surveyor Agency (SSA) validated the implementations of the facility's Jeopardy Removal Plan as follows: 1 .Observation completed by the SSA on 04/13/2022 at 2:55 PM, revealed the pharmacy courier completed the new medication pick-up process. The courier scanned a list of medications which contained four (4) residents. Each resident had one (1)

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure an effective system was in place for pharmaceutical services to meet the needs of each resident. The facility failed to develop a system to ensure medications received from the pharmacy were accounted for. In addition, the facility failed to collaborate with their contracted pharmacy to develop safeguards and put systems in place to control, account for, and periodically reconcile medications to prevent diversion, and there was no documentation that the causes of the discrepancies were thoroughly investigated. These failures affected eight (8) of seventy-one (71) sampled residents (Residents #19, #30, #63, #77, #150, #151, #161 and #162). The facility failed to ensure discontinued medications were accounted for while awaiting removal by a representative of the contracted pharmacy. Review of the Police Report, dated 02/25/2021, revealed Licensed Practical Nurse (LPN) #7 admitted to the Police she took medications from residents at the facility. LPN #7 was implicated for the charge of Theft of a Legend Drug (a drug approved by the Food and Drug Administration {FDA} that can be dispensed to the public only with a prescription) 9 (nine) counts, Illegal Possession of a Legend Drug, Possession of Marijuana, and Drug Paraphernalia-Buy/Possess; ninety-three (93) medications which she had misappropriated from the facility. However, interview with the Pharmacy revealed they were not aware of the drug diversion/misappropriation identified on 02/25/2021. The pharmacy only reconciled medication cards returned to the pharmacy; the facility was responsible to have a process in place to ensure reconciliation of all medications. Further, the pharmacy did not identify an issue with systems in place to control, account for, and periodically reconcile medications to prevent diversion. Interviews with the previous Administrator, the Pharmacy, and the Medical Director revealed they were not aware of a procedure to maintain an accurate accounting of residents' medications in the facility until they were returned to the pharmacy. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/04/2022 and was determined to exist on 02/24/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation; F602 Free from Misappropriation Exploitation at a scope and severity (S/S) of K, and at 42 CFR 483.25 Quality of Care F 689 Free from Accidents/Hazards/Supervision/Devices at a S/S of J. Immediate Jeopardy was identified at 42 CFR 483.21 Comprehensive Person-Centered Care Plans F656 Comprehensive Resident Centered Care Plans at a S/S of J 42 CFR 483.45 Pharmacy Services F755 Pharmacy Services/Procedure /Pharmacist/Record at a S/S of K at 42 CFR 483.70 Administration F835 Administration and F837 Governing Body at a S/S of K at CFR 42 483.75 Quality Assurance and Performance Improvement F867 QAPI/QAA Improvement Activities at a S/S of K. The facility was notified of the Immediate Jeopardy on 04/05/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 04/12/2022, with the facility alleging removal of the Immediate Jeopardy, on 04/09/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 04/09/2022, prior to exit on 04/14/2022. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility policy, Provider Pharmacy Requirements, dated 2007, revealed the facility provided regular and reliable pharmaceutical service to provide residents with prescription and non-prescription medications, services, and related equipment and supplies. Additionally, the pharmacy's obligation was set forth in the written agreement/contract. Continued review revealed pharmacy was responsible to render services in accordance with local, state, and federal laws and regulations, nursing care policy, and procedures, community standards of practice and professional standards of practice. Further, the pharmacy assisted the center in determination of the appropriate acquisition, receipt, dispensing and administration of all medication to meet the medication needs of the residents. Review of the facility's Pharmacy Contract, dated 12/21/2020, revealed the pharmacy had an obligation to deliver prescription and non-prescription drugs in accordance with the orders of the resident's licensed prescriber. Additionally, the pharmacy would have a licensed pharmacist available twenty-four (24) hours each day, seven (7) days per week to respond to requests for pharmacist consultation. Per contract, the pharmacy would manage medication returns in accordance with the current policy. Further, when a resident had unused medication, it would be returned unused to the pharmacy for credit. Review of the facility's policy titled, Discontinued Medications, dated 2007, revealed when a prescriber discontinued medications, a resident was transferred or discharged and did not take medications with him/her, or in an event of a resident's death, the medications were marked as discontinued and destroyed or returned to the pharmacy, if applicable per regulations. Additionally, if a prescriber discontinued a medication, the medication container was removed from the medication cart immediately. Continued review revealed medications awaiting disposal or return were stored in a locked secure area as designated until destroyed or picked up by pharmacy staff. Medications subject to return were picked up by the pharmacy staff along with proper paperwork within a timely manner to avoid inadvertent administration. Further, discontinued medication that were unopened (such as unit-dose, sealed containers) may be returned to the pharmacy in accordance with the medication return policy and procedure. Discontinued medication not returned to the pharmacy were destroyed in accordance with the destruction policy and procedure. Review of the facility's policy titled, Returning Medications to the Pharmacy, dated 2015, revealed medications issued by the pharmacy would be accepted for return and credit, when required by state law, following proper storage and handling guidelines to assure maintenance of the products strength, quality, and purity. Additionally, the process for handling of returned goods, was consistent with all applicable state and federal laws and regulations. Continued review revealed not all medications were accepted for return to the pharmacy, including but not limited to controlled medications; medication requiring special storage conditions (refrigeration); special order medication (split tablets); opened eye drops, inhalers, creams, or liquids; medications dispensed forty-five (45) days prior to return date; and medication with compromised integrity. Further, the nursing center should have documentation of all returned medications Review of the facility's policy titled, Disposal, dated 2015, revealed discontinued medications left in the nursing care center after a resident's discharge, which did not qualify for return to the pharmacy, were identified and removed from the current medication supply in a timely manner for disposition. Additionally, the Director of Nursing and the consultant pharmacist monitored for compliance with federal and state laws and regulations regarding the disposal of medication. Non-controlled medications were destroyed in the nursing care center in the presence of a pharmacist or nurse and one (1) other witness. Further, documentation of non-controlled medication was retained per federal privacy and state regulation. Review of the Long-Term Care Facility-Self-Reported Incident form/Final Report, dated 03/03/2021 at 3:56 PM, signed by the facility's previous Administrator, revealed an Allegation of Misappropriation of resident property occurred on 02/25/2021, and involved Resident #151. Additional review of the facility's Report revealed other residents involved in the allegation of misappropriation were unknown at the time of the Report and staff involved in the incident was LPN #7. Per summary of the incident, the facility was not able to validate if the medication was prescribed to the resident at the time of the allegation or if the allegation was valid based on their investigation. Review of KYIBRS (Kentucky Incident Based Reporting System) Report of incident 2021-1594, dated 02/25/2021 at 3:35 PM, revealed the facility's previous Administrator contacted the police and reported LPN #7 allegedly took medication from residents at the facility. Continued review of the Police Report revealed the Administrator provided a picture taken by State Registered Nurse Assistant (SRNA) #8, at LPN #7's residence, which showed a blister pack of medications labeled with a prescription for Resident #151's medication ([MEDICATION(S)] 150 mg). Additionally, the Administrator provided a written statement from SRNA #8, which stated the resident's medication was seen in a drawer at the LPN's home and SRNA #8 felt the LPN took the medication from the facility. The Police report revealed LPN #7's home residence was searched, and multiple prescription medications were found. Ninety-three (93) medications were found and identified as medication of current/former residents at the facility. Review of the documented evidence listed on the Police Report revealed the following resident medications were found at LPN #7's home residency: four (4) unit doses of [MEDICATION(S)] (anti-fungal medication), 150 milligrams (mg), Resident #151; seven (7) [MEDICATION(S)] 25 mg (antiemetic medication), Resident #19; twenty-five (25) [MEDICATION(S)] (muscle relaxer medication) 5 mg, Resident #77; eight (8) Acetaminophen Arthritis Extended Releases 650 mg (non-controlled pain medication), Resident #30; three (3) [MEDICATION(S)] 500 mg (antibiotic medication), Resident #63; two (2) [MEDICATION(S)] 20 mg (steroid medication), Resident #161; one (1) [MEDICATION(S)] 150 mg (anti-fungal medication), Resident #150; seven (7) [MEDICATION(S)] 25 mg (antiemetic medication), twenty-five (25) [MEDICATION(S)] 150 mg (antidepressant medication), and nine (9) Omeprazole 40 mg (decreases the amount of acid in the stomach medication), Resident #162. Further review of the Police Report revealed LPN #7 admitted she took the medications from the facility in her backpack. Per report, a warrant of arrest was issued for LPN #7 for the charge of Theft of a Legend Drug (9 counts), Illegal Possession of a Legend Drug, Possession of Marijuana, and Drug Paraphernalia-Buy/Possess. 1. Review of Resident #151's closed medical record revealed the facility admitted the resident on 01/10/2019 with diagnoses to include Dementia with behavioral disturbance, Diabetes Mellitus Type II, Chronic pain, [CONDITION(S)], Pressure Ulcer sacrum, and history of Candidiasis. The facility assessed Resident #151, in a Quarterly Minimum Data Set (MDS) Assessment, dated 02/28/2021, with a Brief Interview for Mental Status (BIMS) exam with a one (1) of fifteen (15), indicating severe cognitive impairment. The record revealed a discontinued Physician's Order, dated 11/12/2020 for [MEDICATION(S)] 150 mg. The facility discharged the resident on 03/12/2021. 2. Review of Resident #19's medical record revealed the facility admitted the resident on 02/01/2016 with diagnoses that included Dementia, Major Depressive Disorder, and [CONDITION(S)]. The facility assessed Resident #19, in a Quarterly MDS Assessment, dated 01/05/2021, as a fourteen (14) of fifteen (15) on the BIMS' assessment, indicating intact cognition. The record revealed a discontinued Physician's Order, dated 08/20/2020 for [MEDICATION(S)] 25 mg. 3. Review of Resident #77's medical record revealed the facility admitted the resident on 12/28/2015 with diagnoses to include Dementia, Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), and [CONDITION(S)] (CHF). The facility assessed Resident #77, in a Significant Change MDS Assessment, dated 02/15/2021, as a fifteen (15) of fifteen (15) on the BIMS' assessment, indicating intact cognition. The record revealed a discontinued Physician's Order, dated 03/16/2020 for [MEDICATION(S)] 5 mg. 4. Review of Resident #30's medical record revealed the facility admitted the resident, on 07/07/2017 with diagnoses that included Autistic Disorder, Dysphagia and Anxiety disorder. The facility assessed Resident #30, in an Annual MDS Assessment, dated 02/01/2021, as a three (3) of fifteen (15) on the BIMS assessment, indicating severe cognitive impairment. The record revealed a discontinued Physician's Order, dated 01/31/2020 for Acetaminophen Arthritis Extended Releases 650 mg. 5. Review of Resident #63's closed medical record revealed the facility admitted the resident on 06/01/2019 with diagnoses to include Unspecified Dementia, Major Depression Disorder, and Anxiety Disorder. The facility assessed Resident #63, in a Quarterly MDS Assessment, dated 12/09/2021, as a three (3) of fifteen (15) on the BIMS' assessment, indicating severe cognitive impairment. The record revealed a discontinued Physician's Order, dated 12/26/2020 for [MEDICATION(S)] 500 mg. 6. Review of Resident #161's closed medical record revealed the facility admitted the resident on 11/13/2013 with diagnoses that included [CONDITION(S)], Dementia, Pseudobulbar Affect, and Dysphagia. The facility assessed Resident #161, in a Quarterly MDS Assessment, dated 01/15/2021, as short and long-term memory problems. The record revealed a discontinued Physician's Order, dated 01/13/2021 for [MEDICATION(S)] 20 mg. The facility discharged the resident on 08/24/2021. 7. Review of Resident #150's closed medical record revealed the facility admitted the resident on 02/12/2018 with diagnoses to include End Stage Renal Disease ([CONDITION(S)]), [CONDITION(S)] and CHF. The facility assessed Resident #150, in a Quarterly MDS Assessment, dated 12/15/2020, as a fifteen (15) of fifteen (15) on the BIMS' assessment, indicating intact cognition. The record revealed a discontinued Physician's Order, dated 11/08/2020 for [MEDICATION(S)] 150 mg. The facility discharged the resident on 05/27/2021. 8. Review of Resident #162's closed medical record revealed the facility admitted the resident on 06/24/2019 with diagnoses that included [CONDITION(S)], Dysphagia, and Opioid Use. There was no MDS data. The record revealed Physician's Orders, dated 09/24/2020 for [MEDICATION(S)] 25 mg; 12/04/2020 for [MEDICATION(S)] 150 mg; and 09/03/2020 for Omeprazole 40 mg. The facility discharged the resident on 02/22/2021. Interview with LPN #5, on 03/25/2022 at 11:30 AM, revealed she has worked at the facility for six (6) years. Per interview, the practice at the facility was when medication was discontinued, it was pulled from the medication cart and placed in an empty tote, in the medication room; then someone placed a green tie to secure the tote. Additionally, the discontinued medications stayed in the pharmacy tote, until pharmacy staff arrived for pick up. Further interview with LPN #5 revealed, there was no documentation regarding what discontinued medications were placed in the pharmacy tote. Interview with the Clinical Care Consultant, on 03/25/2022 at 2:15 PM and 03/26/2022 at 11:10 AM, revealed she had worked in her role for five (5) years; however, she had been assigned to other facilities since April of 2021. Per interview, she was an active participant in the investigation of misappropriation identified on 02/25/2021. Additionally, during the investigation she had identified no concerns with the medication audit or the facility's process for accounting for medications. Therefore, the facility did not contact the pharmacy related to the incident of misappropriation of medication on 02/25/2021. Per interview, after April 2021, she was no longer assigned as a consultant for the facility and did not know what the outcome of the investigation was after that. Interview with Clinical Care Consultant and Regional Director, on 03/26/2022 at 10:00 AM revealed Unit Managers reviewed all discontinued orders in clinical meetings, Monday through Friday. Additionally, the Unit Managers noted the discontinued orders, returned to floor, and ensured those medications were pulled from each medication cart, scanned, and placed in the pharmacy return bin in the locked medication rooms. Per interview, the facility did not have a process to view what discontinued medications were scanned to compare to discontinued orders, to ensure all discontinued medications were reconciled and destroyed at the facility or sent back to the Pharmacy for reimbursement. Further, there was no documentation of discontinued, non-controlled medication destroyed at the facility or returned to the pharmacy. Interview with the previous Administrator, on 03/26/2022 at 9:54 AM, revealed he was the Administrator at the facility from January 2021 until May 2021. Per interview, the facility completed a medication reconciliation for all residents and their active medication orders and determined nothing was missing, per the nursing department. However, he could not recall if all medications including discontinued and extra medications were reconciled at the time of the investigation; but stated they should have been. Additionally, he could not remember if the facility implemented an action plan to mitigate a similar incident from occurring again. Continued interview revealed he felt the normal safeguards in the facility related to medication, which were in place prior to the incident, were strict, and he did not know how to do more to stop a nurse from taking medications. Per interview, he could not confirm if the facility contacted the pharmacy after they identified drug diversion/misappropriation for consultation. Interview with Director of Nursing (DON), on 03/26/2022 at 11:09 AM, revealed she had been in the role for one (1) year and was previously a Unit Manager for one (1) year at the facility. Per interview, she was responsible for the medication audits after the identified misappropriation, on 02/25/2021. She stated staff completed a medication audit to reconcile medicine in the medication carts to the active orders for each resident to ensure each active medication was in the medication carts, available to residents. After the audit, she did not identify any concerns; therefore, she did not contact Pharmacy related to the allegation of possible drug diversion of discontinued medication. However, per interview, the audit did not include all medications (discontinued or extra medication) or a review of the process for discontinued medications. She stated after the investigation, the nurse management who attended the Clinical meetings Monday through Friday were responsible to ensure discontinued medication orders discussed were removed from the medication carts and placed in medication rooms for pharmacy pick up. The DON stated prior to the incident on 02/25/2021, there was no process in place to account for non-controlled medications at the facility and the new process did not include reconciliation of discontinued orders to the medications in the return pharmacy tote. Per interview, the pharmacy scanner was only used for controlled medications during the reconciliation/destruction process. There was no documented evidence non-controlled discontinued medications were reconciled, destroyed, or sent back to Pharmacy, other than the discontinued order in the Electronic Medical Record (EMR). Per interview, it was important that the facility had systems in place to account for, and periodically reconcile medications to prevent diversion to ensure residents were free from misappropriation (medication). Interview with Unit Manager/RN #3, on 03/26/2022 at 12:00 PM, revealed she had been in the role for three (3) weeks and was previously a direct care nurse at the facility. Per interview, Clinical meetings were Monday through Friday and attendees include the Minimum Data Set (MDS) Nurse, the Staff Development Nurse, the DON, the Assistant DON, and Unit Managers. In the meetings, a print-out from the EMR, of all new orders from the last twenty-four (24) hours was reviewed. The print-out included discontinued medication orders. The team ensured the Medication order, the Medication Administration Record, laboratory, and Care Plans all reflected the change of the medication being discontinued. Additionally, during the meeting she noted any resident's discontinued medications reviewed were to be physically removed from the cart after the meeting, and placed in the pharmacy tote in the locked medication room. Per interview, nurses did not have access to scan with the view master (the pharmacy scanner) nor had the facility trained nurses on the scanner, only the DON. Continued interview revealed if there was a discontinued medication order, the nurse was supposed to remove it from the cart and place it in the medication room, in the pharmacy tote. She stated there was no process in place to ensure discontinued medications were returned to the Pharmacy and no documentation of what medications were placed in the pharmacy return totes to ensure all medications were returned. Per interview, the Pharmacy came to the facility Monday through Friday, twice a day and once per night on weekends, to pick up discontinued medications. Continued interview revealed the facility should make sure discontinued medications were properly sent back to Pharmacy and there should be a system in place to reconcile the discontinued medications to ensure residents were reimbursed. Interview with the Medical Director, on 03/28/2022 at 10:02 AM, revealed he was aware of the 02/25/2021 incident with LPN #7 related to the identified misappropriation of medication, on 02/25/2021. However, he was not aware of an action plan that the facility implemented/changed to make improvement with the current practice in the facility to minimize diversion or misappropriation of medications. Further, it was very important for the facility to have safeguards in place to ensure the incident did not occur again. Telephone interview with the contracted Pharmacist and the Pharmacy Director, on 03/28/2022 at 2:20 PM, revealed the pharmacy was not contacted by the facility or made aware of the drug diversion/misappropriation of the ninety-three (93) medications, identified on 02/25/2021, involving LPN #7 and eight (8) residents at the facility. Additionally, the Pharmacy expected the facility to communicate all diversion issues, due to the need to have medication available to residents and for necessary review of policy and procedures; and, collaboration to ensure best practice. Continued interview revealed there should have been an audit immediately to ensure correct medications were on hand in the facility. He stated a review of the process on how the facility handled discontinued medications. In addition, a review of policy and procedures related to pharmacy procedures with staff should have been completed after the incident as a safeguard to prevent it from occurring again in the future. Further, the facility should have documentation of the actions implemented to ensure medication were accounted for in the facility. Interview with current Administrator, on 03/26/2022 at 11:35 AM, revealed he came to facility on 06/01/2021. Per interview, he was not aware if the facility contacted the pharmacy related to the 02/25/2021 incident. Additionally, he was not aware of processes in the nursing department that ensured the accountability for medications while at the facility. Further, he did not expect the Nursing department to have a system in place to reconcile medications to ensure they were accounted for at the facility prior to destruction or returned to pharmacy for reconciliation and reimbursement; that was the responsibility of the Pharmacy. Review of the IJ Removal Plan revealed the facility implemented the following: 1. Residents #19, #30, #63 and #77's medications were reconciled to the Physician's Orders by the Pharmacy Consultant Nurse to ensure all discontinued medications were removed from the med cart. This was completed on 04/07/2022. 2. The Signature Care Consultant (SCC) educated the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), Staff Development Coordinator ( (SDC), Medical Records Nurse (MRN) and the Administrator related to the facility's policy for Discontinued Medication, discharged Medication and Return Medication to the Pharmacy. This was completed on 04/05/2022. 3. Once management staff was trained, they were assigned to re-educate current licensed nurses, Kentucky Medication Aides (KMA) and SRNAs on the facility's policy for Discontinued Medication, discharged Medication and the Return of Medication to the Pharmacy. This was started on 04/05/2022 and completed on 04/07/2022. All staff currently still on payroll were sent certified letters and no staff were allowed to return to work without completing this training. 4. Residents #19, #30, #63 and #77 still resided at the facility. They were assessed for physical/psychosocial well-being to ensure no related outcome to alleged misappropriation of discontinued medications on 04/06/2022. This was completed by the DON, ADON and/or UM. 5. Starting on 04/05/2022 the SCC or Vice President of Regulatory Compliance provided daily administrative oversight to the facility which continued until immediacy was removed. 6. Starting on 04/05/2022, for the first seven (7) days the Quality Assurance meeting will be completed by the Regional Vice President of Operations or a member of the regional/corporate staff until removal of the Immediate Jeopardy. This will be done weekly for the first month and then monthly after that. The State Survey Agency validated the implementation of the facility's IJ Removal Plan as follows: 1. Record review on 04/13/2022 at 11:30 AM, revealed six (6) medication carts were audited. Audit findings were sent to the facility. Medications for Residents #19, #30, #63 and #77 were reconciled and no concerns were found. 2. Interview with the DON, ADON, UM, SDC, MRN and the Administrator on 04/14/2022 at 4:30 PM, revealed they were re-educated by the SCC on the new process for discontinued medication, discharged medication, and returning medication to the pharmacy. They reviewed the policy and had a question-answer session, no concerns were noted. Interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON), the Unit Manager (UM), Staff Development Director (SDD), Medical Records Nurse (MRN) and the Administrator revealed they were all reeducated by the Signature Care Consultant on the facility policies for Discontinued Medications, discharged Medications and Return Medications to the Pharmacy and this was completed on 04/05/2022. 3. Interview with RN #3 on 04/13/2022 at 10:30 AM, RN #14 at 11:00 AM and interview with LPN #6 on 04/14/2022 at 10:25 AM, LPN #4 at 11:05 AM, and RN #4 at 11:00 AM, revealed each of them were educated on the new discontinued medication process. Each staff member was able to explain the process, however they explained the ADON, and DON handled picking up the medication and putting it in the locked med room. Also, the ADON and DON handled the transaction with the pharmacy. 4. Interview with DON, ADON and UM on 04/14/2022 at 4:30 PM, revealed they met with Residents #19, #30, #63 and #77 to assess them for any physical/psychosocial concerns related to misappropriation of medication. Record review completed on 04/13/2022 at 11:30 AM, of Social Services progress notes, revealed Residents #19, #30, #63 and #77 were assessed for physical and or psychosocial concerns related to misappropriation of medication. No concerns were found. Residents #150, #151, #161, and #162 had been discharged . LPN #7 was suspended on 02/25/2021 and terminated on 03/02/2021. Electronic Medical Record (EMR) was validated. 5. Interview with the SCC, on 04/14/2022 at 4:00 PM, revealed she had been present every day in the facility while they worked to remove the IJs. She attended daily QAPI meetings and oversight throughout. She provided ongoing training with the administrative team and reviewed audits. Any adjustments were made throughout the process if needed. Interview with the Regional Vice President of Operations, on 04/14/2022 at 2:45 PM, revealed he provided oversight for the facility via telephone daily during QAPI. He revealed he listened and provided input when needed. The Immediate Jeopardy (IJ) was discussed, along with ongoing education for the staff. He was also involved with reviewing all audits and ongoing conversation with the Administrator. He revealed he had not identified any concerns. Interview with the Director of Pharmacy Services, on 04/13/2022 at 10:20 AM, revealed he had worked in close contact with the facility's Regional Consultant Director and the Vice President of Regulatory Compliance discussing past concerns and how to prevent those things in the future. They also developed a new procedure on how to deal with discontinued medication which included a way to track them. 6. Interview with the DON, ADON, UM, SDC, MRN and Administrator on 04/14/2022 at 4:00 PM, revealed they were all involved in doing audits daily for seven (7) days, in clinical meetings to discuss root cause for falls, to ensure new interventions were put in place, and included additional supervision. Additionally, the DON and the Administrator reviewed all audits to ensure they were completed properly, and any concerns were identified. The DON and Administrator revealed no new concerns were found.

Based on interview, record review, review of the facility's policy, and review of the facility's Administrator's Job Description, it was determined the facility failed to be administered in a manner which enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's administration failed to ensure thorough actions were taken after the 02/25/2021 misappropriate/drug diversion involving eight (8) residents. In addition, the facility failed to ensure the safety of residents to prevent falls for a resident assessed as a high risk for falls. Additionally, the facility's administration failed to maintain substantial compliance, after the 01/24/2019, Recertification Survey, in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656, F657); 42 CFR 483.25 Quality of Life (F689); and 42 CFR 483.45 Pharmacy Services (F755). Further, the facility's administration failed to maintain substantial compliance, after the 11/05/2019, Abbreviated Survey, in the areas of CFR 483.12 Freedom from Abuse (F610); and 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656). The facility's failure to ensure it was administered effectively and failure to follow their policy has caused or is likely to cause serious injury, serious harm, or death to other residents in the facility. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/04/2022 and was determined to exist on 02/24/2021 in the area in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation, F602 Free from Misappropriation Exploitation at a scope and severity (S/S) of K; 42 CFR 483.21 Comprehensive Person-Centered Care Plans, F656 Comprehensive Resident Centered Care Plans at a S/S of J; 42 CFR 483.25 Quality of Care, F689 Free of Accidents/Hazards/Supervision/Devices at a S/S of J; 42 CFR 483.45 Pharmacy Services, F755 Pharmacy Services/Procedure/Pharmacist/ Record at a S/S of K; 42 CFR 483.70 Administration, F835 Administration and F837 Governing Body at a S/S of K; and at 42 CFR 483.75 Quality Assurance and Performance Improvement, F867 QAPI/QAA Improvement Activities at a S/S of K. The facility was notified of the IJ and SQC on 04/04/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 04/12/2022, with the facility alleging removal of the Immediate Jeopardy, on 04/09/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 04/09/2022, prior to exit on 04/14/2022. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility's policy, titled Facility Administration, last reviewed 09/05/2018, revealed the facility operated under the direction of the Administrator in accordance with Federal and State laws and professional standards. Additionally, current surveys by state and/or local health authorities were on file, along with the facility's plan of action to correct deficiencies. Continued review revealed the Administrator was part of the facility's Governing Body that was legally responsible for establishing and implementing policies regarding the management and operations of the facility. Further review revealed the facility's policies and procedures were maintained and updated periodically to reflect current professional standards and practice through annual review. Review of the facility's Job Description for the Administrator, dated December 2018, revealed the Administrator led and directed the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Additionally, the Administrator identified and participated in process improvement initiatives to improve customer experiences, enhance workflow, and/or improve the work environment. Continued review revealed the Administrator was responsible for the Quality Assurance (QA) Program. Further, the Administrator maintained a working knowledge of and confirmed compliance with all governmental regulations. The Administrator consulted with department managers, concerning the operation of their department to assist in eliminating/correcting problem areas, and/or improvement of service. Review of the 01/24//2019 Recertification Survey's Plan of Correction (POC), the Abbreviated Survey's POC, dated 11/05/2019, and the 04/14/2022 Recertification Survey, revealed the facility failed to maintain compliance, and be administrated in a manner to provide quality care and services. The facility was previously cited, on the 09/30/2021 Recertification Survey and the Abbreviated Survey, dated 11/05/2019, the same areas of deficient practice as identified on the 04/14/2022 Recertification survey. Continued review of the 01/24/2019 Recertification Survey's POC revealed previously cited deficiencies, included F656, Care Plans, the facility failed to implement care plans related to Activities of Daily Living (ADL) needs; F657 Care Plans, failed to revise the care plans after falls with interventions to prevent falls; F689, Free of Accident Hazards, failed to ensure routine maintenance of assistive devices to prevent unavoidable accidents; and F755 Pharmacy Services, failed to ensure drug records were maintained to account for controlled medication. Further, the facility failed to provide effective Administrative oversight of day-to-day operations of the facility and failed to ensure an effective Quality Assurance program to provide quality care and services to meet the needs of the residents. Continued review of the 11/05/2019 Abbreviated Survey's POC revealed a previous cited deficiency, included F610, Investigate/Prevent/Correct/Alleged Violation, the facility failed to conduct a thorough investigation and protect residents from abuse after an allegation was made; and F656 Care Plan, failed to implement the care plan related to treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with the Director of Nursing (DON), on 03/28/2022 at 5:19 PM, revealed she had worked at the facility for one (1) year as the DON, and was previously a Unit Manager for one (1) year at the facility. Per the interview, she directly reported to the Administrator. Continued interview revealed her job was to provide oversight to the nursing department and report any concerns to the Administrator. Additionally, she was responsible for the care needs of the facility's residents and supervision of its nursing staff. She ensured residents received the necessary care and services and provided the supervision of nursing staff as required through the departments morning clinical meeting, Quality Assurance (QA) audits, and daily rounds. Further interview revealed the Clinical Care Consultant was in the building at least bi-weekly and provided support and resources via email and telephone, as needed. In addition, the interview on 03/26/2022 at 11:09 AM with the DON, revealed on 02/25/2021, possible drug diversion/misappropriation of medications was identified. The facility investigated the allegation which included reconciliation of active medications only. The investigation did not identify any concerns with the facility's current practice of accounting for medication in the facility. She stated the allegation of drug diversion/misappropriation was discussed with the Clinical Care Consultant and the Administrator. Continued interview revealed the nurse leadership in the facility ensured discontinued medications were returned to the pharmacy after the allegation. However, the action plan implemented did not include documentation or reconciliation of non-controlled discontinued medication destroyed in the facility or returned to pharmacy. Interview with the Clinical Care Consultant, on 03/25/2022 at 2:15 PM, revealed she had worked in her role for five (5) years; however, she had been assigned to other facilities since April of 2021. Per interview, it was her job to provide clinical resources and to support the DON and the Administrator as necessary. Continued interview revealed she worked closely with the leadership in the building. Further interview revealed if concerns were identified with clinical processes it was discussed with the DON and the Administrator. Interview with the Administrator, on 03/28/2022 at 3:40 PM, revealed he had been in his role for nine (9) months. Per interview, he was responsible to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently, in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. He stated his responsibilities were accomplished through ongoing QA. Continued interview revealed his job description was reviewed with him by the Regional Vice President of Operations (RVPO) upon hire into the Administrator's role. Per interview, the Administrator stated he was responsible for the overall operations of the facility. He stated he was the DON's direct supervisor. Interview with the Administrator revealed he was not aware of the deficiencies which were cited during the 01/24/2019 Recertification Survey and the 11/05/2021 Abbreviated Survey because they occurred long ago. Per interview, it was his understanding that in February 2021, an allegation related to misappropriation of resident property (medication) was identified; however, QA discussed the allegation and implemented change to address discontinued medications. The Administrator stated he believed the facility had addressed the identified concern through its QA program. Further interview revealed he was uncertain if the QA Committee completed audits related to the POCs to include; Abuse; Comprehensive Resident Centered Care Plan; Quality of Care; and Pharmacy Services. Review of the IJ Removal Plan revealed the facility implemented the following: 1. The Clinical Reimbursement Specialist reviewed the past thirty (30) days of falls on current residents to ensure the root cause was identified, new interventions were put in place, the Care Plan was revised to include supervision if it applied for recent falls. This was completed on 04/05/2022. 2. Regional Social Services reviewed the last thirty (30) days of progress notes for root cause was identified, new interventions were put in place with supervision, if the resident required it. This was completed on 04/05/2022. 3. The Regional Clinical Reimbursement Nurse (RCRN), the ADON, and the DON completed observations of Care Plan interventions to ensure they were effective and were implemented. They also reviewed all At Risk for Falls Care Plans, to ensure they reflected the correct intervention, determined the Root Cause of the fall and to put new interventions in place to include extra supervision for residents who required it. 4. The Pharmacy Consultant completed medication cart audits as compared to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This was completed on 04/07/2022 and no concerns were found. 5. Two Regional Social Services Directors reviewed all current residents' progress notes, events, and grievances to ensure residents were free from misappropriation of property. This was completed by 04/05/2022. 6. Signature Care Consultant (SCC) collaborated with the Pharmacy Director on 04/06/2022 and put the following plan in place: the nurses will remove the medication from the carts; store them properly; the medications being sent back would be listed on a form and the driver or two (2) licensed nurses will sign the form once the driver picked up the medication and returned it to the pharmacy. 7. The Vice President of Regulatory Compliance educated the Administrator/Regional Vice President, Medical Director, the Regional Nurse Consultant and the DON on the CMS regulations F835 on 04/06/2022 and CMS regulations for F755, F689, F602, and F656 on 04/06/2022. 8. The facility conducted Ad Hoc Quality Assurance meetings which started 04/05/2022 and an Immediate Jeopardy Plan was developed and implemented. On 04/06/2022, another Quality Assurance meeting was held to review the plan and make needed revisions to include further education. 9. Starting on 04/07/2022, QAPI meetings were held the first seven (7) days, then weekly for four (4) weeks. These meetings will continue until monthly for ongoing recommendations and follow-up. 10. The QA Committee will determine as to what frequency these meetings will continue. The Administrator has the oversight to ensure the effective plan was in place and was working to meet the resident's needs. The Regional Vice President of Operations will provide oversight daily until the removal of immediacy. The State Survey Agency validated the implementation of the IJ Removal Plan as follows: 1. Interview with the Clinical Reimbursement Consultant (CRC) on 04/14/2022 at 12:10 PM, revealed she audited the last thirty (30) days of event notes and interventions. She revealed she also looked at Root Causes for falls. The CRC revealed she went room-to-room and evaluated the equipment on hand, safety in the resident's room and the interventions being used. She revealed no concerns were found. 2. Interview with Social Service Director-Floaters (SSD) #1 and #2 on 04/14/2022 revealed they were called upon for special projects to review all clinical Progress Notes, events, and grievances for any concerns about misappropriation of resident property, to include medication. The look back period was for thirty (30) days. Both RSSD #1 and #2 reported no concerns were identified. Record review on 04/13/2022 at 11:30 AM, revealed audits were completed of all residents' Progress Notes for misappropriation of resident property to include medications. Concerns found were addressed. Grievances were audited for misappropriation complaints and no concerns were found. 3. Interview with the Clinical Reimbursement Specialist (CRS) on 04/14/2022 at 12:10 PM, revealed she completed audits on the last thirty (30) event notes for new interventions and Care Plan updates. She also revealed she looked at root causes to see if the facility determined the actual cause of a fall; if the root cause was not documented it was discussed with the SCC for the team to address the findings in QAPI. She stated she completed room to room audits for safety, ensured required equipment was available and proper interventions were in place. 4. Observation completed by SSA on 04/13/2022 at 2:55 PM, revealed the pharmacy courier completed the new medication pick-up process. The courier scanned a list of medications which contained four (4) residents. Each resident had one (1) medication listed. The blue tote bag was secured with a pull tie and the pull tie had a number on it. Tag number five (#5) was written on the medication list. Once the medication was secured the courier met with the DON in the lobby and they reviewed the list. Medications remained locked up and were dropped off at the pharmacy. Interview with the Regional Pharmacy Consultant on 04/14/2022 at 1:30 PM, revealed each medication cart was audited and each resident's medications were reconciled to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pharmacy audits will be ongoing. Record review on 04/13/2022 at 11:30 AM, revealed six (6) medication carts were audited. Audit findings were sent to the facility. Medications for Residents #19, #30, #63 and #77 were reconciled and no concerns were found. 5. Interview with Social Service Director-Floaters (SSD) #1 and #2 on 04/14/2022 revealed they were called upon for special projects to review all clinical Progress Notes, events, and grievances for any concerns about misappropriation of resident property, to include medication. The look back period was for thirty (30) days. Both RSSD #1 and #2 reported no concerns were identified. Record review on 04/13/2022 at 11:30 AM, revealed audits were completed of all residents' Progress Notes for misappropriation of resident property to include medications. Concerns found were addressed. Grievances were audited for misappropriation complaints and no concerns were found. 6. Observation on 04/13/2022 at 2:55 PM, revealed the pharmacy courier completed the new medication pick-up process. The courier scanned a list of medications which contained four (4) residents. Each resident had one (1) medication listed. The blue tote bag was secured with a pull tie and the pull tie had a number on it (five). Tag number five (#5) was written on the medication list. Once the medication was secured the courier met with the DON in the lobby and they reviewed the list. Medications remain locked up and were to be dropped off at the pharmacy. Interview with the Pharmacy Director (PD) on 04/13/2022 at 10:27 AM, revealed he worked with the SCC and the RVPRC to develop a plan for discontinued medications and how they would be returned to the pharmacy. Pharmacy Services will continue to have consultants present in the facility, for ongoing audits. The PD also revealed pharmacy staff were educated on the new process and expectation. Record review on 04/13/2022 at 11:30 AM, revealed six (6) medication carts were audited. Audit findings were sent to the facility. Medications for Resident #19, #30, #63 and #77 were reconciled and no concerns were found. 7. Interview with the Medical Director, Regional Vice President of Operations, the SCC and the DON on 04/14/2022 at 4:30 PM, revealed they all received reeducation on the Federal Regulations for F835 on 04/06/2022 and F656, F602, F689 and F755. They revealed they were each present during the meetings and discussed concerns as they came up. Policies were also discussed and it was reported the focus was to get the facility trained and get the immediacy removed. No ongoing concerns were found. 8. Interview with the Medical Director on 04/14/2022 at 3:25 PM, revealed he was present via phone for all Ad Hoc meetings since Immediate Jeopardy was determined. He was involved in all discussions and ensured the audits were being completed as required. Through the meetings any concerns were addressed, and necessary changes were made. Interview with the Director of Nursing (DON) on 04/14/2022 at 3:35 PM, revealed she was present for the Ad Hoc meetings and all aspects of the IJs were discussed. 9. Interview with the Vice President of Operations (VPO) on 04/14/2022 at 2:45 PM, revealed he was present at the QAPI meetings to provide oversight via phone. The QAPI meetings were led by the Administrator and all questions and concerns were addressed. 10. Interview with the Regional Vice President of Regulatory Compliance on 04/14/2022 at 4:12 PM, revealed he will continue to monitor the IJ process and the QAPI meetings will continue as outlined in the plan. Any adjustments or concerns would be addressed as they arise.

Based on observation, interview, record review, and review of the facility's policy, the Cedar-Sanai Health Library, and the John Hopkins Fall Risk Assessment Tool, it was determined the facility failed to provide supervision to ensure an environment that was free from accidents and hazards for two (2) of seventy-one sampled residents (Residents #49 and #86). The facility assessed Resident #49 as a high fall risk on three (3) Quarterly Minimal Data Set (MDS) assessments on 02/01/2021, 05/04/2021, 08/03/2021, and one (1) annual MDS assessment on 11/04/2021. The facility initiated a falls risk care plan on 12/11/2019. Interview with staff revealed the resident would leave the nursing station area without staff's knowledge. Staff would find the resident in his/her room on the floor, either by the bed or in the bathroom with an unwitnessed fall. Interview with Family Member #14 revealed they requested a seat/bed alarm to alert staff when the resident tried to get up from the bed or wheelchair (W/C) to keep the resident safe. The family stated the facility staff could not supervise Resident #49 to prevent continued falls. Interview with the Assistant Director of Nursing (ADON) revealed residents' rights included the right to fall and the facility could not prevent Resident #49 from further falls because of this right. Interview with the Director of Nursing (DON) revealed the facility did everything it could do to prevent Resident #49 from further falls. Record review revealed from 02/01/2021 to 12/25/2021 Resident #49 fell twenty-four (24) times and fourteen (14) of the 22 falls resulted with an injury. On 05/01/2021, Resident #49 fell in his/her bedroom. Review of event report, dated 05/01/2021, revealed staff found Resident #49 in his/her room, next to his/her bed. The resident hit his/her head as evidenced by a bruise to his/her head. The facility sent Resident #49 to the hospital for further evaluation and the resident's computer tomography (CT) scan of the head showed the resident's neck had an old cervical (neck) C1 and a new C2 fracture. Resident #49 returned to the facility with a Cervical (C) collar to wear at all times. The facility admitted Resident #86, on 05/06/2021. Review of Event Reports dated 05/07/2021, 05/12/2021, 11/02/2021, and 03/09/2022, revealed the resident had four (4) unwitnessed falls in his/her room from 05/06/2021 to 03/09/2022. After the fall on 11/02/2021, the resident had pain that was assessed as an eight (8) out of ten (10). On 11/04/2021, the Advanced Practice Registered Nurse (APRN), ordered x-rays of the resident's back (thoracic and lumbar areas), but no injury was detected. Due to his/her pain, Resident #86 was unable to tolerate/continue with Physical Therapy (PT). On 12/07/2021, Resident #86 was transferred to an acute care hospital Emergency Department (ED) due to an abnormal Electrocardiogram (EKG). While at the ED, Resident #86 had a Computerized Tomography (CT) scan that revealed he/she had an Ischiopubic (Pelvic) fracture. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/04/2022 and was determined to exist on 02/24/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation; F602 Free from Misappropriation Exploitation at a scope and severity (S/S) of K, and at 42 CFR 483.25 Quality of Care F 689 Free from Accidents/Hazards/Supervision/Devices at a S/S of J. Immediate Jeopardy was identified at 42 CFR 483.21 Comprehensive Person-Centered Care Plans F656 Comprehensive Resident Centered Care Plans at a S/S of J 42 CFR 483.45 Pharmacy Services F755 Pharmacy Services/Procedure /Pharmacist/Record at a S/S of K at 42 CFR 483.70 Administration F835 Administration and F837 Governing Body at a S/S of K at CFR 42 483.75 Quality Assurance and Performance Improvement F867 QAPI/QAA Improvement Activities at a S/S of K. The facility was notified of the Immediate Jeopardy on 04/05/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 04/12/2022, with the facility alleging removal of the Immediate Jeopardy on 04/09/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 04/09/2022, prior to exit on 04/14/2022. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Falls revised 11/06/2019, revealed the intent of the facility was to provide residents with supervision to minimize the risk of falls and fall related injury. The IDT (interdisciplinary team) determined the root cause of a fall, identified interventions, and documented the resident's response to the intervention(s). The Quality Assurance and Performance Improvement (QAPI) committee would review, track, and trend falls to determine the course of action. Review of the facility's policy titled, Safety and Supervision of Resident, dated 05/13/2018, revealed the facility's priority included safety, supervision, and assistance to prevent accidents. The facility identified safety risks through Quality Assurance (QA) review of safety and incidents reports. The facility's resident-oriented approach to safety included the use of medical history, physical exams, observations, and the Minimum Data Set (MDS). The facility's clinical IDT analyzed assessments and made observations to identify specific risks for residents with targeted interventions to reduce the potential for an accident. The facility was to monitor the effectiveness of the intervention to determine if the intervention was effective. Review of the facility's policy titled, Aspects of Care, undated, revealed the facility's care provided to residents was coordinated by the medical provider to achieve and maintain optimal standard of quality of care to residents. Clinical care under the direction of the DON (Director of Nursing) included to assess and deliver nursing needs of the residents to prevent complications and promote safety. The goal of clinical care included to assist the resident to attain and maintain the maximum physical well-being to ensure the residents had a good quality of life. 1. Review of Resident #49's clinical admission record revealed the facility admitted the resident on 04/02/2015, with diagnoses of Alzheimer's Disease, [CONDITION(S)] Disease, and Communication Deficit. On 04/21/2020, the facility added the history of falls to the resident's diagnoses list. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15) and determined the resident had cognitive deficit and was not interviewable. The facility completed the Quarterly MDS assessments on 02/01/2021, 05/04/2021, 08/04/2021, and an Annual MDS assessment on 11/04/2021. The facility determined the resident required extensive assist with one staff for transfers, toileting, and bed mobility. The resident used a wheelchair for mobility. On 02/01/2021 and 05/04/2021, the facility assessed the resident's locomotion as requiring the extensive assistance of one (1) staff. However, on the MDS assessments for 08/04/2021 and 11/04/2021, the assessment changed to supervision and set up for locomotion in the wheelchair. Review of Resident #49's Physician's Orders revealed the resident's medications included [MEDICATION(S)] for [CONDITION(S)] Disease, [MEDICATION(S)] five-three hundred and twenty-five milligrams (5-325 mg) one tablet twice a day, and as needed every four (4) hours for pain, and [MEDICATION(S)] twenty-five (25) mg at night for sleep. Review of Resident #49's Comprehensive Care Plan (CCP), dated 12/11/2019, revealed the facility identified the focus for the resident at risk for falls due to [CONDITION(S)], muscle weakness, [CONDITION(S)] medication, incontinence, and falls. On 09/08/2020, the facility initiated an intervention by placing the resident in his/her wheelchair at the nurses' station when out of bed. Review of Resident #49's event reports revealed from 02/12/2021 to 12/25/2021 the resident fell 23 times. The resident fell on [DATE], 03/15/2021, 03/26/2021, 04/05/2021, 05/01/2021, 05/08/2021, 05/12/2021, 05/17/2021, 05/28/2021, 06/05/2021, 06/10/2021, 06/16/2021, 07/15/2021, and two (2) times on 07/29/2021, (at 4:40 PM and 5:00 PM), 08/03/2021, 08/14/2021, 09/27/2021, 10/04/2021, 11/19/2021, 11/29/2021, 12/21/2021, and on 12/25/2021. Further review revealed 14 of Resident #49's falls resulted in an injury. Review of the Morse Fall Scale (a rapid and simple method of assessing a resident's likelihood of falling), dated 02/01/2021, revealed the facility assessed Resident #49's as a fall's risk on the resident's Quarterly MDS assessment. The facility assessed the resident with history of falls, secondary diagnoses, ambulatory aides, weak gait, and forgot limitations. The resident scored eighty (80), which determined the resident was at high risk for falls. Review of the Event Report, dated 02/12/2021, at 6:45 PM revealed Resident #49 had a witnessed fall after standing up from the wheelchair. The IDT determined the resident had a right wrist skin tear from the fall and reviewed the care plan. Review of the Event Report, dated 03/15/2021 at 5:20 AM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident on the floor beside the bed with the bed in the highest position. Staff found no injury. The IDT reviewed the care plan. Review of the Event Report, dated 03/26/2021, time stamped 11:45 PM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff documented the resident wandered around the nurses' station in the wheelchair (w/c). Staff were busy with other residents. Staff heard a loud bang in the resident's room. Further review revealed staff found the resident on the fall mat on the floor with the w/c turned on its side in a dark room. The IDT determined Resident #49 attempted to force the w/c over the floor mat in an attempt to reach the bed. The IDT's intervention included leaving the bathroom light on with the door open enough to provide light in order to monitor the resident in the room. Review of the Event Report, dated 04/05/2021, time stamped 1:50 PM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident in front of his/her chair. The staff assessed the resident with a bruise on the upper part of his/her nose. The IDT determined the resident's feet slipped getting out of a recliner. The fall caused skin tears to the resident's right elbow and left forearm, and the doctor ordered x-rays. Review of the Radiology Report, dated 04/06/2021, revealed Resident #49 broke his/her nose on 04/05/2021. Review of the Event Report, dated 05/01/2021, time stamped 6:41 PM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident on the floor next to the bed. The staff assessed the resident with a hand laceration and bruise on the head. The doctor sent the resident to the emergency room (ER). The IDT determined with staff interviews that the resident reached for the phone in a chair at the end of the bed. The resident grabbed the bed which caused the laceration and skin tear. Resident #49 hit his/her head on the footboard, which caused a bruise. The resident's computer Tomography (CT) scan of the head showed an old cervical (neck) C-1 fracture and a new C-2 fracture. The resident returned to the facility with a cervical (C) collar with instructions to follow up with an orthopedic surgeon as soon as possible. Review of the Cervical Spine radiology report, dated 05/01/2021, revealed the C-1 fracture was an acute injury of a ligament. The C-1 fracture was categorized as a burst fracture (bone to spread out in all directions). In addition, a fracture with an undetermined age of the resident's neck was found at C-2. Review of the Cedar-Sanai Health Library resource titled, Burst Fracture, dated 2022, revealed burst fractures were more severe than a compression (to reduce in size) fracture. A burst fracture caused the bone in the spine to spread out in all directions with the potential to cause damage to the spinal cord. The spinal cord damage could cause injury to the nerves and the nerves controlled a person's ability to move. Furthermore, a fall from a high area typically caused a burst fracture. Review of the John Hopkins Fall Risk Assessment Tool, dated 05/04/2021, revealed the facility assessed Resident 49's fall risk for the Quarterly MDS assessment. The assessment identified the resident's risks included the categories of: having one or more falls; an age greater than 80; a fall within the last six (6) months; the frequent need to urinate; the resident was prescribed two (2) or more medications which could cause a resident to fall; the need for assistance or supervision for mobility, transfer, or ambulation; unsteady gait; having an altered sense of awareness of surroundings; impulsive behavior; and, the lack of understanding of his/her limitations. The resident's total score was twenty-six (26). Review of the resident's score revealed a number greater than thirteen (13) meant the resident was a high fall's risk. Review of the Event Report, dated 05/08/2021, time stamped 10:40 AM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident on the floor next to the bed. Staff assessed the resident with a re-injured skin tear to the right hand. The IDT determined nurses were called to the room and found the resident sitting on the fall mat next to the bed with a re-injured area to the right hand and a bump to the forehead. The doctor sent the resident to the ER (emergency room ) and he/she returned with a dressing to the right hand. Review of the Nurse's Note, dated 05/12/2021, at 11:50 PM, revealed staff heard Resident #49 in his/her bedroom moving around. The nurse entered the room and observed the resident attempting to transfer to bed, but he/she sat down on the floor. The nurse notified the resident's family, and his/her medical provider that the resident fell . Further review revealed an Event Report was not completed by staff or the IDT. Review of the Event Report, dated 05/17/2021 time stamped 8:10 AM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident on the floor by the end of the bed, fall mattress to the side, and w/c behind the resident. The IDT determined the resident ate breakfast in the hallway and went to his/her room while staff assisted other residents. The resident stood up and the w/c rolled backward. No injury was noted. Review of the Event Report, dated 05/28/2021, time stamped 2:00 PM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident on the floor by the closet. Staff assessed the resident with a bruise to the right frontal area of the head and skin tears to both hands. Physician's Orders were received to send the resident to the ER to rule out further injury because the resident had two (2) falls with injury to the head in 1 month. The IDT determined the head scan ruled out injury to the resident's head. Review of Resident #49's CCP, revealed on 05/28/2021 the facility initiated the intervention to keep the resident near the nurses' station when up in the w/c. Review of the Event Report, dated 06/05/2021, time stamped 6:06 AM, revealed Resident #49 had a witnessed fall in the hallway. Staff saw the resident lean forward and fell on to the floor before staff could stop the fall. The IDT determined the blanket got caught in the resident's wheelchair wheel, the blanket pulled forward, and the resident fell forward. The resident sustained a bruise to his/her head as a result of the fall. Review of the Event Report, dated 06/10/2021, time stamped 9:45 AM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident on the bathroom floor. Staff assessed the resident with an injury to a previous skin tear to the left hand and left hip, with scratch marks to the resident's left hip. The IDT determined staff found the resident on his/her left hip in the bathroom. The resident sustained scratches to the left hip and re-injured the existing right-hand skin tear. Review of the Event Report, dated 06/16/2021, time stamped 9:00 AM, revealed Resident #49 had an unwitnessed fall from his/her wheelchair in the bathroom. Staff found a skin tear on the resident's left elbow. The IDT determined another resident found the resident on the bathroom floor with the w/c by the toilet. The Medical Provider sent the resident to the ER (emergency room ) for x-rays of his/her left shoulder. The resident returned with a diagnosis of a dislocated left shoulder. Review of the Event Report, dated 07/15/2021, time stamped 7:50 AM, revealed Resident #49 had an unwitnessed fall in his/her room next to the w/c. Staff found a skin tear to the resident's left hand and a scrape to the top of the resident's head. The IDT determined the resident fell from the w/c. Staff reported the resident had nights when he/she did not sleep well. The Medical Provider increased the resident's sleeping medication. Review of the Event Report, dated 07/29/2021, time stamped 4:40 PM, revealed Resident #49 had an unwitnessed fall in his/her bathroom. Staff found no injuries. The IDT determined staff found the resident in the bathroom on his/her knees with an attempted transfer from the toilet to the w/c. Staff moved the resident into the hallway to watch him/her. However, the resident fell twenty (20) minutes later at 5:00 PM on 07/29/2021. Review of the Event Report, dated 07/29/2021, time stamped 5:00 PM, revealed Resident #49's unwitnessed fall occurred in the hallway near the nurse's station. Staff found skin tears to both hands and a cut in the center of the resident's forehead next to the previous cut from the fall on 07/15/2021. The Medical Provider sent the resident to the ER because the resident had a history of neck fractures and two (2) head injuries in ninety (90) days. The IDT determined the resident returned with negative x-rays. The IDT submitted a request for an evaluation for a lap tray or vest for the w/c related to a request by the family. Review of the John Hopkins Fall Risk Assessment Tool, dated 08/03/2021, revealed the facility assessed Resident 49's fall risk for his/her Quarterly MDS assessment on 08/03/2021. The staff assessed the resident with a history of one or more falls; age greater than 80; one (1) fall within the previous six (6) months; having urgency with elimination; taking two (2) or more high risk fall drugs; requiring assistance or supervision for mobility, transfer, or ambulation; having an unsteady gait with an altered awareness of environment; and, lacking understanding of his/her limitations. The resident scored twenty-four (24) and remained at high risk for falls. Review of the Event Report, dated 08/03/2021, time stamped 7:55 PM, revealed Resident #49 had an unwitnessed fall from the w/c in his/her room. No injury was noted. The IDT determined the resident fell out of the w/c while he/she moved around the unit. The IDT submitted a request for Occupational Therapy (OT) to assess the resident for a vest when the resident sat in the wheelchair. The facility had ordered a chair and bed alarm. In addition, the alarms were ordered after the 06/16/2021 incident where the resident dislocated his/her shoulder. However, the alarms had not arrived in the facility as of 08/03/2021. Review of the Event Report, dated 08/14/2021, time stamped 8:15 PM, revealed Resident #49 had an unwitnessed fall while in the hallway. The floor staff determined the resident fell when he/she leaned over the front of the w/c to stand up. The staff assessed the resident and noted he/she re-injured a skin tear to the left wrist. The IDT determined the resident re-injured a left wrist skin tear. Review of Resident #49's care plan revealed on 09/15/2021, the facility initiated a motion pad sensor to the resident's bed with an alarm sensor at the nurses' station. The alarm was to alert the staff when the resident moved off the mattress. Review of the Event Report, dated 09/27/2021, time stamped 9:40 AM, revealed Resident #49 was up in the w/c and slipped out of the w/c onto the floor. Staff assessed the resident with no injuries noted. The IDT determined the resident did not have any injuries and should be in direct view of staff when the resident was awake. Review of the Event Report, dated 10/04/2021, time stamped 1:15 PM, revealed Resident #49 had an unwitnessed fall in his/her bathroom. The IDT determined through interview and record review that Resident #49 was restless and anxious around the time he/she fell . The IDT determined the resident took himself/herself to the bathroom and attempted to get on the toilet. No injuries were noted Review of the In-service Attendance Record, dated 10/18/2021, revealed the ADON (Assistant Director of Nursing) and DON (Director of Nursing) educated staff on residents who were identified as a falling star. The facility initiated a falling star program which provided a picture of a falling star beside the name of the resident on the resident's door. When the staff saw the falling star, the staff were to visualize the resident more often and to ask if the resident needed or wanted anything. Review of the signed attendance record revealed thirty-two (32) facility direct care staff were educated on 10/18/2021. Review of the John Hopkins Fall Risk Assessment Tool, dated 11/04/2021, revealed the facility assessed Resident 49's fall risk for his/her Annual assessment. The staff assessed the resident with a history of one or more falls, had a age greater than 80; one (1) fall within the previous 6 months, having urgency with elimination, taking 2 or more high risk fall drugs, requiring assistance or supervision for mobility, transfer, or ambulation, having an unsteady gait with an altered awareness of environment, and lacking understanding of his/her limitations. The resident scored a twenty-four (24) which kept the resident at high risk for falls. Review of the Event Report, dated 11/19/2021, time stamped 7:00 PM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff found the resident in a fetal position on the floor, next to the bed. The resident reported to staff he/she had attempted to get into the bed. The IDT determined the resident fell when he/she attempted to get into bed without help and staff did not find any injuries. Review of the Event Report, dated 11/29/2021, time stamped 8:00 PM, revealed Resident #49 had an unwitnessed fall in his/her bathroom. The IDT determined the resident fell when he/she attempted to go to the bathroom without help. No injuries were noted. Review of the Event Report, dated 12/21/2021, time stamped 8:15 PM, revealed Resident #49 moved around the nursing unit in his/her w/c and fell in the hallway. The staff found multiple skin tears; and placed strips over the skin tears. The IDT determined the resident fell forward and fell on his/her face. Staff found a raised bruise to Resident #49's forehead, two (2) skin tears in the middle of the bruise on the forehead, and a skin tear to the right wrist. Review of the Event Report, dated 12/25/2021, time stamped 7:30 PM, revealed Resident #49 had an unwitnessed fall in his/her room. Staff were alerted of the resident's fall when the roommate yelled for staff to come to the room. Resident #49 was found on his/her right side on the floor next to his/her w/c. The resident had large amounts of red drainage because the resident re-opened the skin tears to his/her forehead which the resident obtained with the fall on 12/21/2021. The aides had reported Resident #49 had increased restlessness with anxiety, so the staff got the resident up to his/her w/c. When the Medical Provider was notified, orders were received to send the resident to the ER for further evaluation. The resident returned from the ER with negative x-ray results. The IDT determined the resident had increased anxiety, refused to lay down and found the resident on the floor next to his/her w/c. The resident had injuries which included a cut to his/her forehead and a skin tear to his/her right hand. Interview with Family #1, on 03/20/2022 at 9:30 AM, revealed residents fell a lot in the facility. Interview with Family #14, on 03/31/2022 at 8:45 AM, revealed Resident #49 did not comprehend the use of a call bell. Family #14 stated the resident did not understand his/her physical limitations and attempted to get out of the bed and the w/c. Continued interview revealed the nursing unit at times had low nursing staff and was unable to supervise residents. The family member stated when staff served and cared for residents at dinner, Resident #49 wandered in the w/c, left the area, and staff would find the resident in his/her room or bathroom on the floor. Further interview revealed the facility discussed closer supervision for Resident #49 to prevent falls. However, the facility did not discuss 1:1 supervision. Family #14 stated Resident #49 fell and separated his/her left shoulder June 2021 and cut his/her forehead. Continued interview revealed the ER could not place sutures due to the width of the cut. The Family Member stated after the resident separated his/her shoulder they requested the bed/chair alarms to alert staff when the resident attempted to stand up. Family #14 stated the family requested the alarms to keep Resident #49 safe. Interview with State Registered Nurse Assistant (SRNA) #18, on 03/30/2022 at 4:00 PM, revealed Resident #49 fell a lot when the unit was short of staff. The SRNA stated when two (2) SRNA's assignment included up to thirty-four (34) residents, staff could not meet all the residents' needs. The SRNA stated she could not identify any specific time the unit was short, and residents had falls. SRNA #18 stated three (3) aides were needed to watch residents. The SRNA revealed the falling star on the resident's door identified a high fall risk resident. SRNA #18 stated that the facility expected staff, that were assigned residents identified as high risk, to round every thirty (30) minutes. However, when two (2) aides were assigned to the 34 residents, they could not round every 30 minutes, transfer residents, and residents would not wait for staff. Interview with Licensed Practical Nurse (LPN) #20, on 03/30/2022 at 3:45 PM, revealed Resident #49 fell many times on the unit. Most of the resident's falls occurred in the resident's room and were unwitnessed. The LPN stated staff moved the resident to the nurses' station on 11/29/2021 after staff found the resident on the floor in the bathroom. The LPN stated all the staff on the unit helped pass trays, feed residents, and the nurses passed medications to residents. LPN #20 stated staff found the resident on the floor in front of his/her w/c in the hallway. She stated the resident had blood down his/her face and she was unable to close the head wound above the resident's eye because it was too wide. The LPN stated the resident frequently left the nurses' area while staff went in and out of rooms and then staff would find the resident in his/her room in the bathroom or by the bed on the floor. The LPN stated the facility could not have stopped the resident's falls because of the determination of the resident to get up. LPN #20 stated the facility did not offer or discuss 1:1 supervision for the resident. She stated the family asked for the bed/chair alarm because the resident continued to fall. Interview with Registered Nurse (RN) #1, on 03/30/2022 at 2:40 PM, revealed Resident #49 had frequent falls and the family requested the bed/chair alarm to alert staff when the resident changed position. She stated the resident did not understand the need for assistance and fell when he/she attempted to go the bathroom or bed. RN #1 stated the resident would go to his/her room after staff brought the resident to the nurses' station without staff's knowledge. Continued interview with RN #1, on 03/30/2022 at 3:00 PM, revealed the white scar above Resident #49's left eye occurred when the resident fell and hit his/her head on 11/29/2021 at 5:00 PM. The resident was found with blood in his/her hair and eyes, and blood dripped from his/her chin. The RN stated the ER could not place stitches because the wound was too wide to close. RN #1 stated one of the falls caused the skin on the resident's right hand to peel back from the knuckles to the wrist. The RN stated all the white lines on the resident's hands were the result of skin tears from falls. Interview with MDS Coordinators #1 and #2 on 03/30/2022 at 4:45 PM, revealed residents were assessed on admission, quarterly and with a change of condition. The MDS Coordinators stated the residents' assessments included a fall risk assessment. Medical records, Nurses' Notes, Event Reports, observations, and care plans were reviewed quarterly and as needed when the resident had a fall. Further interview revealed when the Coordinators started the resident's quarterly assessment, they reviewed back to the resident's last assessment. However, they stated they did not look for patterns when reviewing a resident's falls. The MDS Coordinators revealed the At-Risk IDT looked for patterns for the resident's falls. They stated they did not attend the At-Risk IDT meetings and may or may not stay to discuss falls in the daily IDT meetings. Continued interview revealed the definition of a fall included an unintentional change in surface and it also included if staff lowered a resident to the floor. The MDS Coordinators stated the QAPI Committee members reviewed the number of falls, the number of residents who fell , and the shifts when the falls occurred, during the monthly meetings. However, the clinical IDT held daily meetings and discussed residents' falls. They stated the IDT updated a board to help track residents' falls, which listed the resident and the date of the fall. The MDS Coordinators stated QAPI members did not identify trends with falls during the QAPI meetings. Interview with the Nurse Practitioner (NP), on 03/31/2022 at 9:00 AM, revealed Resident #49 fell a lot and it upset the staff that they could not stop the falls. The NP stated the resident's diagnoses included Dementia. Therefore, the resident did not understand he/she needed assistance with transfers. The NP stated staff placed the resident at the nurses' station, but the resident would leave the area. Continued interview revealed the resident had impressive wounds and injury as a result of the multiple falls. Interview with the ADON (Assistant Director of Nursing), on 03/29/2022 at 5:10 PM, revealed the facility used the John Hopkins' Assessment Tool to identify a resident's risk for falls along with his/her diagnoses and history. She stated staff would increase rounding for residents identified as high risk for falls. The ADON stated when residents were found on the floor, whether witnessed or unwitnessed, the facility classified this as a fall. However, the facility did not consider when staff assisted residents to the floor as a fall. She stated the IDT daily meeting discussed residents' falls and reviewed falls weekly at the AT RISK IDT meeting. The ADON stated during the at-risk meetings, they discussed residents' falls, reviewed the event report and placed a new intervention on the resident's care plan. She stated the team reviewed a 2-week period prior to the fall. However, the MDS Coordinators reviewed back to the last MDS assessment to determine if there were patterns to the resident's falls. Further interview revealed the team reviewed the interventions to make sure they were appropriate for the resident, along with review of the root cause of the fall. She stated the facility did neighborhood model scheduling. Model scheduling assigned the same staff to care for the same residents in order to know/better understand the resident's established routines. She stated the facility

Based on observation, interview, record review, policy review, and Centers for Medicare and Medicaid Services, Resident Assessment Instrument Manual 3.0, it was determined the facility failed to develop and/or implement a person-centered Comprehensive Care Plan (CCP) which included measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for two (2) of seventy-one (71) sampled residents (Residents #12 and #49) 1. Review of Resident #49's Comprehensive Care Plan (CCP) revealed an intervention to place the resident near the nurses' station when out of bed on 09/08/2020. On 05/28/2021, the facility added the intervention to keep the resident near the nurses' station when up in the wheelchair (w/c). On 09/27/2021, the facility initiated the intervention for the resident to be in the direct view of staff when up in the w/c. However, record review and staff interviews revealed they would be busy and unable to monitor the resident. Staff stated the resident often left the nurse's area and they would find the resident in his/her room on the floor from an unwitnessed fall. The resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Review of Resident #12's Comprehensive Care Plan (CCP) revealed the resident was on isolation precautions which required Transmission-Based Precautions (TBP). However, observations, on 03/22/2022, revealed the staff did not wear appropriate PPE (Personal Protective Equipment) into the resident's room while providing care to the resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/04/2022 and was determined to exist on 02/24/2021 in the areas of 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation; F602 Free from Misappropriation Exploitation at a scope and severity (S/S) of K, and at 42 CFR 483.25 Quality of Care F 689 Free from Accidents/Hazards/Supervision/Devices at a S/S of J. Immediate Jeopardy was identified at 42 CFR 483.21 Comprehensive Person-Centered Care Plans F656 Comprehensive Resident Centered Care Plans at a S/S of J 42 CFR 483.45 Pharmacy Services F755 Pharmacy Services/Procedure /Pharmacist/Record at a S/S of K at 42 CFR 483.70 Administration F835 Administration and F837 Governing Body at a S/S of K at CFR 42 483.75 Quality Assurance and Performance Improvement F867 QAPI/QAA Improvement Activities at a S/S of K. The facility was notified of the Immediate Jeopardy on 04/05/2022. The facility provided an acceptable Immediate Jeopardy Removal Plan on 04/12/2022, with the facility alleging removal of the Immediate Jeopardy, on 04/09/2022. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 04/09/2022, prior to exit on 04/14/2022. The facility's remaining non-compliance was at a Scope and Severity of a F while the facility developed and implemented a Plan of Correction and the facility's Quality Assurance (QA) monitored to ensure compliance with systemic changes. The findings include: Review of the facility's CCP policy, revised 07/19/2018, revealed the facility developed and maintained the CCP for each resident which identified the highest level of function a resident may be expected to attain. The facility developed the CCP's based on thorough assessments and designed the CCP to identify problem areas, add risk factors with the identified problem, reflect treatment, goals, timetable and objective in a measurable outcome, aide to prevent or reduce decline of a resident's functional status or level. The CCP included desired outcomes. The implementation of CCP interventions started after consideration of the resident's problem area and their causes. The intervention addressed the underlying source of the problem area, rather than to address the symptom or trigger. The intervention reflected action, treatment, or procedure to meet the objective toward the achievement of the resident's goals. 1. Review of Resident #49's clinical record revealed the facility admitted the resident on 04/02/2015, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility added the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #49 with a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15). The facility determined the resident had a cognitive deficit and was not interviewable. The facility completed Quarterly MDS assessments on 02/01/2021, 05/04/2021, 08/04/2021, and an Annual MDS assessment on 11/04/2021. The facility assessed the resident required the extensive assistance of one (1) staff for transfers, toileting, and bed mobility. The resident used a w/c (wheel chair) for mobility. Review of the Comprehensive Care Plan (CCP), dated 12/11/2019, revealed Resident #49 was at risk for falls due to [CONDITION(S)], Muscle Weakness, [CONDITION(S)] Medication, Incontinence, and history of falls. On 09/08/2020, the facility initiated the intervention to place the resident in his/her w/c at the nurses' station when out of bed. On 05/28/2021, the facility added the intervention to keep the resident near the nurses' station when up in the wheelchair. On 09/27/2021, the facility initiated the intervention for the resident to be in the direct view of staff when up in the w/c. Further review revealed the three (3) interventions were active on the resident's care plan. Review of Resident #49's event reports revealed the resident had twenty-four (24) falls from 02/12/2021 to 12/25/2021. Review of the Event Reports revealed on 02/12/2021, 03/15/2021, 03/26/2021, 04/05/2021, 05/01/2021, 05/04/2021, 05/08/2021, 05/12/2021, 05/17/2021, 05/28/2021, 06/05/2021, 06/10/2021, 06/16/2021, 07/15/2021, 07/29/2021 at 4:40 PM and 5:00 PM, 08/03/2021, 08/14/2021, 09/27/2021, 10/04/2021, 11/29/2021, 11/29/2021, 12/21/2021, and 12/25/2021 were unwitnessed falls while the resident was up in his/her wheelchair. Further review of the Event Reports with unwitnessed falls revealed, on 04/05/2021, Resident #49 sustained a nasal fracture from an unwitnessed fall in his/her bedroom. On 05/01/2021, the resident fell in his/her room and suffered a skin tear on the top of the right hand which required sutures and steri-strips because the skin tear exposed the resident's muscle. On 05/09/2021, Resident #49's right hand skin tear required antibiotic treatment due to an infection. On 06/16/2021, staff found Resident #49 in another resident's bathroom and he/she had dislocated his/her left shoulder. Continued review revealed, on 07/29/2021 at 5:00 PM, Resident #49 had an unwitnessed fall in the hallway which resulted in a cut to his/her head which could not be sutured due to the width of the head wound. Observation, on 03/30/2022 at 8:30 AM, revealed Resident #49 sat in a wheelchair and propelled himself/herself on the unit by his/her room. Interview with Family #14, on 03/31/2022 at 8:45 AM, revealed Resident #49 did not understand his/her physical limitations. The Family member stated the resident stood up while in the wheelchair or transferred himself/herself from the bed. Continued interview revealed the facility started watching the resident at the nurses' station related to the increased falls the resident experienced in 2021. However, the Family member stated the resident wandered in the w/c back to his/her room and staff would not be aware he/she had left the area. Family #14 stated they attended care plan meetings for the resident and the intervention regarding keeping the resident at the nurses' station was intended to keep the resident safe and to decrease injury and falls. Interview with State Registered Nurse Assistant (SRNA) #17, on 03/26/2022 at 10:00 AM, revealed Resident #49's interventions included to watch the resident at the nurses' station because the resident would stand up while in the w/c and fall. The SRNA stated the resident was mobile around the unit in the w/c. The aide stated staff would bring the resident to the nurses' station and the resident would later be found in his/her room on the floor. Continued interview revealed staff would not be aware the resident left. The SRNA stated the facility expected all staff to follow residents' care plans. Interview with SRNA #18, on 03/30/2022 at 4:00 PM, revealed Resident #49's care plan included to have the resident in eyesight of the nurses' station to monitor the resident. However, the aide stated staff could not watch the resident due to responsibilities to other residents and Resident #49 would go back to his/her room. SRNA #18 stated staff were to follow residents' care plans as the CCP interventions were intended to keep residents safe. However, due to low staffing on variable days, staff could not follow Resident #49's care plan. The aide stated the facility expected staff to follow residents' care plans and interventions. Interview with Licensed Practical Nurse (LPN) #20, on 03/30/2022 at 3:45 PM, revealed Resident #49's interventions included to place the resident at the nurses' station area to monitor the resident. The nurse stated Resident #49 attempted to stand up from the w/c and would fall. LPN #20 stated staff moved the resident to the nurses' station to monitor, as per the care plan, on 11/29/2021 at 4:40 PM, because staff found the resident in his/her bathroom on the floor. However, staff continued with their duties and staff found the resident on the floor in the hallway with an injury to the head. Interview with Registered Nurse (RN) #1, on 03/30/2022 at 2:40 PM, revealed residents' care plans were found in the electronic record. The aides' care plans were available at the nurses' station. RN #1 stated Resident #49 had frequent falls and the resident's care plan included supervision at the nurses' station when the resident was awake. The nurse stated the resident moved around well in his/her wheelchair, and would leave the nurses' station without staff's knowledge, and often was found on the floor after an unwitnessed fall in his/her room. Further interview revealed staff did not follow the care plan because the resident left the area. RN #1 stated the facility expected all staff to follow residents' care plans because each intervention specifically addressed a resident's care needs. RN #1 stated two (2) of the resident's falls resulted in major injury. The RN stated Resident #49 had a dislocation of his/her shoulder and a skin tear which started at the resident's knuckles with the skin pulled away to the resident's wrist. RN #1 stated the scars on the resident's hands and forehead were due to the injuries from his/her falls. Interview with MDS Coordinator #1, on 10/30/2022 at 4:45 PM, revealed the facility developed resident care plans at admission, and revised them quarterly and, as needed. The Coordinator stated all residents were considered a fall risk at admission and the facility completed a fall risk assessment upon admission and quarterly. MDS Coordinator #1 stated moderate to high fall risk for falls triggered a fall care plan focus. Interventions would be started and individualized to meet the resident's needs. The Coordinator stated the care plans developed were to be followed by staff to keep the residents' safe and the clinical managers ensured staff followed the care plans. MDS Coordinator #1 stated the facility expected staff to follow policies and to follow residents' care plans. Interview with the Assistant Director of Nursing (ADON), on 03/29/2022 at 5:10 PM, revealed the facility initially identified a resident's fall risk with a fall risk assessment. The facility used the John Hopkins assessment tool, diagnoses, and history to identify residents at risk for a fall. the MDS Coordinators gathered all the initial assessments and developed the individual CCP's. She stated the clinical IDT discussed resident falls daily and reviewed falls weekly at the AT RISK IDT team meeting. The ADON stated the teams would identify a new intervention, add to the care plan, and they notified staff. She stated staff were to follow resident care plans. The ADON stated the clinical IDT made sure staff followed residents' care plans by frequent daily walking rounds. She further stated the facility did not identify issues with staff not following resident care plans. Interview with the DON (Director of Nursing), on 03/31/2022 at 12:25 PM, revealed the facility identified residents at risk for falls at admission with the completion of a fall risk assessment and the resident's overall mobility. She stated the MDS Coordinators initiated the admission care plan. She further stated the clinical IDT team reviewed falls the next day and then weekly at the At-Risk IDT team meeting. Further interview revealed the facility expected staff to follow residents' care plans which provided safety and resident care needs. She stated Resident #49's care plan included to supervise the resident at the nurses' station when awake. The DON stated she completed walking rounds several times a day to observe staff providing care. She stated she had not identified any concerns of staff not following Resident #49's care plan. Interview with the Administrator, on 03/26/2022 at 4:00 PM, revealed the clinical IDT reviewed events daily and At-Risk residents weekly. He stated the clinical nursing team's responsibility included to ensure residents' care plans were followed. Continued interview revealed the clinical management team was on the residents' floors throughout the day and the tea had not reported issues with staff not following residents' care plans. He further stated the Quality Assurance and Performance Improvement (QAPI) had not identified issues with residents' care plans. 2. Interview with the Minimum Data Set (MDS) Coordinator, on 03/04/2022 at 12:00 PM, revealed the facility utilized the Centers for Medicare and Medicaid Services, Resident Assessment Instrument Manual 3.0, as a guideline for timely revision of residents' CCP. Review of the CMS Resident Assessment Instrument (RAI) Manual 3.0, dated October 2019, revealed the CCP was to be reviewed and revised periodically, and the services provided or arranged were to be consistent with each resident's written plan of care. Continued review revealed the CCP was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, review revealed a CCP was based on a thorough assessment and effective clinical decision making, compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. Further review revealed a well prepared assessment re-evaluating the resident's status at prescribed intervals (quarterly, annually, or when a significant change in a resident's status occurred) using the RAI process, ensured the resident's individualized CCP was modified as appropriate and necessary. Review of Resident #12's Electronic Medical Record (EMR) revealed the facility admitted the resident, on 06/17/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/20/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (09) which indicated the resident had moderate cognitive impairment. Record review revealed on 02/03/2022 and 03/16/2022, the facility placed Resident #12 on contact isolation due to [MEDICATION(S)] Resistant Enterococcus (VRE) in his/her urine. VRE is a bacterial infection that is resistant to the antibiotic [MEDICATION(S)], which is commonly used to treat this type of infection. Transmission Based Precautions (TBP) was implemented to prevent the spread of infection. Review of Resident #12's Comprehensive Care Plan (CCP) revealed, on 02/03/2022, the facility care planned the resident for infection control due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included but not limited to: Contact Isolation per order; vital signs every shift until completion of antibiotic; administer antibiotic, as ordered; observe for side effects related to antibiotic therapy; and report to physician (rash, itching, nausea/vomiting, diarrhea, difficulty breathing). Review of Resident #12's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order to start [MEDICATION(S)] (antibiotic) 50 mg (milligrams), oral every six (6) hours, times five (5) days. Additional review of Resident #12's IDT Progress Notes, dated 03/17/2022 at 4:19 PM, revealed antibiotic use for urinary tract infection; continue without adverse reactions, Care Plan updated and contact isolation in place. However, additional review of Resident #12's CCP revealed no documentation the facility developed an Infection Control care plan related to the resident's [CONDITION(S)] and order for Contact Isolation. Observations on 03/20/2022 at 4:05 PM, revealed Resident #12 was in Contact Precautions. The door was open and there were two (2) isolation signs on the door. One (1) noted Contact Isolation and the other one (1) noted Droplet Precaution. Additional observations revealed the Droplet and Contact sign on the door listed: N95 mask, close door and use dedicated equipment. Continued observations revealed an instructional sheet on the door which noted how to don and doff (put on and take off) PPE. Further observations revealed a plastic three (3) drawer cart in the hallway at the doorway for PPE with gowns, gloves, and surgical mask; however, there was no evidence of sanitizing wipes or brown bags for dedicated mask outside the room. Continued observations on 03/20/2022 at 4:05 PM, revealed Certified Nursing Assistant (SRNA) #1, SRNA #2, and Hospitality Aide (HA) #3, don (put on) Personal Protective Equipment (PPE) in the hallway outside Resident #12's room. All three (3) aides donned a gown, then gloves, but failed to change their dedicated mask to a N95 mask; they all wore their dedicated surgical mask and eye protection into the room. Further observation revealed staff left the isolation door open, and as the State Survey Agency (SSA) observed from the hallway, the staff assisted both Resident #12, who was in contact isolation, and his/her roommate, who was in Droplet Precautions, without changing their PPE. Additional observations revealed the staff doff (took off) their PPE (gown, gloves) in the isolation room and disposed of it in the dedicated bins, washed their hands, and exited the room. However, staff did not clean their eye protection or change their surgical mask after exiting the room. The aides went to the nurses' station. Observation and interview of Resident #12, on 03/21/2022 at 8:40 AM, revealed he/she was lying in bed, watching television. There were no odors in the room and the resident was clean and dry; he/she voiced no complaints. Interview with Resident #12, at the time of the observation, revealed the resident did know why he/she had been placed in isolation; I often get this type of infection in my urine, and it is unfortunate and irritating at times. Interview with State Registered Nurse Aide (SRNA) #1, on 03/20/2022 at 4:15 PM, revealed Resident #12 was in Contact isolation related to a type of contagious bacteria in his/her urine. She stated she read about Resident #12's care on the Kardex. Further interviews with SRNA #1, SRNA #2 and HA #3, revealed they had received training on Care Plans, they stated they were aware that the Care Plans were on the Kardex, in a notebook at the nurse's station. Per interview, they should have followed the Care Plan when caring for Resident #12 to ensure his/her safety and the safety of the staff. Further interview revealed staff should follow the isolation precautions posted on the doors and encourage other staff to practice infection control measures to decrease the spread of infection. They stated that it was important to follow the care plan for all residents in order to provide the correct care. Interview on 03/22/2022 at 2:30 PM, with SRNA #2 revealed she referenced the Kardex (SRNA care plan for residents) for the type of care residents received. SRNA #2 added, the facility provided care plans for the staff and the nurses updated the Kardex with changes as needed. The aide stated the facility expected staff to follow both the care plan and Kardex to meet the residents' needs and safety. SRNA #2 stated she received training on the types of isolation, and how and what PPE to wear for each type of isolation. The SRNA stated, the facility expected all staff to wear PPE when the resident was care planned for contact isolation. Interview with SRNA #12 and SRNA #13 on 03/26/2022 at 2:54 PM, revealed all nursing staff worked together as a team, and an individualized resident Kardex (Care Plan) was located on all units, at each nursing station for all staff to reference for resident care needs. Continued interview revealed the Kardex was updated daily per the Unit Manager. Both SRNA's stated they were not aware if the care plan had been updated for Resident #12's current and active infection. Additionally, the aides used the Kardex routinely throughout shift; at the beginning of every shift the nurses performed rounds to discuss, reviewed and checked all residents for any changes in conditions and what type of specific care to provide. Continued interview revealed the direct care nursing staff reviewed the care plans, orders and updated the Kardex. Further, the nurse management routinely audited residents' records to ensure accuracy and resident safety. Interview with the Unit Manager, Registered Nurse (RN) #3, on 03/26/2022 at 12:10 PM, revealed residents' care plans were found in the electronic record and in the Kardex at every nursing station for the aides. Per interview, she expected staff to use the Care Plans and for the Care Plans to be revised and followed to ensure proper and safe care was provided per the assessed needs for the residents. Continued interview revealed staff were expected to refer to the care plan each time they provided care to any resident because the care could have changed. Additionally, all staff were responsible to ensure the care plan was implemented and revised to include active infection and interventions followed. All clinical staff were responsible to identify any concerns with the care plan being followed and immediately address and intervene to correct the care. RN #3 added, the floor nurses, MDS Coordinator and IDT were responsible for initiating and revision of care plans. Further, she ensured the Care Plan was implemented by participating in morning meetings, rounds and helping with care on the floor: making observations of care and speaking with residents, staff, and family. She revealed she had not identified concerns with care plans being developed or followed. Interview with RN/Minimum data Set (MDS) #1 on 03/26/2022 at 3:41 PM, revealed the facility's policy and Resident Assessment Instrument (RAI) manual was the guide she used to complete the Minimum Data Set (MDS). She stated she personally used a worksheet as a guide, information gathered from the chart, resident, family, staff, face to face and hands on assessments. She stated she used the MDS assessment data to develop care plans. However, the floor nurse initiated the Baseline Care Plan, at the next clinical meeting; and the staff reviewed the Baseline Care Plan, and Minimum Data Set (MDS) Nurse took over the process. Additionally, she stated care plans should be followed as a guide for care of the residents. Interview with the Infection Control Nurse/Director of Nursing, on 03/26/2022 at 4:00 PM revealed floor nurses, MDS Nurses, and members of the Interdisciplinary Team (IDT) developed and revised the Baseline Care Plans. Continued interview revealed all nursing staff were responsible to ensure the care plan was current and specific to the resident's identified needs. Additionally, she expected staff to refer to, and follow the care plan because it was developed according to the resident's individualized plan of care. Further, she had not identified any issues with the development or revisions. However, after review of observations by the State Survey Agency (SSA), on 03/20/2022, she stated staff should have updated/revised and followed the care plan for infection control. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed all staff were responsible to initiate, revise and follow the Care Plans for each resident, to ensure their safety, their wishes and wellness were met. He stated to ensure care plans were followed, staff made rounds to observe care; talked to residents/families and staff. Additionally, care plans were discussed in morning meetings and the clinical management team was on the residents' floors throughout the day and had not reported issues with staff not following residents' care plans. Furthermore, he stated he had not identified any concerns with care plans not being developed. Continued interview revealed, after review of the SSA's observation on 03/20/2022, ongoing education was necessary.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store, handle, prepare, distribute, serve food, maintain safe temperatures of food in storage, in order to ensure food safety. Observation, on 03/20/2022 during the initial kitchen tour at 2:00 PM, revealed dirty floors, staff members with their masks positioned below the nose, open food not labeled or dated, a dirty stove, pitchers of tea and coffee uncovered and not labeled, a trash can with its lid open, the dishwasher was broken, the sanitizing solution in the three (3) compartment sink and the sanitizing bucket were not maintained at the correct concentration. Additionally, observation, on 03/20/2022, revealed inconsistencies with documentation logs for the standing refrigerator and dry storage, and the dishwasher was not in use/broken. Further observation, on 03/21/2022 at 11:35 AM, during lunch meal service, revealed two (2) male staff with hair on their face and neck with no beard restraint, and another staff person was observed with the mask below the nose. The findings include: Review of the facility's policy titled, Manual Warewashing, dated 09/2017, revealed all cookware, dishware, and service ware that was not processed through the dish machine would be manually washed and sanitized. Additionally, the staff would be knowledgeable of proper techniques including wash temperature at no less than 110 F (Fahrenheit); chemical sanitizer testing and proper concentration of the sanitizing solutions. Further, appropriate test strips would be utilized to measure the concentration of the sanitizing solution. Results would be recorded on the three (3) compartment sink log. Review of the facility's policy titled, Warewashing, dated 05/2014, revealed all dishware, serviceware, and utensils will be cleansed and sanitized after each use. Additionally, the dining staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware. Further, temperature and/or sanitizer concentration logs would be completed as appropriate. Review of the facility's policy titled, Equipment, dated 09/2017, revealed all food service equipment would be clean, sanitary and in proper working order. Additionally, all equipment would be routinely cleaned and maintained in accordance with the manufacturer's direction and training materials. All staff would be properly trained in the cleaning and maintenance of all equipment. All food contact equipment would be cleaned and sanitized after every use. All non-food contact equipment would be clean and free of debris. The Dining Service Director would submit requests for maintenance or repair to the Administrator and/or Maintenance Director, as needed. Copies of a service repair and preventative maintenance report would be submitted monthly. Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 08/2017, revealed all garbage and refuse would be collected and disposed of in a safe and efficient manner. Additionally, the Dining Service Director would ensure appropriately lined containers were available within the food service area for disposal of garbage. Appropriate lids were provided for containers. Garbage was removed from the kitchen area routinely during the day and at the end of the workday. Staff were to observe proper hand washing and glove practices after handling garbage. Further, the Dining Services Director would ensure appropriate recycling practices were in place as required by state and local authorities. Review of the ECOLAB Scout Pot and Pan Wash Procedure, dated 2011, revealed the Environmental Protection Agency (EPA) registered no rinse quat sanitizer that was effective across a dilution range of 0.25-0.67 per gallon of water. Further there were illustrations noted on the Paper Hydrion testing strips (withdrawal 2 inches); temperature 65-75 F, 10 second, compare to strip for acceptable range diagram on testing paper label. Review of the Sani Safe Quaternary Ammonia QUAT test paper label, revealed an expiration date of 11/01/2023. In addition, there were instructions to compare the paper strip when wet to the color-coded diagram listing with parts per million concentration (0-100-200-300-400). Review of Dining Services Department In-Service, dated 12-20-2021, revealed kitchen staff attended an in-service on Hair nets and beard guards, name tags, uniforms not worn during DM unit inspection. Review of Dining Services Department In-Service, dated 01/31/2022, revealed kitchen staff attended an in-service on New COVID/CDC regulations with quarantine, vaccines, wearing Personal Protective Equipment while in the facility. Observation during the initial kitchen tour, on 03/20/2022 at 2:00 PM, revealed the stove had a blackened substance on the backsplash of the stovetop, dried up substance with crumbs was noted beside the stovetop and the griddle. Additionally, there was a pitcher of tea and coffee in front of the coffee machines not covered, labeled, or dated. Continued observations revealed the lid of the trash can was raised up and leaning against the wall. The trash can was overflowing with a box containing coffee grounds and condiment cups. Review of the Refrigerator Temperature Log, dated March 2022, revealed staff did not consistently document AM and PM temperatures. Further review revealed the following: nineteen (19) blanks on 03/05/2022 AM; 03/15/2022 AM; 03/16/2022 AM and PM; 03/17/2022 AM and PM; 03/18/2022 AM and PM; and 03/19/2022 PM. Continued observations on 03/20/2022 at 2:00 PM, revealed the Dry Storage Temperature log, dated March 2022, revealed missing documentation of the AM and PM temperatures. There was a total of eight (8) blank spaces which included 03/15/2022 AM; 03/16/2022 AM; 03/17/2022 AM; 03/18/2022 AM; 03/16/2022 PM; 03/17/2022 PM; 03/18/2022 PM; and on 03/19/2022 PM. Observation on 03/20/2022 at 2:00 PM, revealed Dietary Aide #1 washing dishes at the three (3) compartment sink. Dietary Aide #2 was rinsing washed items at the solution sink; her face mask was below her nose. Per interview, at the time of the observation Dietary Aide #1 stated that she had just made the water and solution in the sink. Additionally, she did not know what the temperature of the water was, or the location of the thermometer. She stated she checked the water by touching it with her hand to ensure it was hot. Dietary Aide #2 stated she usually worked with the dish machine and was not familiar with the temperature, solution, and documentation for the three (3) compartment sink. Further, she stated she wore her mask below her nose because she was hot. However, she had received training on how to properly wear a face mask and on infection control. Continued observations revealed the sanitizing solution concentration in the three compartment sink and the solution in the red bucket were below 150 parts per million (PPM). The thermometer could not be found to take the temperature of the water. Review of the Three (3) Compartment Sink Log, undated, revealed eight (8) blanks on the 15th, 16th, 17th, 18th, 19th lunch, and dinner meals and, on the 20th lunch meal were blank. Observation revealed there was no documentation of the time, temperature of the water, concentration, or staff initials. Further, the bottom of the log, to document to the Manufacturer Recommendation Sanitizer PPM was blank. Observations on 03/21/2022 at 11:35 AM, of the lunch tray line, revealed Dietary Aide #4, was plating food, but was not wearing a beard guard. Additional observations revealed Dietary Aide #2 plating food with a face mask below her nose. Further, the Dietary Manager was noted at the three (3) compartment sink, and was not wearing a beard guard. Observations on 03/23/2022 at 10:30 AM, revealed blackened food crumbs/substance on the stove burners. Interview with the District Manager, at the time of the observation, revealed the cook was responsible to clean the stove one (1) time a week to ensure food crumbs were cleaned off, so food served was not contaminated. Additional observations on 03/23/2022 at 10:30 AM, revealed a trash can by the coffee pot. The trash can lid was open with a brown dried food substance and dried liquid. The trash can was full to the top and contained old grapes in a bag, and open condiment containers. Interview with the District Manager, at the time of the observation, revealed the trash can lid should be clean and closed to maintain infection control and prevent contamination of food. Continued interview revealed the observations of the uncovered pitchers of coffee and tea, that were not tabled, should have been covered to prevent contamination. Interview on 03/20/2022 at 3:09 PM, with the Assistant Dietary Manager, revealed she had worked at the facility since June 2021, and her direct supervisor was the Dietary Manager. Per interview, the kitchen staff had been hand washing dishes for three (3) weeks since the dish machine had been down. Additionally, the three compartment sink log was completed by staff, each time the water was made (three {3} times a day), including the red bucket of sanitizing solution. Continued interview revealed the temperature of the water, the solution concentration and staff's initials should be documented on the log. The staff assigned to the dishes was responsible to complete the documentation after making the water/solution. It was important to have a record to prove the temperature and concentration could sanitize properly to prevent the spread of food borne illness and communicable illness. Per interview, she had not identified any issues with the temperature or concentration of water at the three compartment sink or the log. She also was unaware of any training provided to kitchen staff three (3) weeks ago (after the dish machine broke), related to the three compartment sink, temperatures of water, or concentration of the solution. Further, she normally looked at the refrigerator and dry storage temperature logs a couple times a week, to ensure temperatures were not too hot or cold; however, she had not identified any blanks in the logs. She was unsure why there were blanks on the logs, but they should have been filled in completely. Continued interview revealed the stove should be cleaned if it was visibly dirty with food crumbs or blackened food particles to ensure food being cooked was not contaminated. She stated it was everyone's responsibility that used the stove to ensure it was clean and the stove should be cleaned at least weekly. Per interview, the garbage can lid should be clean and placed on the can for infection control purposes, to ensure food and equipment were not contaminated. Lastly, she stated the pitchers of beverages, coffee and tea, should be covered to ensure they were not contaminated, and staff who filled the pitchers should have covered them. Interview with the Dietary Manager, on 03/21/2022 at 10:08 AM, revealed that one (1) year ago he was a dish washer and cook at the facility. Since 02/28/2022, he had been the Dietary Manager in Training. Per interview, the Training Manager was in the building two (2) days a week and available via telephone, as needed, and the Registered Dietician (RD) was in the building twice a week. Continued interview revealed the RD completed meal tracker audits. The Training Manager completed audits for temperature logs, preparation of food, attended the morning meetings, and provided staff in-services. Additionally, the District Manager was in the building one (1) time a week, and he completed audits with the Dietary Manager on temperature logs, the three (3) compartment sinks, signs, the cooler and dry stock, and in-services with staff. The Dietary Manager stated there was no tracking process or policy for when test solution strips were changed, where they were stored, label requirements, etc. All staff members were responsible to change the strips, which were kept in the manager's office and also taped to wall by the three (3) compartment sink. After review of observations made on 03/20/2022 with the Manager, he stated there should be a label in the test strip box to note the expiration date to ensure the strips were viable. However, the strips taped to the wall by the sink, were observed to not have a label. He stated that he expected the staff to use the strips in the manager's office, and to know the expiration date, and the solution level using the ECO lab posters on the wall behind the sinks. Observation at the time of the interview revealed the manager searched his office drawers and found two (2) loose boxes of strips and said the one (1) taped on the wall was in the same lot as the strips in the office. The expiration date was 11/01/2023. Further interview with the Dietary Manager revealed that each log should be fully completed at the designated time and that he expected his staff to complete all of them. He stated he expected staff to wear masks appropriately, to decrease the risk for the spread of infection, and that staff had been educated in infection control and on wearing Personal Protective Equipment (PPE) appropriately. Staff was provided in-service education related to necessary changes in the process because the dish machine was broken, but staff was already aware of the expectation because it was the same process (3 compartment sink) before the dish machine broke. However, there was no documentation provided related to an in-service training for the kitchen staff approximately three (3) weeks ago related to the three compartment sink, sanitizing solution concentration, and test results of the sanitizing solution. Review of Dining Services Department In-Service, dated 02/11/2022, revealed kitchen staff attended an in-service on Fridge/freezer/dish machine logs filled out correctly, and tray-line accuracy. Review of Dining Services Department In-Service, dated 02/15/2022, revealed kitchen staff attended an in-service on Label and dating, temperature log usage, daily/weekly cleaning matrix, and menu compliance. Interview with the Training Manager, on 03/22/2022 at 8:30 AM, revealed he had been with the facility for one (1) year. Per interview, the repair company was at the facility on 03/22/2022, and was supposed to return in (2) days to repair the main board, which was the identified broken area. Continued interview with the Training Manager revealed they were made aware that the three (3) compartment sink on 03/20/2022, was not in appropriate range. She stated the facility had staff turnover and struggled to keep and train staff. She stated the new staff members were not familiar with policies and practices. Additionally, it was important that the water temperature and the sanitizer were at the right temperature and concentration to protect residents from contamination, and to decrease the risk for food borne illness. Continued interview with the Training Manager revealed documentation should be consistently completed each time the sink concentrations were made. Further, she was not aware of staff members in the kitchen who wore a face masks improperly, below the nose. She stated staff had been provided education on properly wearing face masks. The Dietary Manager provided education on beard guards, and if a staff member had facial hair, the employee should have a beard guard on while in the kitchen. The Dietary Manager stated, We do not want hair to fall in the food. Per interview, monthly in-service education covered infection control, use of masks, documentation of temperatures and concentrations. Interview with the Staff Development Coordinator, on 03/21/2022 at 11:30 AM, revealed she had been in that role since 03/01/2022. Additionally, she had provided in-services on Personal Protective Equipment, handwashing and infection control. However, she had not provided in-servicing to kitchen staff. Further, she stated she was responsible to provide training and education related to all identified concerns in the building, for all staff, and all departments as applicable. Interview with Dietary Aide #1, on 03/24/2022 at 11:40 AM, revealed he had worked in the kitchen for two (2) and a half years, and had been trained on temperature logs, refrigerator logs, the three (3) compartment sink log, and the dry storage log. Per interview, it was important to have record of temperatures, in order to know they were in the right range to ensure food was not spoiled. He stated dishwater was made and tested every two (2) hours and he would know the right concentration was prepared by testing the sink water with the strip paper for 10 seconds. He said the strip's color would be compared to the color key on the side of the box of strips. He stated the strip dipped in the sanitizer treated water should read 200 PPM, because that would be the acceptable range. Continued interview with Dietary Aide #1 revealed the proper chemical concentration was important for proper sanitation of the cookware/dishware. In addition, he said the number was important, because if the dishes used for serving food were contaminated, that could lead to food borne illnesses. Per interview, he stated the water temperature should be 120 degrees Fahrenheit for soap water, rinse water should be 110 degrees Fahrenheit; and sanitizer water should measure 65-75 degrees Fahrenheit. The Dietary Aide stated the stove should be cleaned at least once a week, and the cook cleaned it. Further, the trash can lids were cleaned weekly, and the trash can tops should always be in the down position, to prevent food and refuse from falling on the floor. He said pitchers of beverages should be covered and labeled to prevent contamination. He stated it had been awhile since he received training on those issues, but he had received training on wearing beard guards in the kitchen, in order to keep hair out of the food. Interview with the Director of Nursing, on 03/26/2022 at 4:00 PM, revealed that she expected the kitchen to be clean and sanitary at all times to ensure Infection Control. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed he expected the kitchen to be clean and sanitized at all times so food would be served in a safe manner.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to complete a thorough investigation in order to prevent and protect residents from further misappropriation of property (medications). It was reported Licensed Practical Nurse (LPN) #7 had taken medications for eight (8) of seventy-one (71) sampled residents (Resident #19, Resident #30, Resident #63, Resident #77, Resident #150, Resident #151, Resident #161, and Resident #162). On 02/25/2021, the facility initiated an investigation, and the local law enforcement were notified related to an allegation of misappropriation of resident property (medication), after State Registered Nurse Assistant (SRNA) #8 reported to the facility's previous Administrator that Licensed Practical Nurse (LPN) #7 had taken medication from a resident at the facility. However, there was no documentation the facility conducted a thorough investigation into the allegation. On 02/25/2021, LPN #7 admitted to the Police she had taken medication from residents. LPN #7 was charged for the Theft of a Legend Drug (a drug approved by the Food and Drug Administration {FDA} that can be dispensed to the public only with a prescription) nine (9) counts, and Illegal Possession of a Legend Drug, Possession of Marijuana, and Drug Paraphernalia-Buy/Possess. Review of the Police report revealed on 03/01/2021, the Police contacted the previous Administrator and confirmed the prescription medications found in LPN #7's possession belonged to current and/or former residents of the facility However, there was no documentation of the facility's communication with the Police. The facility failed to obtain the final Police Report to determine the extent of the drug diversion/misappropriation. In addition, on 03/01/2021, the facility obtained a statement from LPN #7. The LPN stated she had taken discontinued and extra medications from the medication rooms. However, there was no documented evidence a thorough investigation into the allegation that residents' discontinued, and extra medications were taken from the facility' medication rooms. Further, review of the facility's investigation revealed inconsistencies in documentation of the investigation. The investigation did not include documentation that the facility reviewed its policy and procedure; or that the pharmacy was contacted related to the investigation. The facility also failed to identify the incident as misappropriation/drug diversion and failed to implement an effective action plan to ensure discontinued medications were sent back to pharmacy. The findings include: Review of the facility's policy titled, Abuse, Neglect, or Misappropriation of Resident Property, last revised 05/08/2019, revealed the facility's intention was to prevent the occurrences of misappropriation of resident property and to assure that all alleged violations of federal or State laws which involved misappropriation of resident property were investigated and reported immediately to agencies. Under the section on Investigation Guidelines, the policy revealed the Administrator was ultimately responsible to oversee and complete the investigation and to draw a conclusion regarding the nature of the incident. Further, the Administrator would make reasonable efforts to determine the root cause of the alleged violation and would implement corrective action consistent with the investigation's findings and take steps to eliminate any ongoing danger to the resident(s). 1. Review of Resident #151's closed medical record revealed the facility admitted the resident, on 01/10/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #151, in a Quarterly Minimum Data Set (MDS) Assessment, dated 02/28/2021, as a one (1) of fifteen (15) on the Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 03/12/2021. 2. Review of Resident #19's medical record revealed the facility admitted the resident, on 02/01/2016 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #19, in a Quarterly MDS Assessment, dated 01/05/2021, as a fourteen (14) of fifteen (15) on the BIMS' assessment, which indicated intact cognition. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Review of Resident #77's medical record revealed the facility admitted the resident, on 12/28/2015 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #77, in a Significant Change MDS Assessment, dated 02/15/2021, as a fifteen (15) of fifteen (15) on the BIMS' assessment, which indicated intact cognition. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Review of Resident #30's medical record revealed the facility admitted the resident, on 07/07/2017 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #30, in an Annual MDS Assessment, dated 02/01/2021, as a three (3) of fifteen (15) on the BIMS' assessment, which indicated severe cognitive impairment. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Review of Resident #63's closed medical record revealed the facility admitted the resident, on 06/01/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #63, in a Quarterly MDS Assessment, dated 12/09/2021, as a three (3) of fifteen (15) on the BIMS' assessment, indicating severe cognitive impairment. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Review of Resident #161's closed medical record revealed the facility admitted the resident, on 11/13/2013 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #161, in a Quarterly MDS Assessment, dated 01/15/2021, to have short and long-term memory problems. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 08/24/2021. 7. Review of Resident #150's closed medical record revealed the facility admitted the resident, on 02/12/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility assessed Resident #150, in a Quarterly MDS Assessment, dated 12/15/2020, as a fifteen (15) of fifteen (15) on the BIMS' assessment, which indicated intact cognition. The record revealed a discontinued physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 05/27/2021. 8. Review of Resident #162's closed medical record revealed the facility admitted the resident, on 06/24/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on 02/22/2021. Review of SRNA (State Registered Nurse Aide) #8's telephone Witness Statement, dated 02/25/2021, signed by the previous Administrator and the Director of Nursing (DON), revealed she was moving out of LPN #7's house on the night of 02/24/2021, and when she looked in a drawer, she saw Resident #151's prescription medication ([MEDICATION(S)]). Further review revealed she took a picture of the medication with the resident's name on it. Review of the statement revealed that SRNA #8 stated she believed LPN #7 took the medication from the facility. However, there was no documentation provided by the facility of the photograph of Resident #151's medication. Review of the Long-Term Care Facility - Self-Reported Incident Form/Initial Report, dated 02/26/2021 at 3:31 PM, signed by the facility's previous Administrator, revealed an Allegation of Misappropriation of resident property had occurred on 02/25/2021, which involved Resident #151. Additional review revealed SRNA #8 reported to the Administrator that LPN #7 had medication at her house that belonged to a resident at the facility. Further review revealed the facility was not able to validate the allegation based on record review which indicated the resident had not missed any doses of his/her medication. Further, LPN #7 and SRNA #8 were suspended immediately pending the investigation. Review of LPN #7's telephone Witness Statement, dated 03/01/2021, signed by the previous Administrator and Clinical Care Consultant, revealed the LPN stated she recently had taken discontinued and extra medications from the medication rooms and kept them in her backpack in her truck. The LPN stated that her intention was to keep the medications for the residents in case the Emergency Drug Kit was out, or a different shape of the same medication would be easier on the resident to swallow. Further, she stated she knew it was stupid, illegal and against policy. Review of the Long-Term Care Facility - Self-Reported Incident form/Final Report, dated 03/03/2021 at 3:56 PM, signed by the facility's previous Administrator, revealed an Allegation of Misappropriation of resident property had occurred on 02/25/2021, which involved Resident #151. Additional review of the facility's Report revealed other residents involved in the allegation of misappropriation were unknown at the time of the Report and staff involved in the incident was LPN #7. Per summary of the incident, the facility was not able to validate if the medication was prescribed to the resident at the time of the allegation or if the allegation was valid based on their investigation. Review of the Final Report, dated 03/03/2021, revealed on 02/24/2021, the facility re-educated current staff on the facility's abuse policy with an emphasis on misappropriation. Further review revealed the facility interviewed employees who routinely worked with LPN #7 on the Abuse policy and if they had knowledge of any misappropriation; no concerns were identified. However, review of a Staff List revealed handwritten across the top, 02/23/2021 Abuse Training, revealed one hundred and fifty-one (151) names and telephone numbers; seventeen (17) additional names had a handwritten line drawn through the name. Additional review revealed a blank Abuse Policy Post Test; however, there was no documented evidence provided by the facility of the Abuse policy referenced, or documentation of staff signatures validating they had received and completed the re-education. Additionally, per the Final Report, on 02/25/2021, a one (1) time audit of medications on each medication cart was counted and reconciled to ensure all medications were accounted for; no issues were identified. Further review revealed handwritten across the top of the Report Medication Audit, 02/26/2021; signed by LPN #11 (no title written), Minimum Data Set (MDS) Nurse #2, and the Assistant Director of Nursing (ADON). However, there was no documentation that the medications were audited to include discontinued or extra medications. Per the Final Report, on 03/01/2021, the current resident population with BIMS' scores below eight (8) were observed for nonverbal signs or symptoms of ADL or Psychosocial decline. The current resident population with BIMS' scores above eight (8) were interviewed and asked if they received their medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Daily Census Report, dated 02/26/2021, revealed ninety-seven (97) residents' names. Review of a MDS Indicator Report, dated 03/01/2021 revealed a list of ninety-seven (97) residents' BIMS' scores. There were check marks beside forty-four (44) residents' names; those residents had BIMS' scores below eight (8). Further, ADL/Psychosocial Evaluations, dated 03/01/2021, signed by LPN #11, for each of the forty-four (44) residents were accounted for, and noted no resident exhibited signs or symptoms or pain or had shown decline in ADL or Psychosocial decline from his/her baseline. Further review revealed check marks beside fifty-three (53) residents' names; those residents had a BIMS scores below eight (8). Review of Residents' interviews, dated 03/01/2021, signed by the Activities Director and the Social Services Assistant, revealed the fifty-three (53) residents were accounted for and that all residents stated they had received their medications per Physicians' Orders. Record review revealed One South; One North; Two South; and Two North each had front and back medication carts and a treatment cart. However, further review revealed there was no documented evidence provided by the facility related to cart audits to include discontinued or extra medications. Review of a list of forty-four (44) licensed facility staff including LPNs and RNs. Additional review revealed handwritten across the top License Validation; signed by the Clinical Care Consultant Validated and dated 03/01/2021. Continued review revealed handwritten check marks by all forty-four (44) licensed staff names. However, there was no documented evidence provided by the facility of the licensure validations. Record review revealed there was no documentation provided of the facility's efforts and/or conversations with the Police Department related to the drug diversion/misappropriation investigation. Further, review of the facility's Final Report, dated 03/03/2021, revealed the facility concluded that through their investigation current residents at the facility were never without prescription medication and no resident had an ADL (Activities of Daily Living)/Psychosocial decline as a result of the incident. Per the Final Report's conclusion, once the Police released their findings, if it was proven any medication came from the facility, residents would be reimbursed. However, review of the KYIBRS (Kentucky Incident Based Reporting System) Report of incident 2021-1594, dated 02/25/2021 at 3:35 PM, revealed the police were contacted by the facility's previous Administrator, who reported that LPN #7 had allegedly taken medication from residents at the facility. Continued review of the Police Report revealed the Administrator provided a picture taken by SRNA #8, at LPN #7's residence, which showed a prescription for Resident #151's medication ([MEDICATION(S)] 150 mg). Additionally, the Administrator provided a written statement from SRNA #8, which stated the resident's medication was seen in the LPN's drawer at her home and SRNA #8 felt the LPN had taken the medication from the facility. The Police report stated LPN #7's home was searched, and multiple prescription medications were found. Ninety-three (93) medications were found and identified as medication of current/former residents at the facility. Review of the evidence listed on the Police Report revealed the following residents' medications were found at LPN #7's home: four (4) unit doses of [MEDICATION(S)] (anti-fungal medication), 150 milligrams (mg), Resident #151; seven (7) [MEDICATION(S)] 25 mg (antiemetic medication), Resident #19; twenty-five (25) [MEDICATION(S)] (muscle relaxer medication) 5 mg, Resident #77; eight (8) Acetaminophen Arthritis Extended Releases 650 mg (non-controlled pain medication), Resident #30; three (3) [MEDICATION(S)] 500 mg (antibiotic medication), Resident #63; two (2) [MEDICATION(S)] 20 mg (steroid medication), Resident #161; one (1) [MEDICATION(S)] 150 mg (anti-fungal medication), Resident #150; seven (7) [MEDICATION(S)] 25 mg (antiemetic medication), twenty-five (25) [MEDICATION(S)] 150 mg (antidepressant medication), and nine (9) Omeprazole 40 mg (decreases the amount of acid in the stomach medication), Resident #162. Further review of the Police Report revealed LPN #7 admitted that she had taken the medications from the facility in her backpack. Per the report, a warrant of arrest was issued for LPN #7 for the charge of Theft of a Legend Drug (9 counts), Illegal Possession of a Legend Drug, Possession of Marijuana, and Drug Paraphernalia-Buy/Possess. Review of LPN #7's schedule for February 2021, revealed she worked 02/18/2021, 02/22/2021 and 02/23/2021. Additional review of the Daily Schedule for 02/18/2021, 02/22/2021, and 02/23/2021 revealed RN #4 and LPN #9 usually worked with LPN #7. The SSA attempted to contact with the Social Services Assistant in regard to ADL/Psychosocial Evaluations, on 03/24/2022 at 3:55 PM, however she was unavailable and a voice message was left to return the call. The State Survey Agency (SSA) attempted to contact LPN #7, on 03/25/2022, at 9:24 AM; however, her voice mail box was full and the SSA was unable to leave a message to return the call. Telephone interview with SRNA #8, on 03/25/2022 at 3:47 PM, revealed she reported the medication misappropriation/drug diversion to the previous Administrator, on 02/25/2021. Per interview, she was at LPN #7's house and was in the bathroom, opened a drawer and saw medication with Resident #151's name on it. Additionally, she took a picture and sent it to the previous Administrator. Further, she wrote a statement for the facility; however, she did not talk to the police because she wanted to be left out of it. SRNA #8 stated she had been harassed for a year over this incident and would not talk to the SSA anymore and ended the call. Interview with RN #4, on 03/25/2022 at 3:56 PM, revealed she had worked at the facility for seven (7) years on day shift. Per interview, LPN #7 worked night shift and she worked day shift and she had received report from LPN #7 many times. Continued interview revealed one (1) morning last year (could not recall a date reference), she received report from LPN #7 and had noticed that LPN #7 was not acting right, she was overly tired/lethargic. RN #4 reported the behavior to the Unit Manager and previous Administrator and provided a written statement. However, she was unaware of what came of that incident. Additionally, last year (could not recall a date reference) she had noticed LPN #7 was the only nurse who was giving as needed (PRN) narcotics to residents, which she brought to management's (Unit Manager's) attention. RN #4 stated, she wrote a statement about her concerns and even made copies of narcotic count sheets that looked sketchy and provided them to management. She stated she had never seen LPN #7 take medication from the medication carts, or medication rooms. The RN stated she had received abuse training including misappropriation, around the time of the investigation February 2021. However, she did not recall anyone interviewing her related to LPN #7; she had just heard through the grapevine the nurse was let go because she took medications from the facility. Per interview with the Clinical Care Consultant, on 03/25/2022 at 4:00 PM, revealed LPN #7 did not have any investigations in her employee file related to concerns related to possible medication diversion/misappropriation or questionable behaviors at shift change. The SSA attempted to contact Unit Manager, LPN #6, regarding RN #4's reported concerns with LPN #7's PRN narcotic administration and her mental status/ behavior concerns, on 03/26/2022 at 10:20 AM. A message was left to return the call. The SSA, attempted to contact LPN #11, regarding Medication Audits on 02/26/2021, on 03/26/2022 at 10:21 AM. A Message was left to return the call. Interview with LPN #9, (worked with LPN #7 in 2021), on 03/26/2022 at 10:22 AM, revealed she had worked at the facility for one (1) year. Per interview, LPN #7 worked night shift and she worked day shift. She stated she had noticed that LPN #7 would regularly administer PRN narcotic medication, but she never felt the residents were in pain or lethargic. LPN #7 stated she had received abuse training including misappropriation, around the time of the investigation February 2021. However, she did not recall anyone interviewing her about LPN #7 around that time. Interview with the Clinical Care Consultant, on 03/25/2022 at 2:15 PM and on 03/26/2022 at 11:10 AM, revealed she had worked in her role for five (5) years. However, she had been assigned to other facilities since April of 2021. Per interview, she was an active participant in the investigation in February 2021. She stated she was aware of the medication audits that were completed related to the active medications for current residents and the evaluations/interviews with residents. Continued interview revealed she conducted Medication/Treatment Cart audits during the investigation to ensure proper functioning of all medication and treatment carts in the facility; that they locked and functioned properly. Additional interview revealed the facility did not have sufficient evidence to validate that medication was taken from the facility by LPN #7. Continued interview revealed during the investigation, she verified licensure for nurses in the facility as a preventative measure to ensure there were no issues. Per interview, she did not document the validation and did not identify any concerns with any nurse's license. When the SSA inquired about her role in the investigation to ensure all medications including discontinued and extra medications were accounted for, she stated that part of the Medication/Treatment Cart Audit she completed included her checking the medication rooms, for discontinued and extra medication. She stated she would have ensured if discontinued medication were in the medication rooms and medication carts, that the medications were accounted for and sent back to pharmacy. However, there was no documentation of the evidence of the process she verbalized. She stated she failed to document that part of the investigation. Further, she stated that she and the previous Administrator followed up on the Police Investigation routinely and tried to obtain a copy of the Police Report. However, the last time she contacted the Police related to the investigation of the alleged drug diversion from residents at the facility was in April of 2021. She stated she was not aware of any documentation of the facility's communication or effort to obtain the Police Report. After April 2021, she was no longer assigned as a consultant for the facility and did not know the outcome of the investigation. Interview with the Chief of Police, on 03/28/2022 at 10:53 AM, revealed the facility's previous Administrator had called and reported the allegation of drug diversion and provided LPN #7's address on 02/25/2021. Further, he had reviewed the Police Report after the arrest and the previous Administrator had been contacted on 03/01/2021 to confirm that all the prescriptions that were located at LPN #7's house belonged to current or discharged residents at the facility. Interview with the previous Administrator, on 03/26/2022 at 9:54 AM, revealed he was the Administrator at the facility from January 2021 until May 2021. Per interview, he recalled the misappropriation of residents' medications involving LPN #7 in February 2021. Continued interview revealed it was reported to him, on 02/25/2021, by SRNA #8. He stated he immediately started an investigation, reported the allegation, and notified the local Police. Per interview, the Police went to LPN #7's house and reported to the facility that they had found medications at her house that belonged to residents at the facility. He stated the Police would never give the facility a list of what exactly they had found at the LPN's house or what specific residents' medications were found. The facility completed a medication reconciliation for all residents and their active medication orders, and it was determined nothing was missing. He could not recall if all medications including discontinued and extra medications were reconciled; however, they should have been. Additionally, he stated he believed the facility completed a thorough investigation and made adequate documentation of their investigation. Per interview, he stated he could not remember if the facility implemented an action plan to mitigate a similar incident from occurring again or what the facility's investigation concluded. However, according to LPN #7's statement, she admitted she had taken the medications from the residents, and the Police confirmed there were residents' medications at the LPNs house. He stated LPN #7 was taking residents' medications, which was their personal property, and that was misappropriation. Further interview revealed he felt the normal safeguards, related to medication, that were in place prior to the incident, were as strict as you could get. He stated he did not know how to do more to stop a nurse from taking medications. Interview with the Clinical Care Consultant and Regional Director, on 03/26/2022 at 10:00 AM revealed Unit Managers attended the clinical morning meetings, Monday through Friday, and a review of all discontinued orders was conducted. Additionally, the Unit Managers made note of the discontinued orders and ensured those medications were pulled from each medication cart, scanned and placed in the pharmacy return bin in the locked medication rooms. Per interview, the facility did not have a process to view what discontinued medications had been scanned to compare to discontinued orders, to ensure all discontinued medications were reconciled and destroyed at the facility or sent back to the Pharmacy for reimbursement. Interview with the Director of Nursing (DON), on 03/26/2022 at 11:09 AM, revealed she had been in the role for one (1) year and was previously a Unit Manager for one (1) year at the facility. Per interview, the previous Administrator notified her on 02/25/2021 of the allegation of misappropriation of medication. She was responsible to audit medications in the medication carts to the active orders for each resident to ensure each active medication with an order was in the medication carts. She did not identify any concerns. However, the audit did not include all medications (discontinued or extra medication) or a review of the process for discontinued medications. She stated she did not contact Pharmacy related to the allegation of possible drug diversion of discontinued medication. Additionally, she stated she reviewed all investigation audits and evaluations/interviews, completed by other staff related to the allegation. Further interview revealed, the previous Administrator completed the investigation and ensured the investigation was thorough and documented appropriately. The DON stated she probably was updated before it was all over by the previous Administrator on the conclusion. Further, she had no concerns related to misappropriation, drug diversion. Continued interview revealed after the investigation, nursing management, who attended the clinical meeting Monday through Friday, was responsible to ensure discontinued medication orders discussed were removed from the medication carts and placed in medication rooms for pharmacy pick up. She stated there was no documented evidence that non controlled discontinued medication was reconciled, destroyed, or sent back to Pharmacy, other than the discontinued order in the Electronic Medical Record (EMR). Per interview, she was not aware of what the facility's investigation concluded. The DON stated it was important that the facility ensured a thorough investigation to ensure residents were free from misappropriation of property (medication) and that residents were not in situations where they were abused by their care takers. Interview with Unit Manager/RN #3, on 03/26/2022 at 12:00 PM, revealed she had been in the role for three (3) weeks and was previously a direct care nurse at the facility. Per interview, Clinical meetings were held Monday through Friday and attendees included the Minimum Data Set (MDS) Nurse, the Staff Development Nurse, the DON, the Assistant DON, and Unit Managers. In the meeting a print-out from the EMR, of all new orders from the last twenty-four (24) hours was reviewed. The print-out included discontinued medication orders. The team would ensure the medication order, the Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, she would write down any discontinued medications and the resident's name. After the meeting, she would take the paper and go physically to the medication carts, and remove the discontinued medication from the cart and place it in the pharmacy tote in the locked medication room. Per interview, nurses did not have access to scan or log in to the view master the pharmacy scanner and had not been trained on the scanner, only the DON. Continued interview revealed if there was a discontinued medication order, the nurse was supposed to remove it from the cart and place it in the medication room, in the pharmacy tote. She stated there was no process in place to ensure discontinued medications were returned to the Pharmacy. Per interview, the Pharmacy came to the facility Monday through Friday, twice a day and once per night on weekends, to pick up discontinued medications. Continued interview revealed the facility should make sure discontinued medications were properly sent back to Pharmacy and there should be a system in place to reconcile the discontinued medication to ensure residents were reimbursed. Interview with the Medical Director, on 03/28/2022 at 10:02 AM, revealed he was aware of the 02/25/2021 incident with LPN #7 related to misappropriation of medication; however, he was not aware of the specific details of the facility's investigation. Per interview, he could not recall discussion related to an action plan that the facility implemented/changed to make improvement with the current practice to minimize diversion or misappropriation of medications. Additionally, it was very important for the facility to thoroughly investigate incidents to determine the root case and implement safeguards to ensure the incident did not occur again. Further, the facility was responsible for all care and wellbeing for each resident. Telephone interview with the contracted Pharmacist and the Pharmacy Director, on 03/28/2022 at 2:20 PM, revealed the pharmacy was not contacted by the facility or made aware of the drug diversion/misappropriation of the ninety-three (93) medications, on 02/25/2021, involving LPN #7 and eight (8) residents at the facility. Additionally, the Pharmacy expected the facility communicate all diversion issues, due to the need to have medication available to residents and for necessary review of the facility's policy and procedures; collaboration to ensure best practice. Continued interview revealed there should have been an audit immediately to ensure correct medications were on hand; and, a review of the process on how the facility handled discontinued medications. In addition, a review of policy and procedures related to pharmacy procedures with staff should have been completed after the incident as a safeguard to prevent it from occurring again in the future. Further, the facility should have documentation of the actions implemented to ensure diversion of the same nature did not happen again.

Based on observation, interview, record review, review of the facility's policies, review of the Centers' for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS) guidelines; and the CDC's website, HTTPS://www/Coronavirus, it was determined the facility failed to implement the CDC's and CMS's interventions to establish and maintain an infection prevention and control program designed to provide a safe, and sanitary environment to help prevent and control the development and transmission of communicable diseases including COVID-19. Total census was 97. Observations on 03/20/2022, revealed staff did not use Personal Protective Equipment (PPE) in residents' rooms, who were under Droplet Precautions and Contact Precautions. Resident #299 and Resident #12 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional observation revealed staff exited Resident #299's and Resident #12's isolation room, into a common hallway with a mechanical lift brought from the isolation room. Observations revealed staff left the lift in the hallway without disinfecting it after it was used in the room. In addition, staff continued with resident care without cleaning their eye protection worn in the room, and did not change the surgical masks worn in the room. Observation of the facility's mechanical lifts (ML)s revealed the calf rests had dried brown and black matter on the surface, and the lift handles had dried white matter. Interviews revealed staff was unsure when the mechanical lifts were routinely disinfected. In addition, the facility could not provide documentation to show staff cleaned the mechanical lifts/equipment on a scheduled time frame. The findings include: Review of the facility's policy, Infection Control (IC), revised 10/2018 revealed the facility intended to maintain a safe, sanitary and comfortable environment to help prevent and manage transmission of disease and infection. The objectives with the IC policies and practice included to prevent, detect, investigate and control infections in the facility and provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Review of the facility's policy, Resident Lift, dated 05/30/2018, revealed the policy did not address infection control guidance after or with use of the equipment. Review of the facility's policy titled, Personal Protective Equipment (PPE), revised 10/2018, revealed the facility provided PPE for specific requirements for staff. Review of the facility's policy titled, Novel Coronavirus (COVID-19), revised 03/18/2022, revealed general prevention measures included PPE. Review of the facility's policy titled, Isolation-Categories of Transmission-Based Precautions (TBP), revised 10/2018, revealed TBP included additional measures which protected staff from becoming infected. The three (3) types included contact, droplet, and airborne. Review of CDC's website (https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor ), Transmission-Based Precautions, Droplet Precautions, review date of 03/21/2022, revealed before entering a resident's room who was on the precautions, the person(s) entering the room ensured their eyes, nose and mouth were fully covered and were to remove the face protection prior to leaving the room. Review of the CDC guide titled, How to safely remove PPE., undated, revealed upon exit of the area, masks were to be discarded in the waste container. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, revealed all Durable Medical Equipment (DME) must be cleaned and disinfected before reuse by another resident. Review on 03/24/2022 at 3:45 PM, of a sign posted in the nurses' station, revealed the Hoyer (brand name of a mechanical lift) was to be cleaned weekly and when visibly soiled. Review of the sign titled, Special Droplet/Contact Precautions, dated 03/09/2020, revealed Personal Protective Equipment should be worn and included: gown, gloves, eye protection, and a N-95 mask. Additionally, before leaving an isolation room, the gown, and gloves should be disposed of, and all shared equipment should be cleaned and disinfected. Furthermore, the room door was to be closed at all times. Review of the facility's Education In-Service Attendance Record, dated 10/20/2021, revealed eighty (80) staff, including nurses, aides, housekeeping, dietary, maintenance, laundry, therapy, administrative, social services, and human resource staff received training that included review of the CDC Module, Responding to Coronavirus and Keeping COVID-19 Out. Further review revealed the facility's training included hand hygiene; donning and doffing Personal Protective Equipment (PPE); COVID-19; and following Transmission Based Precautions (TBP). Review of Resident #229's Electronic Medical Record (EMR), revealed the facility admitted the resident from an acute hospital, on 03/17/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #299's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had an end date of 03/31/2022. Review of Resident #299's Immunization record revealed he/she had received one (1) Moderna COVID-19 vaccine on 09/07/2021. Review of Resident #299's Baseline Care Plan, dated 03/17/2022, revealed a Problem for Infection Control, because the resident was at risk for active infection related to potential exposure to COVID-19. The goal was the resident would not demonstrate signs or symptoms of active COVID-19 infectious process. Interventions included but were not limited to: Isolation as warranted per resident's condition and Maintain appropriate Personal Protective Equipment (PPE) use according to state requirements and availability. Observation of Resident #299's room, on 03/20/2022 at 4:05 PM, revealed an open door with Droplet Precautions and Contact Precautions Isolation signs. Per the signage, droplet isolation required an N-95 face mask, gown, a closed door, and dedicated equipment. Continued review revealed a don and doff (put on/take off) PPE instructional sheet was on the open door. Additional observations revealed a plastic three (3) drawer PPE cart at the door in the hallway with gowns, gloves and surgical masks; however, there was no evidence of availability of sanitizing wipes, N-95 masks, or brown bags for storing dedicated masks. Further observation, 03/20/2022 at 4:10 PM revealed State Registered Nursing Assistant (SRNA) #1, SRNA #2, and Hospitality Aide (HA) #3 put on PPE in the hallway outside Resident #299's room. Gowns and gloves were donned, but the aides failed to change their dedicated mask to a N-95 mask, and they all wore their dedicated surgical mask and eye protection into the room. Further, staff left the isolation door open, and the State Survey Agency observed from the hallway, while the staff assisted Resident #299 and his/her roommate, who was in Contact isolation, without changing PPE. Additional observations revealed the staff doffed and disposed of their PPE (gown, gloves) in the isolation room, washed their hands, and exited room. SRNA #1 brought the mechanical lift out of the room without sanitizing it, and they did not clean their eye protection or change their surgical mask after exiting the room. The lift, that was used in the room, was not disinfected, but SRNA parked it on the opposite hallway (Civil War). Then the aides went to the nurses' station. Interview with SRNA #1, SRNA #2 and HA #3, on 03/20/2022 at 4:15 PM revealed they had received training on infection control, including COVID-19, types of Transmission-based Precautions (TBP), what PPE to wear in each type of isolation, using dedicated equipment recently (2-3 months ago). Per interview, they should have changed their surgical masks and cleaned their eye protection with Clorox (brand of bleach) wipes; however, they forgot to do it because the SSA was watching and they didn't check the PPE container to see if they were available. Further review revealed they should not have pushed the mechanical lift out of the isolation room into the clean hallway and placed at the other hallway without wiping it down/cleaning it with Clorox wipes. She stated they did not check to see if there were wipes available to clean the lift and they forgot they should clean the lift. They stated that it was important to maintain infection control practices per policy to not contaminate other residents and spread infection. Interview with Licensed Practical Nurse (LPN) Staff Development Coordinator, on 03/21/2022 at 11:30 AM, revealed that she had been in the role since 03/01/2022. Per interview, since she had been in the role, she had provided In-Service education on use of PPE, handwashing and general infection control refreshers. She said she had not identified concerns related to infection control. Interview with the Unit Manager (UM)/Registered Nurse (RN) #3, on 03/26/2022 at 12:10 PM, revealed she had been in the role for three (3) weeks. Per interview, she expected staff to follow Infection Control Guidelines, policies, and practices related to isolation on a daily basis. She stated residents in contact isolation required staff to wear PPE per the instructions posted on the door. Additionally, staff members were expected to don and doff and use the appropriate PPE when providing care when droplet isolation precautions were in effect. The UM stated nursing staff should obtain the isolation order, ensure PPE, signage, and other necessary supplies were in place per the guidelines and policy. The UM stated there was adequate PPE available in the facility, and she had not identified concerns with Infection Control practices on Two (2) North or with the isolation rooms. However, she stated she had not conducted walking floor rounds to observe for potential infection control issues on equipment and that proper isolation supplies/equipment were available. She stated she did participate in Ambassador rounds, and resident rooms were checked for cleanliness, availability of Personal Protective Equipment, and that door signs for isolation were in place. She stated the rounds were completed daily and all management staff participated and were responsible for assigned rooms, but she was unaware if the rounds were documented as completed. Observations, that were made on 03/20/2022, at Resident #299's room, were discussed with the UM, and she stated the information provided would not be acceptable practice. She stated droplet isolation required staff to wear an N-95 mask, and residents not fully vaccinated were treated as potentially positive for COVID-19. She said if staff did not wear the proper mask while caring for that resident, there was a potential for spreading infection to other residents. The UM stated the lift used in Resident #299's should have been disinfected before it was parked in the hallway, because it could have been soiled by respiratory droplets while in use in the resident's room. She stated the direct care staff should have cleaned their eye protection and changed their masks after caring for Resident #299, and before they exited the room. The UM said the direct care staff should have located and donned the appropriate PPE before entering the room, because it was important to maintain IFC practices, and prevent the potential for the spread of infection to other residents at the facility. The UM said she had received annual and as need IFC training. Interview with the Infection Control Nurse/Director of Nursing (DON), on 03/26/2022 at 4:00 PM, revealed she had been in that role for one (1) year, and had previously served as the Unit Manager for one (1) year. She stated Infection Control policies were based on information from the Centers for Disease Control and Prevention (CDC) and reviewed by the corporation. When the Corporation sent the policies to the facility, she ensured staff was educated on the policy. Continued interview revealed it was the facility's practice to screen new admissions related to their COVID-19 vaccination status and their diagnoses. If residents were not completely vaccinated for COVID-19, the resident would be placed under Droplet Precautions for ten (10) days. She stated direct care nurses were responsible for ensuring all necessary orders, equipment, and signs were in place for residents who required isolation. She stated nurse managers completed rounds to ensure PPE was available on the floors and in central supply. Further interview revealed the facility completed education on infection control and would continue to provide training to ensure, as much as possible, that the facility maintained practices that prevented the spread of germs/bacteria. After discussion of the infection control concerns identified on Sunday 03/20/2022, the DON stated the observations were not acceptable. She stated the staff had been provided ongoing education and should have been able to provide Resident #299's care in a safe/acceptable manner. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed he had served as administrator since 06/01/2021. He stated all staff were responsible for following infection control guidelines and policies. He stated infection control practices were essential for halting the spread of infections. Per interview, education for infection control was ongoing, and any issues identified were discussed in the facility's Quality Assurance Performance Improvement (QAPI) meetings. The Administrator stated no issues had been identified related to infection control. After the SSA Surveyor discussed the infection control concerns identified on Sunday 03/20/2022, he stated the observed practices were not acceptable, and the policy guidelines should always be followed to stop the spread of infection. 2. Review of the facility's mechanical lifts manifest revealed the facility had full body lifts #1, #4, #7 and #9, and stand assist lifts #3, #6, #8, and #10. Observation on 03/20/2022 at 2:50 PM, revealed lifts #3 and #6 were in the hallway by room [ROOM NUMBER] and 2304. Both lifts had white and brown matter crusted on the bilateral calf rests and a white and brown matter on the footrests. Interview with Registered Nurse (RN) #1, on 03/20/2022 at 3:30 PM, revealed she could not identify the white or brown encrusted matter on lifts #3 and #6 without a microscope. The RN stated she did not have knowledge of a cleaning schedule, or a form which identified when the lifts were to be cleaned, and who was responsible to clean the lifts. She stated she would have to ask the supervisor about a log for cleaning the lifts. The RN did not provide the requested information during the survey. Observations on 03/24/2022 at 12:51 PM, revealed lifts #3 and #6 were in the hallway next to resident rooms [ROOM NUMBERS]. Observation of lift #3 revealed brown and white matter on the footrests and on the back of the calf rests. The left and right handles had white encrusted matter on the surfaces. Observation of lift #6 revealed splattered brown matter on both lower calf rests; the footrest had white, brown, and black debris; and, the left handle had a white encrusted matter on the surface. Observation on 03/24/2022 at 2:00 PM, revealed SA lift #8 and FB lift #1 were observed on the resident hallways with a sling. Lift #8 had white crusted matter on the left handle the size of one-half (1/2) of a dime and white and brown matter on the entire surface of the footrest/surface. Observations of lift #1 revealed the footrests had a white powdery substance with brown crumb-like matter over the entire footrest. Interview and observation with LPN #4, on 03/24/2022 at 2:52 PM, revealed she observed lifts #1 and #8. The lifts had brown and white matter on both lifts and white dried matter on lift #8's handle. She stated she did not know what the matter was and when asked to provide a cleaning log for the lifts or an equipment cleaning log for the unit, the LPN stated she would have to ask the supervisor about the logs. Interview with Registered Nurse (RN) #13, on 03/24/2022 at 2:52 PM, revealed with the State Survey Agency Surveyor present, she observed lifts #1 and #8 with brown and white matter on the lift foot rests and white dried matter on the handle of lift #8. She said she could not identify the matter. Observation on 03/24/2022 at 2:55 PM, revealed RN #13 obtained a wipe from the medication cart. The container was labeled as Sani-wipe (a no-rinse disposable wipe which kills common viruses and bacteria). The RN returned to lifts #1 and #8 and wiped the handles, calf rests, and footrest. The use of the wipe by the RN removed the brown matter and the matter on the handles of the lifts. The white matter was identified by the RN as possible break down of the pad. Continued interview with RN #13, on 03/24/2022 at 3:00 PM, revealed the Sani- wipe removed the brown, black substance on the calf rests and footrest and the white substance on the handles. She stated the lifts were dirty and obviously not cleaned by staff. She said the lifts were to be cleaned after use with a resident and weekly. However, she was unsure when the weekly cleaning occur. Observation, on 03/24/2022 at 2:16 PM, revealed a lift identified as #10. Observations revealed the calf rest and footrest had white and brown crusted matter on the surface and a quarter size brown sticky matter on the left leg rest. Continued observations revealed the right black handle had white raised matter. Further observation of lift #7 revealed the base of the lift had white and brown matter scattered over the surface on the base of the lift. Interview with SRNA #7, on 03/24/2022 at 2:24 PM, revealed with the State Survey Agency Surveyor present, the SRNA identified matter on lifts #7 and #10 as dried brown and white dirt. The aide stated after resident use, staff cleaned the lifts when they removed the lift from the room. The aide stated the facility cleaned the lifts to prevent cross contamination and possible spread of infection. The aide stated when staff did not clean multi-resident use equipment (lifts) bacteria could be transferred to another resident which could cause the resident to get sick. The aide stated staff should clean the lifts with a bleach wipe or Sani-wipe. The aide stated the units had a checklist to document when staff routinely cleaned the lifts. However, the aide stated she was not sure what day or shift the lifts were to be cleaned. She said the facility provided education for prevention of the spread of infection, and anyone in m,the facility could clean a lift. Interview with the ADON, on 03/24/2022 at 3:45 PM, revealed staff cleaned the lifts after each use, weekly, and when dirty. She stated the staff did not document on a form when they completed weekly cleaning of the lifts and to her knowledge the facility did not have a log. She stated the nurses' stations had a sign with instructions about when to clean the lifts. Continued interview with the Assistant Director of Nursing (ADON), on 03/24/2022 at 3:45 PM, revealed the units completed the lift cleaning task on different days. However, she did not know what days the different units completed the task. She stated the facility wanted to make sure the lifts were cleaned to prevent the risk of the transmission of infection. The ADON stated if cross contamination occurred, residents could get sick or decline. She stated staff was to follow the policy for infection control in order to prevent cross contamination. Further interview revealed staff members were to clean the lifts after use with a resident who was under isolation precautions. She said anyone in the facility could clean a lift. Interview with the DON (Director of Nursing), on 03/26/2022 at 3:10 PM, revealed direct care staff cleaned all lifts on Friday nights, after use with a resident, and after a lift was used for a resident under isolation precautions. However, observation, during the interview revealed a posted sign for weekly cleaning of lifts did not specify a day, a shift, or which staff members were responsible for the weekly disinfection of the lifts. She stated clinical staff observed lifts for cleanliness during walking rounds. She further stated staff was educated on infection control prevention measures. The DON stated the staff cleaned the lifts to prevent the spread of infections. The DON said the clinical IDT had not identified issues with dirty lifts. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed all staff members were responsible for following Infection Control guidelines and policies. Additionally, he stated Infection Control measures were the most important steps to stop the spread of infections. He stated the facility provided ongoing Infection Control education, and any issues identified were discussed in Quality Assurance Performance Improvement (QAPI) meetings. However, he stated dirty mechanical lifts had not been an identified issue. 2. Review of the facility's Electronic Medical Record (EMR) for Resident #12 revealed the facility admitted the resident, on 06/17/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/20/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (09) which indicated he/she had moderate cognitive impairment. Review of Resident #12 record revealed on 02/03/2022 and 03/16/2022, the resident was placed on Contact Isolation due to [MEDICATION(S)] Resistant Enterococcus (VRE) in his/her urine; a bacterial infection that is resistant to the antibiotic [MEDICATION(S)], which is commonly used to treat this type of bacteria and required transmission- based precautions (TBP) to prevent the spread of infection. Review of Resident #12's Comprehensive Care Plan (CCP) revealed, on 02/03/2022, the resident was care planned for Infection Control due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included Contact Isolation per order; vital signs every shift until completion of antibiotic; administer antibiotic, as ordered; observe for side effects related to antibiotic therapy; and report to physician (rash, itching, nausea/vomiting, diarrhea, difficulty breathing. Review of Resident #12's CCP revealed no documentation the facility revised the most recent Infection Control order of Contact Isolation, with VRE in urine, dated 03/16/2022. Review of Resident #12's Physician Orders, dated February 2022, revealed an order dated 02/03/2022, for Contact Isolation, due to [MEDICATION(S)] Resistant Enterococcus (VRE) in urine. Further review revealed an order to start [MEDICATION(S)] (antibiotic) 600 milligram (mg) per oral every twelve (12) hours times seven (7) days. Review of Resident #12's Interdisciplinary Team (IDT), Progress Note, dated 02/04/2022 at 9:27 AM, revealed the resident remained in isolation precautions; IDT discussed antibiotic use with no adverse drug reaction (ADR) noted. Review of Resident #12's Physician Orders, dated March 2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed an order to start [MEDICATION(S)] (antibiotic) 50 mg, oral every six (6) hours, times five (5) days. Continued review of Resident #12's Progress Note dated 03/16/2022 at 3:50 PM, revealed urinalysis results of VRE greater than one-hundred (100) colony forming unit (cfu) per milliliter (ml). Observation on 03/20/2022 at 4:05 PM, revealed Resident #12 was in Contact Precautions. The door was open and there were two (2) isolation signs on the door. One (1) noted Contact Isolation and the other one (1) noted Droplet Precaution. Additional observations revealed the Droplet and Contact sign on door listed precautions: N95 mask, close door and use dedicated equipment. Continued observations revealed an instructional sheet on the door which noted how to don (put on) and doff (take off) PPE. Further observations revealed a plastic three (3) drawer cart in the hallway at the doorway for PPE with gowns, gloves, and surgical mask; however, there was no evidence of sanitizing wipes or brown bags for dedicated mask outside the room. Continued observations on 03/20/2022 at 4:05 PM, revealed Certified Nursing Assistant (SRNA) #1, SRNA #2, and Hospitality Aide (HA) #3, don Personal Protective Equipment (PPE) in hallway outside Resident #12's room. All three aides donned gown, then gloves, but failed to change their dedicated mask to a N95 mask; they all wore their dedicated surgical mask and eye protection into the room. Further observation revealed the staff assisted both Resident #12 who was in Contact isolation, and his/her roommate, who was in Droplet Precautions, without changing PPE. Additional observations revealed the staff doffed the PPE (gown, gloves) in the isolation room and disposes it in dedicated bins, washed their hands, and exited the room. However, staff brought a mechanical lift out of the room without sanitizing it and staff did not clean their eye protection or change their surgical mask after exiting the room. The lift was not cleaned before leaving the isolation room and was parked on the opposite hallway. The aides went to the nursing station. Observation and interview of Resident #12, on 03/21/2022 at 8:40 AM, revealed he/she was lying in bed, watching ('television) without any signs/symptoms of distress noted. There were no odors in the room and the resident was clean and dry; he/she voiced no complaints. Interview with Resident #12, at the time of the observation, revealed the resident did know why he/she had been placed in isolation; I often get this type of infection in my urine, and it is unfortunate and irritating at times. Interview with SRNA #1, on 03/20/2022 at 4:15 PM, revealed Resident #12 was in contact isolation related to a type of contagious bacteria in his/her urine. Additionally, SRNA #1 stated it was required to wear gown, gloves, mask, and eye protection in the isolation room. SRNA #1 added, ongoing Infection Control trainings and education occurred to stop the spread of bacteria and germs. Interview with SRNA #1, SRNA # 2 and HA #3, on 03/20/2022 at 4:15 PM revealed they received training on infection control, including COVID-19, types of Transmission-based Precautions (TBP), what PPE to wear in each type of isolation, using dedicated equipment two (2) to three (3) months ago. Additionally, they stated they should have worn PPE per the signs on the door and changed their PPE in between residents. Per interview, they also should have changed their surgical masks and cleaned their eye protection with Clorox wipes when they exited the isolation room; however, they forgot. Further, they should not have pushed the mechanical lift out of the isolation room into the clean hallway and placed at the other hallway without wiping it down/cleaning it with Clorox wipes; they did not check to see if there were wipes available to clean the lift and they forgot they should clean the lift. However, it was important to maintain infection control practices per policy to not contaminate other residents and spread infection. Interview on 03/22/2022 at 2:30 PM, with SRNA #2 revealed she received training on types of isolation, and how and what type of PPE to wear for each type of isolation. SRNA #2 added Resident #12 was in isolation due to infection of VRE in his/her urine. She revealed staff should always follow the isolation precautions posted on doors and encourage residents in isolation to stay in their rooms. Further, staff should also encourage residents to practice infection control measures to decrease the spread of infection to other people in the facility. Interview with SRNA #12 and SRNA #13, on 03/26/2022 at 2:54 PM, revealed all nursing staff worked together as a team, and an individualized resident Kardex (Care Plan) was located on all units, at each nursing station for all staff to reference for resident care needs. Continued interview revealed the Kardex was updated daily per the Unit Manager. Additionally, the aides used the Kardex routinely throughout shift; at the beginning of every shift the nurses perform rounds to discuss, review and check all residents for any changes in conditions and what type of specific care to provide, including TBP. Continued interview revealed the admissions office notified the nurse management team and the Unit Manager of the type of TBP's a newly admitted residents required. Additionally, the Unit Manager ordered the needed supplies for the new resident. Per interview, the direct care nursing staff would prepare all supplies for the infection control cart to be placed in front of the room and place proper signage/type of TBP's on the door. Further, the nurse management in the facility routinely audited and made observations of resident rooms and staff's performance to ensure proper type of isolation was ordered and provided. Continued interview revealed Administration took infection control practices very serious, all staff were monitored routinely and if they were not performing properly and/or safely staff would be written up; would require re-training's and a performance improvement was placed in the staff records. Interview with SRNA #10, on 03/26/2022 at 9:20 AM, revealed she was provided education on ways to help residents minimize the spread of COVID-19 and transmission-based infections such as in hand washing, wearing masks, following isolation precautions, and social distancing. Continued interview with the aide revealed the staff encouraged all residents and other staff to practice and promote the correct type of isolation practices when in isolation rooms and providing nursing care to residents. SRNA #10 stated, it was necessary for all staff to practice correct and proper infection control practices in order, to prevent the spread of germs and to keep the residents well. Interview with Licensed Practical Nurse (LPN)/ Staff Development Coordinator #23, on 03/21/2022 at 11:30 AM, revealed she provided In-services, re-education on PPE, handwashing, and infection control, as refreshers. The SDC stated she had not identified any concerns in those areas. Additionally, LPN/SDC #23 added, if any identified concern would arise, she would provide education to all staff in all departments as applicable. Interview with RN #3 (Unit Manager on Two (2) North and Two (2) South), on 03/24/2022 at 10:03 AM, revealed she received infection control training which included the types of transmission-based precautions (TBP) to use; what PPE to wear in each type of isolation, and the proper use of and how to properly don/doff (put on/take off) PPE. Per interview, RN #3 stated the facility placed the resident in contact isolation for VRE in his/her urine. She stated antibiotics were started on 03/16/2022 and completed on 03/21/2022. Continued interview with RN #3, revealed all staff should don PPE each time they entered an isolation room regardless of whether the resident was in their room or not. RN #3 additionally stated, it was important for residents and staff to follow infection control standards of practice, as well as the facil [TRUNCATED]

Based on interview and record review it was determined the facility failed to protect one (1) of seventy-one (71) sampled residents (Resident #88) from physical abuse. Interview revealed on 11/02/2020, staff witnessed Resident #148 approach Resident #88 without provocation. Resident #148 grabbed Resident #88's arms and shook the resident. When Resident #88 requested Resident #148 to let go of his/her arms, Resident #148 attempted to hit Resident #88. The findings include: Review of the facility's policy, Abuse, Neglect and Misappropriation of Property, revised 05/08/2019, revealed abuse included the willful infliction of injury, unreasonable confinement, intimidation, or punishment. The policy defined willful as non-accidental. Physical abuse included the touch of a resident which did not have purpose and the person acted deliberately. 1. Record review revealed the facility admitted Resident #88 on 04/27/2020, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #88 with a Brief Interview for Mental Status (BIMS)examination score of three (3) and determined the resident was not interviewable. Interview with Family Member #13, on 03/26/2022 at 2:15 PM, revealed Resident #88 did not display behaviors and sat quietly at the table in the hall or laid in bed in his/her room. 2. Review of the closed record revealed the facility admitted Resident #148 on 04/25/2019, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #148 with a BIMS' score of zero (0) and determined the resident was not interviewable at the time. Review of the Comprehensive Care Plan (CCP) for Resident #148 revealed, on 07/24/2019, the facility developed a focus for Psychosocial Well-Being. The facility identified the resident was at risk and was active with behavior problems such as physical behavioral symptoms toward others. The symptoms included hitting, kicking, pushing, and scratching. Review of an incident report dated 11/03/2020, revealed Resident #148 grabbed Resident #88's arms and shook the resident. Further review revealed while Resident #88 verbalized for Resident #148 to let go of his/her arms, Resident #148 raised his/her hand/arm with what staff described as attempting to hit Resident #88. Interview with Family Member #11, on 03/26/2022 at 11:55 AM, revealed Resident #148 initiated altercations at home and had behaviors in the facility. Family Member #11 stated the resident was confused, would go up to other residents, talk about missing money for rent, and then strike at the other residents. Continued interview revealed the facility was aware of the resident's behaviors and discussed the behaviors in the care plan meetings; and the facility provided one on one (1:1) supervision when incidents occurred involving the resident. Interview with State Registered Nurse Assistant (SRNA) #17, on 03/26/2022 at 10:00 AM, revealed Resident #148 displayed behaviors and the facility placed the resident on 1:1 supervision often due to his/her behaviors. She stated that she received report that Resident #148 wandered onto the other unit where Resident #88 lived and grabbed both of Resident #88's arm and shook the resident. She stated staff intervened before Resident #148 could strike Resident #88. However, Resident #148 was unpredictable with his/her behaviors. Interview with SRNA #7, on 03/26/2022 at 2:10 [NAME], revealed Resident #148 displayed behaviors and at times required 1:1 supervision. She stated Resident #148 wandered around the units in a wheelchair (w/c). She stated she witnessed Resident #148 grab Resident #88 and shake him/her. SRNA #7 stated she observed Resident #148 wheel toward Resident #88 while Resident #88 sat in a chair at the table in front of the nursing station. Resident #148 went up to Resident #88, grabbed both arms and began shaking the resident. While staff proceeded to intervene, Resident #148 raised his/her hand toward Resident #88, in an apparent attempt to hit Resident #88 while Resident #88 stated to Resident #148 to let him/her go. She stated staff arrived in time to separate the residents before Resident #148 could make contact again with Resident #88. Interview with the former Social Service Director (SSD) #2, on 03/26/2022 at 2:40 PM, revealed she submitted a report for abuse which involved Resident #88 and #148 after staff reported Resident #148 grabbed and shook Resident #88. However, the SSD revealed she no longer worked at the facility and could not remember any information. Interview with the Assistant Director of Nursing (ADON), on 03/26/2022 at 2:00 PM, revealed Resident #148 moved from one unit to another in the wheelchair. The resident had severe dementia and could get hostile (unfriendly) toward others and hit staff while they provided care. She stated Resident #88 was usually quiet and did not exhibit behaviors. When Resident #148 displayed behaviors toward others the facility implemented 1:1 supervision or placed the resident in the direct line of vision to prevent other incidents. Interview with the Director of Nursing (DON), on 03/26/2022 at 3:10 PM, revealed Resident #148 had severe Dementia and moved himself/herself around the unit in a w/c. The DON stated the resident did not have altercations with other residents, except for Resident #88. She stated staff were trained in dementia and behaviors, and provided redirection, or reproached the resident when he/she displayed behaviors. She stated the facility provided 1:1 supervision until the facility could decrease the supervision to every fifteen (15) minute checks until it could be stopped. Interview with the Administrator, on 03/26/2022 at 4:00 PM, revealed as the Abuse Coordinator he was involved in all facility investigations. However, he accepted the role on 06/01/2021 and did not have knowledge of the investigation for Resident #148. He further revealed his role included to ensure residents lived in a good environment.

Based on observation, interview, record review, and review of the facility's Baseline Care Plan policy, it was determined the facility failed to ensure the Baseline Care Plan was developed and implemented to provide effective person-centered care for one (1) of seventy-one (71) sampled residents (Resident #299). Resident #299's Baseline Care Plan, initiated on 03/17/2022, revealed the resident required isolation as warranted per the resident's condition. However, the facility failed to further implement the Baseline Care Plan to include interventions related to Resident #299's Droplet Precaution isolation. Observations on 03/20/2022, revealed staff entered the resident's room to provide care without appropriate Personal Protective Equipment (PPE). Further observations on 03/20/2022 revealed staff exited the resident's room without following proper infection control guidelines. The findings include: Review of the facility's policy, Baseline Care Plan Process, dated 07/18/2018, revealed the charge nurse who admitted residents to the facility initiated the Baseline Care Plan to ensure care needs were met, utilizing a person-centered focus. Additionally, the Baseline Care Plan would be the working tool (Care Plan) for the first forty-eight hours. During the first forty-eight hours, all disciplinary team members, along with the resident and/or resident's Power of Attorney (POA)/family, reviewed the Baseline Care Plan and used it to build a Comprehensive Care Plan. Further, the Baseline Care Plan was presented to the resident and/or representative prior to completion of the Comprehensive Care Plan. Review of Resident #229's, Resident Face Sheet, revealed the facility admitted the resident from an acute care hospital, on 03/17/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #299's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had an end date of 03/31/2022. Review of Resident #299's Baseline Care Plan, dated 03/17/2022, revealed a care plan component, Problem of Infection Control. The resident was at risk for active infection related to potential exposure to COVID-19. The goal was the resident would not demonstrate signs or symptoms of an active COVID-19 infectious process. Interventions included but were not limited to: Isolation as warranted per resident's condition; and, maintain appropriate Personal Protective Equipment (PPE) use according to State requirements and availability, dated 03/17/2022. Observation of Resident #299's room, on 03/20/2022 at 4:05 PM, revealed an open door with Droplet Precautions and Contact Precautions Isolation signs. Per the signage, droplet isolation required an N-95 face mask, a closed door, and use of dedicated equipment, which would stay in the resident's room. Continued observation revealed a don and doff (put on/ take off) PPE instructional sheet on the open door. Additional observations revealed a plastic three (3) drawer PPE cart at the door, in the hallway with gowns, gloves, and surgical masks. However, outside the room, there was no evidence of sanitizing wipes, N-95 masks, or brown bags for storage of dedicated masks. Further observation, on 03/20/2022 at 4:10 PM, revealed State Registered Nursing Assistant (SRNA) #1, SRNA #2, and Hospitality Aide (HA) #3 donned PPE in the hallway outside Resident #299's room. The staff members put on gowns and gloves, but the aides failed to change their dedicated mask to an N-95 mask. Instead, they all wore their dedicated surgical masks and eye protection into the room. Further observation revealed the staff assisted Resident #299 and his/her roommate Resident #12, who was in Contact isolation, without changing their PPE. Additional observations revealed the staff doffed the PPE, (gowns and gloves) in the isolation room and disposed of it in dedicated bins, washed their hands, and exited the room. However, staff brought a mechanical lift out of the room without sanitizing it, and they did not clean their eye protection or change their surgical masks after exiting the room. The lift was not disinfected, before it left the isolation room, and SRNA #1 parked the lift on the opposite hallway. The aides then went to the nurses' station. Interview with SRNA #1, SRNA #2 and HA #3 on 03/20/2022 at 4:15 PM, revealed she was aware Resident #299 was in Droplet Isolation related to not receiving all COVID-19 vaccines yet. She stated she read about Resident #299's care on the Kardex. Further interviews with SRNA #1, SRNA #2 and HA #3, revealed they received training on care plans, and they were aware the care plans were on the Kardex, in a notebook at the nurse's station. Continued interview revealed they followed the Care Plan when caring for Resident #299 to ensure his/her safety and the safety of the staff. They stated that it was important to follow the care plan to maintain infection control practices per policy, in order to prevent the spread infection to other residents. Interview with the Unit Manager (UM)/Registered Nurse (RN) #3, on 03/26/2022 at 12:10 PM, revealed she had been in the UM role for three (3) weeks. Per her interview, she expected staff to follow the resident's care plan to ensure proper and safe care was provided per the resident's needs, as assessed. Continued interview revealed staff was expected to refer to the Care Plan each time they provided care to any resident because care interventions could have changed. Additionally, all staff was responsible for ensuring residents' care plans were implemented and followed. She further stated, aides, nurses, and supervisors were responsible for immediately intervening, addressing, and correcting care, if the resident's care plan was not being followed. The UM said she monitored care plan implementation by assisting with resident care, making observations of staff while providing care, and speaking with residents, family, and staff. She said if staff had questions about how to provide resident care, they could ask her or other staff nurses for help. The UM stated she had not identified concerns with implementation of resident care plans. Interview with SRNA #6, on 03/26/2022 at 1:00 PM, revealed she looked at resident Care Plans daily to verify the care needs of the residents. The SRNA stated it was important to follow the resident's Care Plan in order to provide resident care in a safe manner. Interview with RN/Minimum Data Set (MDS) Nurse #1, on 03/26/2022 at 3:41 PM, revealed she used the facility's policies and the Resident Assessment Instrument (RAI) manual for guidance when she completed the Minimum Data Set (MDS). Assessments. She stated, in addition, she used a worksheet with information gathered from the resident's chart, family, staff, and face- to-face, and hands on assessments. She stated the floor nurse initiated the Baseline Care Plan, and it would be reviewed at the next clinical meeting. Continued interview revealed the MDS nurse would continue to develop the care plan. RN/MDS Nurse #1 stated the care plan should be the guide for provision of resident care. Interview with the Director of Nursing (DON)/Infection Control Nurse on 03/26/2022 at 4:00 PM, revealed floor nurses, MDS nurses, and members of the Interdisciplinary Team (IDT) developed and revised the Baseline Care Plan. Continued interview revealed all staff was responsible for ensuring the Baseline Care Plan was followed. Additionally, she expected staff to refer to and follow the Baseline Care Plan, because it was developed according to the resident's needs. She stated she had not identified issues with staff not following Baseline Care Plans. After the SSA (State Survey Agency) Surveyor discussed the observations she made on 03/20/2022, the DON/Infection Control Nurse said staff should have followed the Baseline Care Plan. Interview with the Administrator, on 03/26/2022 at 4:30 PM, revealed all staff members were responsible for following the Baseline Care Plans for each resident, and for ensuring safe care was provided. The Administrator stated staff leaders made rounds and observed resident care to ensure Baseline Care Plans were followed. Further, he stated staff talked with residents, families, and staff; and that Baseline Care Plans were discussed in clinical morning meetings. The Administrator stated he had not identified concerns with Baseline Care Plans. Continued interview revealed after the SSA Surveyor discussed observations made on 03/20/2022, the Administrator stated ongoing education was necessary related to following the Baseline Care Plans, and maintaining proper infection control practices.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to revise a Person-Centered Comprehensive Care Plan (CCP) that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for one (1) of seventy-one (71) sampled residents (Resident #148). On 11/02/2020, staff witnessed a physical altercation between Resident #148 and Resident #88. Review of Resident #148's Behavior CCP revealed the facility initiated a behavior care plan on 07/14/2019, which included behaviors of hitting, kicking, pushing, and scratching. On 11/02/2019, facility staff witnessed Resident #148 physically interact with Resident #88. Resident #88 did not initiate any behavior towards Resident #148 to prompt him/her to grab, shake and attempt to slap the resident. Review of Resident #148's CCP revealed the facility did not revise the focus of behavior to identify the physical altercation with another resident with interventions to promote his/her safety and other residents. The findings include: Review of the facility's policy CCP, revised 07/19/2018, revealed the CCP included measurable objective and timetables to meet the residents' medical, nursing, mental and psychological needs. The CCP included how the facility would assist the resident to meet his/her needs, goals, and preferences. The CCP included goals for the desired outcome gathered from the resident and resident's representatives. CCP interventions were implemented for the resident's problem area. Interventions addressed the underlying source of the problem area, rather than addressing only the symptoms or triggers. The interventions were to reflect action, treat or identify a procedure to meet the objectives toward the resident's goals. The facility revised the residents' CCP's as information about the resident and the resident's condition changed. The clinical IDT's (interdisciplinary team) responsibilities included to review and update residents' care plans which should reflect the current status of the resident and update with changes in the resident's status. The CCP would be changed when a desired outcome had not been met. Closed record review revealed the facility admitted Resident #148, on 04/25/2019, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #148's Brief Interview for Mental Status (BIMS) score of zero (0). Review of an Incident Note, dated 11/02/2019, revealed Resident #148 grabbed Resident #88's arms and shook the resident. Staff intervened before Resident #148 struck Resident #88. Review of Resident #148's Comprehensive Care Plan (CCP) developed on 07/24/2019 revealed the facility addressed the problem for Psychosocial Well-Being. The facility identified the resident was at risk and was active with behavior problems such as physical behavioral symptoms toward others. The resident's symptoms included hitting, kicking, pushing, and scratching. Interventions initiated on 07/30/2019 included: to report change in behavior to the doctor; provide non-confrontational environment with care; anticipate care needs before the resident became stressed; monitor need for psychological/psychiatric services; reinforce positive behavior; re-approach when the resident became less agitated; provide opportunities for positive interaction and attention; invite to activity programs; monitor behavior episodes and determine underlying cause; intervene to protect the rights and safety of others; approach calmly; divert attention; and, remove from situation and take to another location as needed. Further review revealed the facility failed to update the care plan for the 11/02/2020 altercation. In addition, the facility failed to revise the resident's interventions to address and prevent another resident-to-resident altercation. Interview with State Registered Nurse Aide (SRNA) #15, on 03/28/2022 at 1:05 PM, revealed revisions to the aides' care plans were made with changes to the resident's nursing care plans. She stated the care plans included behavior interventions for the aides to follow. SRNA #15 stated the clinical managers updated the care plan when needed and the Minimum Data Set (MDS) Coordinators came once a month to update the care plans. She stated the revisions allowed staff to provide the appropriate care for residents' needs. The SRNA stated if the residents' care plans were not revised it impacted the resident and other residents because the resident may get hurt when new behaviors were not addressed on the residents' care plans. Interview with SRNA #7, on 03/28/2022 at 2:10 PM, revealed Resident #148's behaviors included hitting and resistive to care. She stated Resident #148 went to another resident and initiated aggressive physical contact. SRNA #7 stated the facility should have revised the resident's care plan immediately to reflect new interventions for staff to provide to prevent another altercation. She stated the revised interventions alerted staff that a new behavior had occurred and to make sure the residents were safe with the new interventions. Interview with Licensed Practical Nurse (LPN) #15, on 03/28/2022 at 1:05 PM, revealed the facility revised care plans with a change of a resident's condition or need. She stated if a resident presented with a new behavior, the nursing staff on the floor were able to revise the care plans immediately. LPN #15 stated the facility should have revised Resident #148's care plan to make sure the resident did not have another physical altercation with a resident. Interview with MDS Coordinator #1, on 03/28/2022 at 11: 30 AM, revealed the facility revised care plans annually, quarterly, and as needed. She stated the clinical Interdisciplinary (IDT) team reviewed Nurses' Notes, events, the daily report sheet, and revised residents' care plans as needed. She stated the facility should complete a revision immediately and should include short term and long-term interventions for behaviors. Upon review of Resident #148's care plan, with the State Survey Agency (Surveyor), she stated the facility did not revise the resident's behavior care plan to include the new behavior under the focus of behaviors and did not initiate a new intervention to prevent altercations and possible harm between residents. The MDS Coordinator stated the IDT should have revised the care plan the next day and or the MDS Coordinators should have reviewed the care plan with the quarterly review of the Nurses' Notes as the notes identified the incident between residents. She further stated the Quality Assurance and Performance Improvement (QAPI) committee did not identify issues with revisions of behavioral care plans. Interview with the Assistant Director of Nursing (ADON), on 03/26/2022 at 2:00 PM, revealed residents' CCPs were to be followed at all times. Revisions to the CCP could be made at anytime to reflect a change of the resident's care or behaviors. The Minimum Data Set (MDS) Coordinators reviewed the care plans quarterly and updated the CCP based on their findings. The ADON stated Resident #148's care plan should reflect the resident's behaviors and any situation to which the revision would reflect new behavior. She stated she expected staff to follow the care plan. Continued interview revealed if the care plan did not reflect the resident's new behaviors residents and staff could be harmed. Interview with the Director of Nursing (DON), on 03/28/2022 at 3:00 PM, revealed the facility identified the need to revise a resident's care plan with the daily review of the resident's Nurses' Notes and event reports. She revealed revisions to the behavioral care plans were made to ensure the residents in the facility remained safe. The DON stated the nurses could revise the residents' care plans immediately. She stated after the IDT team concluded the root cause of a behavior, interventions would be revised to address the behavior and the SRNA's care plan would also be revised to reflect the change. The DON stated the IDT's responsibilities included to make sure revisions to the care plan were completed as soon as possible and appropriate for the resident. She further stated the goal of the facility included to maintain a safe environment and to prevent harm to the resident. Interview with the Administrator, on 03/26/2022 at 4:00 PM, revealed the clinical IDT reviewed the resident's Nurses' Notes, event reports and received reports from staff about the resident's care and needs. He stated the IDT reviewed care plans daily and with quarterly assessments by the MDS team. Further interview revealed the monthly QAPI (Quality Assurance and Performance Improvement) meetings discussed quality indicators which involved residents' care plans. He stated the facility had not identified issues with care plan revisions. Further interview revealed the facility's goal with his leadership included to provide the residents with a good environment to live in at the facility.

Based on interview, record review, facility investigation review, and facility policy review, it was determined the facility failed to conduct an investigation of abuse that included interviews and skin assessments with other residents for one (1) of three (3) sampled residents (Resident #1). The findings include: Review of facility policy titled, Abuse, Neglect and Misappropriation of Property, last reviewed on 05/08/19, revealed in cases of alleged resident abuse, the Director of Nursing (DON) or his/her designee will conduct interviews of interviewable residents on the residents' unit, or the entire facility, as appropriate. Additionally, they shall conduct an appropriate physical assessment of residents who are not capable of being interviewed. Record review revealed the facility admitted Resident #1 on 10/17/19 with [DIAGNOSES REDACTED]. Review of allegation dated 11/18/19 revealed an allegation a male staff sexually abused the resident and the resident had bruising to forearm, upper arms, legs, calf muscles, buttocks, and back and that the bruising looked like finger marks. Further review revealed there was no documented evidence resident skin assessments and interviews were conducted per facility policy. Interview with Director of Nursing (DON) on 12/13/19 at 1:47 PM and 2:00 PM revealed she was notified of of suspicious bruising of Resident #1 by Adult Protective Services and heard there was an allegation of sexual abuse per spouse of Resident #1 to another family member. The DON stated that they had completed skin assessments three to four (3-4) days before Resident #1 went out to the hospital. Interview with the Administrator on 12/13/19 at approximately 1:25 PM revealed he, the DON, and Nurse Consultant reviewed the allegations and did interviews with staff with no concerns. He stated they did not interview any residents because Resident #1 had discharged . Further interview with the Administrator on 12/13/19 at 4:19 PM revealed they did not interview residents or perform physical assessments on other residents because they investigated the allegation related to Resident #1 and he/she was out of the facility.

Based on interview, record review, and facility investigation review, it was determined the Acting Director of Nursing failed to report an allegation of staff being abusive to one (1) of five (5) sampled residents to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services) within two (2) hours of the allegation (Resident #2). The findings include: Record review revealed the facility admitted Resident #2 on 03/09/18 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #2's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eleven (11) which indicated the resident was interviewable. Review of the facility's investigation revealed Resident #2 reported that on 10/13/19 at approximately 7:45 PM, Certified Nurse Aide (CNA) #2 and CNA #4 were assisting Resident #2 to the bathroom and CNA #4 was rough and hurt his/her back when she put him/her on the commode. Resident #2 stated when he/she told CNA #4, Be easy, that hurt me, CNA #4 stated you always say that. Resident #1 also reported CNA #4 was rough with him/her again when put him/her to bed. Interview with Registered Nurse (RN) #4 on 10/31/19 at 10:20 AM and review of her written statement dated 10/13/19 revealed Resident #1 made her aware of the allegation that CNA #2 was rough with him/her and hurt his/her back on 10/13/19, and she called the Director of Nursing (DON) on 10/13/19 at 10:14 PM to make her aware. RN #4 stated the DON told her to obtain a written statement from CNA #4 and she would look into it in the morning. However, review of the facility's investigation revealed the allegation was not reported to the Administrator, State Survey Agency, and Adult Protective Services until 10/14/19, after the Social Worker was made aware by Resident #1. Interview with the Interim Director of Nursing on 10/31/19 at 1:45 PM revealed she did not recall RN #4 notifying her of Resident #1's allegation on the night of 10/13/19, she stated it was in the morning on 10/14/19 around 5:45 AM.

Based on interview, record review, and facility investigation review, it was determined the facility failed to interview a witness to the alleged incident and failed to remove the alleged perpetrator from resident care until the day after the allegation was made, for one (1) of five (5) sampled residents (Resident #2). The findings include: Record review revealed the facility admitted Resident #2 on 03/09/18 with [DIAGNOSES REDACTED]. Review of the facility's investigation revealed Resident #2 reported that on 10/13/19 at approximately 7:45 PM, Certifed Nurse Aide (CNA) #2 and CNA #4 were assisting Resident #2 to the bathroom and CNA #4 was rough and hurt the resident's back when she put the resident on the commode. Resident #2 stated when he/she told CNA #4, Be easy, that hurt me, CNA #4 stated you always say that. Resident #1 also reported CNA #4 was rough with him/her again when she put him/her to bed. Interview with Registered Nurse (RN) #4 on 10/31/19 at 10:20 AM and review of her written statement, dated 10/13/19 revealed Resident #1 made her aware of the allegation that CNA #2 was rough with him/her and hurt his/her back on 10/13/19, and she called the Director of Nursing (DON) on 10/13/19 at 10:14 PM and made her aware. However, further review of the facility's investigation revealed CNA #4 was not suspended until 10/14/19. Further interview with RN #4 revealed the DON told her to obtain a written statement from CNA #4 but did not tell her to remove CNA #4 from resident care and CNA #4 worked the rest of her shift. In addition, further review of the facility investigation revealed there was no documented evidence a statement was obtained from CNA #2 related to what she heard and saw but the investigation stated a written statement was obtained. However, interview with CNA #2 on 10/30/19 at 1:30 PM, revealed no one had interviewed her or obtained a written statement from her about Resident #2 alleging CNA #4 was rough with him/her and hurt his/her back. She stated she was not aware of CNA #4 being rough or injuring Resident #1. Interview with the Social Worker (who completed the investigation), on 10/31/19 at 1:05 PM revealed she thought a written statement was obtained from CNA #4. Interview with the Interim Director of Nursing on 10/31/19 at 1:45 PM revealed she did not recall RN #4 notifying her of Resident #1's allegation on the night of 10/13/19, she stated it was in the morning on 10/14/19 around 5:45 AM. She stated she did not tell the RN to remove CNA #4 from care because the RN stated the resident was just complaining.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to implement the comprehensive care plan related to treatment of [REDACTED].#1). The findings include: Review of the facility policy titled, Comprehensive Care Plan, last revised 07/19/19, revealed interventions will reflect the action, treatment, or procedure to meet the objectives of achieving the resident goals. Record review revealed the facility admitted the Resident #1 on 05/21/19 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS assessment, dated 08/28/19, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Review of Resident #1's Admission Skin Assessment, dated 05/22/19 revealed a black, callous was noted to bottom of right foot. Review of the Comprehensive Care Plan for Potential for Compromised Skin Integrity revised on 05/21/19 with area to bottom of right foot, revealed an intervention to complete wound orders per physician. Review of the Physician's Order dated 05/22/19 revealed an order to apply Triple Antibiotic Ointment to bottom of right foot wound, and cover with band aide every shift and as needed (PRN). However, review of the May and June 2019 Treatment Administration Record (TAR) revealed the treatment was initialed as being completed on 05/22/19, however, there was no documentation the treatment was completed after that and no documentation the order was discontinued. Interview with Registered Nurse (RN) #1 revealed she recalled completing the treatment with the antibiotic ointment and applying the band-aide but does not remember exactly on what dates. Interview with RN #4 on 10/31/19 at 4:04 PM revealed when they first started a dressing on Resident #1's wound it was just a calloused area and staff were applying skin prep to try to dry out but she did not recall exactly when and how long those treatments were being completed. Interview with the Administrator on 11/04/19 at 11:55 AM revealed they went to a new system on 05/24/19 and they cannot find anything related to the treatment order being changed or discontinued and no further documentation to show the treatment was completed after 05/22/19.

Based on observation, interview, record review, facility policy review, and review of the facility's fall investigation, it was determined the facility failed to ensure routine maintenance of assistive devices to prevent an avoidable accident for one (1) of thirty-one (31) sampled residents, Resident #82. On 12/06/18, Certified Nursing Assistant (CNA) #13 was pulling the resident backwards in a shower chair, over a lip in the floor, and the chair broke causing the resident to fall and sustain a broken hip. Interview and record review revealed a thorough investigation had not been completed because the shower chair was not fully examined in order to determine how it had malfunctioned. Interview and record review also revealed the shower chair had not been routinely checked by maintenance per the facility's policy and procedures. In addition, interview revealed staff had not been trained on how to maneuver the shower chair safely over the lip in the floor and the incident had not been reviewed by the Quality Assurance and Performance Improvement (QAPI) team to put a plan in place to prevent a similar incident from happening again. The findings include: Review of facility's policy, Accident and Incidents-Investigating and Reporting, dated 07/24/18, revealed accidents or incidents involving residents (employees, visitors, vendors, etc.) occurring on facility premises would be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor would initiate and document an investigation of the accident or incident. The following data would be included in the Event Manager (an electronic incident reporting system). Review of the facility's policy, Maintenance Service, dated (MONTH) 2005, revealed maintenance service was provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times in compliance with current federal, state, and local laws, regulations, and guidelines. The maintenance department provided routinely scheduled maintenance service to all areas. Review of the facility's policy, Work Order, dated (MONTH) 2005, revealed maintenance work orders were completed in order to establish a priority of maintenance service. In order to establish maintenance service, work orders were filled out and forwarded to the Maintenance Director. It would be the responsibility of the department directors or any staff member identifying needed repairs to fill out and forward such work orders to the Maintenance Director. A supply of work orders was maintained at each nurses' station and work order requests were placed in the appropriate file basket at the nurses' station and picked up daily. Emergency request were given priority in making necessary repairs. Review of Resident #82's clinical record revealed the facility admitted the resident on 11/24/15, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of eleven (11) out of fifteen (15) and determined the resident interviewable. The facility determined the resident required two (2) staff for transfers and needed one (1) staff assistance for bathing. The resident used a wheelchair for mobility. Review of the significant change MDS assessment completed after the incident, dated 12/23/18, revealed a BIMS could not be completed and the facility assessed the resident was rarely/never understood. Review of a Fall Investigation, initiated on 12/06/18, revealed on 12/06/18 at 10:00 AM, Resident #82 was in the shower in a shower chair and the shower chair handle broke. The CNA broke the resident's fall. The nursing assessment revealed the resident denied pain and no injury was noted. The overall summary of investigative findings and conclusions revealed the resident fell out of the shower chair after the chair back broke. The physician was notified, STAT (immediate) x-rays were obtained, and the resident was sent to the emergency room for evaluation and treatment. The resident returned to the facility with palliative care orders. Interview with CNA #13, on 01/24/19 at 3:56 PM, via telephone, revealed the resident's family was not sure if they wanted to send him/her to the hospital because they had been considering palliative care. Review of a Hospital Discharge Summary, dated 12/10/18, revealed Resident #82 was assessed at the hospital on [DATE] after a fall with [DIAGNOSES REDACTED]. A complicated surgery was advised; however, given the resident's age and existing comorbid conditions, and likely extensive surgery required to repair the right femoral neck fracture, the resident's family wished not to pursue surgery and rather keep the resident comfortable with non-operative management going forward. Interview with CNA #13, on 01/24/19 at 3:56 PM, via telephone, revealed she was in the shower with Resident #82 and the resident was in the purplish shower chair, which was a wide chair. The CNA stated she pulled the resident in the shower chair, from behind, over the lip of the floor and the back of the chair broke, at the top. Per the CNA, the shower chair was made of [MEDICATION NAME] chloride (PVC) pipes and part of a pipe came out of the socket and broke. The resident fell backwards and half of his/her bottom was in the shower chair so she lowered the resident to the ground. The CNA stated she told her partner to get a nurse and the resident reported no pain at the time of the fall, so staff put the resident in the mechanical lift and transferred him/her to the bed. The CNA revealed the resident later complained his/her right leg hurt and the facility ordered x-rays. She stated when the x-ray results came back; the facility sent the resident to the hospital. The CNA she did not remember receiving training on use of the shower chairs or the method for getting the resident over the lip in the shower. CNA #13 stated she used the side of the shower chair now because she was scared the incident might happen again. The CNA stated she was an as needed (PRN) staff so she was unsure if the facility was auditing shower chairs or completing maintenance on the chairs. Interview with CNA #2, on 01/24/19 at 1:59 PM, revealed she saw Resident #82 on the shower floor and the shower chair handle was off and part of the back was broke. The arm of the shower chair broke off at the base of the chair, where the back of chair and the seat of the chair meet. The CNA stated CNA #13 had the resident in the shower chair, was pulling him/her from behind to get the resident in the shower, and had to get the chair over the lip in the floor when the chair broke. CNA #13 grabbed the resident the best way she could and pulled the call light cord. CNA #2 stated the CNAs were trained to back the residents into the shower, in the shower chairs. The CNA described there were different colors and sizes of shower chairs. CNA #2 revealed there were no new trainings on use of shower chairs that she was aware of at this time. She was not aware of assignments to audit shower chairs; however, she checked the shower chairs when used. Per interview, there was a maintenance and housekeeping book at the nurses' station and anyone could put an order in the book. The CNA stated Maintenance checked the logbook every day and check off the completed tasks. Interview with and observation of CNA #5, on 01/24/19 at 2:29 PM, revealed she heard Resident #82 fell when the shower chair broke when it was pushed over the shower lip. CNA #5 stated she was shown how to use the shower chair by other CNAs, and demonstrated to the surveyor by using the side of a shower chair to enter the shower and lift the chair over the shower lip. Interview with the Staff Educator, on 01/24/19 at 5:18 PM, revealed she was the Acting Director of Nursing (DON) at the time of Resident #82's incident and to her knowledge, CNA #13 took Resident #82 to the shower in the shower chair and the shower chair broke. The back of the shower chair had cracked causing the pipe to come out of the coupling (device used to connect two shafts together at their ends). She stated Maintenance staff disposed of the shower chair and the Plant Operator was informed. She stated there was no training on how to get the resident over the lip in the shower floor while in a shower chair, but if staff was alone, they should back up and lift up over the lip. She revealed staff should always check equipment before using it for resident safety. Interview with the Plant Operator Director (POD), on 01/24/19 at 4:25 PM, revealed staff generally wrote needed repairs in the maintenance book, called maintenance, or documented the needed repair in the computer program. The computer program alerted Maintenance staff for routine repairs around the facility but nothing about maintaining the shower chairs. The POD revealed she did not investigate the shower chair, and the shower chairs came to the facility already put together. The POD stated she looked at the shower chair before it was tossed away and the chair had a hairline crack. She stated she attended Quality Assurance (QA) meetings, attended the morning meetings, stand down meetings, and huddles in the morning, and did not hear anything about shower chairs. Per interview, maintenance did not consider the shower chairs equipment and did not routinely monitor them. Interview with the Central Supply Director (CSD), on 01/24/19 at 4:48 PM, revealed she ordered shower chairs off a website but she did not open the boxes, she just gave the boxes to maintenance. She stated she only ordered the white shower chairs. She stated Resident #82's shower chair was purple, cracked in the back, and the chair was placed in the dumpster. She stated there were no audit system for supplies in the facility and no system for dating how old products were that were in use. The frame for the shower chairs had a five (5) year warranty, the caster had a six (6) month warranty, and all other materials were for one (1) year. Interview with the DON, on 01/24/19 at 5:42 PM, revealed she was not aware of any auditing of shower chairs. She stated when requesting a repair, it was word of mouth or there was a maintenance book at each nurses' station. The DON stated it was the Administrator's function to monitor the maintenance book to make sure all repairs were completed, and Maintenance reported directly to the Administrator. Per interview, she had been DON a short time and did not recall Resident #82's fall. The DON revealed staff discussed safety in the morning meetings but there had been no discussions about the shower chairs, the lip in the shower, or training involving the shower chairs after the incident. The DON stated if a CNA had difficulty transporting a resident, he/she should ask another staff member for assistance. The DON reviewed Resident #82's fall investigation report and stated the report should have the root cause of the incident along with interventions to prevent a similar situation from reoccurring, but it did not. According to the DON, the only audits completed were weekly reports sent to the Clinical Regional Director for the number of falls with injuries, which were reviewed monthly via computer access. Interview with the Administrator, on 01/24/19 at 6:14 PM, reviewed he was informed the resident fell in the bathroom from a malfunctioned shower chair. He stated he was unable to inspect the chair himself because staff immediately put the shower chair in the dumpster after the incident. The Administrator stated the facility logged equipment but he was not sure if the facility logged the shower chairs. He stated prior to the incident, the facility did not perform ongoing audits of the shower chairs, nor did he direct staff to do so after the incident. The Administrator was unsure of the age of the shower chairs or if the facility had a system to maintain for everyday use. He stated all falls were situational in regards to whether they were avoidable or unavoidable. The Administrator stated there were too many factors involved to determine if Resident #82's fall was avoidable or not. He stated the fall was logged into the computer system and it was the responsibility of the clinical nurse team to pull the report from the system and go through the assessment to determine if complete. He stated the computer system did not assist with finding the root cause of the incident and the team determined the root cause, once information was obtained. He stated the facility did not complete a full investigation because the shower chair was not fully examined in order to determine how it had malfunctioned. In addition, the facility had not taken the incident to the QAPI team to put a plan in place regarding the shower chairs or showering process in regards to transferring over the lip in the floor. The Administrator revealed he had no investigation training or experience, and depended on the computer system and the clinical team to investigate and determine the root cause of any incident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure each resident was treated with respect and dignity for four (4) of eighteen (18) sampled residents, Residents #19, #74, #88, and #91. Interviews revealed the facility failed to meet the personal care needs of the residents in a timely manner. The findings include: Review of the facility's policy, Resident Rights, revised 08/16/18, revealed all residents had the right to be treated with respect and dignity. The residents' rights were protected and promoted by the facility in a manner that maintained or enhanced the residents' quality of life. When staff provided care and services, they respected the residents' individuality and valued their input by providing a dignified existence, through self-determination and communication, and with access to persons and services inside and outside the facility. Observation of the first floor north hall, on 01/23/19 at 9:39 AM, revealed the call light for Resident room [ROOM NUMBER] was on and remained unanswered until 9:59 AM, when answered by a Certified Nursing Assistant (CNA). At 9:46 AM, the call light for Resident room [ROOM NUMBER] went on and was not answered until 9:59 AM, by the Administrator. Registered Nurse (RN) #1 was documenting on the computer at the medication cart while the call lights were sounding; however, did not attempt to answer either call light. Interview with RN #1, on 01/23/19 at 9:57 AM, revealed when asked why she did not answer the call lights, she responded she did not usually work on the north hall and had not worked on the hall for over a month. 1. Record review revealed the facility readmitted Resident #19 on 08/17/18, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the facility assessed Resident #19 with a BIMS score of ten (10) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for surface-to-surface transfer and toileting. The resident was always incontinent of bowel and bladder. Interview with Resident #19, on 01/21/19 at 11:05 AM and 01/23/19 at 9:25 AM, revealed he/she required assistance to go to the bathroom and did not always get the help he/she needed. The resident stated he/she waited half an hour or more, and at times, waited for hours. He/she knew how long it took staff to answer the call light because there was a clock on the wall and he/she had a cellphone that showed the time. The resident further stated he/she soiled himself/herself at least once a day, which made him/her feel awful. Resident #19 stated it was very cold when he/she had to sit in wet undergarments when staff did not come to assist him/her. He/she had complained about this to staff but could not recall whom he/she complained too. 2. Record review revealed the facility readmitted Resident #74 on 12/17/18, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed the facility assessed Resident #74 with a BIMS score of twelve (12) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for surface-to-surface transfer and toileting. The resident was occasionally incontinent of bowel and bladder. Interview with Resident #74, on 01/21/19 at 10:26 AM, revealed when he/she turned his/her call light on, it took a good while for staff to assist him/her, sometimes about two (2) hours, which occurred about twice a week. The resident stated he/she used the clock and a cellphone to monitor how long it took staff to answer the call light. According to the resident, staff came to his/her room and did not seem to know he/she needed help with toileting. 3. Record review revealed the facility admitted Resident #88 on 11/26/18, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of eight (8) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required extensive assistance of two (2) staff for a surface-to-surface transfer, and was occasionally incontinent of bladder required extensive assistance of one (1) staff for toileting. Interview with Resident #88, on 01/22/19 at 8:42 AM, revealed the resident soiled himself/herself waiting for staff assistance. The resident stated he/she needed help to go to the bathroom and sometimes wet his/her pants because staff did not assist him/her. The resident stated he/she had waited between a half hour and one (1) hour to get help. The resident further stated he/she requested to speak to the Director of Nursing (DON); however, the DON was not available. Resident #88 stated he/she felt undignified when he/she soiled himself/herself. Interview with the family of Resident #88, on 01/23/19 at 9:30 AM, revealed the resident told her about the long wait times and he/she had wet his/her pants. Resident #88 told her he/she had to wait so long to get assistance it had made him/her feel down. 4. Record review revealed the facility admitted Resident #91 on 02/02/18, with [DIAGNOSES REDACTED]. Review of the Annual MDS, dated [DATE], revealed the facility assessed Resident #91 with a BIMS score of fifteen (15) of fifteen (15) and determined the resident was interviewable. The facility assessed the resident required limited assistance of one (1) staff for surface-to-surface transfer and toileting. Interview with Resident #91, on 01/21/19 at 2:47 PM, revealed when he/she put his/her call light on, it took staff longer than one (1) hour to respond. The resident stated he/she kept track of the time with his/her watch. The resident stated he/she needed help to use the bathroom and would lay waiting, and one time soiled himself/herself and felt embarrassed. Interview with Certified Nursing Assistant (CNA) #1, on 01/23/19 at 3:32 PM, revealed the facility did not have enough CNAs at least twice a week, four (4) to five (5) times a month. She stated some residents got upset and some understood there was not enough help. The CNA revealed some residents required assistance with toileting and she knew some had soiled themselves and got upset and irritated. She further stated there should be enough nursing staff to accommodate residents' need for toileting otherwise the residents felt nasty, awful, and undignified. Interview with CNA #3, on 01/24/19 at 9:04 AM, revealed at times, residents soiled themselves depending on their urgency. She stated the facility was short-staffed two (2) to three (3) times a week, which caused residents to have to wait longer periods for staff to answer call lights and get them to the bathroom. Residents were dependent on staff assistance and if staff could not provide it timely, it affected the quality of care. CNA #3 stated soiling themselves affected residents' dignity, their mood, and at times their behavior. Interview with CNA #2, on 01/24/19 at 9:21 AM, revealed the facility was short staffed at least once a week, mainly on the weekends and during those times, residents would not be changed or toileted frequently enough and residents had accidents and felt down about it. The CNA stated this was not good quality of care and residents should be treated with respect and their call lights should be answered timely. Interview with Licensed Practical Nurse (LPN) #3, on 01/24/19 at 8:45 AM, revealed the facility was short staffed for CNAs three (3) to four (4) times a week and each unit was supposed to have three (3) CNAs. However, most of the time only two CNAs were available to assist residents, which meant residents had to wait at least ten (10) minutes longer to receive assistance with their care needs. LPN #3 stated it was a dignity issue if residents soiled themselves and residents felt disappointed and embarrassed when this occurred. Interview with RN #1, on 01/23/19 at 3:43 PM, revealed there were not enough CNAs scheduled at least three (3) times a week and the residents did not get the care and services they needed in a timely manner. The RN further stated call lights were answered late even when she assisted the CNAs, and some residents got angry and hollered out. She further stated the facility needed more CNAs in order to assist those residents who required the assist of two (2) staff. Interview with Unit Manager (UM) #2, on 01/23/19 at 11:27 AM, revealed the facility was short staffed for CNAs almost daily, as each unit was supposed to have (3) CNAs but often only two (2) CNAs worked even when the facility was almost filled to capacity. The UM stated unfortunately the short staffing affected resident care needs and long wait times for the residents. She stated it took nursing staff longer to answer call lights and residents had to wait to go to the bathroom, which made residents feel bad. She further stated family members had expressed unhappiness about the long wait for nursing staff to answer the call light. Not having enough CNAs affected the residents' bowel and bladder continence and their faith in the care staff provided, which held true for residents' family members. Interview with UM #1, on 01/23/19 at 1:26 PM, revealed the units were supposed to have three (3) CNAs but often only two (2) were available, which affected resident call light wait times. The UM stated she knew some residents urinated on themselves and other personal care needs were not met and made the residents feel awful and humiliated. She further stated nursing staff should answer call lights timely and residents should not have to wait more than ten (10) to twenty (20) minutes. The UM stated she observed CNAs completely ignore call lights and she spoke to Administration about the issue and the call light response time had gotten better for a brief time; however, the response time had gotten worse again. Interview with UM #3, on 01/24/19 at 4:32 PM, revealed if nursing staff did not address care concerns of residents, and if the residents soiled themselves, it could make them feel humiliated. Interview with the DON, on 01/24/19 at 10:33 AM, revealed nursing staff was to accommodate resident care needs, which included toileting and brief changes and she expected nursing staff to answer the call light within three (3) to five (5) minutes. If a CNA could not assist a resident due to completing another resident's care needs, she expected the CNA to let the resident know how long it would take to help him/her. The DON further stated the CNA was to leave the call light on to assure the resident would receive assistance and it was unacceptable for residents to wait an hour because the facility had enough staff to accommodate resident care needs. Interview with the Administrator, on 01/24/19 at 1:47 PM, revealed nursing staff and Unit Managers were to answer call lights timely and if a resident was soiled, nursing staff was to address the situation immediately. He stated the facility was the residents' home and he wanted the residents to have a better experience and feel the facility was an extension of their home. He expected nursing staff to work together and provide the highest quality of care. He stated there had been an issue with nursing staff answering call lights and nursing staff was required to attend an in-service related to the issue in (MONTH) (YEAR); however, not all staff had attended.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop and implement a baseline care plan for one (1) of eleven (11) sampled residents, Resident #10. Resident #10 was admitted to the facility from the hospital where the resident was treated for [REDACTED]. The resident fell at the facility on the day he/she was admitted , sustaining a [MEDICAL CONDITION] that required surgical repair. The findings include: Review of the facility's policy, Interim Plan of Care, not dated, revealed an interim plan of care should be developed within twenty-four hours (24) of the resident's admission and the interim plan of care should be used until staff could conduct the comprehensive assessment and develop an interdisciplinary care plan. Review of Resident #10's closed clinical record revealed the facility admitted the resident from the hospital on [DATE], with the [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of Resident #10's Progress Note, dated 11/16/17 at 5:05 PM, documented by Registered Nurse (RN) #3, revealed the resident arrived via ambulance and transferred to the bed with his/her back brace in place. Continued review of the Progress Note revealed no staff documentation of Resident #10's initial physical assessment or evaluations such as Fall Risk, Neurological, and Behavior Evaluations, as per policy. There was no evidence staff developed a temporary care plan for the resident's history of falls prior to admission. Review of a facility Fall with Injury Report, dated 11/16/17 at 10:45 PM, revealed RN #1 heard a thump down the hall as she was preparing to give report. RN #1 and a Certified Nursing Assistant (CNA) found the resident on the floor, on his/her back. The resident complained of pain and had a suspected head injury. At the time of the fall, there were no fall interventions in place. The facility transferred Resident #10 to the hospital via ambulance. Review of the hospital's Operative/Procedure Note, dated 11/17/17, revealed Resident #10 underwent an Open Reduction and Internal Fixation (type of surgery used to fix broken bones) of the right hip. Interview with RN #1, on 01/05/18 at 2:45 PM, via telephone, revealed she was involved in Resident #10's care the evening the resident fell . RN #1 revealed it was important to complete the admission nursing assessments so staff would know how to care for each resident and to initiate a baseline care plan. She stated it would have been less likely Resident #10 would have fallen and gotten hurt if a care plan had been initiated. Interview with RN #2, on 01/04/18 at 4:00 PM, revealed a temporary care plan should be developed by the nurses for each newly admitted resident within twenty-four (24) hours of admission; however, that did not mean it could not be initiated right away. Any resident deemed a high fall risk should have non-skid footwear, fall mats, and possibly alarms such as bed and chair alarms. A confused resident was capable of pushing a call light, but staff could not depend on a call light to be used solely as a fall intervention when a resident had a history of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #4 via telephone, on 01/05/18 at 11:30 AM, revealed when she received report from a transferring facility that stated the resident had a history of [REDACTED]. She stated a call light was not an appropriate intervention for a resident with Alzheimer's because of the possibility he/she would forget what the call light was, or what it was used for. She stated staff utilized low beds, fall mats, bed alarms, fifteen (15) minute observations, and staff tried to place residents at high risk for falls close to the Nurses' Station. According to LPN #4, the hospital always sent transfer papers with the resident for staff to review to obtain additional information about the resident, such as a history of falls, and staff should initiate a temporary care plan quickly if a resident was a fall risk. Interview with LPN #5, on 01/05/18 at 12:02 PM, revealed residents assessed as a high fall risk could be placed close to the Nurses' Station for closer observation. The nurse also stated the facility had a variety of interventions that staff could put in place for residents who were at a high fall risk such as bed/chair alarms, low beds, and non-skid footwear. Interview, on 01/05/18 at 12:40 PM, with LPN #7, revealed the facility's admission packet contained a fall risk assessment tool and temporary care plan. She stated if a resident had a history of [REDACTED]. Interview with the Director of Nursing (DON), on 01/09/18 at 2:10 PM, revealed each nursing unit contained a Fall Box that contained alarms, and the facility always had other fall interventions available such as floor mats and non-skid socks. She stated staff should always put fall risk precautions in place once a resident was evaluated/assessed as a high fall risk upon admission. She stated fall risk precautions may not prevent a fall, but might prevent an injury. She stated if the nurses had identified Resident #10 as a fall risk, and put fall precautions into place such as fall mats, the resident might not have suffered a broken bone when he/she fell . She stated the temporary care plan was required to be completed within twenty-four (24) hours of a resident admission, but should be initiated by the nurse as soon as a resident was admitted .

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of eleven (11) sampled residents. Resident #10 was newly admitted to the facility with a history of prior falls; however, the facility failed to complete a comprehensive fall risk assessment or implement fall interventions. The resident sustained [REDACTED]. The findings include: Review of the facility's Falls Policy Statement, dated 06/01/15, revealed the facility would provide residents with assistance and supervision in an effort to minimize the risk of falls and fall related injuries. The policy stated all residents would have a comprehensive fall risk assessment on admission and appropriate care plan interventions would be implemented and evaluated as indicated by assessment. Review of the facility's Admission Assessment and Follow Up Policy, dated 06/01/15, revealed staff was to conduct supplemental evaluations, which included the Fall Risk Evaluation, Neurological Evaluation, and Behavior Evaluation. Review of the closed clinical record for Resident #10 revealed the resident was admitted to the facility from the hospital on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital History and Physical prior to admission to the facility, dated 11/13/17, revealed Resident #10 presented to the Emergency Department (ED) after complaining of a fall and had previously discharged from the hospital on [DATE], for a fall injury as well. Review of the Progress Note, dated 11/16/17 at 5:05 PM, documented by Registered Nurse (RN) #3, revealed Resident #10 arrived to the facility by ambulance. The resident was transferred to bed with his/her brace in place and the resident had no complaints. The resident's call bell was placed within his/her reach. Continued review of the Progress Notes revealed no information had been documented by the staff related to Resident #10's initial physical assessment or supplemental evaluations such as the Fall Risk Evaluation Form, Neurological Evaluation Form or Behavior Education Form per the facility's policy. A temporary care plan had not been developed regarding the resident's history of frequent falls prior to admission to the facility. Review of the Fall with Injury Report, dated 11/16/17 at 10:45 PM, revealed RN #1 was preparing to give report when a thump was heard from down the hall. The RN and a nursing assistant found the resident on the floor, on his/her back, in the doorway to his/her room. The resident had previously been in the bed, with his/her back brace on. Resident #10 was confused and stated the back brace was bothering him/her. The resident complained of pain at that time and had a suspected head injury. No fall interventions were in place at the time of the resident's fall. Resident #10 was transferred to the hospital by ambulance. Review of the hospital History and Physical, dated 11/17/17 at 2:11 AM, revealed Resident #10 had Dementia and was just discharged in the last couple of days after a fall and suffered a compression fracture of his/her lumbar spine. The resident fell at the facility the night before (11/16/17) and now fractured his/her right hip. The resident was pleasantly demented, could not provide any history, and was referred for admission for evaluation by orthopedic surgery team for surgical repair. The resident's past medical history included Alzheimer's Dementia, Chronic Gait Dysfunction, Recurrent and Falls, and there was no family present to discuss options at the time. Review of the Operative/Procedure Note, dated 11/17/17, revealed Resident #10 underwent an Open Reduction and Internal Fixation (ORIF) of a right intertrochanteric [MEDICAL CONDITION]. Telephonic interview with RN #1, on 01/05/18 at 2:45 PM, revealed she had been involved in Resident #10's care on the evening the resident fell . She stated she worked on the evening of 11/16/17, from 7:00 PM until 11:00 PM. She stated she did not realize Resident #10 had been admitted to the facility until she heard a loud thump coming from the resident's room, and there were no alarms going off. She stated the resident's room was about as far from the Nurses' Station as you could get. She revealed Resident #10 was found on the floor and apparently had taken his/her back brace off and climbed out of bed. She stated the resident said that his/her hip hurt. RN #1 stated all residents should have an initial admission Nursing Assessment Form completed right away, as soon as the resident was admitted to the facility, which included the Fall Risk Assessment. Per interview, it was important to complete the admission nursing assessments so staff would know how to care for each resident. She stated it would have been less likely the resident would have fallen and gotten hurt if the previous nurse had completed the Fall Risk Assessment Evaluation Form. She revealed she did not receive a verbal or a written report on Resident #10 from RN #3 when she relieved her from duty. RN #3 was not able to be interviewed during the course of the survey. Interview with Licensed Practical Nurse (LPN) #2, on 01/04/18 at 9:30 AM, revealed a Fall Risk Assessment Form should always be completed on each resident upon admission and any resident that had been admitted with a history of prior falls would indicate the resident was a high fall risk. She stated that type of resident should always be placed close to the Nurses' Station and observed frequently, at least every thirty (30) minutes. Interview with LPN #7, on 01/05/18 at 12:40 PM, revealed the facility's admission packet contained a Fall Risk Assessment Tool. She stated as soon as a new resident arrived to his/her room, the nurse should complete the Fall Risk Assessment. Per interview, any time a resident had a history of [REDACTED]. Interview with the Assistant Director of Nursing (ADON), on 01/05/18 at 12:15 PM, revealed she would expect staff to initiate the facility's policy related to admission assessments. Interview with the Director of Nursing (DON), on 01/09/18 at 2:10 PM, revealed the facility had a Fall Risk Program in place. She stated RN #1 was the nurse on duty when Resident #10 fell and RN #1 should have received an oral and written report from RN #3 on Resident #10 when she arrived at 7:00 PM. The DON stated either RN #1 or RN #3 should have completed Resident #10's initial assessments, including the neurological assessment and fall risk assessment. The DON revealed the lack of documentation/lack of assessments did not provide an accurate picture of Resident #10 to determine if the resident was at risk of falls. The DON stated it would have been nice to know the resident's cognition status, but the nurses did not initiate the neurological assessment form, as they should have. She stated all residents in the facility were supposed to be checked/observed at least every two (2) to three (3) hours by staff. She stated the staff could and should have observed Resident #10 more frequently. Interview with the Administrator, on 01/09/18 at 4:00 PM, revealed the Interdisciplinary Team met once a day in the mornings to discuss events and issues going on within the facility and any changes or updates with the residents, to include falls. He stated it was the facility's responsibility to monitor/observe any residents who had been assessed as a high fall risk. He stated the Quality Assurance Performance Improvement Committee met at least monthly; however, he did not recall any audits done recently to measure fall interventions and whether or not fall precautions had been initiated in a timely manner. He stated the facility had done recent education and training related to root cause analysis and fall events. He stated he was ultimately responsible for all staff actions within the facility.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the physician was notified regarding an incident that had the potential for requiring physician intervention for one (1) of the twenty-nine (29) sampled residents (Resident #16). On 07/04/15 at 2:30 AM, Resident #16, who required total assistance with transfers and toileting, was found alone in the bathroom, sitting on a bedside commode, yelling for help. The call light was wrapped around a support bar and could not be activated. The evening staff failed to communicate to the night staff the resident had been placed on the bedside commode at 9:15 PM on 07/03/15. The facility staff failed to conduct the scheduled routine checks on the resident and left the resident sitting in the bathroom alone with no method to call for help for greater than five (5) hours. When the resident was found, on 07/04/15 at approximately 2:30 AM, the resident complained of being cold and experienced pain and numbness in the hips/buttocks area. The resident had a [DIAGNOSES REDACTED]. There was no documented evidence the resident's physician had been notified of the incident until 07/27/15, twenty-three (23) days after the incident occurred and surveyor intervention. The facility's failure to notify the physician of an incident that had the potential to require medical intervention has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 07/24/15 and determined to exist on 07/04/15. An acceptable Allegation of Compliance (AOC) was received on 08/03/15, alleging the Immediate Jeopardy was removed on 07/29/15. The State Survey Agency validated the Immediate Jeopardy was removed on 07/29/15, as alleged, prior to exit on 08/06/15. 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 Change in Resident's Condition, revised October 2013, revealed the physician was to be notified of an accident or incident involving the resident. The notification was to be made within twenty-four (24) hours, except in medical emergencies, of a change occurring in the resident's medical/mental condition or status. Review of the facility's investigation, initiated on 07/04/15, revealed written statements were obtained from Certified Nursing Assistant (CNA) #2 and Licensed Practical Nurse (LPN) #1. Review of CNA #2's written statement, dated 07/04/15, revealed she was conducting a second routine check at 2:30 AM (on 07/04/15), when she heard the resident yelling behind the closed bathroom door. She found the resident sitting on the bedside commode with the call light wrapped around the support bar preventing the resident from activating the call light. Review of LPN #1's written statement, dated 07/04/15, revealed the aide reported Resident #16 was sitting on the bedside commode and believed the resident had been on the commode since 9:00 PM the previous shift (07/03/15). The LPN documented the resident complained of hip pain and the resident's ankles were swollen; however, this was common if the resident was up too long. The resident requested pain medication. The nurse did not indicate she had notified the physician of the incident. During the Resident Council Group Meeting, conducted on 07/21/15 at 1:30 PM, Resident #16 revealed he/she had been left on the bedside commode for approximately five (5) hours and was unable to activate the call light. A private interview conducted with Resident #16, on 07/22/15 at 9:30 AM, revealed he/she had been placed on the bedside commode at approximately 9:15 PM on 07/03/15 to perform his/her nightly care and to use the bedside commode. When the resident tried to activate the call light for assistance from staff, the call light would not activate because it was wrapped around a support bar in the bathroom. The resident stated he/she had yelled out for help several times but nobody came. The resident stated when he/she was found, they were cold and shivering (resident was dressed in a gown), with pain to the hips/buttocks, and the entire body was numb. The resident stated he/she requested pain medication and a blanket after the incident. Review of Resident #16's clinical record revealed the facility admitted the resident on 01/19/12 with a re-admission on 04/30/13, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/26/15, revealed the facility conducted a Brief Interview for Mental Status (BIMS) test with the resident scoring a fifteen (15) out of possible fifteen (15), meaning the resident was interviewable. The facility assessed the resident to require extensive assistance of two (2) persons for all transfers and toileting needs. The resident was non-ambulatory. The facility assessed the resident's balance to be unsteady and required staff assistance when moving on and off the toilet. Review of the comprehensive care plan, dated 03/20/15, revealed interventions to observe and report pain, numbness or tingling, [MEDICAL CONDITION], and general weakness related to the resident's MS, shoulder pain, and muscle spasms. The facility developed an intervention to report changes in pain location and type to the physician. Review of the Nurses' Notes, dated 07/07/15 at 2:30 AM, revealed Certified Nursing Assistant (CNA) #2 reported the resident was in the bathroom for a lengthy time. A skin assessment was conducted and pain medication was given for muscle aches. There was no documented evidence the resident's physician was notified. A telephone interview with LPN #1, on 07/23/15 at 1:40 PM and 08/04/15 at 4:05 PM, revealed she was the House Supervisor and working as a staff nurse (passing medications) on the night of 07/03/15 to earlier morning of 07/04/15. She stated between 1:30 AM and 2:00 AM, CNA #2 reported Resident #16 was found in the bathroom alone sitting on a bedside commode. The CNA told her the resident stated he/she had been on the bedside commode since 9:15-9:30 PM on 07/03/15. She said she assisted CNA #2 with transferring Resident #16 to bed and she performed a full body assessment. No injury was noted. She stated the resident complained of hip pain and the resident's ankles were swollen. She stated the resident requested a pain medication and she administered as requested. The LPN stated she had not notified the family or physician of the incident. Interview with the Social Worker, on 07/23/15 at 2:35 PM, revealed she was responsible for investigation of abuse/neglect and worked with the Administrator with oversight of the Complaint/Grievance Forms. She said with any incident such as the one involving Resident #16, a Complaint/Grievance Form should have been completed and the notification of the Physician and family would be documented on the form. However, she stated she had not investigated the incident because she was informed by the Administrator (previous/former) it had been taken care of. She was not aware the resident's physician had not been notified of the incident. Interview with the Director of Nursing, on 07/23/15 at 5:20 PM, revealed she found no documented evidence the resident's physician had been notified of the incident. No Complaint/Grievance Form was completed; therefore, the physician was not notified of the incident to determine if a change in treatment was needed. She stated this was an incident in which she would have notified the physician. Interview with Resident #16's physician, on 08/04/15 at 12:36 PM, revealed he learned of the incident on 07/27/15. He stated it was reported to him by the Director of Nursing after surveyor intervention. He was informed Resident #16, who was dependent on staff for transfers and toileting, was left on the bedside commode for greater than five (5) hours. He verified he had not been notified right after the incident and due to the resident's advanced MS, he would have wanted to be notified of the incident. He saw the resident on 07/07/15 and if he had been aware of the incident, he would have assessed the resident differently and asked more questions regarding pain. Review of the acceptable Allegation of Compliance (AOC), dated 07/29/15, revealed the facility took the following immediate actions: 1. Resident #16 was removed from the bedside commode and transferred to the bed and assessed by Licensed Practical Nurse (LPN) #1 after the occurrence on 07/04/15. Swelling was noted to the Resident #16's ankles that dissipated by 3:15 AM. Resident #16 received pain medication ([MEDICATION NAME]) at 2:40 AM due to complaints of hip pain. Evaluations and assessments were continued through 07/07/15 with no new concerns. 2. Certified Nursing Assistant (CNA) #2, who was assigned to Resident #16 on the night shift received a coaching and counseling session by LPN #1 and Registered Nurse (RN) #3. An investigation of the incident was initiated by LPN #1 and RN #3. 3. Resident #16 was seen by a Orthopedic physician on 07/07/15 with orders for Physical Therapy and Occupational Therapy. Resident #16 was placed on case load from 07/09/15 through 07/24/15. No change of transfer status was identified. 4. The resident's primary physician was notified of the occurrence involving Resident #16 being left on the bedside commode for an extended period of time on 07/24/15 by the Director of Nursing (DON). The Responsible party was notified on 07/24/15 by the DON. 5. On 07/26/15, the Director of Program Development reviewed the personal files of CNA #2 and LPN #1, who were assigned to Resident #16 the night of the allegation, with no concerns pertaining to their abuse registry and back ground checks. 6. Resident #16 was evaluated by the Customer Service Coordinator for the ability to use a call light on 07/25/15 and found it was difficult for him/her to use the current call light. Resident #16 received a new touch based call light on 07/25/15. The call light in the bathroom for Resident #16 was evaluated on 07/26/15 by the Regional Plant Operations Director and replaced by Technical Solutions on 07/28/15. 7. All residents were assessed for any signs and symptoms of abuse and neglect. Residents with a Brief Interview of Mental Status (BIMS) score of greater than eight (8) were interviewed by the facility's Interim Administrator, DON, Minimum Data Set (MDS) Coordinator, Quality of Life Director and Medical Records for any abuse/neglect concerns starting 07/24/15 and concluding on 07/27/15. One concern from the initial audit was a concern regarding staffing. Residents who were identified to have a BIMS score of less than eight (8), were physically assessed by the Nursing Administration Team for any signs and symptoms of abuse/neglect, no new concerns were identified. Beginning 07/28/15, skin assessments would be completed each shift for ten (10) residents with a BIMS score of eight (8) or less then decreased to three times a week on 08/10/15 by the licensed nursing staff. An attempt to contact Residents' Responsible parties in regards to any abuse/neglect concerns began 07/24/15 and concluded on 07/27/15. 8. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and Central Supply were educated on 07/24/15 by the Signature Care Consultant on the abuse policy and procedure, to include but not limited to a thorough investigation, neglect, and reporting immediately. Department Administrative Managers were educated on 07/24/15. A total of seventeen (17) Department Head members were education on 07/24/15. Department Administrative Managers that did not receive the education could not return to work until abuse education was provided, and a post-test administered with a 100% score obtained. All were reviewed for compliance by the Signature Care Consultant. The facility does not utilize Agency Staff. The Interim Administrator and/or the DON was responsible for ensuring staff members were educated prior to returning to work. 9. Once the facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and Central Supply were educated, then they were assigned to educate the staff on the facility's Abuse Policy, to include but not limited to, a thorough investigation, neglect and reporting immediately, on 07/24/15 and continued until 07/28/15. Staff that had not worked as of 07/28/15 would receive education prior to returning to work. Training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable. Staff members would not return to work until abuse education had been provided, post-test completed with a score of 100 %. If the staff member did not achieve a score of a 100 % on the post-test, the staff member would be re-educated on the Abuse Policy and Procedures and given the post-test again. The process would continue until the staff member achieved 100 % on the post-test. Any staff member who was on vacation or Family Medical Leave would be provided the abuse/neglect education and given the post-test before allowed to return to work. with a score of 100 % to be achieved on the post-test. The Interim Administrator and the DON were responsible for ensuring this occurred. Every shift beginning on 07/28/15, ten (10) staff members on each shift would be given the post-test for abuse/neglect by the Interim Administrator, DON, Assistant Director of Nursing (ADON), Quality of Life Director and Plant Operations Director. A score of 100 % would be required, if less than 100 % the employee would be reinserviced and then given the post-test again until 100 % compliance was obtained. 10. All new hires will receive abuse/neglect education during orientation and would be given a post-test to achieve a score of 100 %. If the new staff member did not achieve a score of 100 % on the post-test, the new staff member would have to be re-educated by the Staff Development Coordinator and DON and be given the post-test to achieve a score of 100 %. This process would continue until the new employee achieved a score of 100 % on the post-test. The Interim Administrator and DON would review the Post-tests given daily for any noted concerns. Any concerns would be addressed immediately. All new hires would complete six (6) modules of the CMS Hand in Hand training, during the general orientation period by the Staff Development Coordinator. The facility was in the process of all staff completing the CMS Hand to Hand training and one module would be assigned per month until all the modules are reviewed. 11. Beginning on 07/24/15 and concluding on 07/28/15 100 % audit of all call lights in the facility were conducted, by the Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and or Central Supply, checking that the call lights were in working order and that the call lights were accessible for each resident and the resident had the ability to use the call light. The Initial call light audits were reviewed by the Signature Care Consultant daily from 07/24/15 through 07/28/15. There were two (2) call lights, room [ROOM NUMBER]-B and 1602-B, which were identified as needing changed. Call light audits and education would remain ongoing, every shift from 07/28/15 until jeopardy was removed. The Call light audits would be reviewed by the Interim Administrator, DON and or regional staff daily. 12. The facility's Performance Improvement Project (PIP) developed to monitor the corrective action through daily audits to ensure accessibility and function of call lights for residents was conducted by the Director of Program Development. The PIP would be reviewed two (2) times a week, then weekly times four (4) weeks by the interdisciplinary Care Team. 13. On 07/24/15 the facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records, Unit Manager and/or Central Supply were assigned to visually observe where each resident in the facility was, if the resident's needs were being addressed, and if the residents felt safe. One hundred percent (100 %) of all current residents were observed and no concerns were identified. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and/or Central Supply would audit this process to ensure compliance. Beginning 07/28/15, daily questionnaires will be completed each shift with ten (10) residents with a BIMS score of 8 or above, by the DON, Interim Administrator, Quality of Life Director and Plant Operations Director asking the following questions: 1. Is everyone treated well? 2. Do you feel safe? 3. Do you have any concerns? These audits will decrease to three (3) times a week on 08/10/15. 14. Visual observations of residents for safety and needs will be conducted every shift by nurses and CNAs at the change of shift. The staff would make visual observation of where each resident was in the facility, that the residents needs were being addressed and that the residents were safe. These rounds would be ongoing. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and/or Central Supply would audit this process to ensure compliance. Ongoing education would be conducted with the staff regarding answering call lights timely, addressing resident needs, and making rounds at shift change. A rounding audit sheet would be filled out during walking rounds. 15. Beginning on 07/24/15 and concluding on 07/27/15, 100 % of all current resident charts were reviewed for physician notification and any allegation of abuse or neglect since 06/01/15 by the Assistant Director of Nursing (ADON), Signature Care Consultant, Unit Manager and Customer Experience Coordinator. Beginning 07/28/15, ten (10) charts would be audited for documentation of allegations of abuse and neglect, physician and responsible party notification daily for two (2) weeks by the Interim Administrator and DON and then decreased to three times a week on 08/10/15. Any issues discovered at the time of the audits would be brought to the attention of the Interim Administrator and DON. Audits would be reviewed by the Interim Administrator, DON, Signature Care Consultant or other regional staff members. 16. Beginning on 07/24/15 and concluding on 07/27/15 100 % of current residents charts were audited by the Nursing Administration Staff and/or Signature Care Consultants for accuracy of care plans and CNA care plans, and assistive devices. Two variances were identified and corrected. 17. All grievances since 01/01/15 were reviewed by the Interim Administrator, DON or Signature Care Consultant or Director of Program Development on 07/24/15 to determine if any items documented were an reportable event. All administrative staff were educated on the Grievance Process including how to fill out and complete a grievance and what was a grievance by the Director of Program Development on 07/27/15. The facility had identified thirteen concerns from the grievance audit that was reported to the Office of Inspector General as allegations of abuse. The current Social Services Director who handled the process was currently suspended and would be terminated. The Administrator resigned from the facility and her last day was 07/19/15. 18. A Resident Council meeting was held on 07/25/15 by the Quality of Life Director and the Quality of Life Assistant, to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. 19. Beginning on 07/25/15 to 07/27/15 all incident/accident reports since 07/01/15 had been reviewed by the DON and Signature Care Consultant to identify any concerns of suspected abuse/neglect and for physician and responsible party notification. 20. On 07/24/15 the facility's Interim Administrator, DON, MDS Coordinators, Activities Director, Medical Records and Central Supply were educated on shift rounds, answering call lights, physician and responsible party notifications, by the Signature Care Consultant. These staff then educated the facility staff on shift rounds, answering call lights and physician notification. This was done face to face with staff interaction. A rounding audit sheet would be completed during the walking rounds. As of 07/27/15 the remaining ten (10) department heads had received their training. Staff members would not return to work until education had been provided. The facility employed 198 stakeholders and 128 employees had received education. 70 employees remained to receive training. 21. A Quality Assurance Performance Improvement meetings was held, on 07/26/15 at 3:15 PM, with a physician representative, the Interim Administrator, a CNA, Central Supply Director, Customer Experience Coordinator, Assistant Director of Nursing, and the Signature Care Consultant. Topics that were discussed included call light response, appropriate call lights, rounding of Licensed Nurses, and CNAs checking on resident whereabouts, resident safety needs, following care plans, education provided, grievance process, abuse and neglect, reporting and investigating abuse and neglect, and physician and responsible party notification. Abuse/Neglect and Care Plan policies were reviewed and there was no changes required to the policies. Results of the resident interviews, assessments and staff questionnaires would be reported to the QAPI committee weekly to determine the need for continued education or revision of the plan. Audits collected from staff members will be presented and discussed in the QAPI meeting. At that time, based on evaluation, the QAPI committee will determine at what frequency the resident interviews, assessments and staff questionnaires would need to continue. Concerns identified would be corrected immediately and reported to the Interim Administrator to ensure investigation of suspected abuse/neglect; the investigation was completed; the investigation and reporting guidelines were met; care plans were updated and followed; with physician and responsible party notifications made. A QAPI meeting will be held weekly until immediacy is removed, then decreased to every four (4) weeks, then monthly for recommendations and further follow up regarding the corrective actions of the AOC. 22. Beginning 07/28/15 and continuing until the Immediacy is removed, the resident change of condition would be reviewed daily in the morning clinical meeting to address any allegation of abuse and neglect, change of condition and that the physician and responsible party had been notified. The information for the clinical meeting would be gathered from but not limited to the twenty-four hour report sheet, Stop and Watch form, SBAR, resident orders, and verbal report from nurses. The information would be gathered by the DON, Unit Manager, Medical Records, Customer Service Director and the Scheduling Coordinator. 23. A nurse from the Regional Team or Corporate Office, Regional Vice President of Operations or Special Projects Administrator has been onsite daily since 07/24/15 providing training or assisting with the review of audits. They will continue weekly visits and or daily review by telephone until the Immediate Jeopardy had been removed and will decrease to every other week for four (4) weeks, then monthly. The nurses for the regional team or home office were assisting with investigations as needed, performing chart audits and providing oversight and consultation. Administrative oversight of the facility would be completed by the Special Projects Administrator, the Regional Vice President of Operations, or member of regional staff weekly on site and daily by telephone until removal of Immediate Jeopardy. 24. The Interim Administrator and DON would review and discuss all abuse investigations daily to ensure the resident was protected; perpetrator was removed from resident care areas; that it was reported to the appropriate agencies timely; and, a thorough investigation was completed beginning 07/24/15 and continued until Immediate Jeopardy is removed. The Interim Administrator would maintain an abuse investigation log. The Interim Administrator and Corporate Staff will review each abuse allegation to ensure a thorough investigation had been completed, protection of the resident, and reported to the appropriate state agencies. 25. During each care plan conference for each resident, any abuse/neglect concerns would be discussed along with any abuse/neglect education to include reporting, would be provided to the resident and or POA with supporting documentation noted starting 07/28/15. The State Survey Agency validated the implementation of the facility's acceptable AOC as follows: 1. Review of the Nurses' Notes dated 07/04/15 at 2:30 AM, and interviews with CNA #1, on 07/23/15 at 3:20 PM and LPN #1, on 07/23/15 at 1:40 PM, revealed the resident was removed from the bedside commode and transferred to the bed where the resident was provided a blanket for warmth, skin assessment was performed, and pain medication was administered as requested. The Nurses' Notes from 07/04/15 through 07/07/15 revealed continued monitoring of the resident. 2. Review of the facility's investigation (initiated on 07/04/15) included a written coaching and counseling session with CNA #2. This was conducted by LPN #1 and signed as witnessed by RN #3. Written statements were obtained from CNA #2, LPN #1, and RN #3. 3. Review of the clinical record, Nurses' Notes dated 07/07/15, revealed the resident was seen by an Orthopedic physician. Interview with the DON, on 07/24/15 at 9:30 AM, revealed this appointment was already scheduled prior to the incident on 07/04/15. Review of therapy notes (07/09-24/15) revealed an evaluation of Resident #16 and services provided as stated in the AOC. Interview with the Physical Therapist, on 08/05/15 at 3:18 PM, revealed the resident remained a two-person assist and mechanical lift with all transfers. 4. Interview with Resident #16's primary physician, on 08/04/15 at 12:36 PM, revealed he was notified of the incident on 07/27/15; however, he had been on vacation and the nursing facility had notified his office on 07/24/15. Interview with the DON, on 08/04/15 at 10:12 AM revealed she had notified the physician's office on 07/24/15. 5. A review of the personnel files for CNA #2 and LPN #1 was conducted during the recertification survey as part of the 5-G Abuse task. No problems were identified. The SSA validated the abuse registry and background checks were conducted prior to hire with no findings. 6. Observation of Resident #16's room, on 08/06/15 at 2:08 PM revealed the facility had provided a new soft touch call light. The call light in the resident's bathroom was replaced on 07/28/15. 7. Review of the skin assessments revealed all residents in the facility received a skin assessment on 07/24/15 through 07/27/15 with no signs or symptoms of abuse/neglect found. Review of the skin assessments conducted by the facility revealed the facility continued to perform skin assessments on residents with a BIMS score of eight (8) or less. Review of the skin assessments conducted by the facility revealed the facility continued to perform skin assessments on residents with a BIMS score of eight (8) or less. Interviews on 08/04/15 with Resident #25 at 9:45 AM and Resident #29 at 10:40 AM, revealed no concerns with abuse/neglect. 8. Review of the training records revealed on 07/24/15, the Corporate Care Consultant provided training on the facility's Abuse/Neglect Policy was provided to the Department Heads. This training included how to investigate an allegation of abuse/neglect and reporting requirements. The training also included physician notification, care plans, rounds, and call lights. Seventeen (17) Department Heads were present at the training including the Interim Administrator and Director of Nursing. Interview with the Corporate Consultant, on 08/06/15 at 3:46 PM, revealed she had provided training to all Department Heads on the Abuse/Neglect- Policy, investigating and reporting, call lights, grievances, and making visual rounds. Interview with the DON, on 08/06/15 at 1:36 PM, Quality of Life Director, on 08/06/15 at 10:00 AM, and Activity Director on 08/05/15 at 2:22 PM, Director of Program Development, on 08/05/15 at 4:08 PM, Customer Experience Director, on 08/05/15 at 4:33 PM, Maintenance Director, on 08/05/15 at 5:09 PM, and the Interim Administrator, on 08/06/15 at 2:36 PM, validated the training was provided on 07/24/15 and they had a good knowledge of how to investigate and report abuse. 9. Review of the training records revealed the facility staff was trained from 07/24/15 through 07/28/15, with as needed staff trained prior to working, on the Abuse/Neglect Policy. Post-tests were given regarding information presented on abuse/neglect with the staff scoring 100%. Training was validated through interviews with the Rehab (1-South) Unit Manager, on 08/06/15 at 9:25 AM, Social Services, on 08/05/15 at 1:45 PM, LPN #11, on 08/05/15 at 1:30 PM, LPN #12, on 08/05/15 at 1:36 PM, LPN #5 on 08/05/15 at 1:55 PM, and LPN #13, on 08/05/15 at 2:08 PM. Additional interviews were conducted with CNA # 10, on 08/05/15 at 1:42 PM, CNA #11 and #12 on 08/05/15 at 1:50 PM, CNA # 3 on 08/05/15 at 2:00 PM, CNA #25, on 08/05/15 at 2:02 PM, CNA # 14 on 08/05/15 at 2:05 PM, CNA #26 on 08/05/15 at 2:08 PM, CNA #6 on 08/05/15 at 2:10 PM, CNA # 7 and #24 on 08/05/15 at 2:15 PM, and CNA #8 on 08/05/15 at 3:05 PM. The staff had good knowledge of the definition of abuse/neglect and how to report. In addition, the nursing staff had been trained on communication rounds between shifts, conducting safety checks, call light accessibility, and the grievance process. Review revealed the facility continued to education on the Abuse/Neglect Policy with post-test given. Review of the results of the post-test revealed staff scored 100%. 10. Review of the new hire list and comparison to the training documentation revealed the new employees would receive training on abuse/neglect with a Post-test required. All new hires must have a 100% pass rate. Interview with the Interim Administrator, on 08/06/15 at 2:36 PM, revealed newly hired employees will be required to complete the Hand in Hand modules (6), one per month. He stated there had been no new hires since 07/29/15. He said the Staff Development Coordinator would monitor the training. Review of the August 2015 schedule for new employee training revealed the Hand in Hand modules would be reviewed on August 10, 11, 12, 18, 19, and 20th. 11. Observation during the extended survey revealed the residents' call lights were functional and within reach. Observation of the call light response time during the survey revealed the call lights were answered within five (5) minutes of activation. Review of the call light audits revealed the facility conduct a facility wide inspection of each resident's room, on 07/24/15, to determine if each call light was functional and within reach of the resident. The call light audits continued through the extended survey. The audits revealed two call lights were replaced and Resident #16's call light was replaced with a soft touch call light. Observation of Resident #16's bathroom, on 08/05/15 at 2:08 PM, revealed a soft touch call light and was within the resident's reach. Observation of the resident activating the new call light revealed the call light activated and staff responded within one minute. Interview with the resident during this observation revealed his/her needs were being met. 12. The facility utilized a computer program (Abaqis) that monitors the corrective actions through daily audits. Members included the Interim Administrat

Based on observation, interview, record review, and review of facility's policies and investigation, it was determined the facility failed to ensure residents were free from neglect for one (1) of twenty-nine (29) sampled residents, Resident #16. The facility failed to have an effective system in place to ensure the necessary care and services related to transfers and toileting needs were provided as needed or requested. On 07/04/15 at 2:30 AM, Resident #16, who required total assistance with transfers and toileting, was found alone in the bathroom, sitting on a bedside commode, yelling for help. The call light was wrapped around a support bar and could not be activated. The evening staff failed to communicate to the night staff the resident had been placed on the bedside commode at 9:15 PM on 07/03/15. The facility staff failed to conduct the scheduled routine checks on the resident and left the resident sitting in the bathroom alone with no method to call for help for greater than five (5) hours. When the resident was found, on 07/04/15 at approximately 2:30 AM, the resident complained of being cold and experienced pain and numbness in the hips/buttocks area. The resident had a [DIAGNOSES REDACTED]. The facility's failure to have an effective system to ensure residents were protected from neglect has caused or was likely to cause serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 07/24/15, and was determined to exist on 07/04/15. The facility was notified of the Immediate Jeopardy on 07/24/15. An acceptable Allegation of Compliance (AOC) was received on 08/03/15, alleging the Immediate Jeopardy was removed on 07/29/15. The State Survey Agency validated the Immediate Jeopardy was removed on 07/29/15, as alleged, prior to exit on 08/06/15. 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 Abuse/Neglect Policy, revised March 2013, revealed abuse and neglect were prohibited. However, the policy did not define neglect. Review of the Routine Resident Checks Policy, revised October 2013, revealed staff would make routine resident checks at least every two hours to help maintain resident safety and well-being, making sure residents needs were being met, and identify any changes in the resident's condition. Any concerns were to be reported to the nurse and the nurse was to document on the Event Reporting Sheet which was forward to the Social Worker and the Administrator for follow-up. Review of the Safety and Supervision of Resident Policy, reviewed on 06/01/15, revealed staff would perform routine resident checks. Routine checks by nursing staff involved entering the resident's room and/or identifying the resident's location on the unit to determine if the resident's needs were met, identify any change in the resident's condition, identify whether the resident had any concerns and see if the resident was sleeping, needed toileting assistance, etc. Review of the facility's investigative file, initiated on 07/04/15, revealed written statements were obtained from Certified Nursing Assistant (CNA) #2 and Licensed Practical Nurse (LPN) #1. Review of CNA #2's written statement, dated 07/04/15, revealed she was conducting a second routine check at 2:30 AM, when she heard the resident yelling behind the closed bathroom door. She found the resident sitting on the bedside commode with the call light wrapped around the support bar preventing the resident from activating the call light. Review of LPN #1's written statement, dated 07/04/15, revealed the aide reported Resident #16 was sitting on the bedside commode and believed the resident had been on the commode since 9:00 PM the previous shift. The LPN documented the resident complained of hip pain and the resident's ankles were swollen; however, this was common if the resident was up too long. The resident requested pain medication. The nurse did not indicate she had notified the physician of the incident. During the Group Resident Council meeting, on 07/21/15 at 1:30 PM, Resident #16 stated he/she had been left alone on the bedside commode in the bathroom for approximately five (5) hours. The event had been reported; however, the resident felt as if nothing had been done because he/she was not given findings or resolution of the voiced complaint. The resident was afraid the incident would happen again. Further interview with Resident #16, on 07/22/15 at 9:30 AM, revealed he/she had been placed on the bedside commode at approximately 9:15 PM on 07/03/15 to perform his/her nightly care and to use the bedside commode. The resident stated this would normally take about 45 minutes to an hour. When the resident tried to activate the call light for assistance from staff, the call light would not activate because it was wrapped around the support bar. The resident said he/she yelled out for help, but nobody could hear him/her. The resident stated it was a very long time before staff found him/her in the bathroom. The resident stated they were cold and shivering (resident was dressed in gown), with pain to the hips/buttocks, and the entire body was numb when the staff found them. The resident stated he/she was afraid this could happen again because the resident was dependent on staff for all transfers on and off the bedside commode with a mechanical lift. Review of Resident #16's clinical record revealed the facility admitted the resident on 01/19/12 with a re-admission on 04/30/13, with [DIAGNOSES REDACTED]. Review of Resident #16's quarterly Minimum Data Set (MDS) assessment, dated on 06/26/15 revealed a Brief Interview for Mental Status (BIMS) test was conducted with a score of fifteen (15) out of possible fifteen (15), meaning the resident was interviewable. The facility assessed the resident to require extensive assistance of two (2) persons for bed mobility, transfers, dressing, hygiene and toilet use. The resident's balance was assessed to be unsteady and the resident required assistance during transition on and off the toilet. The facility assessed the resident to have limited range of motion and impairment to his/her bilateral upper and lower extremities. Review of the Activity of Daily Living (ADL) self-care deficit care plan, dated 03/20/15, revealed an intervention to keep the call light within easy reach. Review of the at risk for developing skin breakdown care plan, dated 03/20/15, revealed an intervention to assist the resident with reposition/shift weight to relieve pressure as needed to promote comfort. In addition, the staff was to assist the resident with toileting and hygiene needs. Review of Nurses' Notes, dated 07/04/15 at 2:30 AM, revealed CNA #2 reported to LPN #1 that Resident #16 was found in the bathroom alone on a bedside commode. The nurse performed a skin assessment that revealed [MEDICAL CONDITION] in the resident's ankles, and the resident requested pain medication for muscle aches. Interview with CNA #1, on 07/23/15 at 2:52 PM, revealed she had placed Resident #16 on the bedside commode at approximately 9:15 PM, placed the call light within reach, and closed the bathroom door. The aide stated the resident's nightly routine took about an hour and it normally started earlier than 9:15 PM. She stated she checked on the resident at 9:30 PM, but the resident had not completed the tasks so she left the resident on the bedside commode. She stated she informed the aide from the night shift the resident was on the bedside commode before she left her shift at 10:00 PM. Interview with CNA #2, on 07/23/15 at 3:20 PM, revealed she received shift report from CNA #1, but could not recall if she received report on Resident #16's status. CNA #2 stated she had conducted a resident check/safety round at approximately 10:15 PM to 10:30 PM and noticed Resident #16's privacy curtain was pulled around the bed and the bathroom door was closed. She stated she did not look behind the privacy curtain or open the bathroom door to visualize the resident. The CNA stated it was a busy night with admissions and she was responsible for twenty-six (26) residents on the Rehab Unit. When conducting a second round at approximately 1:30 AM to 2:00 AM the CNA entered Resident #16's room and heard the resident yelling from the bathroom. She opened the bathroom door and found Resident #16 on the bedside commode and the call light cord was wrapped around a support bar. The resident told the aide he/she had been calling out trying to get someone's attention without success. CNA #2 reported the incident to LPN #1 and they transferred Resident #16 from the bedside commode to the bed using a mechanical lift. Interview with LPN #1, on 07/23/15 at 1:40 PM, revealed she was working as the House Supervisor and passing medications on the night of 07/03-04/15. The nurse stated around 2:30 AM, CNA #2 reported Resident #16 was found in the bathroom on the bedside commode and stated she had been there for awhile. LPN #1 assisted CNA #2 with transferring Resident #16 from the bedside commode to bed, performed a full body assessment and gave him/her a pain medication as requested for pain to the hips and buttocks. LPN #1 stated the Rehab Unit had admissions and it was a busy night. The nurse stated she was not aware CNA #2 had not conducted the routine checks according to the facility's policy. She stated she was too busy and assumed the safety checks had been completed. The nurse stated there was only one nurse and one CNA scheduled for the Rehab Unit to care for twenty-six (26) residents. Interview with the Director of Nursing (DON), on 07/24/15 at 9:30 AM and 1:00 PM, in regards to the event involving Resident #16, revealed she was out of town during the weekend of 07/04/15. Upon her return to the facility, she was informed the investigation of the incident had been completed by the Administrator (previous/former). She stated she was told it was a communication problem between the shifts and CNA #2 had not conducted the routine resident checks according to the facility's policy. In addition, the resident's call light had been wrapped around the support bar and would not activate. She stated re-education was provided to the staff; however, review of the training sheets revealed only the night shift working at the time of the incident received the education. The DON stated she was responsible for ensuring staff nurses were monitoring CNAs for completing routine resident checks and she monitored this by reviewing assignment sheets and manager reports. Further interview with the DON, on 08/04/15 at 10:12 AM, revealed the facility's investigation had not considered staffing to be a contributing factor; however, she revealed the night of the incident, there was only one nurse and one aide on the Rehab Unit and North Unit. She stated the normal staffing pattern would be for two (2) aides on each unit. There was a float CNA to assist. She stated the floating aide did not have a specific assignment, and they were to check with the nurse and aide to determine where the help was needed. The DON stated there had been frequent call-ins during the time of the incident and the facility had used this staffing schedule for awhile. She stated the float CNA was supposed to assist the scheduled aide in performing tasks. Review of the staffing schedule for 07/03/15 and 07/04/15, revealed one nurse and one aide with a float CNA was scheduled for the 1-South (Rehab) Unit and the 1-North Unit. Review of the daily census for those dates revealed there were twenty-six (26) residents on the 1-South Unit and thirty-five (35) residents on the 1-North Unit. Interview with CNA #15 (the float aide working on 07/04/15), on 08/04/15 at 4:19 PM, revealed when she started her shift she was told to work on the 1-North Unit because there were more residents (35) with higher acuity needs. There was only one aide on that unit also. She stated she went to the Rehab Unit (1-South), where Resident #16 resided, around 2:30 AM to relieve CNA #2 for her break. When she came onto the unit, she said Resident #16 had already been found sitting on the bedside commode. She observed LPN #1 and CNA #2 transfer the resident from the bedside commode to the bed. The resident complained of being cold, bottom numb, and kept repeating he/she couldn't use the call light because it was wrapped tightly around the support bar. She stated the resident was very upset. She validated she had not assisted CNA #2 on the Rehab Unit until after the incident with Resident #16. She was not aware the resident was on the bedside commode and had not conducted any resident or environmental checks for that unit. Interview with the Social Services Director (SSD), on 07/23/15 at 2:35 PM, revealed she was the Abuse Coordinator for the facility and was responsible for coordinating abuse/neglect complaints and grievances. The SSD stated the sister of Resident #16 had left her a voice message informing her about the incident of 07/04/15. The SSD stated she had spoken with the Administrator on Monday (07/06/15) following the incident and was told everything was taken care of. Resident #16 came to the SSD later that day and was telling her about the incident. The SSD stated she had spoken with the Administrator a second time and asked if there was anything, such as interviews, she needed to perform in regards to an investigation surrounding the event involving Resident #16 on 07/04/15. The former Administrator told her No, it had been taken care of. Observation, on 07/22/15 at 2:30 PM, of an re-enacting of the location of the call light, revealed there were two (2) call lights in the resident's bathroom. One call light was located on the wall by the toilet and the other was located on the wall of the shower. The call light was draped over the shower head to the support bar and then around the wall to the sink and hooked over the faucet with a loop handle. Resident #16 wrapped the call light cord around the support bar to demonstrate how the call light was placed on 07/04/15. When the resident pulled the call light cord, it would not activate the call system to call for help. Review of the acceptable Allegation of Compliance (AOC), dated 07/29/15, revealed the facility took the following immediate actions: 1. Resident #16 was removed from the bedside commode and transferred to the bed and assessed by Licensed Practical Nurse (LPN) #1 after the occurrence on 07/04/15. Swelling was noted to the Resident #16's ankles that dissipated by 3:15 AM. Resident #16 received pain medication ([MEDICATION NAME]) at 2:40 AM due to complaints of hip pain. Evaluations and assessments were continued through 07/07/15 with no new concerns. 2. Certified Nursing Assistant (CNA) #2, who was assigned to Resident #16 on the night shift received a coaching and counseling session by LPN #1 and Registered Nurse (RN) #3. An investigation of the incident was initiated by LPN #1 and RN #3. 3. Resident #16 was seen by a Orthopedic physician on 07/07/15 with orders for Physical Therapy and Occupational Therapy. Resident #16 was placed on case load from 07/09/15 through 07/24/15. No change of transfer status was identified. 4. The resident's primary physician was notified of the occurrence involving Resident #16 being left on the bedside commode for an extended period of time on 07/24/15 by the Director of Nursing (DON). The Responsible party was notified on 07/24/15 by the DON. 5. On 07/26/15, the Director of Program Development reviewed the personal files of CNA #2 and LPN #1, who were assigned to Resident #16 the night of the allegation, with no concerns pertaining to their abuse registry and back ground checks. 6. Resident #16 was evaluated by the Customer Service Coordinator for the ability to use a call light on 07/25/15 and found it was difficult for him/her to use the current call light. Resident #16 received a new touch based call light on 07/25/15. The call light in the bathroom for Resident #16 was evaluated on 07/26/15 by the Regional Plant Operations Director and replaced by Technical Solutions on 07/28/15. 7. All residents were assessed for any signs and symptoms of abuse and neglect. Residents with a Brief Interview of Mental Status (BIMS) score of greater than eight (8) were interviewed by the facility's Interim Administrator, DON, Minimum Data Set (MDS) Coordinator, Quality of Life Director and Medical Records for any abuse/neglect concerns starting 07/24/15 and concluding on 07/27/15. One concern from the initial audit was a concern regarding staffing. Residents who were identified to have a BIMS score of less than eight (8), were physically assessed by the Nursing Administration Team for any signs and symptoms of abuse/neglect, no new concerns were identified. Beginning 07/28/15, skin assessments would be completed each shift for ten (10) residents with a BIMS score of eight (8) or less then decreased to three times a week on 08/10/15 by the licensed nursing staff. An attempt to contact Residents' Responsible parties in regards to any abuse/neglect concerns began 07/24/15 and concluded on 07/27/15. 8. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and Central Supply were educated on 07/24/15 by the Signature Care Consultant on the abuse policy and procedure, to include but not limited to a thorough investigation, neglect, and reporting immediately. Department Administrative Managers were educated on 07/24/15. A total of seventeen (17) Department Head members were education on 07/24/15. Department Administrative Managers that did not receive the education could not return to work until abuse education was provided, and a post-test administered with a 100% score obtained. All were reviewed for compliance by the Signature Care Consultant. The facility does not utilize Agency Staff. The Interim Administrator and/or the DON was responsible for ensuring staff members were educated prior to returning to work. 9. Once the facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and Central Supply were educated, then they were assigned to educate the staff on the facility's Abuse Policy, to include but not limited to, a thorough investigation, neglect and reporting immediately, on 07/24/15 and continued until 07/28/15. Staff that had not worked as of 07/28/15 would receive education prior to returning to work. Training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable. Staff members would not return to work until abuse education had been provided, post-test completed with a score of 100 %. If the staff member did not achieve a score of a 100 % on the post-test, the staff member would be re-educated on the Abuse Policy and Procedures and given the post-test again. The process would continue until the staff member achieved 100 % on the post-test. Any staff member who was on vacation or Family Medical Leave would be provided the abuse/neglect education and given the post-test before allowed to return to work. with a score of 100 % to be achieved on the post-test. The Interim Administrator and the DON were responsible for ensuring this occurred. Every shift beginning on 07/28/15, ten (10) staff members on each shift would be given the post-test for abuse/neglect by the Interim Administrator, DON, Assistant Director of Nursing (ADON), Quality of Life Director and Plant Operations Director. A score of 100 % would be required, if less than 100 % the employee would be reinserviced and then given the post-test again until 100 % compliance was obtained. 10. All new hires will receive abuse/neglect education during orientation and would be given a post-test to achieve a score of 100 %. If the new staff member did not achieve a score of 100 % on the post-test, the new staff member would have to be re-educated by the Staff Development Coordinator and DON and be given the post-test to achieve a score of 100 %. This process would continue until the new employee achieved a score of 100 % on the post-test. The Interim Administrator and DON would review the Post-tests given daily for any noted concerns. Any concerns would be addressed immediately. All new hires would complete six (6) modules of the CMS Hand in Hand training, during the general orientation period by the Staff Development Coordinator. The facility was in the process of all staff completing the CMS Hand to Hand training and one module would be assigned per month until all the modules are reviewed. 11. Beginning on 07/24/15 and concluding on 07/28/15 100 % audit of all call lights in the facility were conducted, by the Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and or Central Supply, checking that the call lights were in working order and that the call lights were accessible for each resident and the resident had the ability to use the call light. The Initial call light audits were reviewed by the Signature Care Consultant daily from 07/24/15 through 07/28/15. There were two (2) call lights, room [ROOM NUMBER]-B and 1602-B, which were identified as needing changed. Call light audits and education would remain ongoing, every shift from 07/28/15 until jeopardy was removed. The Call light audits would be reviewed by the Interim Administrator, DON and or regional staff daily. 12. The facility's Performance Improvement Project (PIP) developed to monitor the corrective action through daily audits to ensure accessibility and function of call lights for residents was conducted by the Director of Program Development. The PIP would be reviewed two (2) times a week, then weekly times four (4) weeks by the interdisciplinary Care Team. 13. On 07/24/15 the facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records, Unit Manager and/or Central Supply were assigned to visually observe where each resident in the facility was, if the resident's needs were being addressed, and if the residents felt safe. One hundred percent (100 %) of all current residents were observed and no concerns were identified. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and/or Central Supply would audit this process to ensure compliance. Beginning 07/28/15, daily questionnaires will be completed each shift with ten (10) residents with a BIMS score of 8 or above, by the DON, Interim Administrator, Quality of Life Director and Plant Operations Director asking the following questions: 1. Is everyone treated well? 2. Do you feel safe? 3. Do you have any concerns? These audits will decrease to three (3) times a week on 08/10/15. 14. Visual observations of residents for safety and needs will be conducted every shift by nurses and CNAs at the change of shift. The staff would make visual observation of where each resident was in the facility, that the residents needs were being addressed and that the residents were safe. These rounds would be ongoing. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and/or Central Supply would audit this process to ensure compliance. Ongoing education would be conducted with the staff regarding answering call lights timely, addressing resident needs, and making rounds at shift change. A rounding audit sheet would be filled out during walking rounds. 15. Beginning on 07/24/15 and concluding on 07/27/15, 100 % of all current resident charts were reviewed for physician notification and any allegation of abuse or neglect since 06/01/15 by the Assistant Director of Nursing (ADON), Signature Care Consultant, Unit Manager and Customer Experience Coordinator. Beginning 07/28/15, ten (10) charts would be audited for documentation of allegations of abuse and neglect, physician and responsible party notification daily for two (2) weeks by the Interim Administrator and DON and then decreased to three times a week on 08/10/15. Any issues discovered at the time of the audits would be brought to the attention of the Interim Administrator and DON. Audits would be reviewed by the Interim Administrator, DON, Signature Care Consultant or other regional staff members. 16. Beginning on 07/24/15 and concluding on 07/27/15 100 % of current residents charts were audited by the Nursing Administration Staff and/or Signature Care Consultants for accuracy of care plans and CNA care plans, and assistive devices. Two variances were identified and corrected. 17. All grievances since 01/01/15 were reviewed by the Interim Administrator, DON or Signature Care Consultant or Director of Program Development on 07/24/15 to determine if any items documented were an reportable event. All administrative staff were educated on the Grievance Process including how to fill out and complete a grievance and what was a grievance by the Director of Program Development on 07/27/15. The facility had identified thirteen concerns from the grievance audit that was reported to the Office of Inspector General as allegations of abuse. The current Social Services Director who handled the process was currently suspended and would be terminated. The Administrator resigned from the facility and her last day was 07/19/15. 18. A Resident Council meeting was held on 07/25/15 by the Quality of Life Director and the Quality of Life Assistant, to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. 19. Beginning on 07/25/15 to 07/27/15 all incident/accident reports since 07/01/15 had been reviewed by the DON and Signature Care Consultant to identify any concerns of suspected abuse/neglect and for physician and responsible party notification. 20. On 07/24/15 the facility's Interim Administrator, DON, MDS Coordinators, Activities Director, Medical Records and Central Supply were educated on shift rounds, answering call lights, physician and responsible party notifications, by the Signature Care Consultant. These staff then educated the facility staff on shift rounds, answering call lights and physician notification. This was done face to face with staff interaction. A rounding audit sheet would be completed during the walking rounds. As of 07/27/15 the remaining ten (10) department heads had received their training. Staff members would not return to work until education had been provided. The facility employed 198 stakeholders and 128 employees had received education. 70 employees remained to receive training. 21. A Quality Assurance Performance Improvement meetings was held, on 07/26/15 at 3:15 PM, with a physician representative, the Interim Administrator, a CNA, Central Supply Director, Customer Experience Coordinator, Assistant Director of Nursing, and the Signature Care Consultant. Topics that were discussed included call light response, appropriate call lights, rounding of Licensed Nurses, and CNAs checking on resident whereabouts, resident safety needs, following care plans, education provided, grievance process, abuse and neglect, reporting and investigating abuse and neglect, and physician and responsible party notification. Abuse/Neglect and Care Plan policies were reviewed and there was no changes required to the policies. Results of the resident interviews, assessments and staff questionnaires would be reported to the QAPI committee weekly to determine the need for continued education or revision of the plan. Audits collected from staff members will be presented and discussed in the QAPI meeting. At that time, based on evaluation, the QAPI committee will determine at what frequency the resident interviews, assessments and staff questionnaires would need to continue. Concerns identified would be corrected immediately and reported to the Interim Administrator to ensure investigation of suspected abuse/neglect; the investigation was completed; the investigation and reporting guidelines were met; care plans were updated and followed; with physician and responsible party notifications made. A QAPI meeting will be held weekly until immediacy is removed, then decreased to every four (4) weeks, then monthly for recommendations and further follow up regarding the corrective actions of the AOC. 22. Beginning 07/28/15 and continuing until the Immediacy is removed, the resident change of condition would be reviewed daily in the morning clinical meeting to address any allegation of abuse and neglect, change of condition and that the physician and responsible party had been notified. The information for the clinical meeting would be gathered from but not limited to the twenty-four hour report sheet, Stop and Watch form, SBAR, resident orders, and verbal report from nurses. The information would be gathered by the DON, Unit Manager, Medical Records, Customer Service Director and the Scheduling Coordinator. 23. A nurse from the Regional Team or Corporate Office, Regional Vice President of Operations or Special Projects Administrator has been onsite daily since 07/24/15 providing training or assisting with the review of audits. They will continue weekly visits and or daily review by telephone until the Immediate Jeopardy had been removed and will decrease to every other week for four (4) weeks, then monthly. The nurses for the regional team or home office were assisting with investigations as needed, performing chart audits and providing oversight and consultation. Administrative oversight of the facility would be completed by the Special Projects Administrator, the Regional Vice President of Operations, or member of regional staff weekly on site and daily by telephone until removal of Immediate Jeopardy. 24. The Interim Administrator and DON would review and discuss all abuse investigations daily to ensure the resident was protected; perpetrator was removed from resident care areas; that it was reported to the appropriate agencies timely; and, a thorough investigation was completed beginning 07/24/15 and continued until Immediate Jeopardy is removed. The Interim Administrator would maintain an abuse investigation log. The Interim Administrator and Corporate Staff will review each abuse allegation to ensure a thorough investigation had been completed, protection of the resident, and reported to the appropriate state agencies. 25. During each care plan conference for each resident, any abuse/neglect concerns would be discussed along with any abuse/neglect education to include reporting, would be provided to the resident and or POA with supporting documentation noted starting 07/28/15. The State Survey Agency validated the implementation of the facility's acceptable AOC as follows: 1. Review of the Nurses' Notes dated 07/04/15 at 2:30 AM, and interviews with CNA #1, on 07/23/15 at 3:20 PM and LPN #1, on 07/23/15 at 1:40 PM, revealed the resident was removed from the bedside commode and transferred to the bed where the resident was provided a blanket for warmth, skin assessment was performed, and pain medication was administered as requested. The Nurses' Notes from 07/04/15 through 07/07/15 revealed continued monitoring of the resident. 2. Review of the facility's investigation (initiated on 07/04/15) included a written coaching and counseling session with CNA #2. This was conducted by LPN #1 and signed as witnessed by RN #3. Written statements were obtained from CNA #2, LPN #1, and RN #3. 3. Review of the clinical record, Nurses' Notes dated 07/07/15, revealed the resident was seen by an Orthopedic physician. Interview with the DON, on 07/24/15 at 9:30 AM, revealed this appointment was already scheduled prior to the incident on 07/04/15. Review of therapy notes (07/09-24/15) revealed an evaluation of Resident #16 and services provided as stated in the AOC. Interview with the Physical Therapist, on 08/05/15 at 3:18 PM, revealed the

Based on interview, record review, and policy review, it was determined the facility failed to have an effective system in place to ensure the staff followed the resident's care plan for one (1) of twenty-nine (29) sampled residents, Resident #16. The facility staff failed to implement the care plan interventions to keep the call light within easy reach, assist with activities of daily living, assist regularly and as needed to reposition/shift weight to relieve pressure and promote comfort, report changes in pain location/type to MD and assist with transfers. On 07/04/15 at 2:30 AM, Resident #16, who required total assistance with transfers and toileting, was found alone in the bathroom, sitting on a bedside commode, yelling for help. The call light was wrapped around a support bar and could not be activated. The evening staff failed to communicate to the night staff the resident had been placed on the bedside commode at 9:15 PM on 07/03/15. The facility staff failed to conduct the scheduled routine checks on the resident and left the resident sitting in the bathroom alone with no method to call for help for greater than five (5) hours. When the resident was found, on 07/04/15 at approximately 2:30 AM, the resident complained of being cold and experienced pain and numbness in the hips/buttocks area. The resident had a [DIAGNOSES REDACTED]. (Refer to F224) The facility's failure to have an effective system to ensure care plan interventions were implemented has caused or is likely to cause serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified on 07/24/15 and was determined to exist on 07/04/15. An acceptable Allegation of Compliance (AOC) was received on 08/03/15, alleging the Immediate Jeopardy was removed on 07/29/15. The State Survey Agency validated the Immediate Jeopardy was removed on 07/29/15, as alleged, prior to exit on 08/06/15. 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 Comprehensive Care Plan Policy, revised October 2010, revealed care plan interventions were designed for consideration between the resident's problem areas and their causes. Review of the clinical record for Resident #16 revealed the facility admitted the resident on 01/19/12 with a re-admission on 04/30/13 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/26/15, revealed the facility conducted a Brief Interview for Mental Status (BIMS) test with the resident scoring a fifteen (15) out of a possible fifteen (15), meaning the resident was interviewable. The facility assessed the resident to require extensive assistance of two (2) persons for all transfers and toileting needs. The resident was non-ambulatory. The facility assessed the resident's balance to be unsteady and required staff assistance when moving on and off the toilet. Review of the comprehensive care plan for pain, dated 03/20/15, revealed interventions to observe and report pain, numbness or tingling, [MEDICAL CONDITION], and general weakness related to the [DIAGNOSES REDACTED]. The facility developed an intervention to report changes in pain location and type to the physician. Other interventions included provide comfort measures such as repositioning. Review of the Activity of Daily Living (ADL) self-care deficit care plan, dated 03/20/15, revealed an intervention to keep call light within easy reach. Review of the at risk for developing skin breakdown care plan, dated 03/20/15, revealed an intervention to assist the resident with reposition/shift weight to relieve pressure as needed to promote comfort. In addition, the staff was to assist the resident with toileting and hygiene needs. Review of the Certified Nursing Assistant (CNA) Care Plan, dated July 2015, revealed the resident was non-ambulatory and required two (2) staff assist for transfers with a stand-up lift, incontinent check and change every 2 hours and PRN, and total assist for Activities of Daily Living (ADL). Interview with Resident #16, on 07/22/15 at 9:30 AM, revealed he/she had been placed on the bedside commode at approximately 9:15 PM on 07/03/15 to perform his/her nightly care and to use the bedside commode, which would normally take about forty-five (45) minutes to an hour. When the resident tried to activate the call light for assistance from staff, it would not activate because the cord was wrapped around a support bar preventing it from working. The resident said he/she yelled out for help, but nobody could hear him/her. The resident stated it was a very long time before staff found him/her in the bathroom. The resident described how they felt after sitting a while in the bathroom and said they were cold and shivering (resident was dressed in gown), with pain to the hips/buttocks, and the entire body was numb when the staff found them. The resident stated he/she was afraid this could happen again because the resident was dependent on staff for all transfers on and off the bedside commode with a mechanical lift. Interview with CNA #1, on 07/23/15 at 2:52 PM, revealed she had placed Resident #16 on the bedside commode at approximately 9:15 PM, placed the call light within reach, and closed the bathroom door. The aide stated the resident's nightly routine took about an hour and it normally started earlier than 9:15 PM. She stated the resident was dependent on staff for all transfers. Interview with CNA #2, on 07/23/15 at 3:20 PM, revealed CNA #2 stated she had conducted a resident check/safety round approximately 10:15 PM to 10:30 PM and noticed Resident #16's privacy curtain was pulled around the bed and the bathroom door was closed. She stated she did not look behind the privacy curtain or open the bathroom door to visualize the resident. At approximately 1:30 AM to 2:00 AM the CNA entered Resident #16's room and heard the resident yelling from the bathroom. She opened the bathroom door and found Resident #16 on the bedside commode and the call light cord was wrapped around a support bar, pulled tight and could not be activated. The resident told the aide he/she had been calling out trying to get someone's attention without success. Interview with LPN #1, on 07/23/15 at 1:40 PM, revealed she was working as the House Supervisor and passing medications on the night of 07/03-04/15. The nurse stated around 2:30 AM, CNA #2 reported Resident #16 was found in the bathroom on the bedside commode and stated she had been there for awhile. LPN #1 assisted CNA #2 with transferring Resident #16 from the bedside commode to bed, performed a full body assessment and gave him/her a pain medication as requested for pain to the hips and buttocks. The nurse stated she was not aware CNA #2 had not conducted the routine checks according to the care plan and facility policy. She stated she was too busy and assumed the safety checks had been completed. The nurse stated the resident was unable to remove self from the bedside commode and had to wait the extended time for staff to assist him/her with transfers and reposition. She had not notified the resident's physician of the incident and the need for the resident to be medicated for pain. Interview with the Director of Nursing (DON), on 07/24/15 at 9:30 AM and 1:00 PM, in regards to the event involving Resident #16, revealed she had been told it was a communication problem between the shifts and CNA #2 had not conducted the routine resident check according to the care plan and the facility's policy. In addition, the resident's call light had been wrapped around the support bar so tight it would not activate. Review of the acceptable Allegation of Compliance (AOC), dated 07/29/15, revealed the facility took the following immediate actions: 1. Resident #16 was removed from the bedside commode and transferred to the bed and assessed by Licensed Practical Nurse (LPN) #1 after the occurrence on 07/04/15. Swelling was noted to the Resident #16's ankles that dissipated by 3:15 AM. Resident #16 received pain medication ([MEDICATION NAME]) at 2:40 AM due to complaints of hip pain. Evaluations and assessments were continued through 07/07/15 with no new concerns. 2. Certified Nursing Assistant (CNA) #2, who was assigned to Resident #16 on the night shift received a coaching and counseling session by LPN #1 and Registered Nurse (RN) #3. An investigation of the incident was initiated by LPN #1 and RN #3. 3. Resident #16 was seen by a Orthopedic physician on 07/07/15 with orders for Physical Therapy and Occupational Therapy. Resident #16 was placed on case load from 07/09/15 through 07/24/15. No change of transfer status was identified. 4. The resident's primary physician was notified of the occurrence involving Resident #16 being left on the bedside commode for an extended period of time on 07/24/15 by the Director of Nursing (DON). The Responsible party was notified on 07/24/15 by the DON. 5. On 07/26/15, the Director of Program Development reviewed the personal files of CNA #2 and LPN #1, who were assigned to Resident #16 the night of the allegation, with no concerns pertaining to their abuse registry and back ground checks. 6. Resident #16 was evaluated by the Customer Service Coordinator for the ability to use a call light on 07/25/15 and found it was difficult for him/her to use the current call light. Resident #16 received a new touch based call light on 07/25/15. The call light in the bathroom for Resident #16 was evaluated on 07/26/15 by the Regional Plant Operations Director and replaced by Technical Solutions on 07/28/15. 7. All residents were assessed for any signs and symptoms of abuse and neglect. Residents with a Brief Interview of Mental Status (BIMS) score of greater than eight (8) were interviewed by the facility's Interim Administrator, DON, Minimum Data Set (MDS) Coordinator, Quality of Life Director and Medical Records for any abuse/neglect concerns starting 07/24/15 and concluding on 07/27/15. One concern from the initial audit was a concern regarding staffing. Residents who were identified to have a BIMS score of less than eight (8), were physically assessed by the Nursing Administration Team for any signs and symptoms of abuse/neglect, no new concerns were identified. Beginning 07/28/15, skin assessments would be completed each shift for ten (10) residents with a BIMS score of eight (8) or less then decreased to three times a week on 08/10/15 by the licensed nursing staff. An attempt to contact Residents' Responsible parties in regards to any abuse/neglect concerns began 07/24/15 and concluded on 07/27/15. 8. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and Central Supply were educated on 07/24/15 by the Signature Care Consultant on the abuse policy and procedure, to include but not limited to a thorough investigation, neglect, and reporting immediately. Department Administrative Managers were educated on 07/24/15. A total of seventeen (17) Department Head members were education on 07/24/15. Department Administrative Managers that did not receive the education could not return to work until abuse education was provided, and a post-test administered with a 100% score obtained. All were reviewed for compliance by the Signature Care Consultant. The facility does not utilize Agency Staff. The Interim Administrator and/or the DON was responsible for ensuring staff members were educated prior to returning to work. 9. Once the facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and Central Supply were educated, then they were assigned to educate the staff on the facility's Abuse Policy, to include but not limited to, a thorough investigation, neglect and reporting immediately, on 07/24/15 and continued until 07/28/15. Staff that had not worked as of 07/28/15 would receive education prior to returning to work. Training was performed face to face in order to facilitate discussion and questions and included examples of items that would be considered as reportable. Staff members would not return to work until abuse education had been provided, post-test completed with a score of 100 %. If the staff member did not achieve a score of a 100 % on the post-test, the staff member would be re-educated on the Abuse Policy and Procedures and given the post-test again. The process would continue until the staff member achieved 100 % on the post-test. Any staff member who was on vacation or Family Medical Leave would be provided the abuse/neglect education and given the post-test before allowed to return to work. with a score of 100 % to be achieved on the post-test. The Interim Administrator and the DON were responsible for ensuring this occurred. Every shift beginning on 07/28/15, ten (10) staff members on each shift would be given the post-test for abuse/neglect by the Interim Administrator, DON, Assistant Director of Nursing (ADON), Quality of Life Director and Plant Operations Director. A score of 100 % would be required, if less than 100 % the employee would be reinserviced and then given the post-test again until 100 % compliance was obtained. 10. All new hires will receive abuse/neglect education during orientation and would be given a post-test to achieve a score of 100 %. If the new staff member did not achieve a score of 100 % on the post-test, the new staff member would have to be re-educated by the Staff Development Coordinator and DON and be given the post-test to achieve a score of 100 %. This process would continue until the new employee achieved a score of 100 % on the post-test. The Interim Administrator and DON would review the Post-tests given daily for any noted concerns. Any concerns would be addressed immediately. All new hires would complete six (6) modules of the CMS Hand in Hand training, during the general orientation period by the Staff Development Coordinator. The facility was in the process of all staff completing the CMS Hand to Hand training and one module would be assigned per month until all the modules are reviewed. 11. Beginning on 07/24/15 and concluding on 07/28/15 100 % audit of all call lights in the facility were conducted, by the Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and or Central Supply, checking that the call lights were in working order and that the call lights were accessible for each resident and the resident had the ability to use the call light. The Initial call light audits were reviewed by the Signature Care Consultant daily from 07/24/15 through 07/28/15. There were two (2) call lights, room [ROOM NUMBER]-B and 1602-B, which were identified as needing changed. Call light audits and education would remain ongoing, every shift from 07/28/15 until jeopardy was removed. The Call light audits would be reviewed by the Interim Administrator, DON and or regional staff daily. 12. The facility's Performance Improvement Project (PIP) developed to monitor the corrective action through daily audits to ensure accessibility and function of call lights for residents was conducted by the Director of Program Development. The PIP would be reviewed two (2) times a week, then weekly times four (4) weeks by the interdisciplinary Care Team. 13. On 07/24/15 the facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records, Unit Manager and/or Central Supply were assigned to visually observe where each resident in the facility was, if the resident's needs were being addressed, and if the residents felt safe. One hundred percent (100 %) of all current residents were observed and no concerns were identified. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and/or Central Supply would audit this process to ensure compliance. Beginning 07/28/15, daily questionnaires will be completed each shift with ten (10) residents with a BIMS score of 8 or above, by the DON, Interim Administrator, Quality of Life Director and Plant Operations Director asking the following questions: 1. Is everyone treated well? 2. Do you feel safe? 3. Do you have any concerns? These audits will decrease to three (3) times a week on 08/10/15. 14. Visual observations of residents for safety and needs will be conducted every shift by nurses and CNAs at the change of shift. The staff would make visual observation of where each resident was in the facility, that the residents needs were being addressed and that the residents were safe. These rounds would be ongoing. The facility's Interim Administrator, DON, MDS Coordinator, Quality of Life Director, Medical Records and/or Central Supply would audit this process to ensure compliance. Ongoing education would be conducted with the staff regarding answering call lights timely, addressing resident needs, and making rounds at shift change. A rounding audit sheet would be filled out during walking rounds. 15. Beginning on 07/24/15 and concluding on 07/27/15, 100 % of all current resident charts were reviewed for physician notification and any allegation of abuse or neglect since 06/01/15 by the Assistant Director of Nursing (ADON), Signature Care Consultant, Unit Manager and Customer Experience Coordinator. Beginning 07/28/15, ten (10) charts would be audited for documentation of allegations of abuse and neglect, physician and responsible party notification daily for two (2) weeks by the Interim Administrator and DON and then decreased to three times a week on 08/10/15. Any issues discovered at the time of the audits would be brought to the attention of the Interim Administrator and DON. Audits would be reviewed by the Interim Administrator, DON, Signature Care Consultant or other regional staff members. 16. Beginning on 07/24/15 and concluding on 07/27/15 100 % of current residents charts were audited by the Nursing Administration Staff and/or Signature Care Consultants for accuracy of care plans and CNA care plans, and assistive devices. Two variances were identified and corrected. 17. All grievances since 01/01/15 were reviewed by the Interim Administrator, DON or Signature Care Consultant or Director of Program Development on 07/24/15 to determine if any items documented were an reportable event. All administrative staff were educated on the Grievance Process including how to fill out and complete a grievance and what was a grievance by the Director of Program Development on 07/27/15. The facility had identified thirteen concerns from the grievance audit that was reported to the Office of Inspector General as allegations of abuse. The current Social Services Director who handled the process was currently suspended and would be terminated. The Administrator resigned from the facility and her last day was 07/19/15. 18. A Resident Council meeting was held on 07/25/15 by the Quality of Life Director and the Quality of Life Assistant, to discuss any abuse/neglect concerns and to provide education on whom to report any abuse/neglect concerns without fear of retribution. 19. Beginning on 07/25/15 to 07/27/15 all incident/accident reports since 07/01/15 had been reviewed by the DON and Signature Care Consultant to identify any concerns of suspected abuse/neglect and for physician and responsible party notification. 20. On 07/24/15 the facility's Interim Administrator, DON, MDS Coordinators, Activities Director, Medical Records and Central Supply were educated on shift rounds, answering call lights, physician and responsible party notifications, by the Signature Care Consultant. These staff then educated the facility staff on shift rounds, answering call lights and physician notification. This was done face to face with staff interaction. A rounding audit sheet would be completed during the walking rounds. As of 07/27/15 the remaining ten (10) department heads had received their training. Staff members would not return to work until education had been provided. The facility employed 198 stakeholders and 128 employees had received education. 70 employees remained to receive training. 21. A Quality Assurance Performance Improvement meetings was held, on 07/26/15 at 3:15 PM, with a physician representative, the Interim Administrator, a CNA, Central Supply Director, Customer Experience Coordinator, Assistant Director of Nursing, and the Signature Care Consultant. Topics that were discussed included call light response, appropriate call lights, rounding of Licensed Nurses, and CNAs checking on resident whereabouts, resident safety needs, following care plans, education provided, grievance process, abuse and neglect, reporting and investigating abuse and neglect, and physician and responsible party notification. Abuse/Neglect and Care Plan policies were reviewed and there was no changes required to the policies. Results of the resident interviews, assessments and staff questionnaires would be reported to the QAPI committee weekly to determine the need for continued education or revision of the plan. Audits collected from staff members will be presented and discussed in the QAPI meeting. At that time, based on evaluation, the QAPI committee will determine at what frequency the resident interviews, assessments and staff questionnaires would need to continue. Concerns identified would be corrected immediately and reported to the Interim Administrator to ensure investigation of suspected abuse/neglect; the investigation was completed; the investigation and reporting guidelines were met; care plans were updated and followed; with physician and responsible party notifications made. A QAPI meeting will be held weekly until immediacy is removed, then decreased to every four (4) weeks, then monthly for recommendations and further follow up regarding the corrective actions of the AOC. 22. Beginning 07/28/15 and continuing until the Immediacy is removed, the resident change of condition would be reviewed daily in the morning clinical meeting to address any allegation of abuse and neglect, change of condition and that the physician and responsible party had been notified. The information for the clinical meeting would be gathered from but not limited to the twenty-four hour report sheet, Stop and Watch form, SBAR, resident orders, and verbal report from nurses. The information would be gathered by the DON, Unit Manager, Medical Records, Customer Service Director and the Scheduling Coordinator. 23. A nurse from the Regional Team or Corporate Office, Regional Vice President of Operations or Special Projects Administrator has been onsite daily since 07/24/15 providing training or assisting with the review of audits. They will continue weekly visits and or daily review by telephone until the Immediate Jeopardy had been removed and will decrease to every other week for four (4) weeks, then monthly. The nurses for the regional team or home office were assisting with investigations as needed, performing chart audits and providing oversight and consultation. Administrative oversight of the facility would be completed by the Special Projects Administrator, the Regional Vice President of Operations, or member of regional staff weekly on site and daily by telephone until removal of Immediate Jeopardy. 24. The Interim Administrator and DON would review and discuss all abuse investigations daily to ensure the resident was protected; perpetrator was removed from resident care areas; that it was reported to the appropriate agencies timely; and, a thorough investigation was completed beginning 07/24/15 and continued until Immediate Jeopardy is removed. The Interim Administrator would maintain an abuse investigation log. The Interim Administrator and Corporate Staff will review each abuse allegation to ensure a thorough investigation had been completed, protection of the resident, and reported to the appropriate state agencies. 25. During each care plan conference for each resident, any abuse/neglect concerns would be discussed along with any abuse/neglect education to include reporting, would be provided to the resident and or POA with supporting documentation noted starting 07/28/15. The State Survey Agency validated the implementation of the facility's acceptable AOC as follows: 1. Review of the Nurses' Notes dated 07/04/15 at 2:30 AM, and interviews with CNA #1, on 07/23/15 at 3:20 PM and LPN #1, on 07/23/15 at 1:40 PM, revealed the resident was removed from the bedside commode and transferred to the bed where the resident was provided a blanket for warmth, skin assessment was performed, and pain medication was administered as requested. The Nurses' Notes from 07/04/15 through 07/07/15 revealed continued monitoring of the resident. 2. Review of the facility's investigation (initiated on 07/04/15) included a written coaching and counseling session with CNA #2. This was conducted by LPN #1 and signed as witnessed by RN #3. Written statements were obtained from CNA #2, LPN #1, and RN #3. 3. Review of the clinical record, Nurses' Notes dated 07/07/15, revealed the resident was seen by an Orthopedic physician. Interview with the DON, on 07/24/15 at 9:30 AM, revealed this appointment was already scheduled prior to the incident on 07/04/15. Review of therapy notes (07/09-24/15) revealed an evaluation of Resident #16 and services provided as stated in the AOC. Interview with the Physical Therapist, on 08/05/15 at 3:18 PM, revealed the resident remained a two-person assist and mechanical lift with all transfers. 4. Interview with Resident #16's primary physician, on 08/04/15 at 12:36 PM, revealed he was notified of the incident on 07/27/15; however, he had been on vacation and the nursing facility had notified his office on 07/24/15. Interview with the DON, on 08/04/15 at 10:12 AM revealed she had notified the physician's office on 07/24/15. 5. A review of the personnel files for CNA #2 and LPN #1 was conducted during the recertification survey as part of the 5-G Abuse task. No problems were identified. The SSA validated the abuse registry and background checks were conducted prior to hire with no findings. 6. Observation of Resident #16's room, on 08/06/15 at 2:08 PM revealed the facility had provided a new soft touch call light. The call light in the resident's bathroom was replaced on 07/28/15. 7. Review of the skin assessments revealed all residents in the facility received a skin assessment on 07/24/15 through 07/27/15 with no signs or symptoms of abuse/neglect found. Review of the skin assessments conducted by the facility revealed the facility continued to perform skin assessments on residents with a BIMS score of eight (8) or less. Review of the skin assessments conducted by the facility revealed the facility continued to perform skin assessments on residents with a BIMS score of eight (8) or less. Interviews on 08/04/15 with Resident #25 at 9:45 AM and Resident #29 at 10:40 AM, revealed no concerns with abuse/neglect. 8. Review of the training records revealed on 07/24/15, the Corporate Care Consultant provided training on the facility's Abuse/Neglect Policy was provided to the Department Heads. This training included how to investigate an allegation of abuse/neglect and reporting requirements. The training also included physician notification, care plans, rounds, and call lights. Seventeen (17) Department Heads were present at the training including the Interim Administrator and Director of Nursing. Interview with the Corporate Consultant, on 08/06/15 at 3:46 PM, revealed she had provided training to all Department Heads on the Abuse/Neglect- Policy, investigating and reporting, call lights, grievances, and making visual rounds. Interview with the DON, on 08/06/15 at 1:36 PM, Quality of Life Director, on 08/06/15 at 10:00 AM, and Activity Director on 08/05/15 at 2:22 PM, Director of Program Development, on 08/05/15 at 4:08 PM, Customer Experience Director, on 08/05/15 at 4:33 PM, Maintenance Director, on 08/05/15 at 5:09 PM, and the Interim Administrator, on 08/06/15 at 2:36 PM, validated the training was provided on 07/24/15 and they had a good knowledge of how to investigate and report abuse. 9. Review of the training records revealed the facility staff was trained from 07/24/15 through 07/28/15, with as needed staff trained prior to working, on the Abuse/Neglect Policy. Post-tests were given regarding information presented on abuse/neglect with the staff scoring 100%. Training was validated through interviews with the Rehab (1-South) Unit Manager, on 08/06/15 at 9:25 AM, Social Services, on 08/05/15 at 1:45 PM, LPN #11, on 08/05/15 at 1:30 PM, LPN #12, on 08/05/15 at 1:36 PM, LPN #5 on 08/05/15 at 1:55 PM, and LPN #13, on 08/05/15 at 2:08 PM. Additional interviews were conducted with CNA # 10, on 08/05/15 at 1:42 PM, CNA #11 and #12 on 08/05/15 at 1:50 PM, CNA # 3 on 08/05/15 at 2:00 PM, CNA #25, on 08/05/15 at 2:02 PM, CNA # 14 on 08/05/15 at 2:05 PM, CNA #26 on 08/05/15 at 2:08 PM, CNA #6 on 08/05/15 at 2:10 PM, CNA # 7 and #24 on 08/05/15 at 2:15 PM, and CNA #8 on 08/05/15 at 3:05 PM. The staff had good knowledge of the definition of abuse/neglect and how to report. In addition, the nursing staff had been trained on communication rounds between shifts, conducting safety checks, call light accessibility, and the grievance process. Review revealed the facility continued to education on the Abuse/Neglect Policy with post-test given. Review of the results of the post-test revealed staff scored 100%. 10. Review of the new hire list and comparison to the training documentation revealed the new employees would receive training on abuse/neglect with a Post-test required. All new hires must have a 100% pass rate. Interview with the Interim Administrator, on 08/06/15 at 2:36 PM, revealed newly hired employees will be required to complete the Hand in Hand modules (6), one per month. He stated there had been no new hires since 07/29/15. He said the Staff Development Coordinator would monitor the training. Review of the August 2015 schedule for new employee training revealed the Hand in Hand modules would be reviewed on August 10, 11, 12, 18, 19, and 20th. 11. Observation during the extended survey revealed the residents' call lights were functional and within reach. Observation of the call light response time during the survey revealed the call lights were answered within five (5) minutes of activation. Review of the call light audits revealed the facility conduct a facility wide inspection of each resident's room, on 07/24/15, to determine if each call light was functional and within reach of the resident. The call light audits continued through the extended survey. The audits revealed two call lights were replaced and Resident #16's call light was replaced with a soft touch call light. Observation of Resident #16's bathroom, on 08/05/15 at 2:08 PM, revealed a soft touch call light and was within the resident's reach. Observation of the resident activating the new call light revealed the call light activated and staff responded within one minute. Interview with the resident during this observation revealed his/her needs were being met. 12. The facility utilized a computer program (Abaqis) that monitors the corrective actions through daily audits. Members included the Interim Administrator, DON, ADON, Customer Service Director, and a CNA. Review of the Performance Improvement Project (PIP) revealed monitoring of call lights audits (daily the IDT team will discuss), care plan conference concerns, Abuse/Neglect Post-test, physician notification, daily charting audits, Hand in Hand training, and Department Head rounds. Minutes from the PIP meetings were provided and reviewed. The facility met daily from 07/27/15 to 08/03/15. The PIP reviews were reviewed with Administrative Managers on 07/29/15. Interview with the Interim Administrator, on 08/06/05 at 2:36 PM, revealed the facility used PI

Based on interview, record review and policy review, it was determined the facility failed to have an effective system to ensure the implementation of the care plan for ongoing supervision for one (1) of fourteen (14) sampled residents, Resident #1. The facility assessed Resident #1 at risk for elopement with a care plan for staff to monitor the whereabouts of the resident on an ongoing basis. However, the facility staff failed to monitor the whereabouts of the resident and was not aware the resident had left the unit and facility until the resident rang the facility's door bell. On 01/21/15 at 11:42 PM, Resident #1 exited his/her unit without an alarm sounding and exited the building through the unlocked doors to the front lobby without staff knowledge. At 12:30 AM, the resident attempted to re-enter the front lobby doors after recognizing it was too cold outside and he/she would need a jacket. However, these doors locked from the outside and re-entrance was prohibited. The resident walked around the building to the Ambulance Entrance near the One South Unit entrance and rang the door bell. The staff answered the door bell to find the resident outside wearing street clothing; shoes, socks, blue jeans and a pull over shirt. Staff noted the resident appeared cold upon entering the building, with recorded weather conditions on 01/21/15 of cloudy skies and forty-two (42) degrees Fahrenheit at midnight with a westerly wind at 8.1 miles per hour. In addition, upon returning to the unit the resident's alarm did not sound. After the staff checked the alarm it was determined the battery was dead and the alarm was non-functioning. The facility's failure to ensure residents' plans of care were implemented placed residents at risk for elopement in a situation that was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 02/06/15 and was found to exist on 01/21/15. The facility was notified on 02/06/15. The facility provided a credible Allegation of Compliance (AOC) on 02/11/15 alleging removal of Immediate Jeopardy on 02/07/15. However, the State Survey Agency verified Immediate Jeopardy was not removed until 02/13/15 due to re-education of staff. Record review and interview revealed forty-two (42) percent of staff was education via the telephone prior to 02/07/15. The scope and severity was lowered to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of the implemented action plans to achieve and maintain compliance with the plan of correction. The findings include: Review of the facility's policy regarding Care Plan-Comprehensive, revised October 2010, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was developed for each resident. When possible, interventions would address the underlying sources of the problem areas, rather than addressing only symptom or triggers. However, the policy did not address implementation of the care plan. Review of Resident #1's record revealed the facility assessed Resident #1 on admission, on 07/17/14, as an elopement risk. The Elopement Risk Evaluation stated if there was a yes answer to questions four (4), five (5) or six (6), the Resident would be automatically at risk for elopement. The facility identified Resident #1 with a yes answer to cognitively impaired; independently ambulates; has poor decision making skills; had demonstrated exit-seeking behaviors; and, the resident had the ability to exit the facility. Review of Resident #1's Elopement Care Plan, dated 08/14/14, revealed Resident #1 was at risk for elopement due to Dementia and walking around the units. The goal was for Resident #1 not to elope from the facility and staff would monitor the whereabouts of the resident on an ongoing basis. Post survey interview with Certified Nursing Assistant (CNA) #19, on 02/27/15 at 5:00 PM, revealed she was familiar with Resident #1 and if she needed to know how to provide care for Resident #1, she would look at the care plan book or the resident's closet which had a copy of the care plan. CNA #19 stated the care plan binder obtained the comprehensive nursing and CNA care plans. CNA #19 stated as far as she was aware Resident #1 was care planned for an Accutech Tag and for wandering. CNA #19 stated she monitored the residents every two (2) hours and was not aware Resident #1 was to have ongoing supervision. CNA #19 stated there were times when the nurses and aids were in rooms at the same time. CNA #19 stated ongoing meant to monitor the resident every fifteen (15) minutes or continuously until the nurse told her differently. CNA #19 stated she would think the nurses would inform her if a resident was to receive ongoing supervision. Post survey interview with CNA #4, on 02/27/15 at 10:47 PM, revealed she did not remember Resident #1's care plan stating the resident had ongoing supervision. CNA #4 stated ongoing supervision meant every fifteen (15) minutes checks. CNA #4 stated the night of the incident, no staff member was assigned to monitor the halls, especially when the nurse and aids were in the room providing care. CNA #4 stated if Resident #1 was to have ongoing supervision she would have informed the nurse to monitor when she had to provide resident care. CNA #4 stated if the care plan stated to monitor more frequently then the care plan should have been followed. Post survey interview with CNA #9, on 02/27/15 at 10:37 PM, revealed she was familiar with Resident #1 and if she needed to know how to provide care for Resident #1 she would look at the Care Plan Book. CNA #9 stated she had not seen on the care plan that Resident #9 was to be monitored on an ongoing basis. On going meant all night supervision. CNA #9 stated if she wanted to provide care for other residents she would have to inform someone to monitor Resident #1 while she was busy. She stated there were times when the aides and nurses were in rooms together and there was no one to monitor the halls. CNA #9 stated if Resident #1 was not being monitored then the care plan was not followed. She stated if the resident was monitored he/she may not have exited the building. Post survey interview with CNA #20, on 02/27/15 at 10:10 PM, revealed she was familiar with Resident #1 and was aware Resident #1 was an elopement risk and had an Accutech Tag. CNA #20 stated to supervise a resident on an ongoing basis, meant to check on the resident every fifteen (15) minutes. CNA #20 stated she would document the fifteen (15) minute checks if told to do so. CNA #20 stated she had not seen any documents that stated Resident #1 was to be ongoing supervision. CNA #20 stated if the resident was on ongoing monitoring she would expect the nurse to monitor when she was completing her rounds because it was a team effort. CNA #20 stated if she and the nurses were in rooms providing care at the same time, she was not sure how the residents were to be monitored. CNA #20 stated she had never observed Resident #1 trying to leave the unit. Review of the fifteen (15) minute checks, revealed no record of documented checks before 01/21/15. Post survey interview with Licensed Practical Nurse (LPN) #5, on 02/27/15 at 11:00 PM, revealed she monitored behaviors by looking at the behavior book and then dcoumenting in the nurses notes. LPN #5 stated ongoing supervision meant for the resident to be monitored every (15) minutes and the aid would document the monitoring. LPN #5 stated if an aide was completing incontinent care she would expect the aides to inform her so that she could complete the fifteen (15) minute checks. If she had to provide care she would let an aide know to monitor the halls; however, she worked a different unit on the night the resident left the unit. She stated in situations where the nurse and aids were providing care at the same time, then there would be no one to monitor the halls. LPN #5 stated if Resident #1 was care planned to be supervised on an ongoing basis then the care plan should have been followed. Record review of the nurses notes, on 01/20/15, revealed no behaviors of wandering was documented. Interview with Registered (RN) #1, on 02/06/15 at 1:08 PM, revealed she was ultimately responsible to ensure all residents were safe on the unit. She stated there was enough staff to monitor the doors to the unit and that the staff was doing what they needed to do. RN #1 stated there was a possibility that all three staff members, who worked on the unit, could be in rooms assisting other residents without monitoring the halls. RN #1 gave no definition of what ongoing observation on the care plan meant. Interview with the Minimum Data Set (MDS) Coordinator #1, on 02/06/15 at 1:39 PM, revealed the care plan for Resident #1 was not being followed because to monitor the resident ongoing meant to monitor Resident #1 for exit seeking behaviors at all times. The MDS Coordinator #1 stated if they could not visibly see the residents at all times, the Accutech Tab was a second back up to the supervision. The MDS Coordinator stated Resident #1 was known to have intermittent confusion; however, had no changes in his/her status and the care plan was appropriate for this resident. Interview with the Director of Nursing (DON), on 02/06/15 at 2:36 PM, revealed she was not expecting the Accutech Tab alarming system to replace the supervision of the staff and expected the staff to check on the residents. The DON did not provide a definition to what ongoing supervision as documented on the care plan meant, except that Resident #1 was checked at 11:30 PM on 01/20/15 and that staff had completed their rounds every two hours. The DON stated the staff did not document the whereabouts of residents on an ongoing basis. The DON stated Resident #1 did not require more supervision, than any of the other identified elopement residents, just because she was at risk. The DON stated at times the nursing staff would be in resident rooms and could not supervise each resident unless that resident was made one (1) to one (1). However, this was not on the care plan. Interview with the Administrator, on 02/13/15 at 2:28 PM, revealed there were no supervision concerns identified. The Administrator stated she felt like the facility was staffed appropriately. The Administrator stated she did not identify the staff on unit as a concern, but that the concern was the alarm not sounding on the unit. The Administrator stated ongoing supervision meant, for example, that staff would be aware of of the resident's whereabouts as they did rounds and came out of resident rooms. The Administrator stated the only way to provide continuous supervision was to provide one (1) to one (1) coverage. Review of the acceptable Allegation of Compliance (AOC), dated 02/11/15, revealed the facility took the following immediate actions: 1. Resident #1 was assessed by the Charge Nurse on 01/21/15 at approximately 12:45 AM. The Responsible Party and Physician were notified of the incident by the Charge Nurse on 01/21/15. The care plan was updated by the Director of Nursing on 01/21/15 to reflect the recent incident. 2. Resident #1 was placed on 15 minute checks which were completed by the resident's Charge Nurse upon returning to the facility. The RN removed the Accutech tag, checked it, and determined the battery was low. A new Accutech tag was immediately placed by the RN. 3. A head count of the entire facility was conducted on 01/21/15 by the charge nurses with the Administrator and DON oversight to ensure all residents were accounted for and were safe. 4. On 01/21/15 all exits were checked initially by the charge nurses on duty. The Accutech doors were manned and continuously monitored by facility staff until 01/22/15. The Plant Operations Director was notified and immediately came to check all exit doors. One door on the 2nd floor Two North was adjusted by the Plant Operations Director as there was a slight gap in closing: all other exit doors were found to be functioning properly. 5. On 01/21/15, the Administrator, Director of Nursing and Plant Operations Director confirmed the Accutech tag had a low battery. 6. On 01/21/15 all resident Accutech tags were checked for placement and function by the Charge Nurses on duty and the Plant Operations Director. 7. On 02/04/15, the Plant Operations Director and Regional Plant Operations Director utilized an outside vendor to adjust the front interior lobby doors. A keypad lock was activated and the doors would lock automatically at 9:00 PM daily and would unlock at 8:00 AM daily. The doors were wired so that anyone attempting to exit without the door code during the hours of 9:00 PM and 8:00 AM would set off an alarm which would be audible at the nurses stations. The monitoring panel at each nurses station would also visibly show that the front door was being opened without the door code between the hours of 9:00 PM and 8:00 AM. The Delayed egress system was in place on these doors. A Receptionist would be at the front desk from 8:00 AM to 9:00 PM seven days a week. 8. On 02/03/15, staff were placed at the front receptionist desk for 24/7 monitoring. This monitoring would end on 02/06/15 after all staff education was completed. 9. Beginning 01/21/15 the nursing and Social Services staff would follow up with the resident daily for seventy-two hours to identify and address any psychosocial needs Resident #1 may have. 10. On 01/21/15, all 127 residents were reassessed for risk of elopement by the Assistant Director of Nursing (ADON), Director of Nursing (DON) and Social Services Assistant. 11. Care plans and nursing assistant care records were updated for sixteen (16) residents who were identified as being at risk for elopement on 01/21/15 by the DON, Facility Consultant, and the ADON. 12. On 01/21/15, the five (5) binders which identified eighteen (18) residents who were at risk for elopement were reviewed by the Administrator and DON to ensure they were updated and in place at each nurses station and at the receptionist desk. 13. On 01/21/15 The Administrator and DON were reeducated via phone by the Facility Consultant, Regional Vice President and Chief Nurse Executive on the elopement policy, missing resident policy, including how to respond to door alarms, complete a head count, checking the wander-guard function of the doors, Accutech tags and implementation of care plans related to triggered areas including elopement risk assessments. There were no revisions to the elopement and missing person policy and procedure. This education was completed prior to the education being initiated with staff on 01/21/15. 14. Education regarding the elopement policy, missing resident policy including how to respond to door alarms, completing head counts, checking the wander-guard function of the doors, Accutech tags and implementation of care plans related to triggered areas including elopement risk assessments were provided by the Administrator and the DON on 01/21/15 to all the Administrative staff who were to provide education. Education was completed for nursing, housekeeping, laundry, therapy, dietary and plant operations that included 183 staff. Post tests were completed by 02/02/15. 15. Education and return demonstrations on use of Accutech Transmitter (device to check function) to ensure staff competency of the wander-guard function and battery checks were initiated on 01/21/15 by the Plant Operations Director or Plant Operations Assistant for licensed nurses. A post test was given to staff that received the education in which a passing score of 100 % had to be obtained. If a score of 100 % on the test was not obtained the staff member would be re-educated on the spot and a new post-test would be given. Forty-two (42) licensed nurses were educated. 16. Staff that were not working on 01/21/15, would be educated prior to taking their assignment upon return to work. A post test would be given in which a passing score of 100 % had to be obtained. If 100 % was not obtained the staff member would be re-educated and a post test would be reissued. 17. Staff who were PRN (as needed staff) or Family Leave Medical Act (FMLA) or on leave would be issued a certified letter by the Administrator with a return receipt on 01/26/15 alerting them that they must receive an eduction on the elopement policy, missing resident, care plans and Accutech before being allowed to work. There were 33 PRN and 3 FMLA on 01/21/15. The facility does not utilize Agency Staff. 18. On 02/06/15 the ADON and Minimum Data Set (MDS) Coordinator were re-educated by the Administrator and DON on completion of care plans upon admission, quarterly and with changes of condition, including care plans to reflect the nursing assessment. 19. New procedures were implemented on dating Accutech Tags when received in the facility and placed on residents. The Plant Operations Director was opening and dating new wander-guard tags when they arrived to the facility. Manufacturers recommendations state that the Accutech tag would last at least twelve (12) months or longer. The Accutech tags would be replaced at eleven (11) months. The Plant Operations Director and DON would each keep a roster of dates that the Accutech tags were placed on each resident with the activation date and when they needed to be replaced. The Plant Operations Director and DON would notify nursing staff when to replace the Accutech tag at the eleventh (11) month mark. Anytime an Accutech tag was replaced, the tag would be labeled "BAD" and given to the Plant Operations Staff and logged in their Maintenance log in the Maintenance Binder at each nurses station. 20. On 01/21/15, the Quality Assurance (QA) team met consisting of the Administrator, DON, two (2) Regional Nurse Consultants, and Medical Director in regards to root cause of event, education, interventions and plans to prevent reoccurrence. The elopement policy and procedure was reviewed and no revision were made. 21. On 2/04/15, a QA meeting was held with the Medical Director to review the procedure changes related to the front door monitoring. 22. On 02/06/15, a QA meeting was held with the Medical Director to review the elopement plan. 23. The DON and Regional Nurse Consultant reviewed 113 incident and accident reports for the last three (3) months on 01/21/15 for any other concerns of elopement or wandering. None were identified. 24. Beginning 01/24/15 and going through 01/30/15, daily audits would be completed each shift for Accutech tag function on all identified residents, return demonstration by four (4) licensed staff on wander-guard functioning and twelve (12) staff members each shift would be given the post test for elopement by the Administrative staff. A score of 100 % would be required. 25. Daily for two (2) weeks beginning 01/21/15, the Plant Operations Director and the Plant Operations Assistant would check the exit doors in the facility for correct function and place on their log. 26. Daily for two (2) weeks beginning 01/21/15, the Plant Operations Director or Plant Operations Assistant would check the function of the Accutech tags on all identified residents. 27. Charts for residents with a change of condition, new orders, new admissions, discharges, or transfers to the hospital were reviewed at the daily clinical meeting five (5) days a week by the clinical team. 28. The Regional Care Consultant Staff were providing oversight to the audits four (4) times a week beginning 01/21/15 and continued through 02/13/15. 29. The elopement policy and procedure, missing resident, care plans and Accutech system would be in-serviced in orientation for all new hires beginning 01/23/15 in which a post test would be given and a score of 100 % must be obtained. The Staff Development Coordinator would be responsible for the orientation. The State Survey Agency validated the AOC on 02/13/15 through observation, interview and record review prior to exit as follows: 1. Interview with the Charge Nurse (RN #1), on 02/06/15 at 1:08 PM, revealed she notified the family and physician of Resident #1 the morning of the incident. Record review of the Incident Report dated 01/21/15 at 1:00 AM, revealed the Physician was called at 01/21/15 at 3:00 AM and the Family was called on 01/21/15 at 1:20 AM. 2. Review of the fifteen (15) minutes checks revealed Resident #1 was monitored every fifteen (15) minutes starting at 1:15 AM on 01/21/15 through 01/27/15. Interview with RN #1, on 02/02/15 at 10:35 PM, revealed Resident #1 was monitored every fifteen (15) minutes once the resident was back in the building. 3. Interview with Licensed Practical Nurse (LPN) #5, on 02/02/15 at 10:00 PM, revealed on the night of 01/21/15 she had completed a head count of all residents on her unit. Interview with RN #1, on 02/02/15 at 10:35 PM, revealed a head count of all residents occurred through out the building. Interview with the Director of Nursing (DON), on 02/05/15 at 9:40 AM, revealed she instructed the staff to ensure all residents were accounted for the day of 01/21/15 at about 1:00 AM. Interview with the Administrator, on 02/05/15 at 10:10 AM, revealed she instructed the staff to complete a head count when she received a phone call from RN #1 on 01/21/15. 4. Interview with LPN #3, on 02/02/15 at 10:12 PM, revealed she helped with the check of the doors and found that the Two North needed to be manned by staff and all other doors were monitored every fifteen (15) minutes. Interview with RN #1 on 02/02/15 at 10:35 PM, revealed she helped with checking that all doors were secure. RN #1 stated the doors were checked every fifteen (15) minutes and later on that day someone manned all of the doors. Interview with the Plant Operations Director, on 02/03/15 at 4:40 PM, revealed the morning of the incident he received a call and made sure there were staff monitoring the doors until he was sure that the doors were working appropriately. The door on Two North had to be readjusted. The doors were found to be functioning appropriately. 5. Interview with the Plant Operations Director, on 02/03/15 at 4:40 PM, interview with the DON, on 02/05/15 at 9:40 AM and interview with the Administrator, on 02/05/15 at 10:10 AM, revealed when they had observed Resident #1's Accutech tag it was found to have a low battery. 6. The State Agency validated through interview with RN #1 on 02/06/15 at 1:08 PM and Interview with the Plant Operations Director, on 02/05/15 at 2:22 PM, revealed all resident wander-guards were checked. 7. Review a list of items completed to fix the front door from the Regional Plant Operations Director, on 02/04/15, revealed he came to meet with a technician to have him add an additional alarm at the nurses station that would sound when the front corridor door was opened without a code, it would remain in alarm mode until an employee reset the keypad. The System was installed with a timer to automatically lock the door from 9:00 PM until 8:00 AM and the timer was programmable. Interview with the Plant Operations Director, on 02/06/15 at 2:19 PM, revealed on 02/04/15 the front lobby corridor would be locked down after 9:00 PM and the staff would have to utilize a key pad to get out. The delayed egress system was in place on these doors. A Receptionist would be at the front desk Interview with the Administrator, on 02/04/15 at 3:36 PM, revealed she adjusted the monitoring of the front door to the hours of 8:00 AM to 9:00 PM Monday through Sunday which was seven (7) days a week. Observation on 02/05/15 at 8:30 AM, revealed a key pad outside of the front corridor and a sign which stated if in an emergency situation hit the red button to the right to exit. 8. Interview with the Receptionist, on 02/12/15 at 3:47 PM, revealed she could remember staff having to man the front lobby 24/7 to ensure residents were safe. Receptionist #1 stated she would stay until 10:00 PM and would be relieved by another staff member. She stated now the doors were locked automatically after a certain time. Interview with the Administrator, on 02/12/15 at 5:01 PM, revealed on 02/03/15 through 02/06/15, she placed someone at the receptionist desk 24/7. The front interior lobby door was adjusted with a keypad to lock automatically after 9:00 PM. 9. Review of Resident #1's nurses notes revealed, the staff documented behaviors for Resident #1 on an ongoing basis, shift to shift. Review of Resident #1's fifteen (15) minute checks revealed he/she was checked from 1:00 AM on 01/21/15 through 01/27/15 at 10:00 PM. Interview with Social Services on 02/12/15 at 2:33 PM, revealed she attended morning clinical meetings and went over behaviors and wondering concerns of the staff. She also reviewed change of condition to monitor the residents of any changes. Social Services reviewed the Nurses Notes, Incident Reports, twenty-four (24) hour report, admissions, and discharges for any changes. 10. Record review of Residents' #1, #3, #8, #10, #11, #12, #13 and #14 Elopement Risk Assessments revealed all the assessments were re-evaluated on 01/21/15. Interview with the Interim ADON, on 02/12/15 at 1:13 PM, interview with the DON, on 02/12/15 at 4:12 PM and interview with Social Services, on 02/12/15 at 2:33 PM, revealed they reassessed all residents for the risk of elopement on 01/21/15. 11. Record review of Residents' #1, #3, #8, #10, #11, #12, #13 and #14 were all identified to have elopement concerns and all care plans were validated to be up-to-date as of 01/21/15. Interview with the ADON #2 on 02/12/15 at 1:45 PM, interview with DON, on 02/12/15 at 4:12 PM and the Facility Consultant, on 02/12/15 at 3:00 PM, revealed the Care plans and the nursing assistant care records were updated for residents who were identified to be an elopement risk. 12. Observations revealed five (5) binders containing eighteen (18) residents were present on each unit and at the receptionist desk on 02/05/15 at 9:00 AM. Interview with the DON, on 02/12/15 at 4:12 PM, revealed she took the elopement binders to the daily clinical meetings to make sure the binders were up-to-date. Interview with the Administrator, on 02/12/15 at 5:01 PM, revealed there were five (5) elopement binders and they were being reviewed daily in the clinical morning meeting. 13. Interview with the Facility Consultant, on 02/12/15 at 3:00 PM, revealed she provided education to the Administrator and the DON via phone on the morning of 01/21/15 and then came in around 7:00 AM on 01/21/15. The Facility Consultant stated she educated the Administrator and DON, on the elopement policy, validated that they followed the policy and checked all doors. She also ensured the bracelets were checked along with their batteries. She educated the Administrator and DON on the missing resident policy. Interview with Chief Nurse Executive, on 02/13/15 at 12:42 PM, revealed she had educated the DON and Administrator on 01/21/15. She educated them on the elopement policy, missing person policy and checking the Accutech tags, how to complete a head count, update care plans and resident assessments. Interview with the DON, on 02/12/15 at 4:12 PM and the Administrator on 02/12/15 at 5:01 PM, revealed they were educated by the Facility Consultant, Regional Vice President and the Chief Executive on 01/21/15. 14. Interview with the Plant Operations Director, on 02/12/15 at 3:05 PM, revealed he received training from the DON and Administrator on the elopement policy and missing resident policy. He was also educated on the door alarms, completing a head count, checking Accutech tags and implementing a care plan. The Plant Operations Director stated he had to complete a post test. Interview with Receptionist #1, on 02/12/15 at 3:47 PM, revealed she received training on elopement and when to call a code green by the Administrator. Record review of the training record for the elopement and missing resident policy, revealed there were 161 staff who were trained in person and twenty-two (22) persons who were called by phone. Record review of the training on the front doors, revealed 112 staff members were trained in person and seventy-one (71) staff members were trained by phone. Interview with Certified Nursing Assistant (CNA) #17, on 02/13/15 at 4:02 PM, revealed she originally was educated by phone in regards to the front door on 02/06/15. CNA #17 stated stated she was educated in person on 02/12/15 to obtain education on the doors. CNA #17 stated she was taught that the doors would lock down after 9:00 PM at night and that staff would have to utilize a code to get out. If the alarm was to go off at the front door the alarm would alert at the nurses station. Interview with a Physical Therapist Assistant (PTA), on 02/13/15 at 4:05 PM, revealed she was educated on the front doors and the elopement policy by phone. The PTA stated she was asked to come in on 02/13/15 to receive education in person. She stated she had received training by the Dietary Manager and the Chaplain. The PTA stated the Dietary Manager educated her on the elopement policy and how they must assess why the door was alarming. He stated if they did not find a resident to complete a head count, call a code green and grab the elopement binder to see who was missing. The PTA stated she was educated by the Chaplain in regards to the front door locking after 9:00 PM. Interview with the Supply Clerk, on 02/13/15 at 4:10 PM, revealed she received a phone call about education on both the elopement policy and the front door policy. The Supply Clerk stated she obtained education by the Dietary Manager on 02/13/15. The Supply Clerk stated they went over code green and procedures to ensure resident safety. The Supply Clerk was also educated on how the front doors would lock down after 9:00 PM, the door would alarm if a code was not utilized which would alarm at the nurses station. Interview with the DON, on 02/13/15 at 4:30 PM, revealed there were 183 staff members in total. Five (5) of which would have to have a certified letter sent to them because they were either out of the state or on Family Medical Leave Act (FMLA). Interview with the Administrator, on 02/13/15 at 2:28 PM, revealed she and the Administrative staff had educated staff members via phone on the elopement policy and the front door training. The Administrator stated she was not aware she could not provide education by phone. Those staff members who were educated by phone had "by phone" written next to their name. The Administrator stated she had all of the staff members to come in and receive education, as well as meet with staff at their homes and other places to ensure they were educated in person and would obtain there signature. Record review of the signatures, revealed all but five (5) staff members were not educated and would be upon starting their shift. Review of the POS [REDACTED]. 15. Review of the signatures of nurses who had obtained the training for how to complete an Accutech Tag function and battery check revealed return demonstrations were performed. Interviews with three (3) Registered Nurses and five (5) Licensed Practical Nurses revealed they had to complete a check off for how to utilize the Accutech tag to check for the function of the battery with the Plant Operations Director. Interview with the Plant Operations Director, on 02/13/15 at 1:36 PM, revealed the nurses had to complete demonstrations on the Accutech Tag devices. He made the nursing staff show him how to activate and deactivate the Accutech Tag and to identify if a tag was good or bad and if the tag was identified as low battery to have the staff document bad on the back of the Tag. Interview with the Plant Operations Assistant, on 02/12/15 at 3:05 PM, revealed he was educated by the Plant Operations Director on how to use the Stad-N device with the Accutech Tag with return demonstration. He then educated the nurses on how to utilize the machines as well. 16. Interview with the DON, on 02/12/15 at 4:12 PM, revealed she and the Administrator trained the staff and the staff members were given a post test which had to be passed with 100%, or re-education would be provided. The DON stated she had one (1) staff member who had to take the test again with re-education. The DON stated the post tests were completed by 02/06/15. Interview with the Administrator, on 02/12/15 at 5:01 PM, revealed she and the DON ensured staff receive

Based on interview, record review and policy review, it was determined the facility failed to have an effective system in place to ensure the facility staff provided adequate supervision for one (1) of fourteen (14) sampled residents (Resident #1). The facility assessed Resident #1 to be at risk for elopement and the resident's care plan stated staff would monitor the whereabouts of the resident on an ongoing basis. The facility utilized an alarm (Accutech) system and an Accutech Tag was applied to Resident #1. Interview and record review revealed the facility failed to have a system in place to monitor the battery life of the Accutech Tags to determine when the Tags should be replaced. In addition, the resident unit doors were alarmed with the Accutech system; however, the front corridor and lobby double doors to the building were not alarmed. The facility failed to have a system in place to secure the front corridor and lobby double doors to the building on weekday nights between the hours of 9:00 PM and 8:00 AM, and on the weekends between 7:00 PM and 10:00 AM. (Refer to F282) On 01/21/15 at 11:42 PM, Resident #1 exited his/her unit without an alarm sounding and exited the building through the unlocked doors to the front lobby without staff knowledge. At 12:30 AM, the resident attempted to re-enter the front lobby doors after recognizing it was too cold outside and he/she would need a jacket. However, these doors locked from the outside and re-entrance was prohibited. The resident walked around the building to the Ambulance Entrance near the One South Unit entrance and rang the door bell. The staff answered the door bell to find the resident outside wearing street clothing; shoes, socks, blue jeans and a pull over shirt. Staff noted the resident appeared cold upon entering the building, with recorded weather conditions on 01/21/15 of cloudy skies and forty-two (42) degrees Fahrenheit at midnight with a westerly wind at 8.1 miles per hour. Upon returning Resident #1 to the unit, the resident's alarm did not sound. After the staff checked the alarm it was determined the battery was dead and the alarm was non-functioning. The facility's failure to provide adequate supervision placed residents at risk for elopement in a situation that has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 02/06/15 and was found to exist on 01/21/15. The facility was notified of the Immediate Jeopardy on 02/06/15. The facility provided a credible Allegation of Compliance (AOC) on 02/11/15 alleging removal of Immediate Jeopardy on 02/07/15. However, the State Survey Agency verified Immediate Jeopardy was not removed until 02/13/15 due to re-education of staff. Record review and interview revealed forty-two (42) percent of staff was educated via the telephone prior to 02/07/15. The scope and severity was lowered to a "D" while the facility's Quality Assurance Committee monitors the effectiveness of the implemented action plans to achieve and maintain compliance with the plan of correction. The findings include: Review of the facility's policy regarding Elopement/Wandering Residents, effective December 2010, revealed it was the intent of the facility to determine which residents had significant wandering behavior and enhance staff awareness as well as educate them on how to deal with such residents. An elopement/wandering assessment would be completed upon admission located in the nursing admission information packet and quarterly thereafter. Review of the Stad-N Base Components LC 1200 Manual, (utilized as a guideline for monitoring the Accutech tag alarm system), not dated, revealed the Stad-N was used to check the function of an Accutech Tag (wander-guard). The Accutech Tags are operated by internal battery. Over the course of normal operation the Tags eventually lose battery power and the Tags would need to be replaced. The Tag batteries were not replaceable. The Stad-N was used to determine if a tag had sufficient battery power to respond to an activated signal. When the enter button is pressed on the tag a green LED lights. The wait LED will illuminate red for two (2) seconds. The tags graphic LED on the STAD-N will illuminate a pulsing yellow indicting the tag is active. The Tags had been engineered for greater than twelve (12) months of use. Once an Accutech Tag's battery was drained, the low battery LED will illuminate red and the tag would have to be replaced. Review of the clinical record for Resident #1, revealed Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 07/17/14, the facility assessed the resident as being at high risk for elopement related to the resident being cognitively impaired; however, scored a 15 upon admission using the Brief Interview for Mental Status (BIMS); having the ability to ambulate independently; having poor decision making skills; demonstrating exit-seeking behaviors; and, for having the ability to exit the facility. An Accutech Tag was applied to the resident due to the resident's exit seeking behaviors and poor decision skills. Resident #1 was care planned for elopement risk due to his/her dementia and walking around the unit and the staff would monitor the resident's whereabouts on an ongoing basis. Further review of the clinical record revealed, on 01/09/15, the facility assessed the resident as a 12 on the BIMS. Review of the incident report, dated 01/21/15, revealed it was discovered a resident (Resident #1) had left the building, when the ambulance door bell rang and the resident was found outside at the door. The resident was last seen at the nurses station by a Certified Nursing Assistant (CNA). The resident had a Accutech Tag applied, but the device did not function properly and the resident was able to exit his/her unit without staff knowledge. The resident was able to exit the facility through the lobby door. The resident was brought back in to the facility and taken to their room where they were assessed and fitted for a new Accutech Tag. The resident denied any injury or pain. The resident was cold since he/she had gone out without a coat, but did have street clothes on (slacks and a pullover shirt) and shoes. Interview with Licensed Practical Nurse (LPN) #3, on 02/02/15 at 10:12 PM, revealed around 11:30 PM to 12:00 AM, on 01/21/15, when completing a narcotic count with LPN #5, the Ambulance Entrance doorbell rang (on the side of the building). LPN #3 stated she and LPN #5 were expecting Pharmacy Services to arrive at that hour, but when LPN #3 went to the Ambulance Entrance, she found Resident #1 standing outside of the door. Resident #1 had informed LPN #3 that he/she had left "home" to go to the local jamboree, but realized he/she had left their jacket. Resident #1 stated he/she had seen all of the lights on at the side of the building and rang the doorbell. LPN #3 stated when Resident #1 entered the building no alarms sounded. LPN #3 stated once a resident entered the building from the Ambulance Entrance the Accutech alarm should have alarmed. LPN #3 escorted Resident #1 to the One North Unit, where he/she lived and "delivered" Resident #1 to Registered Nurse (RN) #1. When entering the One North Unit the entrance equipped with the Accutech alarm did not sound when Resident #1 re-entered, but an alarm should have sounded. Interview with RN #1, on 02/02/15 at 9:40 PM and at 10:35 PM, revealed when coming out of a resident's room at approximately 12:30 AM on 01/21/15, she saw LPN #3 coming through the One North door with Resident #1. LPN #3 stated someone had rang the doorbell and she found it was Resident #1. RN #1 stated she did not hear any alarms sound when Resident #1 came through the One North door. Since the resident had an Accutech alarm to the left leg, the alarm system should have sounded and alerted staff. Per interview, she completed an assessment of the resident. Resident #1 was not dirty or wet, but appeared to be cold with no injury noted. RN #1 revealed the resident was very talkative and laughing, wearing street clothing; shoes, socks, blue jeans and a pull over shirt. Resident #1 also had his/her cane which he/she utilized. Interview with Certified Nursing Assistant (CNA) #3, on 02/02/15 at 10:50 PM, revealed she came in for her shift at 10:00 PM on 01/20/15. CNA #3 stated the last time she saw Resident #1 was when she was completing her rounds, between 11:00 PM to 11:30 PM. Resident #1 was sitting at the nurses' station in a chair. CNA #3 stated she did not observe Resident #1 wandering in the hall or any exit seeking behaviors. Interview with CNA #4, on 02/02/15 at 10:55 PM, revealed she came in for her shift at 10:00 PM. CNA #4 stated the last time she saw Resident #1, was at 11:30 PM sitting at the nurses' station. CNA #4 stated Resident #1 was wearing a pink top and cream colored pants with his/her shoes on. Interview on 02/13/15 at 2:26 PM, with the Interim Assistant Director of Nursing (ADON) who supervised the first floor units, revealed on 01/20/15 at 11:42 PM, she observed Resident #1 at her office door on the One (1) North Unit. The Interim ADON stated she asked Resident #1 if he/she was tired and Resident #1 responded "no". The Interim ADON stated she remembered as she was leaving the facility, Resident #1 was walking to a chair which was located at the nurses' station. Interview with Resident #1, on 02/03/15 at 12:20 PM, revealed he/she remembered leaving the building to obtain a coke for another resident. Resident #1 did not remember the time he/she left the building, or the time he/she came back to the building. Resident #1 stated he/she remembered it was cold outside and decided to come back home to get a jacket. Resident #1 stated he/she had never left the building before and would inform the staff if he/she wanted to leave the building. Continued interview with RN #1, on 02/02/15 at 10:35 PM, revealed Resident #1 did not inform her of how he/she had left the building. RN #1 stated she then called the Administrator and notified the other nurses on the unit of the elopement. Interview with the Director of Nursing (DON), on 02/05/15 at 9:40 AM, revealed on 01/21/15 at 1:00 AM, she had received a call from RN #1 informing her that Resident #1 had gotten out of the facility and came back and rang the doorbell through the Ambulance Entrance and she came to the facility immediately. The DON asked RN #1 if she had phoned the Administrator. RN #1 stated she was instructed by the Administrator to check all doors, complete a head count of all residents and assess Resident #1 for injuries. Interview with the Administrator, on 02/05/15 at 10:10 AM, revealed she was called around 1:00 AM by RN #1, who informed her Resident #1 had left the facility and rang the doorbell at the Ambulance Entrance to get back in. The Administrator stated she asked RN #1 if the alarm had sounded when the resident had come on the unit and RN #1 stated "no". The Administrator stated she asked RN #1 if the Accutech Tag was not working and if not to replace the Tag. The Administrator informed RN #1 to ensure all residents were accounted for and to check all Accutech Tags and doors to ensure they were functioning. The Administrator stated she informed RN #1 to ensure 100% of the resident count, tags and doors were completed. Interview, on 02/05/15 at 1:19 PM, with ADON #1 who supervised the second floor units, revealed she was pulled to the One North Unit during second shift on 01/20/15 because of a call-in. ADON #1 stated she remembered assessing Resident #1's Accutech Tag between the hours of 3:00 PM and 4:00 PM on 01/20/15 by checking the Accutech Tag with the Stad-N box (which was used to check the function of the Accutech Tag). ADON #1 stated she turned on the Stad-N device, placed the Stad-N next to the Accutech Tag, and then the Stad-N box flashed a yellow color to show the battery had sufficient power. Upon observation of Resident #1's Accutech Tag, ADON #1 recognized the red light blinking on the Accutech Tag to indicate the tag was on. ADON #1 stated she recognized Resident #1 was answering questions appropriately and did not appear to be wandering on the unit. Further interview with RN #1, on 02/02/15 at 9:40 PM, revealed the Accutech Tag located around Resident #1's ankle was checked every shift; however, it had not been checked at the beginning of her shift, but was on her to-do list when she completed her treatments for the night. RN #1 stated it was normal for Resident #1 to sleep most of the day and meander about at night. However, as a nursing judgement the resident was not monitored due to not displaying exit seeking behavior. Further interview with RN #1, on 02/02/15 at 10:35 PM, revealed a head count of all residents in the building was completed, with no concerns. RN #1 then checked all of the doors to ensure they were working properly. Interview with LPN #3, on 02/02/15 at 10:12 PM, revealed they had identified the Two North door did not close completely and a staff member was placed at the door until someone could fix the door. Continued interview with the Director of Nursing (DON), on 02/05/15 at 9:40 AM, revealed the facility ensured a staff member was sitting at the Two North door because the door was not latching all the way. The other seven (7) doors on the units were monitored as well by the nursing staff every 15 minutes. There was also Accutech Tag checks on all the other residents who were identified as an elopement risk. The DON stated she looked at Resident #1's affected Accutech Tag after it was removed from the resident and it was not blinking to indicate that it was on. The DON stated she was expecting the staff to check the Accutech Tags every shift. She stated the staff was to place the Stad-N device next to the Accutech Tag to ensure the system was functioning properly. This was to be done every shift, by the nurse on duty, and documented on the treatment administration record. The battery of the tag was not dated and did not indicate how long the battery would last. The tag would only be changed when the Stad-N LED was red. However, per the Manual for the Accutech system, the red light would indicate the battery was drained. Continued interview with the DON, on 02/05/15 at 9:40 AM, revealed Resident #1 exited the facility through the front door of the building as this was the only way for the resident to leave undetected. There were locks on the front door that automatically lock from the outside preventing re-entry; however, exiting the building through those doors was still possible after 9:00 PM even though it was locked. These doors were not locked when the receptionist was on duty and were locked at 9:00 PM when she left the facility. The DON stated there was an Accutech system in place to protect residents from going outside without staff knowledge. However, the Accutech system was only on the resident unit doors. Continued interview with the Administrator, on 02/05/15 at 10:10 AM, revealed she called the DON and Maintenance. The Administrator stated she became aware that the back door to Two (2) North was not closing appropriately and made sure there was staff present at that door to ensure resident safety. The Administrator stated she began to interview staff, nurses and CNAs, and Maintenance came in to check all of the doors and made the adjustment to the back door of the 2nd floor. The Administrator stated she had an Accutech system to protect the residents who were not cognitive enough to make a decision if it was safe to leave the building on their own. However, the facility did not have a system in place to monitor the life of the tag. Interview with the Plant Operations Director, on 02/03/15 at 4:31 PM, revealed he checked the function of all seven (7) doors that lead out of the building and the eight (8) doors to all four (4) units, which totaled fifteen (15) doors, daily. The Plant Operations Director stated the door exiting from the One (1) North Unit, where the resident resided, and the other resident units, had a Accutech alarm. Continued interview with the Plant Operations Director revealed the exit doors from the unit into the hallways would release after fifteen (15) seconds if held continuously. The Ambulance Entrance was a fire exit, but did not have a wander-guard system. Further interview with the Plant Operations Director, on 02/03/15 at 4:40 PM, revealed the night of the elopement, it was discovered Resident #1's Accutech Tag was functioning and flashing red, but had a low battery. The Plant Operations Director stated the alarm should have sounded even if it was showing a low battery; however, it did not alarm. Per interview, there was a possibility that if the Accutech Tag had a low battery it could have became low between the hours when the Second shift nurse checked it and when Resident #1 eloped. The Plant Operations Director stated he was notified in the early morning of 01/21/15, but could not remember the time. He stated he made sure there was staff monitoring the doors until they were working properly. Continued interview with the Plant Operations Director, on 02/03/15 at 4:31 PM, revealed he had not identified the front door as a possible way for a resident to elope, after the receptionist left for the evening, because there was a working Accutech alarm system in place on the unit doors. The Plant Operations Director stated if a resident was to get through the unit double doors, the resident could walk through the front lobby corridor which leads to the front lobby doors and exit the building without causing the alarm system to activate. Additional interview with the DON, on 02/06/15 at 2:36 PM, revealed she did not expect the Accutech Tag alarming system to replace supervision by the staff and expected the staff to check on the residents. The DON stated she did not identify the front door to be a risk for residents assessed as a risk for elopement. The DON stated she did identify that Resident #1 went through the front door because his/her battery was low on his/her Accutech Tag. The DON stated she had not identified any hazards or any inadequate supervision from staff related to this incident. Additional interview with the Administrator, on 02/13/15 at 2:28 PM, revealed she had not identified any of the doors in the building to be of a concern and had not had any elopements in the building since she had been the Administrator. The Administrator stated she had not identified the front doors as a risk that would allow for an elopement. The Administrator stated the Receptionist was at the front lobby to greet visitors, to help with resident trust, to answer any questions and to monitor residents to ensure approval was given to exit the building. The Administrator stated there were no supervision concerns identified and she felt the facility was staffed appropriately. The Administrator stated she did not identify the staffing on the unit as a concern, but the concern she did have was the alarm not sounding on the unit when the resident left through the unit door. Review of the acceptable Allegation of Compliance (AOC), dated 02/11/15, revealed the facility took the following immediate actions: 1. Resident #1 was assessed by the Charge Nurse on 01/21/15 at approximately 12:45 AM. The Responsible Party and Physician were notified of the incident by the Charge Nurse on 01/21/15. The care plan was updated by the Director of Nursing on 01/21/15 to reflect the recent incident. 2. Resident #1 was placed on 15 minute checks which were completed by the resident's Charge Nurse upon returning to the facility. The RN removed the Accutech tag, checked it, and determined the battery was low. A new Accutech tag was immediately placed by the RN. 3. A head count of the entire facility was conducted on 01/21/15 by the charge nurses with the Administrator and DON oversight to ensure all residents were accounted for and were safe. 4. On 01/21/15 all exits were checked initially by the charge nurses on duty. The Accutech doors were manned and continuously monitored by facility staff until 01/22/15. The Plant Operations Director was notified and immediately came to check all exit doors. One door on the 2nd floor Two North was adjusted by the Plant Operations Director as there was a slight gap in closing: all other exit doors were found to be functioning properly. 5. On 01/21/15, the Administrator, Director of Nursing and Plant Operations Director confirmed the Accutech tag had a low battery. 6. On 01/21/15 all resident Accutech tags were checked for placement and function by the Charge Nurses on duty and the Plant Operations Director. 7. On 02/04/15, the Plant Operations Director and Regional Plant Operations Director utilized an outside vendor to adjust the front interior lobby doors. A keypad lock was activated and the doors would lock automatically at 9:00 PM daily and would unlock at 8:00 AM daily. The doors were wired so that anyone attempting to exit without the door code during the hours of 9:00 PM and 8:00 AM would set off an alarm which would be audible at the nurses stations. The monitoring panel at each nurses station would also visibly show that the front door was being opened without the door code between the hours of 9:00 PM and 8:00 AM. The Delayed egress system was in place on these doors. A Receptionist would be at the front desk from 8:00 AM to 9:00 PM seven days a week. 8. On 02/03/15, staff were placed at the front receptionist desk for 24/7 monitoring. This monitoring would end on 02/06/15 after all staff education was completed. 9. Beginning 01/21/15 the nursing and Social Services staff would follow up with the resident daily for seventy-two hours to identify and address any psychosocial needs Resident #1 may have. 10. On 01/21/15, all 127 residents were reassessed for risk of elopement by the Assistant Director of Nursing (ADON), Director of Nursing (DON) and Social Services Assistant. 11. Care plans and nursing assistant care records were updated for sixteen (16) residents who were identified as being at risk for elopement on 01/21/15 by the DON, Facility Consultant, and the ADON. 12. On 01/21/15, the five (5) binders which identified eighteen (18) residents who were at risk for elopement were reviewed by the Administrator and DON to ensure they were updated and in place at each nurses station and at the receptionist desk. 13. On 01/21/15 The Administrator and DON were reeducated via phone by the Facility Consultant, Regional Vice President and Chief Nurse Executive on the elopement policy, missing resident policy, including how to respond to door alarms, complete a head count, checking the wander-guard function of the doors, Accutech tags and implementation of care plans related to triggered areas including elopement risk assessments. There were no revisions to the elopement and missing person policy and procedure. This education was completed prior to the education being initiated with staff on 01/21/15. 14. Education regarding the elopement policy, missing resident policy including how to respond to door alarms, completing head counts, checking the wander-guard function of the doors, Accutech tags and implementation of care plans related to triggered areas including elopement risk assessments were provided by the Administrator and the DON on 01/21/15 to all the Administrative staff who were to provide education. Education was completed for nursing, housekeeping, laundry, therapy, dietary and plant operations that included 183 staff. Post tests were completed by 02/02/15. 15. Education and return demonstrations on use of Accutech Transmitter (device to check function) to ensure staff competency of the wander-guard function and battery checks were initiated on 01/21/15 by the Plant Operations Director or Plant Operations Assistant for licensed nurses. A post test was given to staff that received the education in which a passing score of 100 % had to be obtained. If a score of 100 % on the test was not obtained the staff member would be re-educated on the spot and a new post-test would be given. Forty-two (42) licensed nurses were educated. 16. Staff that were not working on 01/21/15, would be educated prior to taking their assignment upon return to work. A post test would be given in which a passing score of 100 % had to be obtained. If 100 % was not obtained the staff member would be re-educated and a post test would be reissued. 17. Staff who were PRN (as needed staff) or Family Leave Medical Act (FMLA) or on leave would be issued a certified letter by the Administrator with a return receipt on 01/26/15 alerting them that they must receive an eduction on the elopement policy, missing resident, care plans and Accutech before being allowed to work. There were 33 PRN and 3 FMLA on 01/21/15. The facility does not utilize Agency Staff. 18. On 02/06/15 the ADON and Minimum Data Set (MDS) Coordinator were re-educated by the Administrator and DON on completion of care plans upon admission, quarterly and with changes of condition, including care plans to reflect the nursing assessment. 19. New procedures were implemented on dating Accutech Tags when received in the facility and placed on residents. The Plant Operations Director was opening and dating new wander-guard tags when they arrived to the facility. Manufacturers recommendations state that the Accutech tag would last at least twelve (12) months or longer. The Accutech tags would be replaced at eleven (11) months. The Plant Operations Director and DON would each keep a roster of dates that the Accutech tags were placed on each resident with the activation date and when they needed to be replaced. The Plant Operations Director and DON would notify nursing staff when to replace the Accutech tag at the eleventh (11) month mark. Anytime an Accutech tag was replaced, the tag would be labeled "BAD" and given to the Plant Operations Staff and logged in their Maintenance log in the Maintenance Binder at each nurses station. 20. On 01/21/15, the Quality Assurance (QA) team met consisting of the Administrator, DON, two (2) Regional Nurse Consultants, and Medical Director in regards to root cause of event, education, interventions and plans to prevent reoccurrence. The elopement policy and procedure was reviewed and no revision were made. 21. On 2/04/15, a QA meeting was held with the Medical Director to review the procedure changes related to the front door monitoring. 22. On 02/06/15, a QA meeting was held with the Medical Director to review the elopement plan. 23. The DON and Regional Nurse Consultant reviewed 113 incident and accident reports for the last three (3) months on 01/21/15 for any other concerns of elopement or wandering. None were identified. 24. Beginning 01/24/15 and going through 01/30/15, daily audits would be completed each shift for Accutech tag function on all identified residents, return demonstration by four (4) licensed staff on wander-guard functioning and twelve (12) staff members each shift would be given the post test for elopement by the Administrative staff. A score of 100 % would be required. 25. Daily for two (2) weeks beginning 01/21/15, the Plant Operations Director and the Plant Operations Assistant would check the exit doors in the facility for correct function and place on their log. 26. Daily for two (2) weeks beginning 01/21/15, the Plant Operations Director or Plant Operations Assistant would check the function of the Accutech tags on all identified residents. 27. Charts for residents with a change of condition, new orders, new admissions, discharges, or transfers to the hospital were reviewed at the daily clinical meeting five (5) days a week by the clinical team. 28. The Regional Care Consultant Staff were providing oversight to the audits four (4) times a week beginning 01/21/15 and continued through 02/13/15. 29. The elopement policy and procedure, missing resident, care plans and Accutech system would be in-serviced in orientation for all new hires beginning 01/23/15 in which a post test would be given and a score of 100 % must be obtained. The Staff Development Coordinator would be responsible for the orientation. The State Survey Agency validated the AOC on 02/13/15 through observation, interview and record review prior to exit as follows: 1. Interview with the Charge Nurse (RN #1), on 02/06/15 at 1:08 PM, revealed she notified the family and physician of Resident #1 the morning of the incident. Record review of the Incident Report dated 01/21/15 at 1:00 AM, revealed the Physician was called at 01/21/15 at 3:00 AM and the Family was called on 01/21/15 at 1:20 AM. 2. Review of the fifteen (15) minutes checks revealed Resident #1 was monitored every fifteen (15) minutes starting at 1:15 AM on 01/21/15 through 01/27/15. Interview with RN #1, on 02/02/15 at 10:35 PM, revealed Resident #1 was monitored every fifteen (15) minutes once the resident was back in the building. 3. Interview with Licensed Practical Nurse (LPN) #5, on 02/02/15 at 10:00 PM, revealed on the night of 01/21/15 she had completed a head count of all residents on her unit. Interview with RN #1, on 02/02/15 at 10:35 PM, revealed a head count of all residents occurred through out the building. Interview with the Director of Nursing (DON), on 02/05/15 at 9:40 AM, revealed she instructed the staff to ensure all residents were accounted for the day of 01/21/15 at about 1:00 AM. Interview with the Administrator, on 02/05/15 at 10:10 AM, revealed she instructed the staff to complete a head count when she received a phone call from RN #1 on 01/21/15. 4. Interview with LPN #3, on 02/02/15 at 10:12 PM, revealed she helped with the check of the doors and found that the Two North needed to be manned by staff and all other doors were monitored every fifteen (15) minutes. Interview with RN #1 on 02/02/15 at 10:35 PM, revealed she helped with checking that all doors were secure. RN #1 stated the doors were checked every fifteen (15) minutes and later on that day someone manned all of the doors. Interview with the Plant Operations Director, on 02/03/15 at 4:40 PM, revealed the morning of the incident he received a call and made sure there were staff monitoring the doors until he was sure that the doors were working appropriately. The door on Two North had to be readjusted. The doors were found to be functioning appropriately. 5. Interview with the Plant Operations Director, on 02/03/15 at 4:40 PM, interview with the DON, on 02/05/15 at 9:40 AM and interview with the Administrator, on 02/05/15 at 10:10 AM, revealed when they had observed Resident #1's Accutech tag it was found to have a low battery. 6. The State Agency validated through interview with RN #1 on 02/06/15 at 1:08 PM and Interview with the Plant Operations Director, on 02/05/15 at 2:22 PM, revealed all resident wander-guards were checked. 7. Review a list of items completed to fix the front door from the Regional Plant Operations Director, on 02/04/15, revealed he came to meet with a technician to have him add an additional alarm at the nurses station that would sound when the front corridor door was opened without a code, it would remain in alarm mode until an employee reset the keypad. The System was installed with a timer to automatically lock the door from 9:00 PM until 8:00 AM and the timer was programmable. Interview with the Plant Operations Director, on 02/06/15 at 2:19 PM, revealed on 02/04/15 the front lobby corridor would be locked down after 9:00 PM and the staff would have to utilize a key pad to get out. The delayed egress system was in place on these doors. A Receptionist would be at the front desk Interview with the Administrator, on 02/04/15 at 3:36 PM, revealed she adjusted the monitoring of the front door to the hours of 8:00 AM to 9:00 PM Monday through Sunday which was seven (7) days a week. Observation on 02/05/15 at 8:30 AM, revealed a key pad outside of the front corridor and a sign which stated if in an emergency situation hit the red button to the right to exit. 8. Interview with the Receptionist, on 02/12/15 at 3:47 PM, revealed she could remember staff having to man the front lobby 24/7 to ensure residents were safe. Receptionist #1 stated she would stay until 10:00 PM and would be relieved by another staff member. She stated now the doors were locked automatically after a certain time. Interview with the Administrator, on 02/1