Every finding on record at The Episcopal Church Home

Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate supervision and effective assistance devices to prevent accidents for one (Resident (R) 19) of three sampled residents reviewed for elopement risk. R19, who had severe cognitive impairment, eloped from the facility on 07/30/2025. The facility's equipment (alarm system) used for supervision of location failed to sound in a manner to immediately alert staff when the resident left the facility without staff knowledge/supervision. The failure to prevent R19's elopement, at a time when the outdoor heat index was 107 degrees, created an Immediate Jeopardy situation with the likelihood for serious harm or death.Immediate Jeopardy was identified on 08/15/2025 and was determined to exist as of 07/30/2025 (the day of the elopement), in the area of 42 CFR 483.25, Quality of Care. This deficiency also constituted Substandard Quality of Care (SQC). The Administrator and the [NAME] President of Residential Health Care were notified of the Immediate Jeopardy on 08/15/2025 at 10:12 AM. On 08/15/2025 at 10:12 AM, the Administrator and the [NAME] President of Residential Health Care were provided a copy of the CMS IJ Template and were notified that R19's elopement from the facility on 07/30/2025 constituted an Immediate Jeopardy.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 08/15/2025 at 2:00 PM.The survey team validated the Immediate Jeopardy was removed on 08/06/2025 at 2:00 PM following the facility's implementation of the plan of removal of the Immediate Jeopardy and the deficient practice was determined to be past non-complianceThe findings include:Review of the facility's policy, Elopement/Missing Resident Policy ('Code Yellow'), dated 02/06/2024 and in effect at the time of R19's elopement, revealed the facility defined elopement as, When a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired; wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. Review of the policy revealed that although it addressed the steps to take after a resident eloped, it did not describe steps to prevent elopements from occurring. Review of R19's Resident Face Sheet revealed R19 was admitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder, and insomnia due to mental disorder.Review of R19's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/05/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5/15, indicating severe cognitive impairment. Per this MDS, R19 displayed wandering behaviors 1-3 days during the assessment period, and these behaviors placed the resident at a significant risk of getting to a potentially dangerous place, such as outside the facility. The MDS documented the resident was independent with indoor mobility (ambulation) and used a walker. Review of R19's baseline care plan, initiated on 01/15/2025 and comprehensive care plan, initiated 02/11/2025, revealed the resident was at risk for elopement. The care plans included multiple interventions, including placement on a unit for residents with advanced dementia (secured unit), and the use of a Code Alert bracelet (device which sounds an alarm if the resident comes near a door), with its placement and functionality checked every shift. Additional interventions included elopement assessments, redirection of the resident by talking about her past work as a Missionary, and allowing R19 to speak to her family, which calms her.Review of the Observations, tab in the Electronic Medical Record (EMR) revealed that, per the care plan, the facility assessed R19 as being at risk for elopement on the following dates: 01/14/2025, 01/29/2025, 04/18/2025, and 07/13/2025. Review of the 07/13/2025 ECH Elopement Risk Assessment form (most recent prior to R19 eloping on 07/30/2025) revealed that R19's risk factors included a diagnosis of dementia, attempts to leave the facility, independence with mobility in the presence of dementia, a change in medications, verbalizations of intent to leave, wandering to find family, wandering aimlessly, and actively having exit-seeking behaviors.Review of R19's EMR, under Progress Notes, revealed she attempted to exit the facility on each of the following dates: 05/04/2025, 05/07/2025, twice on 06/30/2025, 07/06/2025, and 07/11/2025. Each of these times, R19 was re-directed by staff once the door alarm was engaged.Review of the facility's Initial Report, dated 07/30/2025 and signed by the Administrator, revealed R19 exited the facility without staff's knowledge or supervision on 07/30/2025. At 1:08 PM, the Director of Life Enrichment (DLE), who was driving through the property, found R19 walking on a sidewalk. At that time, the DLE stopped, got R19 into her car, and returned R19 to the facility. Per the report, R19 was immediately assessed and found to be free of injury, and she displayed no signs or symptoms of heat-related concerns. The document estimated R19 was outside the facility no longer than five minutes, and all necessary parties were informed of the elopement at the appropriate times.Further review of the facility's Initial Report, revealed all the exterior doors and alarms in the facility were inspected, with no concerns identified, and were found to be in proper working order. The document stated education was provided to all staff regarding response to alarms, and the elopement and abuse policies. The incident report stated R19 provided no verbalizations or behaviors to indicate she had suffered any physical or psychosocial harm.Review of the form, Kentucky Cabinet for Health and Family Services, Office of Inspector General - Division of Health Care, Long-term Care Facility - Self-Reported Incident Form, Final Reports/5 Day Follow-Up, (5-Day FU report), dated 08/05/2025 and signed by the Administrator, revealed that all staff members working on R19's secure unit were interviewed following the incident. The form indicated no one saw R19 exit the building. Further review of the 5-Day FU Report revealed the door alarm sounded when R19 pushed the door bar. However, the two Versatile Workers ((VWs), 1 and VW4) on the unit were providing care in another resident's room with the door closed, and did not hear the alarm. During the time that staff could not hear the alarm, R19 had an opportunity to wait for the 15-second egress to engage and then walked out the door undetected and unsupervised.Further review of this report revealed that VW3 had escorted R19 to her neighborhood (secure unit) prior to the elopement, and stated R19 made the comment that she needed to go home. VW3 said she explained to R19 that her daughter knew where R19 was and would come to visit her soon. Per the report, R19 admitted she opened the door, then stated that she, .wasn't looking for anything, but I know I shouldn't have done that. I don't think I have meandered like that before, I won't do that again. Further review of the 5-Day FU Report, revealed the DLE stated R19 was talkative and smiling when she put R19 into her car, and the DLE stated R19 was not sweating and did not feel hot to the touch. The document indicated the DLE brought R19 back into the facility through the front doors at 1:12 PM.Review of facility video records revealed there was no video footage to verify when the resident left the facility. Video footage of the facility's front door verified R19 and the DLE walked back into the facility on [DATE] at 1:11:46 PM.Review of R19's Progress Notes, dated 07/30/2025 at 2:02 PM, entered by Registered Nurse (RN) 1, revealed R19 was assessed immediately after her return to the unit. R19 was alert to self, was in no pain, and denied feeling hot. Further review of RN1's entry in R19's Progress Notes, revealed R19 was tearful and apologized and hoped she had not gotten any staff in trouble. Review of Weather Channel website revealed the temperature on 07/30/2025 (the day of R19's elopement) was 93 degrees, with a heat index of 107 degrees. Observation of R19 on 08/08/2025 at 4:22 PM, revealed the resident was wearing a Code Alert bracelet on her left wrist. The resident was sitting on a couch, watching TV in a common area on the secured unit. The resident was noninterviewable, based on cognitive status. Further observation at this time, revealed that the door through which R19 eloped, on 07/30/2025, was down the hall, approximately 20-25 feet from the kitchenette on the secure unit, where R19 resided. The door was observed to be alarmed, with a sign on the door noting that if you hold the (panic) bar for 15 seconds, it would unlock. Further observation of the door revealed that to open it, a person had to turn the lock above the handle, as well as hold the bar in for 15 seconds, for the door to unlock and be opened. The exit door opened into a sidewalk which led to the parking lot and onto a busy road. In an interview with VW1 on 08/08/2025 at 11:35 AM, she stated she was working on 07/30/2025 when R19 eloped. VW1 stated she and VW 4 were in another resident's room, providing care with the door closed for privacy. VW1 related that all staff were to respond when a door alarm was sounding. However, because they were in the room with the door closed, they did not hear the door alarm going off. VW1 stated they were not aware the alarm went off until they came out of the resident's room, and it was still sounding. She stated she and VW4 opened the door where the alarm was sounding, and when they did not see anyone, they did not go outside to look and see if a resident had gone out the door. VW1 stated she was not aware R19 exited the building until after the resident was found. VW1 stated there were three aides working the floor on 07/30/2025 - herself, VW4 who was her orientee, and VW3, who was R19's aide. VW1 was not aware that VW3 was on a break at the time of the elopement. VW1 stated she did not believe staffing was an issue in contributing to the elopement, adding, The problem is when everyone is busy. VW1 was aware R19 was at risk for elopement and wore a Code Alert bracelet. She stated the last place she saw R19, before the elopement, was in the dining room, and she did not see R19 display exit-seeking behaviors on 07/30/2025, prior to the elopement. VW1 stated, The door she [R19] went out, it should have locked when she [R19] was close to it because she [R19] had a Code Alert bracelet on. In an interview with VW4 on 08/08/2025 at 3:00 PM, she stated VW1 was orienting her on 07/30/2025, as she had only been working in the facility for two weeks. VW4 stated she and VW1 were in a resident's room, cleaning the resident up and putting them back in bed when the incident occurred. She stated the alarm was sounding; however, neither she nor VW1 heard it until they came out of the room. She stated she and VW1 checked the door, but did not see anyone. VW4 stated VW1 thought a staff member had just taken out the trash, causing the alarm to sound. VW4 stated she learned of the elopement shortly after, when other staff members informed her. VW4 was aware R19 was at risk for elopement, stating that was why the resident wore a Code Alert bracelet. VW4 denied observing R19 with any exit-seeking behaviors earlier in the day. VW4 also stated she was not aware of VW3 being on break at the time of the elopement.In an interview with VW3 on 08/08/2025 at 2:32 PM, she stated R19 was sitting in the common area of the secured unit, watching television when she (VW3) left the unit to go to the bathroom. She confirmed that she was not on the secure unit at the time of the elopement, as she left the unit to use the restroom. She then went to the break room for her 15-minute break. VW3 stated that she did not inform VW1 or VW4, who were the other staff on the unit, that she was leaving the unit at that time and would not be available for supervision of other residents while they were providing care in individual resident rooms. She stated she did not hear the door alarm when R19 exited the facility, and did not know that R19 eloped from the facility until she heard other staff members talking about it in the breakroom. VW3 was aware of R19 being at risk for elopement and knew she had a Code Alert bracelet in place. VW3 stated all staff were to respond to a door alarm. VW3 stated R19 did have behaviors related to exit-seeking on 07/30/2025 when R19 stated, I'm going to look for my daughter. VW3 told R19 her daughter knew where she (R19) was, and the daughter was coming to visit later in the day. VW3 stated the day prior to the elopement, R19 woke up and stated, I've got to go, and VW3 reassured R19 her daughters were coming to visit later. An interview with Registered Nurse (RN) 1, on 08/08/2025 at 12:05 PM, revealed she was R19's nurse on 07/30/2025. She stated she last observed R19 walking back to the secure unit after eating lunch in the main dining room. RN1 stated she was on the other side of the unit at the time R19 eloped. RN1 stated her assumption was there were three aides on the unit with R19. She was unaware one of the three was not on the unit, and the other two were in a closed room, providing care, at the time of the elopement. RN1 stated she did not hear the door alarm and did not know about the elopement until another staff told her. RN1 was aware R19 was at risk for elopement and had a Code Alert bracelet on. RN1 stated some of the doors inside the facility locked when a resident with a Code Alert bracelet got near the door. However, she continued, the Code Alert device for the door, through which the resident exited, does not lock due to a Fire Safety Code requirement. RN1 stated she assessed R19 after she was brought back to the secure unit, inside the facility and R19 had no skin issues or injuries.In an interview with the Director of Life Enrichment (DLE) on 08/08/2025 at 2:08 PM, she stated that on 07/30/2025 at approximately 1:07 PM, she was driving around the campus to get to a meeting she was running late for, as the meeting was supposed to start at 1:00 PM. The DLE stated once she drove past the dumpsters, on the left side of the building, she saw a resident walking with her walker, alone, which raised some concern. The DLE stated she put her car into reverse, confirmed the resident was alone, then asked if the resident needed any help. The DLE stated R19 told her while she smiled, I just need to get home. The DLE stated the temperature was in the 90s on this day and she helped R19 get into her car. She noted R19 was not sweating, her skin was cool to the touch, she did not have any shortness of breath and was in no distress. The DLE proceeded to drive R19 back around to the front of the building, where she escorted R19 back into the facility, safely, at 1:12 PM. The DLE recalled the alarm sounding as they walked into the building because of R19's Code Alert bracelet. The DLE stated another VW was in the front lobby and offered to escort R19 back to her secured unit at that time, and the DLE stated she went to inform the Administrator of the elopement at that time. The DLE stated she felt blessed to have found R19 when she did.In an interview with the Director of Nursing (DON), on 08/08/2025 at 3:49 PM, she stated, It's everyone's responsibility to answer the door alarms. Per the DON, the elopement on 07/30/2025 occurred when staff could not hear the alarm, since they were working in a resident's room with the door closed. The DON added that, due to this, the facility had since replaced the alarms with ones that were louder. Further interview with the DON revealed that when a door alarm was sounding, staff should not only look outside the door, but they must also go outside to look around and possibly identify a resident who had eloped. The DON stated R19 did not have exit seeking behaviors or any behaviors out of the ordinary on the day of the elopement and was unaware that VW3 had observed behaviors related to exit seeking prior to the elopement. The DON stated R19 was assessed as being at risk for elopement. She stated once it was known the resident had exited the facility, all units or neighborhoods in the facility must conduct a head count to ensure all residents were accounted for. The DON stated there must be a search of the neighborhood completed by staff, the nurse should call the receptionist desk and notify of the missing resident, notify the DON and the Administrator, begin to search for the resident and expand the search if needed, and lastly the police would be called if the resident was still missing. After the elopement, the DON stated all the staff were interviewed and new elopement assessments were completed on each resident. In an interview with the Administrator, on 08/08/2025 at 4:27 PM, she stated the DLE notified her of R19's elopement on 07/30/2025. She stated immediately after being notified, she initiated a head count on all units of all the residents, then she had maintenance check the door alarms and locks to ensure they were all functioning, which they were. She stated RN1 assessed R19 once she was returned to the unit. The Administrator stated, I decided, ultimately, this was just a perfect storm. She stated that all staff on R19's unit were responsible for R19, but VW4 and VW1 were the only staff on the unit when R19 eloped. She continued that they were in another resident's room, providing care, with the door closed for privacy, and were unable to hear the door alarm. The Administrator stated she went into a resident's room and had another staff person engage the alarms, and she verified the alarm was not able to be heard. To address this, the Administrator stated they purchased new screamer alarms that were much louder.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 08/15/2025 at 2:00 PM.The survey team validated the Immediate Jeopardy was removed on 08/06/2025 at 2:00 PM following the facility's implementation of the plan of removal of the Immediate Jeopardy and the deficient practice was determined to be past non-complianceThe Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:1. R19 was evaluated/assessed immediately for signs and symptoms of any heat-related issues, none were noted. A head-to-toe assessment was completed by a nurse for R19 upon arrival back to the secure unit. R19 was placed on enhanced supervision/observation upon her return to the secure unit, and every 15-minute checks were performed for the 24 hours following the elopement. Notification of the elopement was made to R19's physician and her Power of Attorney (POA). R19 was interviewed for her thoughts/feelings of the elopement. R19's medication regime reviewed for any changes that could have contributed to the elopement, and none were identified. R19's orders and progress notes were reviewed to identify increasing behaviors leading up to the elopement, and none were identified. A new elopement risk assessment was completed for R19. R19's POA was contacted for more detailed information of R19's past, and memorabilia was requested, to develop an individualized activity box. The Comprehensive care plan was updated to reflect the elopement, and more elopement interventions were added.2. A head count of all residents in the facility was done, all residents were accounted for. A facility-wide audit of residents for elopement risk was completed within 24 hours. All residents' care plans were reviewed for elopement risks and any revisions needed were made. Activity programming for all residents was reviewed to validate the appropriateness for the population of residents.3. Statements were obtained from all staff working on 07/30/2025, the date of the elopement, on R19's secure unit. Inspection of all exterior doors for proper functioning and alarms completed, no issues identified, all doors and alarms functioned properly. A Root, Cause, and Analysis of the elopement event completed. In response, new, louder alarms were purchased and installed on all doors that lead outside of the facility. The door alarms were inspected by a technician, the volume was increased to the maximum level, and alarms are functioning properly.In addition, Elopement books on each unit were audited to ensure they were accurate, with updated pictures of the residents who are at risk for elopement. Treatment Administration Record (TARs) audited for proper placement and function of Code Alert device. The procedure for escorting residents back and forth to and from the primary dining room and the secure unit was revised. There will now be an extra staff member available to remain in the dining room to either escort resident(s) or coordinate a staff member to remain in the dining room and/or assist the resident(s) back to their unit.New process implemented for the Versatile Workers, they now must sign in and out for lunch and breaks, to ensure all staff are aware of who is actually available on the units.Staff were educated on elopement risk, door alarm response, supervision requirements, and new escorting residents to and from the primary dining room procedure implemented. All new education was also added to the newly hired staff education and checklists.4. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss elopement policies and procedures. An audit of the door alarms to validate staff's response began 07/31/2025, daily for two weeks, then three days a week for two weeks, then once a week for a total of four weeks.

Based on observation, interview, record review, and facility policy review, the facility failed to provide adequate supervision and effective assistance devices to prevent accidents for one (Resident (R) 19) of three sampled residents reviewed for elopement risk. R19, who had severe cognitive impairment, eloped from the facility on 07/30/2025. The facility's equipment (alarm system) used for supervision of location failed to sound in a manner to immediately alert staff when the resident left the facility without staff knowledge/supervision. The failure to prevent R19's elopement, at a time when the outdoor heat index was 107 degrees, created an Immediate Jeopardy situation with the likelihood for serious harm or death.Immediate Jeopardy was identified on 08/15/2025 and was determined to exist as of 07/30/2025 (the day of the elopement), in the area of 42 CFR 483.25, Quality of Care. This deficiency also constituted Substandard Quality of Care (SQC). The Administrator and the [NAME] President of Residential Health Care were notified of the Immediate Jeopardy on 08/15/2025 at 10:12 AM. On 08/15/2025 at 10:12 AM, the Administrator and the [NAME] President of Residential Health Care were provided a copy of the CMS IJ Template and were notified that R19's elopement from the facility on 07/30/2025 constituted an Immediate Jeopardy.The facility provided an acceptable plan for removal of the Immediate Jeopardy on 08/15/2025 at 2:00 PM.The survey team validated the Immediate Jeopardy was removed on 08/06/2025 at 2:00 PM following the facility's implementation of the plan of removal of the Immediate Jeopardy and the deficient practice was determined to be past non-complianceThe findings include:Review of the facility's policy, Elopement/Missing Resident Policy (‘Code Yellow'), dated 02/06/2024 and in effect at the time of R19's elopement, revealed the facility defined elopement as, When a patient or resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired; wanders away, walks away, runs away, escapes, or otherwise leaves a caregiving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge. Review of the policy revealed that although it addressed the steps to take after a resident eloped, it did not describe steps to prevent elopements from occurring. Review of R19's Resident Face Sheet revealed R19 was admitted on [DATE] with diagnoses including unspecified dementia, anxiety disorder, and insomnia due to mental disorder. Review of R19's admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/05/2025 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5/15, indicating severe cognitive impairment. Per this MDS, R19 displayed wandering behaviors 1-3 days during the assessment period, and these behaviors placed the resident at a significant risk of getting to a potentially dangerous place, such as outside the facility. The MDS documented the resident was independent with indoor mobility (ambulation) and used a walker. Review of R19's baseline care plan, initiated on 01/15/2025 and comprehensive care plan, initiated 02/11/2025, revealed the resident was at risk for elopement. The care plans included multiple interventions, including placement on a unit for residents with advanced dementia (secured unit), and the use of a Code Alert bracelet (device which sounds an alarm if the resident comes near a door), with its placement and functionality checked every shift. Additional interventions included elopement assessments, redirection of the resident by talking about her past work as a Missionary, and allowing R19 to speak to her family, which calms her.Review of the Observations, tab in the Electronic Medical Record (EMR) revealed that, per the care plan, the facility assessed R19 as being at risk for elopement on the following dates: 01/14/2025, 01/29/2025, 04/18/2025, and 07/13/2025. Review of the 07/13/2025 ECH Elopement Risk Assessment form (most recent prior to R19 eloping on 07/30/2025) revealed that R19's risk factors included a diagnosis of dementia, attempts to leave the facility, independence with mobility in the presence of dementia, a change in medications, verbalizations of intent to leave, wandering to find family, wandering aimlessly, and actively having exit-seeking behaviors. Review of R19's EMR, under Progress Notes, revealed she attempted to exit the facility on each of the following dates: 05/04/2025, 05/07/2025, twice on 06/30/2025, 07/06/2025, and 07/11/2025. Each of these times, R19 was re-directed by staff once the door alarm was engaged. Review of the facility's Initial Report, dated 07/30/2025 and signed by the Administrator, revealed R19 exited the facility without staff's knowledge or supervision on 07/30/2025. At 1:08 PM, the Director of Life Enrichment (DLE), who was driving through the property, found R19 walking on a sidewalk. At that time, the DLE stopped, got R19 into her car, and returned R19 to the facility. Per the report, R19 was immediately assessed and found to be free of injury, and she displayed no signs or symptoms of heat-related concerns. The document estimated R19 was outside the facility no longer than five minutes, and all necessary parties were informed of the elopement at the appropriate times.Further review of the facility's Initial Report, revealed all the exterior doors and alarms in the facility were inspected, with no concerns identified, and were found to be in proper working order. The document stated education was provided to all staff regarding response to alarms, and the elopement and abuse policies. The incident report stated R19 provided no verbalizations or behaviors to indicate she had suffered any physical or psychosocial harm.Review of the form, Kentucky Cabinet for Health and Family Services, Office of Inspector General - Division of Health Care, Long-term Care Facility - Self-Reported Incident Form, Final Reports/5 Day Follow-Up, (5-Day FU report), dated 08/05/2025 and signed by the Administrator, revealed that all staff members working on R19's secure unit were interviewed following the incident. The form indicated no one saw R19 exit the building. Further review of the 5-Day FU Report revealed the door alarm sounded when R19 pushed the door bar. However, the two Versatile Workers ((VWs), 1 and VW4) on the unit were providing care in another resident's room with the door closed, and did not hear the alarm. During the time that staff could not hear the alarm, R19 had an opportunity to wait for the 15-second egress to engage and then walked out the door undetected and unsupervised.Further review of this report revealed that VW3 had escorted R19 to her neighborhood (secure unit) prior to the elopement, and stated R19 made the comment that she needed to go home. VW3 said she explained to R19 that her daughter knew where R19 was and would come to visit her soon. Per the report, R19 admitted she opened the door, then stated that she, .wasn't looking for anything, but I know I shouldn't have done that. I don't think I have meandered like that before, I won't do that again. Further review of the 5-Day FU Report, revealed the DLE stated R19 was talkative and smiling when she put R19 into her car, and the DLE stated R19 was not sweating and did not feel hot to the touch. The document indicated the DLE brought R19 back into the facility through the front doors at 1:12 PM. Review of facility video records revealed there was no video footage to verify when the resident left the facility. Video footage of the facility's front door verified R19 and the DLE walked back into the facility on [DATE] at 1:11:46 PM. Review of R19's Progress Notes, dated 07/30/2025 at 2:02 PM, entered by Registered Nurse (RN) 1, revealed R19 was assessed immediately after her return to the unit. R19 was alert to self, was in no pain, and denied feeling hot. Further review of RN1's entry in R19's Progress Notes, revealed R19 was tearful and apologized and hoped she had not gotten any staff in trouble. Review of Weather Channel website revealed the temperature on 07/30/2025 (the day of R19's elopement) was 93 degrees, with a heat index of 107 degrees. Observation of R19 on 08/08/2025 at 4:22 PM, revealed the resident was wearing a Code Alert bracelet on her left wrist. The resident was sitting on a couch, watching TV in a common area on the secured unit. The resident was noninterviewable, based on cognitive status. Further observation at this time, revealed that the door through which R19 eloped, on 07/30/2025, was down the hall, approximately 20-25 feet from the kitchenette on the secure unit, where R19 resided. The door was observed to be alarmed, with a sign on the door noting that if you hold the (panic) bar for 15 seconds, it would unlock. Further observation of the door revealed that to open it, a person had to turn the lock above the handle, as well as hold the bar in for 15 seconds, for the door to unlock and be opened. The exit door opened into a sidewalk which led to the parking lot and onto a busy road. In an interview with VW1 on 08/08/2025 at 11:35 AM, she stated she was working on 07/30/2025 when R19 eloped. VW1 stated she and VW 4 were in another resident's room, providing care with the door closed for privacy. VW1 related that all staff were to respond when a door alarm was sounding. However, because they were in the room with the door closed, they did not hear the door alarm going off. VW1 stated they were not aware the alarm went off until they came out of the resident's room, and it was still sounding. She stated she and VW4 opened the door where the alarm was sounding, and when they did not see anyone, they did not go outside to look and see if a resident had gone out the door. VW1 stated she was not aware R19 exited the building until after the resident was found. VW1 stated there were three aides working the floor on 07/30/2025 - herself, VW4 who was her orientee, and VW3, who was R19's aide. VW1 was not aware that VW3 was on a break at the time of the elopement. VW1 stated she did not believe staffing was an issue in contributing to the elopement, adding, The problem is when everyone is busy. VW1 was aware R19 was at risk for elopement and wore a Code Alert bracelet. She stated the last place she saw R19, before the elopement, was in the dining room, and she did not see R19 display exit-seeking behaviors on 07/30/2025, prior to the elopement. VW1 stated, The door she [R19] went out, it should have locked when she [R19] was close to it because she [R19] had a Code Alert bracelet on. In an interview with VW4 on 08/08/2025 at 3:00 PM, she stated VW1 was orienting her on 07/30/2025, as she had only been working in the facility for two weeks. VW4 stated she and VW1 were in a resident's room, cleaning the resident up and putting them back in bed when the incident occurred. She stated the alarm was sounding; however, neither she nor VW1 heard it until they came out of the room. She stated she and VW1 checked the door, but did not see anyone. VW4 stated VW1 thought a staff member had just taken out the trash, causing the alarm to sound. VW4 stated she learned of the elopement shortly after, when other staff members informed her. VW4 was aware R19 was at risk for elopement, stating that was why the resident wore a Code Alert bracelet. VW4 denied observing R19 with any exit-seeking behaviors earlier in the day. VW4 also stated she was not aware of VW3 being on break at the time of the elopement. In an interview with VW3 on 08/08/2025 at 2:32 PM, she stated R19 was sitting in the common area of the secured unit, watching television when she (VW3) left the unit to go to the bathroom. She confirmed that she was not on the secure unit at the time of the elopement, as she left the unit to use the restroom. She then went to the break room for her 15-minute break. VW3 stated that she did not inform VW1 or VW4, who were the other staff on the unit, that she was leaving the unit at that time and would not be available for supervision of other residents while they were providing care in individual resident rooms. She stated she did not hear the door alarm when R19 exited the facility, and did not know that R19 eloped from the facility until she heard other staff members talking about it in the breakroom. VW3 was aware of R19 being at risk for elopement and knew she had a Code Alert bracelet in place. VW3 stated all staff were to respond to a door alarm. VW3 stated R19 did have behaviors related to exit-seeking on 07/30/2025 when R19 stated, I'm going to look for my daughter. VW3 told R19 her daughter knew where she (R19) was, and the daughter was coming to visit later in the day. VW3 stated the day prior to the elopement, R19 woke up and stated, I've got to go, and VW3 reassured R19 her daughters were coming to visit later. An interview with Registered Nurse (RN) 1, on 08/08/2025 at 12:05 PM, revealed she was R19's nurse on 07/30/2025. She stated she last observed R19 walking back to the secure unit after eating lunch in the main dining room. RN1 stated she was on the other side of the unit at the time R19 eloped. RN1 stated her assumption was there were three aides on the unit with R19. She was unaware one of the three was not on the unit, and the other two were in a closed room, providing care, at the time of the elopement. RN1 stated she did not hear the door alarm and did not know about the elopement until another staff told her. RN1 was aware R19 was at risk for elopement and had a Code Alert bracelet on. RN1 stated some of the doors inside the facility locked when a resident with a Code Alert bracelet got near the door. However, she continued, the Code Alert device for the door, through which the resident exited, does not lock due to a Fire Safety Code requirement. RN1 stated she assessed R19 after she was brought back to the secure unit, inside the facility and R19 had no skin issues or injuries.In an interview with the Director of Life Enrichment (DLE) on 08/08/2025 at 2:08 PM, she stated that on 07/30/2025 at approximately 1:07 PM, she was driving around the campus to get to a meeting she was running late for, as the meeting was supposed to start at 1:00 PM. The DLE stated once she drove past the dumpsters, on the left side of the building, she saw a resident walking with her walker, alone, which raised some concern. The DLE stated she put her car into reverse, confirmed the resident was alone, then asked if the resident needed any help. The DLE stated R19 told her while she smiled, I just need to get home. The DLE stated the temperature was in the 90s on this day and she helped R19 get into her car. She noted R19 was not sweating, her skin was cool to the touch, she did not have any shortness of breath and was in no distress. The DLE proceeded to drive R19 back around to the front of the building, where she escorted R19 back into the facility, safely, at 1:12 PM. The DLE recalled the alarm sounding as they walked into the building because of R19's Code Alert bracelet. The DLE stated another VW was in the front lobby and offered to escort R19 back to her secured unit at that time, and the DLE stated she went to inform the Administrator of the elopement at that time. The DLE stated she felt blessed to have found R19 when she did.In an interview with the Director of Nursing (DON), on 08/08/2025 at 3:49 PM, she stated, It's everyone's responsibility to answer the door alarms. Per the DON, the elopement on 07/30/2025 occurred when staff could not hear the alarm, since they were working in a resident's room with the door closed. The DON added that, due to this, the facility had since replaced the alarms with ones that were louder. Further interview with the DON revealed that when a door alarm was sounding, staff should not only look outside the door, but they must also go outside to look around and possibly identify a resident who had eloped. The DON stated R19 did not have exit seeking behaviors or any behaviors out of the ordinary on the day of the elopement and was unaware that VW3 had observed behaviors related to exit seeking prior to the elopement. The DON stated R19 was assessed as being at risk for elopement. She stated once it was known the resident had exited the facility, all units or neighborhoods in the facility must conduct a head count to ensure all residents were accounted for. The DON stated there must be a search of the neighborhood completed by staff, the nurse should call the receptionist desk and notify of the missing resident, notify the DON and the Administrator, begin to search for the resident and expand the search if needed, and lastly the police would be called if the resident was still missing. After the elopement, the DON stated all the staff were interviewed and new elopement assessments were completed on each resident. In an interview with the Administrator, on 08/08/2025 at 4:27 PM, she stated the DLE notified her of R19's elopement on 07/30/2025. She stated immediately after being notified, she initiated a head count on all units of all the residents, then she had maintenance check the door alarms and locks to ensure they were all functioning, which they were. She stated RN1 assessed R19 once she was returned to the unit. The Administrator stated, I decided, ultimately, this was just a perfect storm. She stated that all staff on R19's unit were responsible for R19, but VW4 and VW1 were the only staff on the unit when R19 eloped. She continued that they were in another resident's room, providing care, with the door closed for privacy, and were unable to hear the door alarm. The Administrator stated she went into a resident's room and had another staff person engage the alarms, and she verified the alarm was not able to be heard. To address this, the Administrator stated they purchased new screamer alarms that were much louder. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 08/15/2025 at 2:00 PM. The survey team validated the Immediate Jeopardy was removed on 08/06/2025 at 2:00 PM following the facility's implementation of the plan of removal of the Immediate Jeopardy and the deficient practice was determined to be past non-complianceThe Removal of Immediate Jeopardy/Past Non-compliance was validated with implementation of the following measures:1. R19 was evaluated/assessed immediately for signs and symptoms of any heat-related issues, none were noted. A head-to-toe assessment was completed by a nurse for R19 upon arrival back to the secure unit. R19 was placed on enhanced supervision/observation upon her return to the secure unit, and every 15-minute checks were performed for the 24 hours following the elopement. Notification of the elopement was made to R19's physician and her Power of Attorney (POA). R19 was interviewed for her thoughts/feelings of the elopement. R19's medication regime reviewed for any changes that could have contributed to the elopement, and none were identified. R19's orders and progress notes were reviewed to identify increasing behaviors leading up to the elopement, and none were identified. A new elopement risk assessment was completed for R19. R19's POA was contacted for more detailed information of R19's past, and memorabilia was requested, to develop an individualized activity box. The Comprehensive care plan was updated to reflect the elopement, and more elopement interventions were added.2. A head count of all residents in the facility was done, all residents were accounted for. A facility-wide audit of residents for elopement risk was completed within 24 hours. All residents' care plans were reviewed for elopement risks and any revisions needed were made. Activity programming for all residents was reviewed to validate the appropriateness for the population of residents.3. Statements were obtained from all staff working on 07/30/2025, the date of the elopement, on R19's secure unit. Inspection of all exterior doors for proper functioning and alarms completed, no issues identified, all doors and alarms functioned properly. A Root, Cause, and Analysis of the elopement event completed. In response, new, louder alarms were purchased and installed on all doors that lead outside of the facility. The door alarms were inspected by a technician, the volume was increased to the maximum level, and alarms are functioning properly.In addition, Elopement books on each unit were audited to ensure they were accurate, with updated pictures of the residents who are at risk for elopement. Treatment Administration Record (TARs) audited for proper placement and function of Code Alert device. The procedure for escorting residents back and forth to and from the primary dining room and the secure unit was revised. There will now be an extra staff member available to remain in the dining room to either escort resident(s) or coordinate a staff member to remain in the dining room and/or assist the resident(s) back to their unit.New process implemented for the Versatile Workers, they now must sign in and out for lunch and breaks, to ensure all staff are aware of who is actually available on the units.Staff were educated on elopement risk, door alarm response, supervision requirements, and new escorting residents to and from the primary dining room procedure implemented. All new education was also added to the newly hired staff education and checklists.4. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to discuss elopement policies and procedures. An audit of the door alarms to validate staff's response began 07/31/2025, daily for two weeks, then three days a week for two weeks, then once a week for a total of four weeks.

Based on record review, observations, interviews, and facility policy review, the facility failed to ensure a resident's care plan was updated with respiratory care directives for one (Resident #9) of two residents reviewed. Findings included: A review of a facility policy titled Comprehensive Care Planning, with an effective date of 12/03/2019, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy further revealed, The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. A review of Resident #9's Face Sheet revealed the resident had diagnoses which included emphysema, hypoxemia, acute bronchospasm, and COVID-19. A review of Resident #9's significant change in status Minimum Data Set (MDS) assessment, dated 10/07/2022, revealed the resident had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of two. The MDS did not indicate the resident received oxygen therapy. A review of Resident #9's Care Plan revealed it did not address that the resident received oxygen therapy. A review of Resident #9's October 2022 Physician Orders revealed the resident received oxygen therapy since 09/22/2022 and updraft nebulizer treatments four times a day since 10/03/2022. On 10/25/2022 at 10:37 AM and 10/26/2022 at 8:38 AM, Resident #9 was observed in bed with oxygen infusing via nasal canula with an oxygen concentrator set at 3.5 liters per minute. During an interview on 10/26/2022 at 12:40 PM, the Director of Nursing (DON) stated she did not include Resident #9's oxygen therapy on the care plan because she forgot to trigger oxygen use on the resident's MDS. The DON indicated she had been attempting to complete residents' MDS assessments and care plans along with her DON-associated duties. According to the DON, the facility was actively looking for a part time MDS Coordinator to complete residents' MDS assessments and care plans. During an interview with the Administrator on 10/27/2022 at 11:50 AM, she confirmed the DON was having difficulty accurately completing MDS assessments and care plans along with her DON duties. The Administrator indicated the facility was actively seeking to employ a part time staff person to complete MDS assessments and care plans for all residents.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of one (1) of three (3) closed records out of a total sample of thirty-six (36) sampled residents (Resident #87). Review of Resident #87's discharge summary dated 11/07/19, revealed the resident was discharged to his/her home. However, review of the MDS assessment dated [DATE], revealed the MDS was coded as Resident #87 was discharged to the hospital. The findings include: Interview with the Director of Nursing, on 12/12/19 at 2:00 PM, revealed the facility did not have a policy related to accuracy of MDS assessments, but utilized the current Resident Assessment Instrument (RAI) Manual. Review of the RAI 3.0 User's Manual revealed staff should code 01 for question A2100, if a resident was discharged to the community (private home/apartment, board/care, assisted living, or group home). Review of the medical record for Resident #87, revealed the facility admitted the resident on 10/29/19, with [DIAGNOSES REDACTED]. Review of the discharge MDS for Resident #87, completed by the facility, on 11/07/19, revealed staff documented the resident was discharged to the hospital; however, a review of Resident #87's discharge summary dated 11/07/19, revealed the resident was discharged to his/her home on 11/07/19. Interview with the MDS Coordinator, on 12/12/19 at 2:27 PM, revealed she completed the discharge MDS assessment for Resident #87. She stated she made a mistake on the MDS and should have coded the resident as discharged home. Interview conducted with the DON, on 12/12/19 at 2:35 PM, revealed she reviewed MDS assessments in a weekly meeting. The DON stated she had not identified any concerns with the accuracy of MDS assessments.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to insure staff implemented resident comprehensive care plans for one (1) of thirty-six (36) residents, Resident #71. Observations and record review revealed staff failed to document meal intake and honor food preferences for Resident #71. The findings include: Review of the facility policy Comprehensive Care Planning, effective 12/03/19, revealed the facility developed and implemented a comprehensive, person-centered care plan including measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs. Review of the clinical record revealed the facility admitted Resident #71 on 08/01/19 with [DIAGNOSES REDACTED]. Review of the physician order sheet revealed the following orders: diet regular, dated 08/13/19; diet finger foods, dated 08/13/19. Review of the comprehensive care plan for Resident #71 revealed the following problem: at risk for imbalanced nutrition: less than body requirements related to weight loss. Interventions for this problem included nutritional supplements as ordered, monitor relevant labs as ordered, determine dietary preferences, portion size, and timing of meals, and monitor food intake at each meal, document percentage eaten. Continued review of the care plan revealed the problem the resident was at risk for impaired nutrition/hydration related to Dementia, refusal of assistance, anxiety, and pain. Interventions for this problem included to provide diet as ordered and to honor preferences, monitor weight as ordered, and resident often received finger foods as resident refused assistance but ate with hands. Review of the facility form, Finger Food Diet Suggested Menu Ideas, undated, revealed finger foods should be cut into bite-sized pieces, slices, wedges, or made into sandwiches. Sandwiches should be cut into quarters or sticks. Review of the meal ticket for the breakfast meal on 12/11/19 at 8:15 AM revealed the resident disliked eggs. The facility was not able to provide meal intake records for Resident #71. Observation of the Clingman Dining area, on 12/11/19 at 8:15 AM, revealed Resident #71 seated at a table. Staff provided a meal consisting of a whole biscuit, a hard-boiled egg, and a drink. Continued observation revealed the resident consumed a few sips of the drink but consumed no food and staff removed Resident #71 at 8:45 AM. Observation of the Clingman Dining area, on 12/11/19 at 11:45 AM, revealed Resident #71 seated at a table. The meal in front of the resident consisted of a full, uncut hamburger patty on a bun, French fries, a dessert and a drink. Continued observations revealed the resident consumed a few sips of the drink but no food and staff removed the resident at 12:30 PM having not consumed any food. Interview with Certified Nursing Assistant (CNA) #9, on 12/11/19 at 2:00 PM, revealed the food for Resident #71 was to be finger foods and CNA's were to report resident food intake to the nurses but CNA #2 could not verbalize why this had not occurred for Resident #71. Interview with Licensed Practical Nurse (LPN) #4, on 12/11/19 at 3:30 PM, revealed no one notified her of Resident #71's lack of food intake. She stated CNA's documented the percentage of meal intake on a dietary form but could not verbalize why this did not occur. Interview with the Director of Nursing (DON), on 12/13/19 at 9:00 AM, revealed the facility did not have documentation of meals recorded for Resident #71. The DON stated CNA's were required to record meal intake and stated perhaps this responsibility was overlooked as a result of Clingman unit management changes. The DON stated the facility monitored resident weights and acknowledged without meal consumption reported a resident could continue to lose weight.

Based on interview, record review, and facility policy review it was determined the facility failed to revise a resident comprehensive care plan after the resident experienced a fall for one (1) of thirty-six (36) residents, Resident #16. Staff found Resident #16 on the floor but no revisions occurred to the resident's care plan to prevent further falls. The findings include: Review of the facility policy Comprehensive Care Plans, effective 12/03/19 revealed the facility developed and implemented a comprehensive, person-centered care plan including measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Further review revealed the Interdisciplinary Team reviewed and updated the care plan when a significant change in the resident's condition occurred, when the desired outcome was not met, when the facility readmitted the resident from a hospital stay, and at least quarterly in conjunction with the required quarterly Minimum Data Set assessment. Review of the clinical record revealed the facility admitted Resident #16 on 06/12/19 with [DIAGNOSES REDACTED]. Review of the care plan for Resident #16 revealed the problem, dated 09/19/19, at risk for falls related to impaired balance, history of falls, and at increased risk for bleeding if fall occurred, receiving aspirin daily. Interventions for the problem included keep call light within easy reach and instruct resident to use call light and to call out for assistance, assure adequate lighting and maintain clear pathways, keep areas free of obstruction, respond promptly to calls for assistance to the toilet, instruct resident on safety measure to reduce the risk of falls. Other interventions included to make sure resident is positioned correctly in the wheel chair, keep personal items within easy reach, bed in lowest position with wheels locked, physical therapy to evaluate and monitor for ability to walk in corridor and make recommendations, and remind resident to call for assistance before moving from chair to bed and bed to chair. Additional interventions included toileting program, provide reminders to use assist devices, and monitor blood pressure for complaints of dizziness or imbalance. All interventions listed appeared with effective date 09/19/19 to present. Review of facility Occurrence Report, dated 10/16/19, revealed staff found Resident #16 on the floor near the foot of the resident's bed. Interview with the Unit Manager (UM), on 12/12/19 at 4:15 PM, revealed the resident was sent out to the hospital for evaluation after the fall but could not specify why the care plan was not revised upon the resident's return. The UM stated failing to revise the care plan could lead to additional falls. Interview with the Director of Nursing (DON), on 12/12/19 at 4:44 PM, revealed updated interventions did not occur to the care plan for Resident #16. The DON stated as there was no updated information on the care plan, staff did not follow the policy and procedure of the facility. The DON revealed care plans were updated to meet the needs of the resident and prevent falls. Interview with the Executive Director, on 12/13/19 at 10:53 AM, revealed staff updated care plans with any change in a resident's condition but was not able to verbalize why no update occurred in this instance.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to insure residents unable to carry out activities of daily living received the necessary services to maintain nutrition for one (1) of thirty-six (36) sampled residents, Resident #14. Observations revealed Resident #14 seated at a dining table with no assistance offered. The findings include: Review of the facility policy Activities of Daily Living, effective 01/01/18, revealed the facility provided residents with care, treatment and services appropriate to maintain or improve their ability to carry out activities of daily living. Further review revealed care and services provided for residents who were unable to carry out activities of daily living independently included dining (meals and snacks). Review of the clinical record revealed the facility admitted Resident #14 on 02/28/19 with [DIAGNOSES REDACTED]. Review of the comprehensive care plan for Resident #14 revealed the problem resident was at risk for impaired nutrition/hydration related to [DIAGNOSES REDACTED]. Interventions listed included to provide diet as ordered, provide encouragement and assist as needed, as resident tends to fall asleep during meals. Review of the Minimum Data Set ((MDS) dated [DATE] revealed under Section G, Eating, the facility assessed Resident #14 with a one (1) indicating the resident required supervision and for support the facility assessed the resident with a two (2) indicating the resident required one (1) person physical assist. Observation of the Clingman Dining area, on 12/11/19 at 8:15 AM, revealed Resident #14 seated, alone, at a table with eyes closed and a meal on the table in front of the resident. Continued observation until 8:45 AM revealed the resident remained at the table with eyes closed and no intervention or assistance by staff. Interview with Certified Nursing Assistant (CNA) #9, on 12/11/19 at 2:00 PM, revealed any resident present in the Clingman Dining area required assistance with meals. Interview with the Unit Manager (UM), on 12/13/19 at 10:13 AM, revealed nurses supervised the CNA's and should insure residents are assisted with meals. She stated if staff did not assist a resident with meals a resident could suffer weight loss. Interview with the Director of Nursing (DON), on 12/13/19 at 12:30 PM, revealed she had not identified concerns with staff not assisting residents at meals. Interview with the Executive Director (ED), on 12/13/19 at 1:08 PM, revealed the facility had not previously identified issues with ADL care during meal service. The ED stated it was important for residents to received dining assistance in order to receive the nutrition necessary, in addition to socialization.

The facility failed to have an effective system to insure the environment remained free from accident hazards for two (2) of thirty-six (36) residents, Residents #16, and #75. Observations of the room for Resident #75 revealed scissors accessible to residents. The facility failed to determine the root cause of an unwitnessed fall for Resident #16 in an effort to prevent future falls. Additionally, a medication room door was observed unlocked allowing access to unauthorized persons. The findings include: 1. Review of the facility policy Resident Safety and Supervision, effective 01/01/18, revealed the facility intended to make the resident environment as free from accident hazards as possible and resident safety and supervision and assistance to prevent accidents was a facility-wide priority. Observation of the room for Resident #75, on 12/10/19 at 1:00 PM, revealed a pair of scissors on a table in the room, accessible to the resident. Review of the medical record revealed the facility admitted Resident #75 on 08/27/19 with [DIAGNOSES REDACTED]. The facility assessed the resident with a Brief Interview for Mental Status exam with a score of fourteen (14) and determined the resident was interviewable. Interview with Certified Nursing Assistance (CNA) #3, on 12/10/19 at 1:10 PM, revealed she assisted the resident at 10:30 AM but did not notice the scissors, and she was unable to explain how the resident came to have the scissors. CNA #3 stated residents should not have items that could cut or harm themselves or other residents. Interview with Licensed Practical Nurse (LPN) #3, on 12/12/19 at 2:40 PM, revealed staff conducted routine observations of resident rooms but was unable to verbalize how the scissors came to be in the resident's room. LPN #3 stated the room observations were to prevent residents from accessing items that could harm them. Interview with the Director of Nursing (DON), on 12/13/19 at 8:57 AM, revealed she rounded daily and made observations of the resident environment but was not able to verbalize how the scissors came to be in the resident's room. 3 2. Review of the facility policy Resident Safety and Supervision, effective 01/01/18, revealed the facility intended to make the resident environment as free from accident hazards as possible and resident safety and supervision and assistance to prevent accidents was a facility-wide priority. Review of facility policy Falls Prevention, effective 12/03/19, revealed the facility evaluated each resident to determine the risk of falls and identified interventions to minimize or prevent falls. Review of the clinical record revealed the facility admitted Resident #16 on 06/12/19 with [DIAGNOSES REDACTED]. Review of facility Occurrence Report, dated 10/16/19, revealed staff found Resident #16 on the floor near the foot of the resident's bed. Continued review revealed no root cause documented. Interview with the Unit Manager (UM), on 12/12/19 at 4:15 PM, revealed the resident was transferred to a hospital after the incident and the UM did not complete the process including determining the root cause of the resident's fall. The UM stated determining the root cause impacted other steps including potentially increased supervision or other interventions to keep residents safe. Interview with the Director of Nursing (DON), on 12/12/19 at 4:44 PM, revealed she was unaware no the facility had not identified the root cause involving the fall of Resident #16. The DON stated the facility provided for the care and safety of the residents but could not verbalize why no root cause was documented. Interview with the Executive Director (ED), on 12/13/19 at 10:53 AM, revealed the staff identification of a resident fall provided the facility with an opportunity to implement interventions to prevent additional falls. The ED was not able to verbalize why not root cause was identified in the fall involving Resident #16. 3. Review of facility policy Resident Safety and Supervision, effective 01/01/18, revealed the facility made the environment as free from accident hazards as possible and resident safety and supervision as assistance to prevent accidents were facility-wide priorities. Additionally, facility and resident oriented approaches were utilized together to create a systems approach to safety, considering individual risks as well as hazards in the environment. Observation and interview, on 12/11/19 at 12:21 PM, revealed Licensed Practical Nurse (LPN) #6 opened the door to the medication room without a key. LPN #6 stated the door should be locked and could not verbalize why the door was not locked. LPN #6 stated staff kept the door locked to prevent residents from accessing items with which they could harm themselves or others. Interview with the Director of Nursing (DON), on 12/13/19 at 12:51 PM, revealed medication room doors should be secured at all times to prevent unauthorized persons from accessing the rooms. The DON stated the doors were secured as a safety measure.

Based on observation, interview, and facility policy review, it is determined the facility failed to serve food in a sanitary manner. Observation revealed staff failed to wear beard guards and failed to ensure eating utensils were sanitized properly to prevent illness. The findings include: 1. Review of the facility's policy, Uniform Dress Code, dated (MONTH) (YEAR), revealed facial hair must be effectively restrained as per local and state regulations. Review of the facility's Staff Standard, Hair Restraints, not dated, revealed hair must be controlled to prevent it from being both a direct and an indirect vehicle of food contamination. Dislodged hair must be kept from falling into food or onto food contact surfaces. Staff must wear hair restraints, which included beard restraints, effectively to keep hair from contacting exposed food, clean equipment, utensils, linens, and single-service and single-use articles. Observation of the main dining room, on 10/02/18 at 12:05 PM, during lunch, revealed the Dietary Director had facial hair and entered the kitchen through the side door and did not don a beard guard. At 12:20 PM, the Dietary Director reentered kitchen area without donning a beard guard. Observation, on 10/03/18 at 12:25 PM, revealed the Dietary Manager had facial hair and walked around in the kitchen area where food was being prepared without a beard guard. Interview with the Dietary Manager, on 10/03/18 at 12:30 PM, revealed it was his understanding that if staff was preparing food, then staff had to wear a beard guard in the food prep area. Observation, on 10/05/18 at 10:45 AM, revealed the Dietary Manager in the kitchen area without a beard guard in place. Interview with Dietary Worker #8, on 10/04/18 at 10:45 AM, revealed beard guards were to be in place when in the kitchen area to prevent hair from getting into food. The Worker stated if a resident found hair in their food, the resident would feel upset and not want to eat, in addition, hair in food could cause bacteria in the food, causing a resident to become sick with diarrhea or vomiting. Interview with Dietary Worker #1, on 10/05/18 at 10:35 AM, revealed beard guards ensured food safety and prevented food borne illnesses. The Worker also stated a beard guard would prevent hair from getting in food and she would not want hair in her food and neither did the residents. She stated it could cause the residents to lose their appetite and probably not want to eat the food. Observation, on 10/05/18 at 10:45 AM, revealed the Dietary Manager in the kitchen without a beard guard in place. Interview with Dietary Worker #2, on 10/05/18 at 11:15 AM, revealed dietary staff should wear beard guards to prevent hair from falling into food and drinks prepared for the residents. The Worker also stated hair in food was unsanitary and the facility wanted the residents to enjoy their meals. She stated if a resident found hair in their food they would become upset and might refuse to eat and start to lose weight. She stated beard guards needed to be in place whenever staff entered the kitchen and when touching utensils. Interview with the Dietary Director, on 10/03/18 at 1:00 PM, revealed beard guards were used to keep hair from dislodging and getting into residents' food. The Director stated hair in food would be unsightly to a resident and had the potential to cause cross contamination and biologicals contaminating food and drink, which could cause a resident to become ill. Interview with the Executive Director (ED), on 10/05/15 at 6:15 PM, revealed she was aware of some concerns regarding the kitchen and hair in food would be upsetting to residents. The ED stated the facility's number one goal was to ensure residents' health and safety. She stated she understood hair in food could possibly contribute to illnesses for residents. 2. Review of the facility's policy, Dish Machine Temperatures, dated (MONTH) (YEAR), revealed temperatures should be maintained to meet the guidelines established by the Food and Drug Administration. Review of the facility's Dish machine Temperature Log revealed the manager should be notified whenever the final rinse does not reach one hundred and eighty (180) degrees Fahrenheit (F) or greater. Observation of the dishwasher's rinse cycle gauge, on 10/02/18 at 9:00 AM, revealed the gauge did not register the temperature of the water. Interview with the Dishwasher Staff, on 10/02/18 at 9:05 AM, revealed the worker did not understand the surveyor's inquiry. The worker replied by touching the wash and final rinse displays on the dishwasher. Interview with the Dietary Director, on 10/02/18 at 9:07 AM, revealed the final rinse temperature should be no less than 180 degrees F. Observation of the Dishwasher Staff, on 10/02/18 at 9:20 AM, revealed he continued to run dishes through the dishwasher machine. The dishwasher rinse cycle continued not to monitor and display the final rinse temperature. Continued interview with the Dietary Director, on 10/02/18 at 9:21 AM, revealed he instructed the Dishwasher Staff to stop using the dishwasher on 10/02/18 at 9:07 AM, and was unsure why he continued to run the dishwasher. Interview with Dietary Worker #1, on 10/04/18 at 3:15 PM, revealed the dishwasher's rinse cycle had to maintain a temperature of 180 degrees F. He revealed incorrect water temperatures could spread germs and make residents sick. Interview with Dietary Worker #3, on 10/05/18 at 10:20 AM, revealed staff received education to monitor safe dishwasher temperatures and to report issues to the supervisor immediately. He stated staff was expected to know that anytime the temperature gauges were incorrect they should stop the dishwasher and report their findings immediately to a supervisor. He continued to state water temperatures were important to monitor in order to protect residents from illness. Interview with the Dietary Director, on 10/05/18 at 10:35 AM, revealed dietary staff was to monitor the dishwasher for safe temperatures and when issues were identified, staff should stop production and notify a supervisor or the Director. He stated the final rinse cycle gauge should work at all times and the final rinse should be 180 degrees F in order to effectively sanitize the dishes and prevent residents from becoming ill.

Based on observation and interview, it was determined the facility failed to ensure resident care equipment was maintained in safe operating condition on three (3) of three (3) units, Clingman, Marmion, and Morton. Observation of emergency carts revealed expired and unusable supplies. The findings include: The facility did not provide a policy for the Emergency Carts. Observation of the Clingman Unit, on [DATE] at 9:32 AM, revealed Licensed Practical Nurse (LPN) #6 reviewed the supplies in the red emergency cart in the medication room. The blood pressure cuff tubing and bulb were dry rotted and broke apart in the nurse's hand when it was moved out of the storage bag. In addition, the nasal cannula expired ,[DATE], the disinfection wipes expired [DATE], and five (5) 10 cubic centimeters (cc) syringes of normal saline expired ,[DATE]. Interview with LPN #6, on [DATE] at 9:32 AM, revealed the blood pressure cuff was rotten and unusable. She stated the oxygen cannula, disinfection wipes, and saline syringes were expired and should not be on the emergency cart. She stated the wipes were ineffective and the expired saline could cause a resident to get ill because of potential bacteria growth in the solution. She stated the central supply person stocked the cart and staff did not check the cart on a routine basis. She further stated equipment should to be intact for emergency use. Observation of the Marmion Unit, on [DATE] at 2:10 PM, revealed LPN #9 opened the red emergency cart in the medication room and identified the self-inflating air resuscitation bag with a manufactured date of ,[DATE]. The mask was milky and the diaphragm was hard to compress. Interview with LPN #9, on [DATE] at 2:10 PM, revealed central supply filled the emergency cart and the cart was to be monitored weekly for expired supplies. She stated the cart was used for an emergency for residents, staff, and visitors. She stated the resuscitation bag was stiff with compression and the expired supplies could break while attempting to use on a person and could cause physical harm. She stated it was the facility's responsibility to ensure the equipment was in working order and the Unit Manager (UM) checked the cart. Observation of the(NAME)Unit, on [DATE] at 2:26 PM, revealed Registered Nurse (RN) #3 opened the red emergency cart in the medication room, which contained two (2) 22 gauge intravenous catheters, one expired ,[DATE] and one expired ,[DATE]; two (2) 24 gauge intravenous catheters with expiration dates of ,[DATE]; one (1) 23 gauge butterfly catheter with an expiration date of ,[DATE]; and one (1) 24 gauge butterfly catheter with an expiration date of ,[DATE]. The cart also contained a self-inflating air resuscitation bag with a manufactured date of ,[DATE]. The mask was milky and the diaphragm hard to compress. Interview with RN #3, on [DATE] at 2:26 PM, revealed the emergency cart would be utilized for family, staff, and visitors as well as all residents on the floor. She stated the resuscitation mask was made in 2001 per manufacture date, and should not be used because it was seventeen (17) years old and hard to compress and the mask looked milky. She stated staff was not checking the cart and she was not sure if the cart was to be used; however, she stated if it was on the unit it should be ready for use. Interview with the(NAME)Unit Manager, on [DATE] at 3:22 PM, revealed the emergency cart was a work in progress. She stated the facility did not have an emergency cart policy but all units had an emergency cart. She stated expired supplies should not be on the carts and the carts were not checked after the central supply person stocked the carts. Interview with the Staffing Coordinator, on [DATE] at 2:23 PM, revealed the central supply person was not in the facility and was not available for interview. Interview with the Clingman Unit Manager, on [DATE] at 3:22 PM, revealed the emergency carts had been on the unit for about a year and she had not assigned staff to check the cart and she had not checked the cart for expired supplies. She stated the central supply person stocked the cart and she was responsible to ensure all equipment was in working order, which included supplies not being expired. She stated she was aware the blood pressure cuff was unusable. Interview with the Director of Nursing (DON), on [DATE] at 4:15 PM, revealed she instituted the availability of the emergency cart on each unit six (6) months ago for use during an emergency. She stated she expected the Unit Managers to ensure the cart was stocked and the supplies not expired. She stated she had not audited the carts' supplies or ensured the supervisors were monitoring the carts for expired supplies. She stated it was her responsibility to ensure the residents were safe at all times and expired supplies and poor equipment were not safe for the residents. Interview with the Executive Director, on [DATE] at 6:00 PM, revealed the emergency carts were put out for use about six (6) months ago. She stated the nurses were responsible to ensure all equipment available was in working order. She stated she was not aware of issues with expired supplies or poor equipment.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure residents were protected from misappropriation of property for six (6) of six (6) sampled residents, Residents #7, #57, #63, #193, #194, and #195. The facility could not reconcile narcotic medication for these residents. The findings include: Review of the facility's policy, Protecting Residents from Abuse, Neglect, and Exploitation, dated 11/28/16, revealed residents had the right to be free from having belongings stolen or misused. 1. Review of a facility Investigation, dated 08/01/18, revealed on 07/13/18, the Director of Nursing (DON) reviewed the perpetual inventory sheet (number of narcotic cards) and the Medication Administration Records (MAR) on the Marmion Unit. The DON informed the Executive Director (ED) one card (30 tablets) of [MEDICATION NAME]/[MEDICATION NAME] (APAP) (for pain) 5-325 milligrams (mg), along with the controlled drug record, was missing for Resident #57. Licensed Practical Nurse (LPN) #10 and LPN #11 had signed the medication into the facility on [DATE] at 4:00 PM. Review of Resident #57's Physician Orders, dated 12/08/18, revealed [MEDICATION NAME]/APAP 5-325 mg, one (1) tablet in the morning, the afternoon, and upon hour of sleep, and on 12/14/17, the order was changed to [MEDICATION NAME]/APAP 5-325 mg, one (1) tablet as needed for pain. Interview with the DON, on 10/05/18 at 10:00 AM, revealed review of the Perpetual Inventory Sheet, also referred to as the Control Inventory Sheet, for (MONTH) (YEAR) revealed on 07/11/18 at 4:00 PM, the facility received thirty (30) tablets of [MEDICATION NAME]/APAP 5-325 mg for Resident #57 from the pharmacy. Review of the Pharmacy Refill Sheet revealed between (MONTH) (YEAR) and (MONTH) (YEAR), one hundred and forty-three (143) [MEDICATION NAME]/APAP 3-325 mg tablets were not accounted for by the facility for Resident #57. Interview with the DON, on 10/03/18 at 1:23 PM and 10/05/18 at 10:00 AM, revealed the facility's investigation determined Resident #57 had eighty-two (82) [MEDICATION NAME]-APAP 5-325 mg tablets unaccounted for from (MONTH) (YEAR) to (MONTH) (YEAR). She stated she was unable to locate the completed Controlled Drug Record for Resident #57, which was delivered to the facility on [DATE]. 2. Review of Resident #7's Physician Orders, dated 02/27/18, revealed an order for [REDACTED]. Interview with the DON, on 10/05/18 at 10:00 AM, revealed she identified eighty-two (82) [MEDICATION NAME] 5-325 mg tablets the facility could not reconcile. 3. Review of Resident #195's Physician Orders, dated 06/05/18, revealed an order for [REDACTED]. Review of the Pharmacy List revealed the resident had two (2) [MEDICATION NAME]/APAP tablets unaccounted for from (MONTH) (YEAR) to (MONTH) (YEAR). 4. Review of Resident #63's Physician Orders, dated 01/24/18, revealed an order for [REDACTED]. Review of the Pharmacy List revealed the resident had twenty-eight (28) [MEDICATION NAME] tablets unaccounted for by the facility between (MONTH) (YEAR) and (MONTH) (YEAR). 5. Review of Resident #193's Physician Orders, dated 07/27/17, revealed an order for [REDACTED]. Review of the Pharmacy List revealed the resident had fourteen (14) [MEDICATION NAME]/APAP tablets the facility could not reconcile or account for between 09/17/17 and (MONTH) (YEAR). 6. Review of Resident #194's Physician Orders, dated 10/04/18, revealed an order for [REDACTED]. Interview with the DON, on 10/05/18 at 10:00 AM, revealed the resident had twenty (20) [MEDICATION NAME] pills unaccounted for between 03/29/18 and 04/25/18. Interview with Certified Medication Technician (CMT) #3, on 10/04/18 at 11:15 AM, revealed staff used to remove all the completed sheets from the narcotic book and turned the sheets into Medical Records. Interview with LPN #6, on 10/05/18 at 3:10 PM, revealed in the past, nurses were expected to turn in all completed Controlled Drug Records into Medical Records. She stated nurses were not monitored or questioned when they reordered narcotics for residents. Interview with the DON, on 10/03/18 at 1:23 PM, revealed the facility had a triple check process in place to account for narcotics. She stated two (2) nurses ensured all narcotics were signed into the facility with the pharmacy carrier upon delivery. The two (2) nurses signed the pharmacy packing list, and delivered the medications to the proper units where the receiving nurse would sign and witness delivery for them, and place them into a locked narcotic drawer. She stated any wasted narcotics had to be witnessed by two (2) nurses prior to discarding. She revealed the night shift supervisor verified all narcotics and narcotic logs nightly on each unit to ensure staff signed in the medications appropriately and were present in the locked box. She stated, in the past, nurses were trusted to turn in Controlled Drug Record Sheets into Medical Records once the sheet was completed, reorder narcotics as needed, and wasted narcotics per facility policy. The DON was not aware of any monitoring the facility did to ensure the completed Control Drug Records were submitted to Medical Records as needed and in a timely manner. She stated there had been no red flags that needed to be discussed in Quality Assurance Council or monitored more closely by nursing administration. Interview with the Pharmacist, on 10/05/18 at 1:40 PM, revealed he audited the facility's processes to ensure narcotics were reconciled, received within regulation, and monitored for any discrepancies. He stated he had not tracked exuberant use or reordering of the resident's narcotics. Interview with the Executive Director, on 10/05/18 at 5:30 PM, revealed the DON had the ultimate responsibility to monitor all the narcotics used in the facility; however, she stated she was ultimately responsible for the entire facility.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure medications were securely stored for one (1) of three (3) medication carts on the(NAME)Wing. In addition, the facility failed to ensure medications were labeled with the resident name and date opened, and were not expired on one (1) of three (3) units, the Clingman Unit. The facility also failed to limit access to narcotic keys. The findings include: Review of the facility's policy, Medication Storage and Labeling, effective 01/01/18, revealed nursing staff would be responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals would be locked when not in use, and trays or carts used to transport such items would not be left unattended if open or otherwise potentially available to others. 1. Observation on the(NAME)Unit, on 10/05/18 at 9:50 AM, revealed an unlocked, unattended medication cart located next to Resident Room A12. Interview with Licensed Practical Nurse (LPN) #7, on 10/05/18 at 9:51 AM, revealed he forgot to lock the cart when he left to answer a call light. The LPN stated the cart should be secure at all times to prevent resident access because a resident could potentially ingest a medication and get sick. Interview with Unit Manager (UM) #1, on 10/05/18 at 11:05 AM, revealed medication carts should be locked and secure when unattended. She stated there was a risk a resident could access the medication on the cart. Interview with the Director of Nursing (DON), on 10/05/18 at 4:28 PM, revealed medication carts should be locked at all times. The DON stated she occasionally observed an unlocked cart during her daily walk-through audits, but had not identified any trends. 2. Observation of the Clingman Unit Medication Room, on 10/04/18 at 9:32 AM, revealed LPN #5 removed keys that were attached to a string on a hook in the medication room. LPN #5 used the keys to open the medication refrigerator and the locked narcotic medication box inside the refrigerator. LPN #5 then placed the keys back onto the hook and walked out of the medication room. Observation, on 10/04/18 at 3:08 PM, revealed Certified Medication Technician (CMT) #1 walked into the Clingman medication room and took the keys attached to the string and opened the refrigerator and the locked narcotic box during shift count. CMT #1 returned the keys to the hook and left the room. Observation, on 10/05/18 at 8:30 AM, revealed the keys on the string in the Clingman medication room were on the hook attached to a string. Review of the Control Emergency Drug Check list revealed the drug box contained two (2) [MEDICATION NAME] 2 milligram (mg) vials, two (2) [MEDICATION NAME] 2 mg vials, two (2) [MEDICATION NAME] 5 mg tablets, two (2) [MEDICATION NAME] 0.25 mg tablets, two (2) [MEDICATION NAME]/[MEDICATION NAME] (APAP) 5-325 mg tablets, and two (2) [MEDICATION NAME]/APAP 10-325 mg tablets. Interview with CMT #1, on 10/04/18 at 3:38 PM, revealed the Clingman medication room keys on the string opened the medication refrigerator and the locked box of narcotic medications inside the refrigerator. She stated the keys hung on the hook because there was only one refrigerator key available for each unit. She stated all medication cart key rings had access to all medication rooms in the building. She stated she trusted everyone in the facility because she had worked with the staff for many years. She stated there were no security cameras in the facility. She further stated she was not concerned with the keys being on the hook on the wall. Interview with LPN #2, on 10/05/18 at 3:10 PM, revealed keys had been hanging on the wall in the medication room for several years now. She stated the keys opened the medication refrigerator and the narcotic box. She stated staff did not have their own individual keys to the medication refrigerator or the narcotic box, but rather all staff would just use the keys on the wall. She stated this could possibly lead to stolen narcotics and did not think it was good practice. Interview with Registered Nurse (RN) #2, on 10/04/18 at 3:13 PM, revealed the keys hanging in the medication room opened the refrigerator and the narcotic box in the refrigerator. She stated the keys always hung on the wall, as there was only one key to the refrigerated narcotic medications. She further stated the keys had always hung on the wall. Observation of the(NAME)Unit Medication Room, on 10/04/18 at 3:20 PM, revealed a key attached to a round wooden block in a drawer. A staff's personal backpack was in the room. Interview with RN #3, on 10/05/18 at 2:50 PM, revealed the key to the narcotic refrigerator was stored in a drawer in the medication room. The nurse stated she was unsure how many keys in the facility allowed other staff to enter the medication room; however, she believed all staff with medication keys could enter all the medication rooms in the facility. She stated she had not thought it was a risk, but stated it could be since all staff with keys could freely enter and exit the medication room. She stated she did not notice the backpack in the medication room; however, stated personal items should not be kept in the room. Review of the Control Emergency Drug Check list revealed the drug box contained one (1) [MEDICATION NAME] 2 mg vial, one (1) [MEDICATION NAME] 2 mg vial, one (1) [MEDICATION NAME] 5 mg-325 tablet, two (2) [MEDICATION NAME] 0.25 mg tablets, two (2) [MEDICATION NAME]/APAP 5-325 mg tablets, and two (2) [MEDICATION NAME]/APAP 10-325 mg tablets. Observation of the Marmion Unit, on 10/05/18 at 10:00 AM, revealed two (2) keys in an unlocked drawer in the nurses' station. Review of the Control Emergency Drug Check list revealed the drug box contained three (3) [MEDICATION NAME]/APAP 5-325 mg tablets, and two (2) [MEDICATION NAME]/APAP 10-325 mg. Interview with the Pharmacy Consultant, on 10/05/18 at 1:40 PM, revealed he was not aware staff stored keys to the medication refrigerator in drawers or hung them on the wall. He stated that practice would not be recommended because it could lead to a drug diversion related to the immediate access to narcotics. Interview with the DON, on 10/05/18 at 10:00 AM, revealed she was not aware of how many keys were in the facility that opened the medication rooms and the medication refrigerators, which contained the narcotics. She stated she was unaware of any keys in the facility the nurses or CMTs did not keep on their person. She stated it was not appropriate for staff to store medication keys in a drawer in the nurses' station, and stated other people beside staff were frequently in the nurses' station. She stated it was a safety issue and could lead to the inappropriate use of narcotics. She revealed personal items, such as backpacks, were not to be stored in the medication rooms, and could also lead to narcotic diversion. Interview with the Executive Director, on 10/05/18 at 5:30 PM. revealed the facility should be aware of how many keys to the medication rooms and narcotics boxes were available for use, and who used them. She stated all keys should be accounted for and be with the assigned nurse at all times. She stated she was ultimately responsible for the practice of the facility. 3. Observation of the Clingman Medication Room, on 10/04/18 at 9:32 AM, with LPN #1, revealed one (1) opened bottle of Iodine 10%, unlabeled, and no opened date on the bottle. There was a bottle of multivitamins with an expiration date of (MONTH) (YEAR), unlabeled and undated. The treatment cart contained one (1) tube of [MEDICATION NAME] anti-itch cream opened, undated, and not identified to a resident. A can of Bio-Freeze seventy-four (74) milliliters (ml) was opened, undated, and unlabeled. Further review revealed a tube of antibiotic cream, one (1) ounce, opened, unlabeled and undated. Interview with LPN #1, on 10/04/18 at 10:32 AM, revealed the pharmacy and the CMTs checked the treatment cart once a month for expired and unlabeled medications. She stated the medications were ineffective for the prescribed treatments if they were expired. She stated nursing staff was to put the date on the bottle or tube when it was opened and all mediations were to have the resident's name on the prescribed product. Interview with LPN #2, on 10/04/18 at 9:32 AM, revealed medications were to be discarded in the medication room when unlabeled with a resident name, and not dated with an opened date. She stated medication lost its effectiveness when opened for long periods of time and residents could be affected by medications not being effective for the prescribed treatment. She stated the pharmacy checked the medication rooms once a month; however, staff was not assigned to check for expired medications. Interview with the DON, on 10/05/18 at 4:36 PM, revealed medications were to be labeled and marked with the date opened when staff opened the product. She stated the CMTs checked the carts, as well as the pharmacy technician, once a month and she audited carts randomly. The DON stated she was not aware of issues with expired or unlabeled medications. Interview with the Executive Director, on 10/05/18 at 6:00 PM, revealed she entrusted the pharmacy to ensure the medications in the medication rooms and carts were labeled and dated. She stated there were no reported issues from the CMTs who monitored that for the facility. She stated staff was to ensure all medications and treatments were labeled with the resident name, date opened, and monitor for expired medications.

Based on interview, record review, and facility policy review, it was determined the facility failed to obtain a physician order [REDACTED].#18. The findings include: Review of the facility's policy, Advanced Directives, effective 01/01/18, revealed Advance Directives would be respected in accordance with state law and facility policy. Review of the facility's Residents Bill of Rights handbook revealed the resident had the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. Review of the clinical record revealed the facility admitted Resident #18 on 08/01/18, with [DIAGNOSES REDACTED]. Review of the Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) form revealed the resident signed the consent on 08/03/18 to implement the Advance Directive/DNR. Review of the Physician order [REDACTED].#18 was a Full Code. Review of the Care Plan revealed Resident #18 desired Full Code status with interventions that included a physician order [REDACTED]. However, review of the Nurses Report Sheet revealed Resident #18 was a DNR. Interview with Licensed Practical Nurse (LPN) #8, on 10/05/18 at 9:55 AM, revealed she referred to the nurses report sheet or the clinical record to determine a resident's code status. The LPN stated she was not sure if an Advance Directive/DNR required a physician order. Interview with Registered Nurse (RN) #3, on 10/05/18 at 10:15 AM, revealed the admitting nurse was responsible for obtaining an order for [REDACTED]. Interview with Unit Manager (UM) #1, on 10/05/18 at 11:05 AM, revealed nurses were responsible for obtaining a physician order [REDACTED]. Interview with the Director of Nursing (DON), on 10/05/18 at 4:28 PM, revealed the Interdisciplinary Team and physician conducted weekly Rehabilitation rounds to review orders, therapy progress, code status, and 48-hour baseline care plans. She stated the team should have identified the missing order for Resident #18 during those rounds. She revealed the third shift nurse was responsible for performing daily chart checks to ensure all orders were transcribed and entered; however, the facility did not verify the monthly order summary because all orders were entered and verified by two (2) nurses electronically. The DON stated she had not identified any concerns related to Advance Directives.

Based on interview, record review, and facility policy review, it was determined the facility failed to revise the care plan for two (2) of nineteen (19) sampled residents, Resident #18 and #34. Resident #18's Advance Directive care plan was not revised to reflect the Do Not Resuscitate (DNR) status. Resident #34's care plan was not revised to reflect a Urinary Tract Infection [MEDICAL CONDITION]. The findings include: Review of the facility's policy, Comprehensive Care Planning, effective 01/01/18, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The comprehensive, person-centered care plan reflected the resident's expressed wishes regarding care and treatment goals. The Interdisciplinary Team (IDT) must review and update the care plan when there was a significant change in the resident's condition; when the desired outcome was not met; when the resident was readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly MDS (Minimum Data Set) assessment. 1. Review of the facility's policy, Advanced Directives, effective 01/01/18, revealed Advance Directives would be respected in accordance with state law and facility policy. The policy revealed the plan of care for each resident would be consistent with his or her documented treatment preferences and/or Advance Directive. Review of the clinical record revealed the facility admitted Resident #18 on 08/01/18, with [DIAGNOSES REDACTED]. Review of the Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) order revealed the resident signed the consent on 08/03/18 to implement the Advance Directive/DNR. However, review of the Physician order [REDACTED].#18 was a Full Code. Review of the Care Plan, dated 08/06/18, revealed Resident #18 desired Full Code status. Interventions revealed a physician order [REDACTED]. Interview with Certified Nursing Assistant (CNA) #3, on 10/05/18 at 9:28 AM, revealed she referred to the CNA care sheet or the clinical record to determine a resident's code status. She stated it was important to ensure the Advance Directive was correct to honor the resident's wishes. Review of the CNA care sheet revealed Resident #18 was a DNR. Interview with Licensed Practical Nurse (LPN) #8, on 10/05/18 at 9:55 AM, revealed she referred to the nurses report sheet or the clinical record to determine a resident's code status. The LPN stated the Director of Nursing (DON) revised care plans during morning meetings, but was not sure who else could revise the care plan. Review of the Nurses Report Sheet revealed Resident #18 was a DNR. Interview with Registered Nurse (RN) #3, on 10/05/18 at 10:15 AM, revealed the care plan should be revised to reflect any change in code status; however, she was not sure who was responsible for completing the revision. Interview with Unit Manager (UM) #1, on 10/05/18 at 11:05 AM, revealed the Social Worker (SW) was responsible for revising the Advance Directive care plan. Interview with the MDS Nurse, on 10/05/18 at 2:14 PM, revealed the SW was responsible for revising the Advance Directive care plan. The nurse stated the IDT reviewed new orders during morning meetings and revised the care plans as needed. She stated she reviewed care plans upon admission, and at least quarterly, to verify they were accurate. Interview with the SW, on 10/05/18 at 1:45 PM, revealed the nurse and the SW were responsible for revising the Advance Directive care plan. The SW stated she revised the care plan when staff notified her of a new physician order, and when she completed the scheduled MDS assessment. According to the SW, the IDT also reviewed new physician orders [REDACTED]. She revealed the care plan was person centered and identified a resident's wants and needs. She stated Resident #18's Advance Directive care plan did not reflect the resident's choice for a DNR status. Interview with the DON, on 10/05/18 at 4:28 PM, revealed the IDT and physician conducted weekly rounds to review orders, therapy progress, code status, and 48-hour baseline care plans. She stated the team should have identified Resident #18's care plan discrepancy during those rounds. The DON stated new orders were also reviewed during the daily clinical meetings and the care plans revised as applicable. The DON revealed the IDT reviewed Advance Directives during quarterly care plan meetings to ensure accuracy; however, there was no process in place to review the Advance Directive during the time between the resident's admission and care plan meeting. The DON stated she had not identified any concerns with revisions of care plans. 2. Review of Resident #34's clinical record revealed the facility admitted the resident on 01/01/16, with [DIAGNOSES REDACTED]. Review of Resident #34's Medication Orders, dated 09/27/18, revealed the facility was to administer an antibiotic, [MEDICATION NAME], one (1) gram Intra-Muscular (IM) every day for seven (7) days. Review of Resident #34's Nursing Note, dated 09/27/18, revealed Resident #34's antibiotic was for a UTI. Review of Resident #34's Care Plan, dated 10/05/18, revealed the care plan was not revised to reflect the [DIAGNOSES REDACTED]. Interview with LPN #7, on 10/05/18 at 10:58 AM, revealed staff followed care plans in order to care for residents and effectively treat conditions of the residents. He stated care plans were revised when the unit managers reviewed orders. He stated new orders, or changes in care or condition, required a new or revised care plan. LPN #7 stated it was all staff's responsibility to ensure care plans were correct. He stated he was unsure how acute conditions were dealt with on resident care plans. Interview with LPN #2, on 10/05/18 at 11:23 AM, revealed UTIs were to be added to resident care plans to include physician orders [REDACTED]. She stated updating care plans was a group effort with upper management. She stated the care plan outlined the care required for residents. Interview with UM #1, on 10/05/18 at 3:22 PM, revealed staff utilized the care plans to know how to care for residents and all nursing staff was able to update and revise care plans, and the UMs were ultimately responsible to ensure care plans were updated and correct. She stated the facility entrusted the nurses to revise the care plans with new issues or update an existing issue and then the care plans were reviewed during the residents' quarterly MDS review. She further stated the facility did not have acute care plans available for staff to initiate for acute issues such as infections. Interview with UM #2, on 10/05/18 at 3:22 PM, revealed care plans were used to direct the care for the residents and she was responsible to ensure resident care plans were accurate and up to date. Resident #34's care plan was not revised to reflect the [DIAGNOSES REDACTED]. She stated she did not audit resident care plans. Interview with the DON, on 10/05/18 at 4:03 PM, revealed resident care plans were guides on how to care for the resident and were reviewed at random and quarterly. She stated acute [DIAGNOSES REDACTED]. She stated she was fully responsible to ensure care plans were updated and correct. She further stated the facility had not identified issues with revisions of resident care plans. Interview with the Executive Director, on 10/05/18 at 6:00 PM, revealed care plans were reviewed and updated during the morning meeting. She stated the facility had completed a recent review of care plans and had not found issues concerning revisions.

Based on observation, interview, record review, and review of the facility's policy, it is determined the facility failed to provide an effective infection control program for one (1) of six (6) sampled residents, Resident #11, during wound care. The findings include: Review of the facility's policy, Handwashing/Hand Hygiene, dated 11/09/17, revealed proper hand hygiene was the most important aspect of infection control. Staff was to wash their hands when visibly soiled or after contact with a resident. Staff was to use alcohol base rubs before handling clean or soiled dressings, after contact with residents' skin, after handling used dressings, after contact with objects, and after removing gloves. Further review revealed staff was to lather soap and create friction to all surfaces of the hands and fingers for twenty (20) seconds. Review of the facility's policy, Transmission Based Precautions, dated 11/09/17, revealed staff was to change gloves during the care of the resident to prevent cross-contamination and change gloves when moving from a dirty site to a clean site. Review of the facility's policy, Handling Medical Waste, dated 11/09/17, revealed the facility was to dispose of secretions of a resident in a red plastic bag before removal from the premises of the facility. Review of the facility's policy, Infection Control Guidelines for All Nursing Procedures, dated 01/25/16, revealed staff was to wash their hands for ten (10) to fifteen (15) seconds using a antimicrobial soap after contact with visible body fluids/blood, after removing gloves, after handling potentially contaminated blood or body fluids, after contact with the skin, and before moving from a contaminated body site to a clean body site. Record review revealed Resident #11 was at risk for infection related to bilateral leg [MEDICAL CONDITION] and compromised circulation. Observation of Resident #11's wound care, on 10/03/18 at 9:12 AM, revealed Licensed Practical Nurse (LPN) #1 placed clean wound supplies on the over the bed table without cleaning the table. LPN #1 removed the resident's soiled dressings from both legs and without changing gloves and performing hand hygiene, assessed the open leg wounds by physically pressing into the wounds with her gloved hands. LPN #1 changed gloves and placed new gloves on her hands without washing hands between the dirty and clean procedures, and proceeded to complete Resident #11's wound care. LPN #1 placed the soiled dressings into a clear bag, took the bag to the utility room, and placed the clear bag inside the trash bin. The LPN placed opened wound supply packages, which laid on an unclean surface, back into the treatment cart for future use. Further, the nurse washed her hands with soap for less than ten (10) seconds and then rinsed her hands. Interview with LPN #1, on 10/03/18 at 10:09 PM, revealed handwashing included washing before care, after care, and between all stages of wound care, and should be conducted if gloves become contaminated. She stated handwashing was important because the wound could be contaminated by introducing bacteria into the wound. She further stated while evaluating Resident #11's wounds to see if the wounds were weeping, she did not change her gloves or wash her hands. She stated biohazard material included dressings with blood or fluids from the resident and it was okay to put the bag with the soiled dressing into the regular trashcan because it was not saturated with blood. The LPN stated she should have cleaned the over the bed table prior to placing supplies on it to prevent infection. She stated she attended in-services on handwashing, infection control, and wound care with the wound nurse and the infection control nurse. Interview with Certified Nursing Assistant (CNA) #5, on 10/05/18 at 10:31 AM, revealed handwashing included washing hands vigorously for the length of time it took to say the alphabet. She stated hands should be washed after contact with each resident and in between treatments of one resident. She stated everyone was responsible for good handwashing. She stated the facility was responsible for the prevention of spreading germs and handwashing was the primary way to prevent infections. She stated the facility competed task check offs a couple months ago, which included a handwashing station. Interview with LPN #7, on 10/05/18 at 10:58 AM, revealed hands were to be washed anytime they were contaminated or visibly soiled and washed for two (2) minutes with a full lather of soap. He stated poor hand washing was the number one way to spread germs to residents in the facility and all staff was responsible to have good handwashing skills to prevent the spread of infection and promote wound healing. He further stated resident wounds should not be touched with contaminated gloves. He stated in order to prevent cross contamination, unused dressings should be left in the residents' room and not returned to the treatment cart. He stated the trash bag with the soiled dressing should be placed in the red biohazard bin in the utility room. Interview with LPN #6, on 10/0518 at 11:23 AM, revealed handwashing was the most important task in preventing infections and hands should be washed at every opportunity and in between tasks. She stated nurses were responsible to ensure cross contamination did not occur with wound care. She stated soiled dressing were to be placed in a bag and then removed and placed in the red biohazard bag at the end of the session. She stated contaminated gloved hands should not be used to assess wounds. She further stated all surface areas should to be cleaned with disinfectant prior to placing wound supplies on the surface. Interview with LPN #9, on 10/05/18 at 2:10 PM, revealed correct handwashing was important or it could be a source of infection. She stated wound dressings were to be placed in the red biohazard bin and all surfaces were to be cleaned prior to wound care. She stated all staff was required to complete skill check offs, which included handwashing and wound care. She stated the facility completed an annual skill lab in (MONTH) (YEAR). Interview with the Wound Nurse, on 10/05/18 at 2:54 PM, revealed the facility completed annual skill check offs in (MONTH) (YEAR), which included handwashing and wound care. He stated he taught the nurses to complete handwashing during wound care and staff could never wash their hands too many times. According to the Wound Nurse, the nurses should clean the surface area and place a barrier to the surface before placing supplies on the surface. He stated soiled dressing, with any amount of drainage, should be placed in the red biohazard bin and unused dressing packages should be left in the residents' room. He stated he attended wound care with the nurses to evaluate their technique, weekly, and had not identified any issues. He stated all nurses attended the in-service in (MONTH) (YEAR). Interview with the Unit Supervisor, on 10/05/18 at 3:22 PM, revealed she participated in the (MONTH) in-service as an educator. She stated the Wound Nurse followed the nurses during orientation and as need to monitor proper wound care. She stated she had not followed nursing staff in several months to evaluate wound care technique, and the observations of staff were not documented. She stated she had not identified issues with wound care or infections of wounds. Interview with the Infection Control Nurse, on 10/05/18 at 3:22 PM, revealed singing two (2) courses of the happy birthday song was the length of time taught to the staff for handwashing. She stated handwashing was the single most important task in the prevention of the spread of infection. She stated surfaces were to be cleaned prior to wound care if used for dressings. Interview with the Director of Nursing (DON), on 10/05/18 at 4:45 PM, revealed the facility conducted random audits of wound care with staff. She stated the supervisors, Wound Care Nurse, or she would randomly pick a nurse to observe wound care and had not identified issues with hand hygiene or technique during wound care observations. She stated the infection control trend was reviewed monthly with Quality Assurance (QA) and no trend has been identified. She stated it was her responsibility to ensure all care and services were provided to ensure the residents achieved and maintained their highest levels. Interview with Executive Director (ED), on 10/05/18 at 6:00 PM, revealed the facility reviewed and monitored infection control on many aspects. She stated the nursing administration completed observations, record review, and provided training to ensure infection were not transmitted throughout the facility. The ED stated the facility conducted a glow test to evaluate the effectiveness of the environmental cleaning and found areas that needed improvement. She revealed the QA committee met once a month and infection control was discussed at every meeting and the facility had not identified a trend of increased infections with wounds. She stated it was her responsibility to lead the staff to provide quality of care to the residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide a safe environment for residents in one (1) of three (3) dining areas, the(NAME)Unit dining room. Observation revealed during a fire alarm, staff did not move three (3) residents to a safe area or account for the residents. The findings include: Review of the facility's policy, Fire Alarm Response Plan, revised (MONTH) 2010, revealed during a fire alarm, the primary responsibility of all employees was to protect the residents. The Certified Nursing Assistant (CNA) assignment was to remove all residents from neighborhood common areas and place them into resident rooms, and close and latch each door. Residents were not required to be placed in their own room; any room with a latching door would get them out of harm's way. The policy revealed it was the nurse's responsibility in all neighborhoods to complete the Fire Alarm Assessment Log. Fire alarm response drills were conducted unannounced on a quarterly basis on each shift and evaluated for efficiency and effectiveness. Observation of the(NAME)Unit, on 10/02/18 at 12:12 PM, revealed a fire alarm sounded and staff responded timely to the alarm, relocated residents to rooms, and closed the doors, except for three (3) residents and a family member seated in the restorative dining room. Two residents were from the Marmion Unit, and one (1) resident was from the Clingman Unit. Interview with the Billing Coordinator during the observation revealed it was okay for residents to remain in the dining room during a fire alarm. Interview with CNA #1 (Restorative Aide), on 10/02/18 at 12:18 PM, revealed she was responsible for ensuring hallways were clear and residents were behind fire doors during a fire alarm. She further revealed neither residents nor visitors should be in the common areas during the alarm. Observation, on 10/02/18 at 12:20 PM, revealed fire department personnel arrived to the unit and inspected the steam table area of the dining room. Further observation, on 10/02/18 at 12:23 PM, revealed CNA #1 relocated the residents in the dining room to Room A13. An all clear was announced on the unit at 12:26 PM. Interview with CNA #3, on 10/05/18 at 9:28 AM, revealed all staff was responsible for ensuring residents were moved to their rooms and the door closed during a fire alarm. The CNA stated it was important for residents to be behind fire doors to ensure their safety. She further stated staff was responsible for performing a head count of all residents on their assigned hall and notifying the nurse of the count to ensure all residents were accounted for. Interview with CNA #4 (Restorative Aide), on 10/05/18 at 2:42 PM, revealed the Restorative Aides were responsible for taking four (4) restorative dining residents to the(NAME)dining room for meals. CNA #4 stated she was responsible for the head count for her assigned residents and stated residents should be visualized during the count. She stated she did not report the count to the nurses during an alarm because she told the nurses when she took the residents off the units to the dining room. Interview with Registered Nurse (RN) #3, on 10/05/18 at 10:15 AM, revealed all staff was responsible for ensuring residents were in a room and accounted for during a fire alarm. She stated neither residents nor visitors should be in the dining room during an alarm because there was no fire door. The RN revealed she could not remember the process regarding head counts and stated she hoped other units would know if their residents were on the(NAME)Unit. She stated it was important to perform a head count to ensure all residents were safe. According to the RN, nurses were responsible for completing a Fire Alarm form to include the date, time, resident census, and number of visitors on the unit. She stated all staff was required to sign the form following the alarm. She stated the fire alarm procedure failed on 10/02/18 because staff left residents in the dining room and did not ensure they were safe. Interview with Unit Manager (UM) #1, on 10/05/18 at 11:05 AM, revealed all staff was responsible for ensuring residents were behind fire doors during an alarm. She stated staff used a meal sheet as a checklist to account for each resident and the assigned nurse was responsible for collecting the head counts. According to the UM, residents were not signed out when they left the unit and if a resident from the Marmion Unit was in Restorative Dining on the(NAME)Unit, he/she would be checked off the list and the nurse would verify to ensure the resident was accounted for. She stated there was a breakdown in the fire alarm procedure on 10/02/18 because staff left residents in the dining room during the alarm. Interview with the Director of Nursing (DON), on 10/05/18 at 4:28 PM, revealed the nurses on each unit collected and verified head counts to ensure all residents were accounted for during a fire alarm. She further revealed all staff was responsible for communicating with other units, the therapy department, and the dining room, to account for residents. The DON stated Restorative Dining residents should be moved to the nurse manager's office during a fire alarm. The DON stated she monitored staff during fire drills and was not aware of any concerns or issues related to alarms or drills. Interview with the Director of Residential Services, on 10/05/18 at 5:09 PM, revealed the fire alarm triggered for Room A40 (Morton Unit) on 10/02/18. She stated nurses were responsible for ensuring every person was accounted for according to the census on the hall and each unit was responsible for filling out a fire drill/alarm response form. She stated all residents should be counted and should be behind a fire door. She stated it was okay for Restorative Dining residents to stay in the dining room because they were near an exit door. The Director of Residential Services revealed she monitored staff during fire alarms to ensure staff knew what to do, to make sure residents were safe, and ensure the system worked as designed, and she had not identified any concerns with the facility's process for fire alarms/drills. Review of the Fire Alarm Response Assessment/Log, dated 10/02/18, for the(NAME)Unit revealed all residents were removed from immediate danger and there was no unusual occurrence during the alarm. Further review revealed there was no resident or visitor census documented on the form for three (3) of four (4) units.

Based on observation, interview, and facility policy review, it was determined the facility failed to prepare, distribute, and serve food in a sanitary manner. Observations in the kitchen, over three (3) days, revealed male staff in the kitchen with uncovered beards. The findings include: Review of the facility's policy, Associate Conduct: Personal Appearance and Handwashing, dated July 2015, revealed team members working in food service areas should wear hairnets or hats. Continued review revealed no language in the policy regarding team member beards or use of beard restraints. Observation of the kitchen, on 08/08/17 at 8:25 AM, revealed a male dietary cook working in the kitchen with his beard not covered. Observation of the kitchen, on 08/09/17 at 7:38 AM, revealed Wait Staff #2 working in the kitchen with his beard not covered. Observation of the kitchen, on 08/10/17 at 9:50 AM, revealed Wait Staff #1 working in the kitchen with his beard not covered. Interview with Wait Staff #1, on 08/10/17 at 1:18 PM, revealed staff was to wear beard restraints any time they were in the kitchen and working with food. He stated unrestrained hair might fall into resident food, which would be unappetizing to the resident and may result in a negative outcome for the resident. Wait Staff #1 stated he received training on proper hair and beard restraints when hired. He revealed when he entered the kitchen on 08/10/16, the beard restraints had been moved from their usual location, and he got busy and failed to locate a beard restraint. Interview with Wait Staff #2, on 08/10/17 at 1:44 PM, revealed staff wore hair and beard restraints to keep hair out of the residents' food, as they would likely find hair in the food unappetizing. He stated he received training on proper hair/beard restraint usage when hired. Wait Staff #2 denied failing to wear a beard restraint while in the kitchen. Interview with the Director of Food Services (DFS), on 08/10/17 at 1:26 PM, revealed staff wore beard restraints when in the food preparation area. The DFS stated beard restraints prevented hair from entering and contaminating the residents' food and dishware, which might cause the resident to stop eating that particular dish and possibly refuse future food service provided by the facility. The DFS stated he monitored for beard restraint usage any time he was in the kitchen and informed staff to don beard restraints when appropriate. Continued interview revealed the DFS was at the facility for approximately two and one half (2 1/2) months and could not speak to facility education provided to staff regarding beard/hair restraint usage. Interview with the Executive Director, on 08/10/17 at 2:43 PM, reveled staff should wear beard restraints when in the kitchen to prevent hair from entering the residents' food. Continued interview revealed the facility had not previously identified any issues with beard restraint usage.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary environment in one (1) of three (3) common areas, and in one (1) of four (4) dining rooms, both on the Morton Unit. In addition, there were soiled carpet and air vents, peeling wallpaper, missing privacy curtains in shower rooms, soiled shower room, and missing baseboards in other areas of the facility. The findings include: Review of the facility's policy, Cleaning Procedure, undated, revealed routine and terminal cleaning and disinfecting were important measures to prevent transmission of infections. Routine and terminal cleaning assured all current and new residents a clean and sanitized living space. All public and care environments should be cleaned and sanitized daily with appropriate germicidal and disinfectant solutions. Vinyl floors and baseboards should be dusted and wet mopped daily and as needed, with particular attention to scuff marks and corners. High traffic carpeted areas, including but not limited to, entrance ways, hallways, and meeting rooms should be vacuumed and the baseboards in these areas cleaned twice weekly and as needed. Bathrooms should be cleaned and sanitized daily. All surfaces should be sanitized, including spot cleaning walls. Review of the facility's policy, Safety and Security, reviewed January 2017, revealed Environmental Techs must make regular rounds throughout the work area daily to uncover potential safety and security problems that would need to be reported. A temporary patch should be placed over ripped carpeting until it could be replaced. Review of the Morton Neighborhood Environmental Services (EVS) Tech Wing Assignments, revealed the tech was responsible for daily tasks that included wiping down and cleaning the hallway wall air vents, sweeping and wet mopping the whirlpool room floor, cleaning and sanitizing the dining room chairs and tables, wiping walls around the kitchen area, cleaning windows, and high and low dusting of the area. The assignment further revealed the EVS tech was responsible for replacing privacy curtains when needed. In addition, the tech was responsible for checking upholstery furniture for soil and cleaning as needed. Observation during initial tour of the Morton Unit, on 08/08/17 at 8:25 AM, revealed the hallway air vent adjacent to room A15 was soiled with a gray, fuzzy substance. Continued observation during initial tour revealed the wallpaper was torn and scuffed near the love seat sofa located in the common area. Observation of the Morton Shower Room, on 08/08/17 at 12:00 PM, revealed no privacy curtain between the shower area and the toilet stall. Observation of the Marmion Shower Room, on 08/08/17 at 12:25 PM, revealed no privacy curtain between the shower area and the toilet stall. Observation of the Morton Common Area, on 08/08/17 at 4:53 PM, revealed the wallpaper was peeling off at the edge of the electrical outlet located on the column at the entrance to the area. The carpet was soiled with a black substance in various areas of the common area. Further observation of the Morton Unit, on 08/08/17 at 5:00 PM, revealed the carpet was soiled with a black substance at the entrance to room A30 and the entrance to the utility room across from room A15. The carpet was worn and frayed near the entrance to room A37. In addition, the carpet was torn and had loose edges with a flap that lifted away from the floor outside the entrance to room A35. Observation of the Morton Restorative Dining Room, on 08/09/17 at 7:40 AM, revealed the air conditioner wall unit cover was pulled away from the unit. The wallpaper above the air conditioner unit was soiled with a black and brown substance. The windowsills above the air conditioner unit had a black substance with gray silvery webs at the bottom edges of windows. There was a brown substance spattered on the wallpaper and light fixtures at the entrance to the Restorative Dining Room. Further observation of the common area revealed a yellow fabric wingback chair and a red fabric armchair soiled on the seats and arms with black and white substances. A clear plastic covering on the edge of a column was loose and had an exposed nail sticking out from the wall. Observation of the Clingman Unit, on 08/08/17 at 11:25 AM, revealed the carpet at the entrance to the utility room was soiled with a black substance. Observation of the Clingman Shower Room, on 08/08/17 at 11:27 AM, revealed a brown substance splattered on the shower wall. Observation of the Clingman Unit, on 08/09/17 at 9:05 AM, revealed the baseboard was pulled away from the wall near the exit door. Further observation revealed the hallway air vent was soiled with a gray, fuzzy substance. The water fountain located near the exit door had an orange brown substance scattered in the basin. Observation of the Marmion Unit, on 08/09/17 at 11:17 AM, revealed the hallway air return vent located across from the utility room was soiled with a gray, fuzzy substance. The baseboard was missing at the entrance to the housekeeping closet. In addition, the baseboard was pulled away from the wall at the shower room door. Interview with the Floor Tech, on 08/09/17 at 10:32 AM, revealed he was responsible for cleaning the carpets for assigned rooms. The Tech further revealed he conducted a daily walk through of high traffic areas and performed spot cleaning of those areas, as needed. Interview with Certified Nursing Assistant (CNA) #12, on 08/09/17 at 5:00 PM, revealed CNAs were responsible for spraying down and sanitizing the showers after each resident use. The CNA further revealed staff should have cleaned the spattered brown substance on the shower room wall immediately and prior to showering other residents. The CNA revealed she would not want to use the shower room because it was not sanitary. Interview with Registered Nurse (RN) #2, on 08/09/17 at 5:10 PM, revealed CNAs were responsible for cleaning the shower room if a resident defecated/urinated in the shower. The RN further revealed environmental services was responsible for cleaning and sanitizing the shower rooms daily and as needed. The RN revealed CNAs were responsible for notifying a nurse, so the nurse could notify environmental services to have the shower sanitized. The RN revealed she was unaware of the brown substance on the shower room wall. The RN further revealed she did not routinely check the cleanliness of the shower because she was not the police. Interview with Environmental Services (EVS) Tech #1, on 08/09/17 at 1:35 PM, revealed he was assigned to clean the Morton Unit. The EVS Tech revealed he had a daily checklist with assigned tasks. The Tech stated he had not wiped down the dining room and common area walls because he had not noticed they were soiled. The Tech further revealed he was assigned to clean fixtures and windowsills. He stated some tasks were daily and others were performed as needed. The Tech revealed it was important to sanitize common areas and maintain cleanliness to prevent illness among residents. Interview with the Environmental Services Supervisor, on 08/09/17 at 1:05 PM, revealed the Floor Tech was responsible for walking the perimeter of the facility and spot-checking the carpets on all units daily. The Supervisor revealed he directed the Floor Tech to any problem areas as needed. Further interview with the Supervisor revealed he was responsible for ensuring the cleanliness of the facility. The Supervisor stated he conducted random audits of the facility to observe for cleanliness. In addition, the Supervisor stated he reviewed the EVS Tech daily checklists to ensure tasks were completed. He revealed there were concerns with staff work performance. He further revealed it was important to maintain a clean and sanitary environment in order to prevent illness among residents. Interview with the Director of Nursing (DON), on 08/10/17 at 2:20 PM, revealed CNAs were responsible for cleaning showers after each resident use. The DON further revealed Environmental Services was responsible for sanitizing the shower rooms and shower stall on each unit daily. The DON stated there were infection control concerns for residents related to the soiled shower rooms. Interview with the Director of Residential Services, on 08/10/17 at 2:45 PM, revealed she conducted daily walking rounds of the facility. The Director further revealed there were concerns with the work performance of some of the Environmental Services staff. The Director stated it was important for residents to have a clean environment to reduce the risk of illness. Interview with the Executive Director, on 08/10/17 at 1:00 PM, revealed she conducted frequent rounds of the facility. She stated it was important for residents to enjoy their surroundings because it was their home.

Based on observation, interview, and record review, it was determined the facility failed to maintain a hazard free environment on two (2) of three (3) units, the Clingman and Marmion Units. Observations revealed unlocked chemicals assessable to residents. The findings include: Review of the facility's policy, Safety and Security, reviewed January 2007, revealed the environmental services staff was an integral component for the safety and security of the residents and staff. The Environmental Services Tech should make regular rounds throughout the work area daily. Common safety oversights included failure to lock or completely close doors, environmental services carts left unattended, and chemicals used from unmarked bottles. 1. Observation of the Clingman Shower Room, on 08/08/17 at 11:27 AM, revealed the door was propped open and accessible to residents. The cabinet in the room was unlocked and contained one (1) bottle of nail polish remover, one (1) pair of scissors, two (2) unlabeled bottles of shampoo, one (1) unlabeled tube of protective skin cream, three (3) unlabeled tubes of deodorant, four (4) unlabeled cans of shaving cream, one (1) unlabeled bottle of body lotion, one (1) jar of hair styling gel, and one (1) electric styling hair brush. In addition, there were three (3) spray bottles labeled freshener, disinfectant, and multipurpose restroom cleaner stored inside the unlocked bottom cabinet. Interview with Certified Nursing Assistant (CNA) #12, on 08/09/17 at 5:00 PM, revealed nail polish remover, scissors, and disinfectants should not be stored in an unlocked cabinet and accessible to residents. The CNA revealed it was important to keep hazardous items secured to prevent a resident from being injured. Interview with CNA #11, on 08/10/17 at 10:14 AM, revealed staff should label hygiene products with the resident's name and store them in their room. Interview with Registered Nurse (RN) #2, on 08/09/17 at 5:10 PM, revealed hazardous chemicals should be stored in a secured area to prevent resident access. The RN revealed a resident could be injured if the chemicals were ingested or splashed in the resident's face. The RN revealed the shower room door should be locked and secured at all times. Interview with the Environmental Services Supervisor, on 08/10/17 at 11:15 AM, revealed shower room doors should not be propped open and accessible to residents. 2. Observation of the Marmion Unit, on 08/08/17 at 9:00 AM, revealed the shower room and housekeeping closet were unlocked. The housekeeping closet contained a multipurpose bathroom cleaner and Virex (disinfectant cleaner). The shower room contained antifungal cream, Calazime (skin protectant), and razors in drawers that were not locked. Observation of the Marmion Unit, on 08/09/17 at 7:40 AM, revealed the shower room door was propped opened and the items in the drawers were still there. Unsampled Resident A was sitting in a wheelchair outside the shower room and peering into the shower room. Observation at 8:35 AM revealed Resident #10 pushing Unsampled Resident B in a wheelchair past the propped open shower door. Continued observation of the Marmion Unit, on 08/09/17 at 11:55 AM, revealed the shower room door was closed but unlocked and had an unlocked cabinet under the sink that contained chemicals. There was one (1) bottle of multipurpose cleaner called Diversey in the cabinet with a precautionary label that revealed to keep out of the reach of children. Whirlpool Disinfectant and Cleaner was also in the cabinet that contained a label that stated to keep out of reach of children-danger. The label continued with Danger: Broad Spectrum Cleanser, fungicide, virucide, and deodorant, corrosive-irreversible eye damage and skin burns could occur. The label also stated harmful if swallowed or inhaled and it was a hazard to humans and domestic animals. A note to the physician was on the label warning not do a gastric lavage because of probable mucous damage. Observation of the unlocked drawers revealed two (2) shaving creams, three (3) razors, fingernail polish, antifungal cream, and Calazime were in the drawers. Interview with CNA #4, on 08/09/17 at 12:05 PM, revealed the shower room door should be closed and locked; however, she stated staff had been having problems with the lock and a new lock had been put on about two (2) weeks ago. CNA #4 revealed they were still having problems with it not latching. She stated it was locked for resident safety because they could fall or get into trouble. Observation of the Marmion Unit, on 08/09/17 at 12:15 PM, with the Unit Coordinator, revealed the shower door was propped open and as the surveyor and Unit Coordinator entered the shower room, Unsampled Resident C followed in a wheelchair into the shower room. Interview with the Unit Coordinator, on 08/09/17 at 12:15 PM, revealed the shower room door should be locked because confused residents could access the room as Unsampled Resident C had done. The Unit Coordinator looked in the unlocked drawers and unlocked cabinets and stated there were chemicals stored in the unlocked areas and a confused resident could get hold of them. The Unit Coordinator revealed the cabinets had a lock on them, but she did not know if there was a key for the lock. Review of Unsampled Resident A's clinical record revealed the facility admitted him/her on 03/02/17, with [DIAGNOSES REDACTED]. Review of Unsampled Resident A's quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99) and determined the resident could not complete the BIMS and therefore was not interviewable. Review of Unsampled Resident B's clinical record revealed the facility admitted her/him on 01/15/17, with a [DIAGNOSES REDACTED]. Review of Unsampled Resident B's quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of three (3) out of fifteen (15) and determined the resident not interviewable. Review of the clinical record for Resident #10, revealed the facility admitted him/her on 09/03/16, with a [DIAGNOSES REDACTED]. Review of Resident #10's quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of eight (8) out of fifteen (15) and determined the resident interviewable. Review of the clinical record for Unsampled Resident C, revealed the facility admitted her/him on 08/03/17, with a [DIAGNOSES REDACTED]. Further review revealed the facility had not yet completed a MDS. Interview with the Director of Nursing (DON), on 08/10/17 at 10:30 AM, revealed chemicals should be behind locked doors and the door should never be propped open. The DON revealed residents with Dementia could access the chemicals if not properly stored and locked. Interview with the Executive Director, on 08/10/17 at 1:00 PM, revealed during rounds, staff checked to make sure doors were locked and chemicals were secured. She revealed no resident should have access to chemicals or other products because the chemicals could be swallowed or get in the eyes of a resident.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure staff followed infection control practices for one (1) of six (6) unsampled residents, Unsampled Resident F. Observation revealed staff failed to perform hand hygiene after providing care to Unsampled Resident F in his/her isolation room. In addition, staff failed to perform hand hygiene during meal service and used the same personal hygiene items on multiple residents. The findings include: 1. Review of the facility's policy, Infection Control, dated 07/21/10, revealed staff was required to wash their hands after each direct resident contact. Review of the clinical record for Unsampled Resident F revealed the facility admitted the resident on 04/18/17, with [DIAGNOSES REDACTED]. Review of Unsampled Resident F's Physician Orders, for August 2017, revealed and order for the resident to be in contact isolation due to MRSA of the wound. Observation, on 08/09/17 at 8:52 AM, revealed Licensed Practical Nurse (LPN) #4 entered Unsampled Resident F's room after donning Personal Protective Equipment (PPE). LPN #4 attempted to administer medication through an intravenous (IV) pump and was unsuccessful. LPN #4 removed her PPE and exited the room without performing hand hygiene. LPN #4 went to the medication cart and obtained new IV equipment. LPN #4 donned PPE and re-entered the resident room without performing hand hygiene. After replacing the IV tubing, she continued to have difficulty with the IV pump. She removed her PPE, exited the room without performing hand hygiene, and walked down the hall to the nurses' station. Interview with LPN #4, on 08/09/17 at 12:50 PM, revealed she had forgotten to wash her hands on both occasions prior to leaving Unsampled Resident F's room. She further stated gloves did not replace hand washing and she should have performed hand hygiene after removing her gloves and before exiting the room. She stated failure to wash hands after providing care for a resident was an infection control issue and could lead to the spread of infection or illness to other residents in the facility. Interview with the Unit Manager, on 08/10/17 at 1:00 PM, revealed staff should always perform hand washing before exiting a resident room after providing care. She further stated hand washing must be performed after removing gloves because gloves did not replace hand hygiene. She stated failure to wash hands correctly would be an infection control concern and she would be concerned about the spread of illnesses or infection to other residents. Interview with the Director of Nursing (DON), on 08/10/17 at 2:20 PM, revealed hand washing should be performed before and after resident care, and after the removal of gloves. She stated use of gloves during resident care did not replace proper hand washing. She further stated that there was not a monitoring system in place for ensuring staff was washing their hands. 2. Observation of the Marmion Shower Room, on 08/08/17 at 9:00 AM, revealed antifungal cream, [MEDICATION NAME] cream, NutraShield cream, shaving cream, razors, two (2) hair brushes, and [MEDICATION NAME] in an unlocked drawer. None of the items were labeled as to who they belonged to. In addition, a brown substance and a soiled bandage were on the floor in the shower area of the room. Observation of the Marmion Shower Room, on 08/09/17 at 7:40 AM, revealed a brown substance on the floor of the shower room. Interview with Certified Nursing Assistant (CNA) #3, on 08/09/17 at 12:15 PM, revealed staff used the items in the shower room drawer on multiple residents; however, staff did not use the brushes. CNA #3 stated none of the items were labeled because staff used them on different residents and it was not an infection control issue. CNA #3 further stated the CNAs did not clean the shower room, only the whirlpool, after each use. Interview with the Unit Coordinator/Restorative Supervisor, on 08/09/17 at 12:25 PM, revealed the CNAs did not use the items in the shower room drawer because each resident had their own personal hygiene items. She stated CNAs brought the creams and shampoos in with them when they took the resident in for their whirlpool. However, if the CNAs were using the items, there would be a problem with infection control and cross contamination. The Unit Coordinator/Supervisor revealed each item in the drawer should be labeled with a resident's name and put in a bag. She revealed the CNAs should not be using items in the drawer on multiple residents. She further revealed it would be a cross contamination infection control problem if multiple residents used the hairbrushes. The Unit Coordinator/Restorative Supervisor further revealed the floor of the shower was dirty, stained, and there was a brown substance on the floor. She stated she was not sure what the brown substance was. Interview with the DON, on 08/10/17 at 10:30 AM, revealed residents should have their own supplies and should be taken to the shower room with them when they were given their showers. The DON further revealed it was an infection control problem when the same items were used for different residents because germs could be passed from resident to resident. She revealed the items should be labeled and there should not be any community items such as the lotions, creams, shampoos, and hairbrushes available in the drawer in the shower room. The DON stated the environmental department cleaned the shower room. Interview with the Environmental Services Supervisor, on 08/10/17 at 1:30 PM, revealed the showers rooms were cleaned daily. He stated staff swept and mopped with sanitizer every day. The Environmental Services Supervisor revealed his staff had a checklist they followed every day and turned in to him. He reviewed the checklist, which revealed the housekeeping staff had documented they mopped the Marmion shower floor on 08/09/17. He revealed that normally, he made rounds to be sure the checklist was correct, but had not been in the Marmion shower room for a couple of days. Interview with the Executive Director, on 08/10/17 at 1:00 PM, revealed the Environmental Services Supervisor should audit the areas by walking through the areas and making sure they were clean and not in need of repair. 3. Review of the facility's policy, Handwashing, dated January 2006, revealed the purpose of the policy was to provide guidelines to employees for the proper and appropriate handwashing techniques that would aid in the prevention of the transmission of infections. The objective was to prevent the spread of infectious diseases. Hands should be washed with warm water and soap after three (3) to four (4) uses of the waterless antiseptic, before performing invasive procedures, before preparing or handling medications, after handling used dressing, specimen containers, and contaminated tissues. Hand washing should be done after contact with blood, bloody fluids, secretions, excretions, mucous membranes, and broken skin. Hand washing should be done after handling items potentially contaminated with a resident's blood, body fluids, excretions, secretions, and after removing gloves. The policy further revealed handwashing was the single most important aspect of infection control. Observation of the breakfast meal, on 08/09/17 at 8:35 AM, in the Marmion dining room, revealed staff went from assisting one resident to assisting another resident, without sanitizing or washing their hands. Staff set up the plate, cut the food, and positioned a resident, and then assisted another resident without performing hand hygiene. Throughout the breakfast meal, staff that assisted residents with their breakfast meal did not wash or sanitize their hands. Interview with Wait Staff #1, on 08/09/17 at 08:35 AM, revealed he did not have any hand sanitizer. Interview with CNA #2, on 08/09/17 at 3:00 PM, revealed staff should sanitize hands after helping each resident with their meal especially when cutting up food, positioning residents, and setting up their plates. She further revealed there was no sanitizer in the dining area and staff did not carry sanitizer in their pocket. CNA #2 further stated she had not sanitized her hands and it was an infection control problem because bacteria could pass from resident to resident if hands were not sanitized. Interview with the Unit Coordinator/Restorative Nurse, on 08/09/17 at 3:55 PM, revealed staff that assisted residents should have washed their hands or sanitized them if they had cut up food or touched a resident, before assisting another resident. She further revealed if a staff member had repositioned a resident, they should have washed their hands before they assisted another resident. The Unit Coordinator/Restorative Nurse stated there was no sanitizer in the Marmion dining room and the sink for washing hands was behind the nurses' station. She stated it was an infection control issue because if staff touched a resident and then touched another resident, they could contaminate the other resident and their food. Interview with the DON, on 08/10/17 at 10:30 AM, revealed staff should have sanitized their hands after contact was made with each resident and then they should have washed their hands. In addition, the DON revealed staff not sanitizing or washing hands was an infection control issue. She revealed washed and sanitized hands helped reduce the spread of infection from resident to resident. Interview with the Executive Director, on 08/10/17 at 01:00 PM, revealed the facility did not have any type of audit tool to monitor staff sanitizing their hands during meal times.