Every finding on record at The Seasons at Alexandria

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's documents, policies, and procedure, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the total census of 99 residents. On [DATE], the Local Health Department (LHD) informed the facility that Resident (R) 121 had been diagnosed with Legionnaire's disease while in the hospital. Testing conducted by a third-party water specialist revealed positive areas for legionella in the facility. On [DATE] uncontrolled levels of growth were identified in the hot shower of room [ROOM NUMBER] and in the cooling tower. Before this incident, there was no written water management program in place, and the facility was not actively flushing dead legs (an area of piping system where fluid flow was minimal or nonexistent) in the water system. The resident passed away at the hospital on [DATE]. Additionally, observation on [DATE] of Registered Nurse (RN) 3 revealed she failed to clean and disinfect a glucometer according to the facility's policy, the manufacturer's instructions, and the recommended dwell time for the sanitizing wipe.Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE], in the area of 42 CFR 483.80 Infection Control, F-880 at a Scope and Severity (S/S) of an L. The facility's Administrator was notified of the IJ on [DATE].The facility provided an acceptable Immediate Jeopardy Removal Plan, on [DATE], alleging removal of the IJ on [DATE]. The State Survey Agency (SSA) determined the IJ had been removed on [DATE] as alleged, prior to exit on [DATE], with remaining non-compliance at a S/S of an F. The findings include:Review of the Centers for Disease Control and Prevention (CDC) document Clinical Guidance for Legionella Infections, dated [DATE], revealed minimizing Legionella growth in complex building water systems and devices was key to preventing infection. The CDC recommended healthcare facilities develop and implement comprehensive water management programs (WMPs). Review of the facility's policy titled, Infection Prevention and Control Program, revised [DATE], revealed the facility created and maintained an infection prevention and control program. Per the policy, the Infection Prevention and Control Program [IPCP] was designed to prevent the development and transmission of communicable diseases and infections, in accordance with national standards and guidelines.Review of the facility's policy titled, Legionella Surveillance, revised [DATE], revealed the facility would establish primary surveillance (approaches to prevent and control legionella infections with no identified cases). The primary surveillance strategies included routine maintenance of the cooling towers; however, the policy did not address routine flushing of empty rooms. According to the policy, legionella surveillance was one component of the facility's water management plan for reducing the risk of legionella and other opportunistic pathogens in the facility's water system. Review of sign-in sheets for staff education titled, Legionella Awareness and Prevention, dated [DATE], revealed staff was responsible for helping to prevent Legionella by following the facility water management plan and regularly running water at sinks and showers in low-use rooms.1. Review of an admission Record, found in R121's Electronic Medical Record (EMR), revealed the facility admitted Resident (R) 121 on [DATE], with diagnoses to include unspecified cerebrovascular disease with aphasia, type 2 diabetes mellitus, and occlusion and stenosis of left carotid artery.Review of R121's hospital records revealed the resident was admitted to the local hospital on [DATE], with diagnoses to include atrial fibrillation with rapid ventricular response, congestive heart failure, and acute respiratory failure with hypoxia. The resident's vital signs included a blood pressure reading of 80/70 millimeters of mercury (mm/Hg), temperature of 100.4 degrees Fahrenheit, and a peripheral capillary oxygen saturation (SpO2) of 87 percent. A chest radiography, dated [DATE], revealed right peripheral infiltrate, suspect pneumonia. A urine antigen test, dated [DATE], was positive for legionella.Review of the entry Minimum Data Set [MDS], found in R121's EMR with an assessment review date (ARD) of [DATE], revealed staff did not assess R121's long- and short-term memory. The resident could not complete the Brief Interview for Mental Status [BIMS] and was documented as 99. Review of the Care Plan Report, found in R121's EMR and dated [DATE], revealed R121 was care planned to discharge from the facility to the community/private residence after skilled nursing services concluded. Additionally, the resident was care planned to be resuscitated in the event of cardiac arrest.Review of the hospital's Critical Care Consult Note, dated [DATE] to [DATE], revealed R121 was admitted to the intensive care unit (ICU) on [DATE] with diagnoses that included atrial fibrillation, acute hypoxic respiratory failure, and pneumonia complicated by sepsis and septic shock. According to the physician's notes, critical care was necessary because one or more vital organ systems were impaired, leading to a high probability of imminent or life-threatening deterioration in R121's condition. According to the notes, R121 was critically ill with overwhelming infection. The resident transitioned to a do not resuscitate (DNR) code status on [DATE], and R121 expired on [DATE]. Further review of hospital records revealed R121's chest radiograph, dated [DATE], revealed the resident had right perihilar infiltrate, suspect of pneumonia, and R121's urine antigen test, dated [DATE], revealed the resident had tested positive for Legionella.During an interview with the Administrator on [DATE] at 4:34 PM, she stated that prior to [DATE] the facility did not have a WMP in place. She stated a plan was developed by the third-party contractor in late [DATE].During an interview with the Director of the Local Health Department (LHD) on [DATE] at 4:17 PM, he stated the LHD was contacted by the local hospital regarding R121, who had tested positive for Legionnaire's disease on [DATE]. The Director stated, We reached out to the facility on [DATE] to inform them of the positive findings. When asked about where R121 might have contracted the disease, he said, He could have been exposed at the facility, adding, I definitely wouldn't rule that out. The LHD did not identify any other potential exposures for R121. He stated the cooling tower could be a potential source, as it had shown positive results for legionella for the longest duration. He further explained that the mist from the cooling tower was released outside, creating a situation where staff and residents coming and going from the facility would have been exposed. He stated, under certain weather conditions, wind could carry aerosols, which could lead to exposure just by persons being in the vicinity of the cooling tower. During an interview with the Infection Preventionist (IP) on [DATE] at 3:00 PM, she stated when the resident was sent to the local hospital's emergency room, he exhibited no respiratory issues; his primary concern was hypertension. The IP stated the facility did not diagnose him with pneumonia and noted the onset of symptoms was rapid. She stated the resident had been admitted to the facility from a local hospital and had only been at the facility for about a week. She stated on day four or five of his stay, he experienced a change in condition, presenting symptoms that included low blood pressure, an increased heart rate, and oxygen saturation levels that dropped to 87 percent. She stated the facility transferred the resident to the local hospital on [DATE], and the local health department informed the facility that R121 had been diagnosed with Legionnaires' disease. She stated the health department also conducted a legionella risk assessment, which found the acidity (pH) and chlorine levels of the facility's water were not within normal limits. During continued interview on [DATE] at 3:00 PM, the IP stated, on [DATE], the facility hired a third-party contractor specializing in water testing to conduct facility-wide testing to identify any potential sources of Legionella bacteria within the facility. She stated the testing confirmed that the cooling tower and the hot shower in room [ROOM NUMBER] tested positive for legionella pneumophila serogroup 1 (strain that causes Legionnaire's disease). The IP stated, on [DATE], the facility conducted a video call with the local health department and a third-party contractor to discuss the results of testing. During the call, she stated, the facility received specific protocols to follow, which included guidelines for flushing procedures. She stated as part of the local health department guidelines she was trained on legionella through video instruction. She stated staff received general infection control, not just Legionella specific training annually and quarterly. She stated the last training specific to Legionella was in [DATE]. When asked by the State Survey Agency (SSA) Surveyor as to what environmental controls the facility had in place to prevent the growth of Legionella before [DATE], she stated that prior to the local health department performing a Legionella Environmental Assessment Form (LEAF) assessment for the facility on [DATE], the facility did not have a water management program (WMP) in place and had not completed the CDC's LEAF assessment. She stated maintenance was testing water temperatures, but she did not know if water flushing protocols were in place. During an interview with the Certified Legionella Expert (CLE) on [DATE] at 8:48 AM, he stated the facility hired his company to investigate sources of Legionella. The CLE stated that he wrote the WMP, including a schematic of the water flow, for the facility in [DATE]. He stated the facility did not have a WMP in place when he was brought in as a consultant. He stated he continued to provide consultation and water testing services. He stated he was a member of the facility's WMP team. Per the interview, he said he conducted water temperature checks and tested the facility's water every two weeks. In addition to the WMP, the CLE stated he conducted a LEAF assessment, which the CDC provided to help facilities gain a comprehensive understanding of their water systems and aerosolizing devices, assisting them in minimizing the risk of Legionnaires' disease. Additionally, the CLE stated samples taken on [DATE], resulted in two positive findings of legionella pneumophila in the hot shower head of room [ROOM NUMBER] and in the cooling tower. He stated the hot shower in room [ROOM NUMBER] tested at 66 colony-forming units (CFUs), while the cooling tower tested at 1500 CFUs, which indicated uncontrolled legionella growth. The CLE stated while the cooling tower was being treated, two further treatments were required for proper remediation. According to the CLE, the latest testing, conducted on [DATE], showed negative results for Legionella pneumophila.During an interview with the Maintenance Director on [DATE] at 5:16 PM, he stated prior to the local health department informing the facility about a positive case of Legionella, there was no active water management plan (WMP) in place. He stated the facility hired a third-party contractor who provided a WMP in [DATE]. Additionally, the Maintenance Director stated staff began flushing empty rooms after [DATE], and the maintenance department continued to flush water in empty rooms.During an additional interview with the IP on [DATE] at 10:10 AM, she stated the Legionella education in [DATE] consisted of slides and verbal education provided during a staff meeting. She stated no written tests were provided to gauge staff comprehension. However, she stated she had provided questions for group discussion.During an interview with Registered Nurse (RN) 6 on [DATE] at 9:28 AM, he stated he provided education to staff regarding Legionella, including its symptoms, in [DATE]. RN6 stated the IP and the Administrator educated him on the topic. He stated he was unsure when staff had received education specific to Legionella prior to 2025. During an interview with the Director of Nursing (DON) on [DATE] at 2:10 PM, he stated the WMP was on the Quality Assurance and Performance Improvement (QAPI) Committee's agenda, but he had not had direct involvement with the WMP team. He stated the QAPI Committee met today for an ad-hoc meeting to discuss the latest Legionella test results. During an interview with the Administrator on [DATE] at 3:08 PM, she stated she was concerned about the detection of Legionella in room [ROOM NUMBER] and in the cooling tower, and once the facility was notified by the local health department, they hired a third-party contractor to assist with testing and to create a WMP. The Administrator stated after the WMP was fully implemented, in-house staff was assigned specific responsibilities to monitor water temperatures, flush unused lines, and maintain the cooling tower. She stated that adhering to infection control policies and guidelines was important for ensuring the safety and well-being of residents, staff, and visitors.During a telephone interview with the Medical Director on [DATE] at 2:59 PM, she stated she regularly attended QAPI meetings to address water quality. She stated it was her expectation that staff followed CDC guidelines and facility policies to prevent infections. The Medical Director stated the importance of infection control was to ensure the residents' health and safety.Review of the facility policy titled, Blood Glucose Monitoring, dated 11/2024, revealed nurses were required to adhere to infection control practices to include cleaning and disinfection of the glucometer according to the manufacturer's instructions. Review of the facility's procedure titled, Blood Glucose Monitoring Device Disinfection, reviewed [DATE], revealed blood glucose monitoring devices would be disinfected according to the manufacturer's recommendations between uses. However, the procedure did not address the manufacturer's sanitation wipe recommendations for dwell time.2. Observation and interview on [DATE] at 6:35 AM on the Maple Unit revealed RN3 approached the nurses' desk and placed a contaminated glucometer down without using a barrier cloth to prevent contamination. She then took out a disinfectant wipe, cleaned the glucometer for approximately 30-seconds, and set it back down on the nurse's desk without placing it on a barrier cloth. When asked about the process for cleaning and disinfecting the glucometer, she stated she used a disinfectant wipe to clean it and then let it dry before putting it back in the medication cart. RN3 showed the SSA Surveyor a bleach wipe that had a three-minute kill time. However, when asked what kill time or dwell time meant, she was unable to answer. RN3 stated she did not realize the glucometer needed to remain wet for the entire three minutes to ensure proper disinfection. Additionally, she stated she was unaware she should place the glucometer on a barrier cloth to prevent cross-contamination. RN3 stated the glucometer was shared equipment and was available for any resident who required fingerstick testing for glucose. RN3 stated following IPCP guidelines was important to prevent disease and the spread of infection. During an interview with the Staff Educator (SE) on [DATE] at 2:10 PM, she stated nursing staff was educated to properly clean and disinfect the blood glucose monitors according to manufacturer's instructions and according to the disinfectant wipe dwell-time. She stated staff was instructed to wipe the glucometer after each resident tested, ensuring that it was thoroughly wiped down, and then allow it to dry in place. She stated the equipment should be placed on a barrier cloth to prevent contamination and the spread of blood-borne pathogens. During an interview with the Director of Nursing (DON) on [DATE] at 2:10 PM, he stated that following the guidelines of the IPCP was a team effort. He stated it was his expectation for nursing staff to properly clean and disinfect the blood glucose monitors according to manufacturer's instructions and according to the disinfectant wipe dwell-time. The DON stated that was important to prevent the spread of blood-borne pathogens. During an interview with the Administrator on [DATE] at 3:08 PM, she stated it was her expectation that staff followed the facility's infection control policies to prevent the spread of infection to residents and staff.The facility provided their Immediate Jeopardy (IJ) Removal Plan on [DATE] verbatim:1. Corrective Action for Residents Affected: All residents with symptoms of pneumonia were tested via urine antigen test for Legionnaires' disease initiated [DATE]. No positive cases were identified at the time of testing. Out of an abundance of caution, the resident in room [ROOM NUMBER] Assisted Living was relocated to room [ROOM NUMBER] Assisted Living on [DATE] related to a positive test result in the shower head in room [ROOM NUMBER] (See Exhibit A). Urine Antigen Test done and Respiratory Monitoring put into place (See Exhibit B). Water outlets in room [ROOM NUMBER] were flushed, and the showerhead was replaced on [DATE] (See Exhibit C).2. Identification of Others at Risk: A comprehensive risk assessment was completed by the Northern Kentucky Health Department to identify all residents, staff, and visitors potentially exposed on [DATE] (Exhibit D). Water samples were collected from all facility wings to determine the scope of contamination on [DATE] by Legionella Control Systems, Inc. (Exhibit E). Residents, families, and staff were notified and educated about signs, symptoms, and transmission risks of Legionella on [DATE] (Exhibit F).3. Systemic Changes to Prevent Reoccurrence: [DATE] -A Legionella Environmental Assessment Form (LEAF) Assessment was conducted in partnership with the Northern Kentucky Health Department. [DATE] - The facility's Infection Preventionist completed additional training on Legionella guidance (Exhibit 0). [DATE] - Flushing protocols were implemented facility-wide and are documented and monitored. (Exhibit I). A Legionella Surveillance Log was established and will be monitored by Infection Preventionist (Exhibit Z). [DATE] - Site visit conducted by Legionella Control Systems; Risk Assessment, Engineering Report, and on-site water testing performed (Exhibit G). [DATE] - Video Call with Legionella Control Systems to go over findings (Exhibit H). [DATE] - Positive Results Bl 158 Hot Shower and Cooling Tower. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit E). [DATE]-Notified ChemSearch of the need for inspection and evaluation of water safety procedures. [DATE] - ChemSearch added Bio-Xile and Chlorine Pellets to cooling tower (Exhibit J). [DATE] - Testing repeated (Exhibit K). [DATE] - 12 month Surveillance Legionella started per Northern Kentucky Health Department. [DATE] - Staff Development provided education to staff including Legionella (Exhibit S). [DATE] - Staff Development continued education (Exhibit S). [DATE] - COO sent out message to staff, residents, families about Legionnaires' Disease (Exhibit Y). [DATE] - Reported to Office of Inspector General via telephone. [DATE] - Positive Results Mech Room Tower. Relevant parties informed (Exhibit K). [DATE] - Corporate Maintenance contacted OBR Cooling Towers (OBR) to schedule a cleaning and sanitization of the cooling tower. [DATE] -Notified Solid Blend, a certified water management company, for consultation and services. [DATE] - Shower Head disinfecting put in place. Started by maintenance [DATE], completed [DATE]. To be done every 6 months (Exhibit M). [DATE] - Solid Blend conducted a separate LEAF assessment and sampled water (Exhibit N). [DATE] - Kentucky Health Department came to facility to discuss risk assessment with Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer. [DATE] - LEAF Assessment Final Report shared Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer. (Exhibit N and H). [DATE] - Positive Result Cooling Tower Basin. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit Q). [DATE] - ChemSearch adjusted chemicals in cooling tower; chemical treatment changed to daily (Exhibit R). [DATE] - Water testing (Exhibit T). [DATE] - Building Maintenance added Float Chlorine to cooling tower. [DATE]-Positive Results Cooling Tower Basin. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit T). [DATE] - Disinfectant concentration monitoring (Maintenance). [DATE] - Water testing (Exhibit U). [DATE] - Water management team reported to QAA committee. Committee members include the Medical Director, Administrator, Infection Preventionist, Social Services, Environmental Services Director, Building Maintanance [sic], Director of Nursing. Also present was Chief Operating Officer. [DATE] - Bioxide Added (Maintenance). [DATE] - Positive Results Water Tower. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit U). [DATE] - Call out to ChemSearch. [DATE] - Water Testing (Exhibit V). 7/!5 [sic]/2025 -Negative Results. Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit V). [DATE] - Water Testing (Exhibit W). [DATE] - Water Management Plan Completed. [DATE] - Negative Results Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit W). [DATE] - Water Testing (Exhibit X). [DATE] - Negative Results Corporate Maintenance, Building Maintenance Director, Administrator, Director of Nursing, Infection Preventionist, [NAME] President Chief Operating Officer, Northern Kentucky Environmental Health Coordinator made aware (Exhibit X). [DATE] -Ad Hoc QAPI meeting held with QAA committee to discuss Water Sample results and Timeline.4. Date of Compliance:IJ removal by: [DATE]

Based on observation, interview, and review of facility policies, the facility failed to ensure food items located in dry storage, the walk-in refrigerator, the number five kitchen reach-in refrigerator, and unit nourishment refrigerators were properly labeled and dated, and that expired food items were discarded. This deficient practice affected all 99 current residents.The findings include:Review of the facility's policy titled, Food and Supply Storage, revised 01/2024 revealed foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded. Further review revealed unused portions and opened packages of food should be covered, labeled, and dated.Observation during an initial brief kitchen tour on 08/12/2025 at 10:53 AM revealed one pork ham with a discard date of 08/11/2025 located in the walk-in refrigerator; an undated, opened package of devil's food cake mix, an undated, opened 11 pound tub of chocolate fudge icing, and an expired loaf of bread located in dry storage; and an expired container of italian salad dressing located in the number five reach-in refrigerator.Observation of the Maple Unit nourishment refrigerator on 08/13/2025 at 2:02 PM revealed one container of yogurt with a best-by date of 08/06/2025.Observation of the Dogwood Unit nourishment refrigerator on 08/13/2025 at 2:30 PM revealed one container of yogurt with an expiration date of 05/11/2025, one chocolate pudding cup with an expiration date of 08/03/2025, and one chocolate pudding cup that had burst opened and leaked out of the container.Observation of the Magnolia Unit nourishment refrigerator on 08/13/2025 at 2:38 PM revealed eight containers of gelatin with an expiration date of 10/2024, one container of gelatin with an expiration date of 01/2024, two containers of gelatin with expiration dates of 02/2025 and 07/2025, and one container of gelatin with an expiration date of 11/29/2023.Observation of the Walnut Unit nourishment refrigerator on 08/13/2025 at 2:49 PM revealed one bottle of french salad dressing with an expiration date of 05/2025, a four-serving snack pack of gelatin with an expiration date of 10/22/2024, and one bottle of mustard with a best-by date of 06/13/2024.Observation of the [NAME] nourishment refrigerator on 08/13/2025 at 3:14 PM revealed three 4-ounce containers of orange juice with a best-by date of 08/09/2025.During an interview with Patient Server 1 on 08/13/2025 at 1:58 PM, she stated she had not been instructed to check nourishment refrigerators for expired items. During an interview with Dietary Checker 1 on 08/13/2025 at 2:02 PM, she stated it was primarily the responsibility of the Chef to ensure items were labeled and dated when received from the food truck. She further stated when items were received from the truck, they were marked with a sticker that contained the received date. She stated when items were opened, they were marked with a sticker that contained the opened date. Dietary Checker 1 stated any expired food items should be thrown away immediately to prevent residents from getting sick. During an interview with Dietary Runner 1 on 08/13/2025 at 2:05 PM, he stated he placed the meal trays in the boxes and delivered them to the floors. He further stated that on a typical day there were three runners, and one of those runners was designated to check the nourishment refrigerators on the units. Dietary Runner 1 stated if expired or unlabeled items were found in the refrigerators, they were immediately discarded, and the supervisor was notified. Dietary Runner 1 stated it was important expired food items were discarded and not served to residents to prevent sickness. During an interview on 08/13/2025 at 2:15 PM, the Executive Chef stated he unloaded the truck and was primarily responsible for ensuring items were labeled and dated, but every dietary staff member was responsible for ensuring expired food items were not left on the shelf. The Executive Chef stated everything that came off the truck was given a received date label unless it contained an expiration date. He further stated individual items were each labeled with an opened and a discard date. The Executive Chef stated checking for expired items in the kitchen was a shared responsibility, and the nutrition refrigerators on the units were checked at least once a week. He further stated out-of-date or expired items could potentially cause sickness to residents if they were ingested.During an interview on 08/13/2025 at 2:22 PM, the Culinary Manager stated when staff removed items from the delivery truck, the box or container was marked with a received date. She further stated when staff removed a food item from its case, the item was labeled with both an opened date and a discard date. The Culinary Manager stated that runners usually checked the unit nourishment refrigerators for expired items when they stocked them with new items, and dietary management checked them weekly. When asked about the number of expired items discovered, the Culinary Manager stated she was unsure how they were missed, but it was important the residents were not served outdated items because of the potential for food borne illnesses. During an interview on 08/15/2025 at 11:30 AM, the Director of Nursing (DON) stated he expected dietary staff was aware and observed that food items were labeled and dated appropriately and not kept past their expired date for both the kitchen and the unit nourishment refrigerators. The DON stated it was important the residents were not served expired foods for their health and wellness and for the prevention of sickness. During an interview with the Administrator on 08/13/2025 at 2:29 PM, she stated it was her expectation that all food items in the facility were properly labeled and dated and expired items were discarded. She further stated it was important expired foods were discarded and not served because of the possibility of food borne illness to the residents.

Based on observation, interview, and review of the facility's document and policies, the facility failed to ensure medications designed for multiple administrations were labeled to identify the specific resident for whom it was prescribed and/or the date the medication was opened in 1 of 7 sampled medication carts for the Maple Unit. Additionally, the facility failed to ensure the provision of appropriate environmental controls to preserve the integrity of medications in 1 of 7 sampled medication refrigerators, the Maple Unit medication storage refrigerator. Also, the facility failed to ensure when medications were prepared or compounded for use, a label containing the required information was attached to the compounded medication label for 1 of 1 sampled resident, Resident (R) 56 The findings include:Review of the facility's policy titled, General Dose Preparation and Medication Administration, last revised date [DATE], revealed staff should enter the date opened on the label of medications with shortened expiration dates. Additionally, staff should not administer a medication if the medication prescription label was missing or illegible.Review of the facility's policy titled, Storage and Expiration Dating of Medication and Biologicals, last revised date [DATE], revealed when an ophthalmic solution or suspension had a manufacturer shortened beyond use date once opened, staff should record the date opened and the date to expire on the container. Additional review revealed the facility should ensure medications and biologicals were stored at their appropriate temperatures according to the United States Pharmacopeia (USP) guidelines for temperature ranges and manufacturer guidance. Refrigeration parameters were documented as 36 to 46 degrees Fahrenheit (F).Review of the facility's document Refrigerator/Freezer Temp Log included directions to record temperatures at 6:00 AM and 6:00 PM upon shift change. 1. Observation on [DATE] at 2:15 PM of the Dogwood Unit Medication Cart revealed opened medications of one Fluticasone nasal spray, one Lantus insulin pen, one Humalog insulin pen, one tube of Erythromycin 5 milligram per gram eye ointment, one bottle of Atropine 1% eye drops, one bottle of Brimonidine 0.2% eye drops, and one Albuterol inhaler. Those medications were not labeled to identify the specific resident for whom it was prescribed and/or the date the medication was opened.2. Observation on [DATE] at 7:00 AM revealed the medication storage refrigerator on the Maple Unit's facility thermometer measured the temperature inside the refrigerator was 20 degrees Fahrenheit (F). One unopened bottle of Tuberculin purified protein derivative (PPD) was stored on the door shelf. Additionally, three unopened bottles of Latanoprost Ophthalmic Solution 0.005 % with fill dates of [DATE], [DATE], and [DATE] were also stored in the refrigerator. However, review of the medication refrigerator temperature log revealed no temperature was documented for [DATE] at 7:00 AM.During an interview on [DATE] at 7:00 AM with Registered Nurse (RN) 3, she stated the refrigerator was temperamental, and she would check it throughout the day. She stated she should have notified maintenance related to the refrigerator not working, but she did not. During an interview on [DATE] at 10:27 AM with Kentucky Medication Aide (KMA) 8, she stated the nurses were responsible for logging the refrigerator temperatures.During an interview on [DATE] at 6:25 AM with Licensed Practical Nurse (LPN) 7, she stated all the nurses were responsible for checking the medication refrigerator temperatures. LPN7 further stated on night shift, she usually checked the temperature around midnight after the residents were in bed, and things were quiet. LPN7 stated she did not know what nursing supervisor was responsible for managing the medication room and refrigerators.During an interview on [DATE] at 10:26 AM, the Unit Manager (UM) stated she had been at the facility for 15 years and temperatures in the refrigerators on the unit were checked once a day by the nurses. The State Survey Agency (SSA) Surveyor showed the log to the UM with directions for twice a day, and she stated, Oh. 3. Observation on [DATE] at 10:28 AM of the Walnut Unit medication refrigerator revealed a 250-milliliter bag of normal saline labeled mixed in black marker but was unlabeled as to resident and what was mixed in the bag.During an interview 0n [DATE] at 10:28 AM with LPN4, she stated the bag in the medication refrigerator on the Walnut unit marked mixed with black marker belonged to Resident (R) 56 and contained the drug gentamycin which was used in his suprapubic catheter once a day. When asked how she knew what was contained in the unlabeled bag and who the unlabeled bag was for, she stated she had added the gentamycin to the bag that morning per pharmacy instructions. LPN4 further stated she and one other day shift nurse were the only nurses to instill the medication into the resident's bladder, and they both knew who the medication in the bag was for. LPN4 further stated a label for the medication came from pharmacy, but she did not place it on the bag after she mixed it, and she knew the medication was good for one week after mixed if kept in the refrigerator. LPN4 stated she could see if another nurse picked up the bag and did not see a label on it, that nurse would not know what was in the bag, which was not safe, and could cause a medication error.During an interview on [DATE] at 9:45 AM with LPN6, she stated the instructions for mixing of R56's irrigation solution for his suprapubic catheter came on a label on the bag of the gentamycin vials. LPN6 stated there were several bottles within the bag, and she would not remove the label on that bag to place it on the mixed bag she prepared for R56. She stated she would create a separate label for the mixed bag with R56's name on it with the contents of the bag, the day and time she mixed it, and her initials. LPN6 stated if she came to work and found a bag in the refrigerator, unlabeled with the word mixed on it, she would not use it because that was not safe for the resident and could result in a medication error. During an interview on [DATE] at 11:41 AM with the Staff Development Coordinator (SDC) she stated she educated nursing staff to the labeling of compounded medications in the annual Medication Administration skills fair. Per the interview, she stated any compounding education would have included the labeling of the compounded medication with the resident's name and room number, date of compounding, contents, dosing information, usage instructions and the initials of the person who compounded or mixed the medication. She stated the storage of an unlabeled compounded medication could lead to many things happening, and avoiding medication errors and resident safety should be the staff's first concern. During an interview on [DATE] at 12:44 PM with the Pharmacist, he stated the gentamycin for R56 was delivered to the facility in two 40 milligram (mg) per milliliter (ml) per two ml vials and included directions for staff to mix 3 ml into a 250 ml bag of 0.9 Normal Saline (NS). The Pharmacist then stated the resulting drug mixture in the 250 ml bag would be stable at room temperature for 24 hours and stable in the refrigerator for seven days. The Pharmacist further stated since R56 received 60 ml of the medication from the 250 ml bag each day, the bag would be good for four days, and the remaining 10 ml in the bag would be discarded after the dose was delivered on the fourth day. Additionally, the Pharmacist stated the facility was responsible for monitoring and auditing the medication rooms and carts for expired or discontinued medications, as that task was not included in the contract the pharmacy had with the facility. During an interview on [DATE] at 1:05 PM with the Director of Nursing (DON), he stated the responsibility for maintaining the cleanliness of the refrigerators, checking the temperatures of the refrigerators and the monitoring for the labeling of medications and the removal of expired and discontinued medication was whomever was assigned to the medication cart that day. The DON further stated the storage of medications in the refrigerator at the proper temperature, and the labeling of medications was important for the safety of the residents to avoid medication errors.During an interview on [DATE] at 2:40 PM with the Administrator, she stated the floor nurses were responsible for the monitoring of the residents' medication and the residents' supplement refrigerators located in the unit medication rooms both for temperature and cleanliness. She stated the Nurse Manager on the unit was responsible for ensuring the temperature logs and the refrigerators were being maintained. The Administrator stated it was her expectation all medications that had been opened were labeled with an opened date to ensure they would be used and disposed of properly. Additionally, the Administrator stated she expected any mixed or compounded medication to be labeled with the resident's name, the name of the medication, and dosage. Finally, the Administrator stated her concern with undated and unlabeled medication was the possibility the medication would be ineffective or cause harm to the resident.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal and oral hygiene for 1 of 2 residents investigated for ADLs, Resident (R) 122.The findings include:Review of the facility's policy titled, Activities of Daily Living (ADLs), dated 10/23/2024, revealed, The facility will provide care and services for activities of daily living including, bathing, dressing, grooming and oral care. Further review revealed, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of R122's admission Record revealed the facility admitted the resident on 08/08/2025 with diagnoses including COVID-19 and syncope.Review of R122's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/15/2025, revealed the facility assessed to resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Further review revealed R122 required partial to moderate assistance with showering. Review of R122's Comprehensive Care Plan, dated 08/08/2025, revealed a focus of impaired ADL function and need for assistance with self-care activities. Further review revealed an intervention for partial/moderate assistance with toileting, transfers, bathing, dressing, and grooming.Review of R122's ADL Charting revealed the section Resident Received a Shower was marked Yes for 08/11/2025. Observation on 08/12/2025 at 12:15 PM revealed signage outside of R122's room that indicated the resident was in droplet/contact precautions.During an interview with R122 on 08/12/2025 at 4:04 PM, she stated she was in isolation for an infection with COVID-19, and staff informed her they were not allowed to assist her with a shower in her room until her precautions were lifted. She further stated staff helped her clean up with wipes, but she wanted a shower because she came to the facility after a hospital stay. She further stated she had not had a shower in a while and needed one.During an interview with Family Member (FM) 9 on 08/14/2025 at 6:57 PM, she stated she was informed by Registered Nurse (RN) 4 that staff was unable to assist R122 with a shower until the resident came out of isolation. FM9 stated she did not quite understand, but when told it was the facility's policy, she accepted that. During an interview with State Tested Nurse Aide (STNA) 4 on 08/13/2025 at 3:29 PM, she stated R122 was on precautions for COVID-19, and she was not allowed to assist with showers when residents were on droplet precautions for COVID. STNA4 stated she was given that information by one of the nurses but was unable at the time to remember which nurse. STNA4 stated she helped R122 clean up with wet wipes.During a follow-up interview with STNA4 on 08/14/2025 at 11:29 AM, she stated she had not cared for a resident that was COVID positive and asked RN4 for guidance. STNA4 further stated RN4 informed her it was facility protocol that residents were not assisted with showers until they were out of droplet precautions. During an interview with RN4 on 08/15/2025 at 9:03 AM, she stated the facility protocol for staff when they provided ADL assistance to COVID positive residents was to follow precautions and properly don (put on) and doff (remove) the appropriate personal protective equipment (PPE). RN4 stated, in the past, the facility protocol was staff provided bed baths instead of showers to residents who were COVID positive, particularly if they were symptomatic. RN4 further stated she had communicated that information to the aides because that was her understanding of the process. Also, she stated R122 was not symptomatic.During an interview with Licensed Practical Nurse (LPN) 1 on 08/13/2025 at 4:00 PM, she stated it was not the facility's policy that residents were given a bed bath only and no shower when they were on droplet precautions for COVID.During an interview on 08/15/2025 at 9:18 AM, the Infection Preventionist (IP) stated it was her expectation staff used a gown, mask, and gloves when they provided care to residents with COVID. Further, she stated there had been situations in the past where the doctors did not want the resident(s) to have a shower if the resident(s) was symptomatic. Further, she stated R122 was asymptomatic, and it was not applicable to her.During an interview at 08/15/2025 at 11:30 AM, the Director of Nursing (DON) stated it was his expectation that staff was familiar with each resident's care plan/Kardex, and staff followed those care guides and ensured residents' needs were met and ADLs completed. He further stated there was no specific policy for showers for residents with COVID, but rather a practice they instituted at the height of the COVID pandemic. However, he stated the practice addressed residents individually based on symptoms. He stated R122 should not have been denied a shower because she was asymptomatic. The DON stated he was not sure why the STNA told R122 she was unable to assist her with a shower. He stated it was possibly related to information provided to her by another staff member related to old COVID policies. During an interview on 08/15/2025 at 3:07 PM, the Medical Director stated she generally recommended that staff avoid showers for COVID residents, especially if they had an active cough or were otherwise symptomatic. She stated she still preferred the original CDC guidelines for COVID, but determinations were made on a case-by-case basis, and ultimately, the resident's wishes were honored at the facility.During an interview on 08/15/2025 at 2:29 PM, the Administrator stated she expected staff to provide ADL assistance to residents with COVID in a safe manner by wearing PPE. When asked if there were limitations on the type of assistance provided to COVID positive residents by staff, she stated it was decided on a case-by-case basis. She further stated the Medical Director typically did not want COVID positive residents showered. She stated the Medical Director's decision was based on the Centers for Disease Control and Prevention (CDC) recommendations during the COVID pandemic. The Administrator further stated the facility honored resident preferences, and if they wanted a shower, they were given a shower. The Administrator stated she was unaware that R122 requested a shower and was not given one.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs for five of five sampled residents, Resident (R) 4, R37, R38, R40, and R41. R4, who was left unsupervised outside in 90-degree weather for 30 to 45 minutes on 08/04/2024 required a transfer to the Emergency Department (ED) for evaluation of mental status changes and a temperature of 105 degrees Fahrenheit (F) and as of 08/07/2024, the resident had not yet returned to the facility. Review of R4's Comprehensive Care Plan (CCP) revealed no care plan interventions in place for supervision while he was outside. Additionally, it was reported by staff R4 went outside to the courtyard daily with R37, R38 and R40. R38, R40, and R41 were observed by the State Survey Agency (SSA) Surveyor outside the facility in the courtyard on 08/07/2024. However, review of CCPs for R37, R38, R40 and R41 revealed no interventions in place for supervision when outside. The facility's failure to have an effective system in place to ensure development and implementation of a comprehensive person-centered care plan is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) was identified on 08/09/2024 at 42 CFR 483.21 Develop and Implementation of a Comprehensive Person-Centered Care Plan (F656) with a Scope and Severity (S/S) of a J. The Immediate Jeopardy was determined to exist on 08/04/2024. The facility was notified of Immediate Jeopardy on 08/09/2024. An acceptable Immediate Jeopardy Removal Plan was received on 08/13/2024, which alleged removal of the Immediate Jeopardy on 08/14/2024. The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 08/14/2024, prior to exit on 08/14/2024. Non-compliance remained in the areas of 42 CFR Comprehensive Care Planning (F656) at a Scope and Severity (S/S) of an E while the facility monitors the effectiveness of systemic changes and quality assurance activities. Refer to F689 The findings include: Review of the facility's policy titled, Comprehensive Care Plans, copyright 2019 and dated as revised on 11/01/2023, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Further review of the policy defined person-centered care as the resident was the focus of control, and staff was to support the resident in making their own choices and having control over their daily lives. 1. Closed Record review of R4's Admission Record revealed the facility admitted R4 on 03/03/2022 with diagnoses of other sequelae following unspecified cerebrovascular disease. Further review revealed on 04/03/2024, muscle weakness and unsteadiness on feet were added, and on 06/05/2024, vascular dementia, mild, with mood disturbance was added. Review of R4's quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) of 06/20/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 11 of 15, indicating moderate cognitive impairment. Review of R4's CCP, initiated on 03/10/2023 for activities, revealed among other activities, R4 enjoyed the outdoors, and during his down time he enjoyed relaxing outdoors. Documented goals included active participation in at least three activity programs a week in one on one and/or group settings, and he would remain active with his daily routine by interacting with others, listening to music, reading, using the computer, drawing, painting, watching television, and watching movies throughout the week each week. Documented interventions included encourage family involvement, introduce to other residents with common interests, invite, remind, offer assist to and from group activities, offer materials and supplies for down time, praise for all positive responses, okay to participate in movement-based activity and work with staff to visit one on one engaging in activities of his interests. Further review of R4's CCP revealed no care plan for supervision when outdoors and no interventions in place for when R4 was outdoors. 2. Review of R37's Admission Record revealed the facility admitted R37 on 07/10/2023 with diagnoses of malignant neoplasm of the lung, chronic obstructive pulmonary disease (COPD), and atrial fibrillation. Review of R37's quarterly MDS, with an ARD of 07/06/2024, revealed the facility assessed R37 to have a BIMS score of 13 of 15, indicating R37 was cognitively intact. Review of R37's CCP, initiated on 07/14/2023 for activities, revealed among other activities, R37 enjoyed being outdoors. Documented goals included active participation in at least three group programs of interest a week and remaining active with her daily routine by interacting with others, watching television and movies, listening to music, and going outdoors throughout the week each week. Documented interventions included continue to encourage family involvement, introduce to others with common interests, invite, remind, and offer assist to and from group activities of interest every week, offer supplies and materials for down time, praise for all positive responses, and work with staff to assist with one-on-one visits engaging in activities of her interests. Further review of R37's CCP revealed no care plan for supervision when outdoors and no interventions in place for when R37 was outdoors. During an interview on 08/07/2024 at 3:25 PM with R37, she stated she thought staff checked on her and other residents every 30 minutes or so, when they were outside. 3. Review of R38's Admission Record revealed the facility admitted R38 on 06/10/2022 with diagnoses of type 2 diabetes with kidney complication, depression, and hypertension. Review of R38's quarterly MDS, with an ARD of 07/08/2024, revealed the facility assessed R38 to have a BIMS score of 13 of 15, indicating R38 was cognitively intact. Review of R38's CCP, initiated on 06/24/2022 for activities, revealed among other activities, R38 enjoyed going outdoors. Documented goals included active participation in at least three activity programs a week in a one-on-one setting and/or group programs, and remaining active with her daily routine by interacting with others, listening to music, going outdoors, watching television and movies throughout the week each week. Documented interventions included continue to encourage family involvement, introduce to others with common interests, invite, remind and offer assist to and from group programs, offer supplies and materials for down time, offer out of room for one-on-one visits, okay to participate in movement-based activity, praise for all positive responses, and work with staff to visit one-on-one engaging in activities of her interests. Further review of R38's CCP revealed no care plan for supervision when outdoors and no interventions in place for when R38 was outdoors. Observation on 08/07/2024 at 4:10 PM, revealed R38 was outside in the courtyard with R40 and R41. No staff was observed outside with the residents, and no staff was observed in the dining area near the windows that faced out into the courtyard. 4. Review of R40's Admission Record revealed the facility admitted R40 on 04/02/2019 with diagnoses of chronic kidney disease, heart failure, and peripheral vascular disease. Review of R40's annual MDS, with an ARD of 06/21/2024, revealed the facility assessed R40 to have a BIMS score of nine of 15, indicating R40 had moderately impaired cognition. Review of R40's CCP, initiated on 04/10/2019 for activities, revealed among other activities, R40 enjoyed sunbathing. Documented goals included remaining active with her daily routine by interacting with others and watching television throughout the week each week. Documented interventions included introduce to other residents with common interests, invite, remind, offer to assist to and from group programs of interest, offer materials, supplies for down time such as reading and listening materials, okay to participate in movement-based activity, praise for all positive responses, and work with staff to visit one-on-one engaging in activities of her interest once a week. Further review of R40's CCP revealed no care plan for supervision when outdoors and no interventions in place for when R40 was outdoors. 5. Review of R41's Admission Record revealed the facility admitted R41 on 11/09/2023 with diagnoses of Alzheimer's disease, dementia, and anxiety. Review of R41's quarterly MDS, with an ARD of 06/20/2024, revealed the facility assessed R41 to have a BIMS score of 12 of 15, indicating R41 had moderately impaired cognition. Review of R41's CCP, initiated 11/30/2023 for activities, revealed R41 enjoyed being outdoors and relaxing outdoors. Documented goals included remaining active with her daily routine by interacting with others, watching television, movies, reading, listening to music, throughout the week each week, and accepting and actively participating in at least three group programs of her interest a week. Documented interventions included continue to encourage family involvement, introduce to other residents with common interest, invite, remind, offer assist to and from group programs of her interest once a week, offer materials, supplies for down time, praise for all positive responses, and work with staff to assist with one-on-one visits engaging in activities of her interests. Further review of R41's CCP revealed no care plan for supervision when outdoors and no interventions in place for when R41 was outdoors. During an interview on 08/07/2024 at 3:33 PM with R40 and R41, both stated they were unsure of how often staff checked on them while they were outside in the courtyard. During an interview on 08/07/2024 at 3:10 PM with STNA40, she stated she had been at the facility since 04/2023. STNA40 stated instructions for resident care and resident tasks to be completed were on the nurse aide Kardex (care plan), which was where she did her charting. STNA40 stated staff knew to check on R4 and any other residents outside in the courtyard, but it was not documented anywhere. During an interview on 08/07/2024 at 3:37 PM with Licensed Practical Nurse 4 (LPN4), she stated when she started to work at the facility, she asked about a policy for supervision of residents in the courtyard and/or any temperature restrictions for allowing residents outside and was told nothing was set in stone. During an interview on 08/09/2024 at 1:34 PM with the MDS Nurse, she stated she had worked for the facility for three months and had been doing MDS for five years. The MDS Nurse stated the admitting nurse, clinical coordinators or the MDS Nurse usually initiated the baseline care plan, and then it was reviewed by the Interdisciplinary Team (IDT) and was in place within 48 hours of admission. She stated the CCP was due within 28 days of admission but was usually completed within 14 days when the MDS admission assessment was due. She stated care plans should be person-centered and specific to the resident. She further stated if there were cognitive or mobility changes for a resident, then the care plan might need to be updated for increased supervision but that would be communicated between on-coming and off-going shift staff. She stated, if it was determined a resident needed increased checks, then the resident's care plan would need to be revamped. For outdoor supervision, the MDS Nurse stated she had no concrete regulatory answer for that, it would be individually based, and taking care of humans was unpredictable, and they had a choice. She stated the facility was the residents' home, they had rights, and were allowed to make bad decisions. However, she stated she would take each patient [resident] day by day and if a resident was outside, she would communicate that to staff to ensure the resident was being monitored every 15 to 20 minutes. She stated, if she felt like the resident was not safe, she would increase monitoring and that would be reflected on the resident's care plan. During a telephone interview on 08/08/2024 at 10:50 AM and an in-person interview on 08/09/2024 at 10:35 AM with Clinical Coordinator 1 (CC1), he stated there was no official care plan for supervision policy for residents in general or in the courtyard, but staff should lay eyes on residents in the courtyard every 15 minutes, so they could immediately respond to any distress. CC1 further stated there were only two patients he knew of that liked to go out in the courtyard, and they both had to be able to self-propel in the wheelchair. He stated those residents were R4 and R40. During an interview on 08/08/2024 at 8:51 PM with the DON he stated there was no facility policy for supervision of residents or care planning for the supervision of residents in the courtyard/outside or for the rounding on residents in general. He stated it was the facility's practice to have eyes on all residents throughout the shift. The DON further stated the practice for the courtyard was if a resident wanted to go outside, they were reminded to take a drink with them, and if it was hot, it was discussed with them, and an agreement was come to about how long they would stay out. The DON stated, at this point, the incident with R4 was viewed as a one-time occurrence, but the facility was discussing practice changes for the future. During an interview on 08/09/2024 at 11:15 AM with the Administrator, she stated residents were not specifically planned for independent activities, but activities that required an assist would be documented in the Activities of Daily Living (ADL) care plan and would be triggered to carry over to a STNA task on the resident's Kardex. The Administrator stated there was no specific care plan for being outdoors. She then stated she would possibly expect a care plan could be developed for every resident who was outside, but signing off for every 15 minute checks would be unrealistic. The Administrator stated residents that were outside needed to be supervised, and the facility processes needed to be reviewed and then implemented and would be going forward.

Based on observation, interview, record review, review of the website localconditions.com, review of the website my.clevelandclinic.org, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five sampled residents, Resident (R) 4. On 08/04/2024, R4 was assisted outside in his wheelchair by State Trained Nurse Assistant (STNA) 40 and was left unattended in 90 degree Fahrenheit (F) weather for 30 to 45 minutes. R4 required transfer to the Emergency Department (ED) for evaluation of mental status changes, a temperature of 105 degrees F, and as of 08/07/2024, the resident had not yet returned to the facility. The facility's failure to have an effective system in place to ensure residents received adequate supervision to prevent accidents is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 08/09/2024 at 42 CFR 483.25 Accidents and Supervision (F689) with a Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Accidents and Supervision (F689). The Immediate Jeopardy was determined to exist on 08/04/2024. The facility was notified of Immediate Jeopardy on 08/09/2024. An acceptable Immediate Jeopardy Removal Plan was received on 08/13/2024, which alleged removal of the Immediate Jeopardy on 08/14/2024. The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 08/14/2024, prior to exit on 08/14/2024. Non-compliance remained in the areas of 42 CFR 483.25 Accidents and Supervision (F689) at a Scope and Severity (S/S) of a D, while the facility monitors the effectiveness of systemic changes and quality assurance activities. Refer to F656 The findings include: Review of the facility's policy titled, Accidents and Supervision, implementation date 10/07/2020, revealed the residents' environment would remain as free of accidents and hazards as was possible; and each resident received adequate supervision and assistive devices to prevent accidents which included identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring for effectiveness, and modifying interventions when necessary. Closed record review of R4's Admission Record, revealed the facility admitted the resident on 03/03/2022 with diagnoses of other sequelae following unspecified cerebrovascular disease. Further review revealed on 04/03/2024, muscle weakness and unsteadiness on feet were added, and on 06/05/2024, vascular dementia, mild, with mood disturbance was added. Review of R4's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/20/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 11 of 15, indicating moderate cognitive impairment. Review of R4's Comprehensive Care Plan (CCP), initiated on 03/10/2023, for activities, revealed among other activities, R4 enjoyed the outdoors, and during his down time he enjoyed relaxing outdoors. However, further review of R4's CCP revealed no care plan for supervision when outdoors and no interventions in place for when R4 was outdoors. Review of R4's Progress Note, dated 08/04/2024 at 3:55 PM by Licensed Practical Nurse (LPN) 4, revealed that afternoon R4 had requested to be taken outside to sit with peers and was outside approximately 30-45 minutes. Staff went to check on R4 because he was no longer under the shaded area, and he was noted to be non-verbal and was unable to be aroused with stimuli. Per the note, R4 was taken into the facility, and he had an axillary temperature of 105.0 degrees F. The note stated ice packs were immediately placed under R4's arms, groin, and neck, and R4 was assisted to bed. Per the note, R4's blood pressure (B/P) was 122/76; pulse (P) was 115 beats per minute (BPM), (normal 60 to 100 BPM), oxygen saturation was 92 percent (normal 95 to 100 on room air) and respirations (R) were 16. The note stated LPN4 continued to attempt to stimulate R4 via sternal rub with minimal response, and an oral temp of 102.0 degrees F was obtained. Per the note, a call was placed to R4's provider to advise and request orders to transfer him to the ED for evaluation related to his status; orders were obtained; and 911 was called at 3:40 PM. Further review of R4's Progress Note, dated 08/04/2024 at 3:55 PM by LPN4, revealed she then returned to R4's bedside with a nursing assistant (not specified). Per the note, R4 had started to arouse, with his eyes opened, and he verbally responded to voice commands. The note stated R4 was then advised that he was going to be transported to the hospital for evaluation. At 3:50 PM, per the note, EMS arrived for transport, and EMS staff was made aware R4's provider had advised that he be transported to the ED. The note stated LPN4 would be calling R4's son and the hospital to give report on R4. Review of the website localconditions.com for the weather conditions at the facility, on 08/04/2024 at 2:00 PM-4:00 PM (the timeframe R4 was alleged to have been outside), revealed the temperature ranged from 89.6 degrees F to 91.4 degrees F with an Ultraviolet Light (the light from the sun which could cause sunburn) Index of moderate to high. Review of the website my.clevelandclinic.org, information last reviewed 09/13/2021, revealed heatstroke was defined as a life-threatening condition when body temperature rose above 104 degrees F. Symptoms could include confusion, seizures, or loss of consciousness. If left untreated, heatstroke could cause organ failure, coma, or death. Review of R4's Emergency Medical Service (EMS) Ambulance Run document titled, [NAME] Fire Rescue Patient Care Record, Incident #2400001422, dated 08/04/2024, revealed EMS arrived on the scene at 3:46 PM. Per the document, R4's chief complaint was described as lethargic, the primary impression was generalized weakness, and the secondary impression was dehydration. R4's signs and symptoms were drowsiness, dehydration, stupor or semicoma, weakness, and his acuity was emergent. Further review revealed at 3:56 PM, R4 was alert with a B/P of 110/71, P of 95, R of 18, oxygen saturation of 93 percent, and a blood glucose level of 102 (normal 70-110). R4's Glasgow Coma Scale (GCS) Score was 12 of 15 (the Glascow Coma Scale was used to rate a patient's level of consciousness by evaluating their eyes, speech, and motor skills. Scores could range from 3 to 15 with 3 being the lowest and 15 being the highest, and were used to determine the severity of a traumatic brain injury. A score of 9 to 12 could indicate the possibility of moderate traumatic brain injury). Further review revealed R4 arrived at the ED at 4:10 PM. Review of R4's ED Flowsheet revealed his temperature at 4:20 PM was 99.4 degrees F. Review of R4's Emergency Department-Hospital Admission/ED Provider Note (EDHAPN), dated 08/04/2024, by Emergency Department Physician 1 (P1), revealed the reason for R4's visit was altered mental status. The note stated, per report from the facility, R4 had been taken outside at 2:30 PM, was at his baseline, which included some confusion, and was outside for approximately 45 minutes. Per the note, the facility had also reported when R4 was checked on, he was unresponsive and noted to have a temperature of 102.7 degrees F. Upon the arrival of EMS, R4 was responsive, appropriate, and blood glucose level was 102. Further review revealed given the concern for syncope with recovering heatstroke, R4 would be admitted to the hospital for further evaluation and management with a diagnosis of altered mental status. Additional review of R4's EDHAPN, under the History and Physical Notes, dated 08/04/2024 and written by Physician 2 (P2) revealed R4's chief complaint was altered mental status. The EDHAPN also revealed R4 had an active hospital problem of acute metabolic encephalopathy (a serious medical condition that occurred when the body lacked oxygen, glucose, or vitamins) and suspected heatstroke. The EDHAPN revealed R4's Computed Tomography (CT) scan of the head, CT of the cervical spine, and Chest Xray were reviewed with a notation to check magnetic resonance imaging (MRI) of the brain, serum creatine kinase (CK), urinalysis (UA), with gentle infusion of intravenous fluids (IVF), and monitor temperature. Review of the facility's Investigation Report, dated 08/05/2024 and attached to the Long-Term Care Self-Reported Incident form, revealed, on 08/04/2024, R4 requested to go outside into the secured courtyard to visit with friends. Staff interviews revealed it was evident R4 routinely spent time in the secured courtyard, and his care plan indicated relaxing outside was part of R4's daily routine. Per the report, STNA40 assisted R4 to the courtyard awning as he requested. The report stated, in interviews with STNA40 and LPN4, on 08/05/2024, they stated R4 was outside for around 45 minutes on 08/04/2024, and he routinely visited residents from neighboring units in the courtyard and was able to self-propel his wheelchair and signal to staff when he was prepared to come back inside. Further review revealed STNA40 and LPN4 stated they were able to see R4 while they were at the nurse's station and while in the dining room. Per the report, LPN4 stated at one point she looked outside and saw R4 propelling his wheelchair toward the unit doors, and he got caught on a grassy patch. LPN4 then requested STNA40 go and make sure R4 could continue to self-propel on the grass. STNA40 reported she went to R4, and he told her, Its hot out here. Further review of the facility's investigation, dated 08/05/2024, revealed STNA40 stated she asked R4 to lift his feet so she could propel him back into the building, and R4 became unresponsive. STNA40 summoned LPN4, and they brought him back into the building, and his temperature was elevated. Per the report, LPN4 placed cool packs on R4's groin, axilla, and head; assisted him to bed; and called the Nurse Practitioner (NP) who advised LPN4 to send R4 to the ED for further evaluation. Additional review revealed R4 arrived at the hospital with a temperature of 98.2 degrees F, and he was admitted with a diagnoses of mental status change. Per the report, review of R4's hospital notes on 08/04/2024, revealed R4's son requested an Adult Protective Services (APS) referral citing the facility's neglect of R4. Further review of R4's EDHAPN's Provider Progress Note, dated 08/06/2024 by Physician 3 (P3), revealed R4 was awaiting transfer to a different nursing facility at the request of his son. During an interview on 08/07/2024 at 3:10 PM with STNA40, she stated she was not taking care of R4 on 08/04/2024, but at approximately 2:00 PM, she walked past R4, and he asked to be taken outside. She then stated she wheeled R4 out into the courtyard in his wheelchair and positioned him under an awning. STNA40 stated R4 went outside nearly every day as long as it was not cold or raining, was usually fine on his own, and would wave at staff or knock on the door when he wanted to come back inside. She also stated she did not tell any other staff she had taken R4 outside, returned to caring for her assigned residents, and did not check on R4 again. STNA40 stated about 45 minutes later, LPN4 asked her to go bring R4 inside because it appeared his wheelchair was off the concrete path. STNA40 stated R4 said to her damn, it's hot when she went to get him. She stated, after she brought R4 inside, he would not move his legs when she asked him to, and he then became unresponsive. She then stated LPN4 took R4's temperature, and it was 105 degrees F under his arm (axillary). STNA40 stated she and LPN4 put R4 in his bed, placed gloves packed with ice on him and a baggie with ice behind his neck, and his temperature went down to 103 degrees F. She stated EMS arrived, and about five to 10 minutes after that, R4 woke up. STNA40 stated staff knew to check on R4 and any other residents outside in the courtyard, but it was not documented anywhere. During an interview on 08/07/2024 at 3:37 PM with LPN4, she stated if she was the staff to let a resident outside, she set her watch alarm for every 15 minutes to monitor the resident. She stated she would only leave a resident unattended if they were able to self-propel their wheelchair or ambulate independently. She also stated most residents in a wheelchair could wheel themselves to the door and knock when they needed something. LPN4 stated that was what usually happened with R4, but on the day of the incident, she did not know R4 had been taken outside until she looked out the window and saw what appeared to be the wheel of his wheelchair caught in between the grass and the concrete, and R4 attempting to use his left arm to move the wheelchair wheel. LPN4 then stated she asked STNA40 to go check on R4 because she feared the wheel of the wheelchair had gotten caught on the grass and would cause him to tip over. LPN4 then stated STNA40 brought R4 in and came to get her for help with R4, stating R4 would not move his legs. LPN4 then stated upon R4's being brought inside, he was unresponsive to verbal and painful stimuli, his temperature was assessed to be 105 degrees F, and R4 was sent to the ED for evaluation. LPN4 stated she asked about a policy for supervision of residents in the courtyard and/or any temperature restrictions for allowing residents outside and was told nothing was set in stone. During a telephone interview on 08/08/2024 at 10:50 AM and an in-person interview on 08/09/2024 at 10:35 AM with Clinical Coordinator 1 (CC1), he stated he had been at the facility for [AGE] years. He stated he was contacted by LPN4 on 08/04/2024 informing him that R4 was being sent to the hospital for mental status changes, but CC1 was not sure what time that was. CC1 stated he was not in the facility at the time and was not made aware of the specifics of the incident until the next day when he received an e-mail from the Director of Nursing (DON). CC1 stated there was no official supervision or care plan policy for residents in the courtyard, but staff should lay eyes on residents in the courtyard every 15 minutes so they could immediately respond to any distress. During an interview on 08/08/2024 at 8:51 PM with the DON, he stated he became aware R4 had been transferred to the ED for a medical condition on 08/05/2024 via a text message from CC1. The DON stated weekend staff on call was on a rotation, and he was not generally made aware of medical events but was made aware of falls with an injury and abuse allegations. The DON then stated there was no facility policy for supervision of residents or care planning for the supervision of residents in the courtyard/outside or for the rounding on residents in general. The DON stated it was facility practice to have eyes on all residents throughout the shift. The DON further stated the practice for the courtyard was if a resident wanted to go outside, they were reminded to take a drink with them, and if it was hot, it was discussed with them, and an agreement was made about how long they would stay out. The DON stated at this point, the incident with R4 was viewed as a one-time occurrence, but the facility was discussing practice changes for the future, but no policy changes had been implemented yet. During an interview on 08/07/2024 at 2:52 PM with the Administrator, she stated staff visually checked on residents that were outside, and R4 would usually take a soda or a popsicle out with him. She stated there was no formal policy on the practice of a resident going out in the courtyard/outside, but it was common practice for staff to do visual 15 minute checks on residents and offer drinks or popsicles when they were outside, but this was not documented. During an additional interview on 08/09/2024 at 11:15 AM with the Administrator, she stated residents that were outside needed to be supervised, and the facility processes needed to be reviewed and then implemented.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to protect two (2) of thirty-nine (39) sampled residents (R) from physical and verbal abuse by staff (R24 and R11). During the first week of May 2024 (exact date unknown), State tested Nurse Aide (STNA) 20 witnessed STNA 9 providing care to R24, and observed STNA 9 being rough while providing care to the resident. However, STNA 20 failed to report the incident of possible physical abuse by STNA 9 towards R24 to administrative staff. Therefore, STNA 9 continued to work, and on 05/19/2024, STNA 9 held R11's wrist and hit the resident repeatedly with her fist in the left upper arm. STNA 8 heard STNA 9 state to R11, I told you not to hit me. I hit harder than you and you don't hit women. The incident resulted in R11 sustaining a large bruise to the left upper arm. The facility's failure to have an effective system in place to ensure residents were protected from verbal and physical abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 05/31/2024 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F600) at the highest Scope and Severity (S/S) of a J. Substandard Quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600). The Immediate Jeopardy was determined to exist on 05/19/2024. The facility was notified of Immediate Jeopardy on 05/31/2024. An acceptable Immediate Jeopardy Removal Plan was received on 06/06/2024, which alleged removal of the Immediate Jeopardy on 05/19/2024. However, the State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 06/06/2024, prior to exit on 06/06/2024. Non-compliance remained in the areas of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F600) at a Scope and Severity (S/S) of a D; while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy entitled, Abuse, Neglect, and Misappropriation of Resident Property dated 11/01/2023, revealed it was the facility's policy for each resident to be free from Abuse. Continued review revealed abuse could include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. Additionally, policy review revealed residents were to be protected from abuse, neglect, and harm while they were residing at the facility. Further review revealed no abuse or harm of any type was to be tolerated, and residents and staff were to be monitored for protection. Review of the facility's policy entitled, Resident Rights, dated 11/01/2023, revealed all residents were to be treated equally regardless of age, race, religion, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression. The policy review also revealed the facility was to ensure all direct care and indirect care staff members, including contractor and volunteers, were educated on the rights of residents and the responsibility of the facility to properly care for its residents. Review of the facility's, Certified Nurse Assistant Job Description, revised 2019, revealed the basic function of Certified Nurse Assistants ([CNA], the term the facility used for State tested Nurse Aides [STNA]) was to provide delivery of care as described on each individual resident's Nurse Assistant care plan; and as directed per nurse aide training standards. Continued review revealed the CNAs were to report any allegation of abuse, neglect, exploitation or misappropriation of resident's property per facility policy. Review of STNA 9's personnel record revealed the STNA had a date of hire of 01/10/2024, and had signed the facility's orientation packet for Agency Certified Nurse Aides located in the facility on 01/03/2024. Continued review revealed STNA 9 signed the facility's Prevention and Reporting of Resident Abuse Acknowledgement of Responsibilities on 01/03/2024. Further review of STNA 9's personnel record revealed no documented verbal or written warnings alleging abuse found in the STNA's personnel record. In addition, review of STNA 9's personnel record also revealed she received her STNA certification prior to being employed at the facility. Review of STNA 9's work schedule for the month of May 2024, revealed she was scheduled to work 05/01/2024-05/03/2024, 05/05/2024-05/06/2024, 05/09/2024-05/10/2024, 05/15/2024-05/16/2024, and 05/19/2024. 1. Record review revealed the facility admitted R24 on 08/18/2008, and had diagnoses of Parkinson's disease without dyskinesia (uncontrolled shakes, tics, or tremors), without mention of fluctuations, dysphagia (difficulty swallowing), and depression, unspecified. During an interview with STNA 20 on 05/30/2024 at 1:00 PM, she stated she had not worked much with STNA 9; however, recalled one incident where she and STNA 9 were providing care for R 24. She stated during the course of transferring R24 with the Hoyer lift (assistive device for transferring), STNA 9 became rough with R24. STNA 20 said she thought to herself, Don't be rough with her, she is my girl. The STNA further stated I guess I should have said something then, that was on me. I guess after hearing about the incident with STNA 9 and R11, I should have said something. During an interview with the Administrator on 05/31/2024 at 11:00 PM, she stated she was unaware of the incident with STNA 9 and R24. She stated if STNA 20 had reported that initial incident involving alleged abuse, the witnessed abuse of R11 by STNA 9 might not have occurred. 2. Review of the facility's investigation dated 05/19/2024 at 11:30 PM, revealed STNA 8 witnessed STNA 9 physically and verbally abusing R11 while attempting to remove R11's shirt. The investigation review revealed STNA 9 held R11's left wrist and hit him repeatedly in the upper arm stating, I told you not to hit me, I hit harder than you and don't hit women. Per review, STNA 10 entered R11's room and observed STNA 9 grabbing R11 by the wrist and placing R11's left arm behind STNA 9's back. Review revealed a full head to toe assessment of R11 was completed by the Nurse Supervisor and no injury was noted to the resident at that time. Continued review revealed body audits were performed on all residents that STNA 9 had came in contact with on that date. Review of the investigation revealed STNA 8 gave STNA 10 a nudge and asked STNA 10 to stay with R11 while she (STNA 8) went to notify the nurse on duty, Licensed Practical Nurse (LPN) 8; the nurse supervisor; and the Administrator. Per review of the investigation, the night shift House Supervisor immediately removed STNA 9 from the patient care area, took STNA 9's statement, and notified the Director of Nursing (DON). Review revealed the Administrator called the local police department at 10:45 PM, and the Nurse Supervisor stayed with STNA 9 in the facility lobby until the police arrived and took STNA 9's statement. Additionally, the investigation review revealed the Nurse Supervisor escorted STNA 9 out of the building accompanied by the police and the STNA was removed from all future schedules. Further review of the investigation from 05/19/2024, revealed because of the failure of STNA 20 to report alleged abuse surrounding STNA 9 during the first week of May 2024, the abuse incident involving STNA 9 and R11 was allowed to occur. Review of the facility's, Final Report/5 Day Follow-Up investigation dated 05/23/2024 at 8:08 PM, revealed physical harm noted to R11 by evidence of a bruise to the resident's left upper arm. Per review, the facility reported the incident to R11's resident representative on 05/19/2024 at 11:25 PM. Review of the summaries of interviews on the Final Report/5 Day Follow-Up revealed STNA 8 noted she witnessed STNA 9 physically abuse R11 at around 10:00 PM, in the resident's room while providing care. Continued review of STNA 8's written statement revealed she witnessed STNA 9 punch R11's left bicep while STNA 9 was attempting to remove the resident's shirt for evening care. STNA 8 also noted STNA 9 stated to R11, I told you not to hit me, I hit harder than you, and don't hit women. Per review of STNA 8's written statement, she then witnessed STNA 9 restrain R11's arm by grabbing his wrist and placing his arm behind her (STNA 9's) back. Review of STNA 8's statement also revealed STNA 10 entered R11's room at that time and observed STNA 9 restraining the resident's arm and making the above statements. Further review of STNA 8's statement revealed she gave STNA 10 a look and asked STNA 10 to stay with R11 STNA 9 while she went to notify LPN 8, the Nurse Supervisor, and the Administrator. Continued review of the facility's, Final Report/5 Day Follow-Up of STNA 10's written statement dated 05/23/2024, revealed she witnessed STNA 9 restraining R11's wrist and being verbally aggressive with R11 while providing care to the resident in his room. Per review of STNA 10's statement STNA 8 gave her a look and a nudge and asked her to stay with R11 while she (STNA 8) went to notify the nurse on duty (LPN 8), the nurse supervisor, and the Administrator. Further review of the facility's, Final Report/5 Day Follow-Up dated 05/23/2024, revealed STNA 9's statement which noted she had been attempting to provide evening care for R11, and he became agitated, then struck her in the chest. Per review of STNA 9's statement she used her forearm to hold R11's arm, then grabbed his arm and held it behind her to prevent him from hitting her again. Continued review of STNA 9's statement revealed she told R11 to stop hitting her, but he continued to try to do that. She noted in her statement she had given a statement to the police and was then released, and the Nurse Supervisor escorted her out of the facility. Additional review of the facility's, Final Report/5 Day Follow-Up investigation dated 05/23/2024 at 8:08 PM, revealed LPN 8 had been assigned on R11's unit (on the date of the incident). Review of LPN 8's written statement dated 05/19/2024 at 10:15 PM, revealed she had not witnessed any of the incident in question, and STNA 9 reported to her R11 was being aggressive without his medication. Per review of LPN 8's statement, she had not witnessed any aggression from R11. Continued review of LPN 8's statement revealed when she entered R11's room, after STNA 8 notified her of the abuse allegation, STNA 9 and STNA 10 were present in the room. Further review of LPN 8's written statement revealed the Nurse Supervisor arrived in R11's room, and STNA 9 was removed from the resident area immediately and walked to the lobby by the Nurse Supervisor. Further review of the facility's Final Report/5 Day Follow-Up investigation dated 05/23/2024 at 8:08 PM, revealed police arrived on 05/19/2024 and questioned all parties, visited R11 in his room, and left without detaining anyone. Per review, a Police Officer and Social Worker (SW) returned to the facility on [DATE], to visit R11 in his room and took photos of the resident's arm. Review revealed the police and SW returned again on 05/22/2024 and took more photos of R11's arms. Additionally, review of the investigation revealed Adult Protective Services (APS) was notified and visited the facility on 05/23/2024. Review of the facility's Final Report/5 Day Follow-Up further revealed the allegation of abuse, where STNA 9 hit and verbally abused R11, had been VERIFIED by the Administrator. Review of the State's Department for Community Based Services, Confidential Suspected Abuse, Neglect, Dependency or Exploiting Reporting Form, (Initial Report) dated 05/19/2024, revealed STNA 9 had been getting R11 out of his chair and into a Hoyer lift sling to lift the resident onto his bed for the night on that date. Continued review of the Form revealed it was noted, STNA 9 stated R11 started punching her as she was assisting him onto the lift sling, and she had grabbed the resident's wrist and told him it was not polite to hit women. Per review of the Form, it was noted STNA 9 told STNA 8 to go get the Charge Nurse to assist in getting R11 onto his bed. Further review of the Form revealed statements given by STNA 8 indicated she witnessed R11 flailing his arms and striking STNA 9, and then witnessed STNA 9 to begin punching the resident in the arm four times. In addition, review of the Form further revealed documentation noting STNA 8 stated STNA 9 said she did not have to take the abuse from R11 and he should not be hitting women. 2(a). Record review revealed the facility admitted R11 on 11/19/2023, with diagnoses of cerebral infarction (stroke) from blood clots; dysphagia (difficulty swallowing); and aphasia (loss of ability to understand or express speech). Additionally, review revealed R11 was also diagnosed with hemiplegia/hemiparesis (muscle weakness or partial paralysis of a side of the body) affecting the right side. Review of R11's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/16/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99, indicating the interview was not completed, and indicated R11's cognitive skills for daily decision making was severely impaired. Review of R11's Progress Note dated 05/19/2024 at 10:42 PM, documented by the Nurse Supervisor revealed STNA 8 witnessed STNA 9 punch R11 in his left arm three or four times with her closed fist, while she reprimanded the resident for hitting her, saying, You don't hit women, I am stronger than you and I will hit back. Per review of the progress note, the incident information involving STNA 9 and R11 was reported to the Administrator and Director of Nursing (DON). Continued review revealed STNA 9 was removed from the unit immediately, and R11 was assessed for any injuries with a complete head to toe assessment completed at that time. Per review, the skin assessment noted old bruising to R11's left forearm and slight redness to R11's left upper arm, an abrasion to the resident's right abdomen and slight redness to his right upper thigh and left knee. Additionally, review revealed R11 was non-verbal and unable to tell staff any information as to what happened. Review of R11's External Progress Notes on 05/20/2024 at 5:47 PM, documented by the Medical Director revealed the resident had no visible sign of injury on left arm, was comfortable and showed no signs of distress. Per review, staff were to continue to monitor R11 for any delayed symptoms or changes in condition. Continued review revealed R11 had a history of occasional agitation, with no specific cause identified. Further review revealed staff were also to continue to observe R11 for behaviors and provide supportive care as needed. Review of R11's Wound Evaluation and Management Summary under the Miscellaneous tab in the medical record dated 05/22/2024, revealed the resident had a left upper extremity contusion. Review of R11's Weekly Wound assessment dated [DATE], revealed a wound site on the resident's left upper arm measuring 8.0 cm (length) X 6.0 cm (width) X NA (depth). Continued review revealed the wound on R11's left bicep area, was faded blue in color, and non-tender to the touch. Review of R11's Wound Evaluation and Management Summary dated 05/29/2024, revealed the contusion (on the resident's left upper arm) was noted as resolved on 05/29/2024. During an interview with STNA 8 on 05/29/2024 at 1:14 PM, she stated we (she and STNA 9) got along. She stated the night of the incident after STNA 9 hit R11, STNA 9 made the statement implying R11 had tried to hit her before and stated to R11, I told you not to hit women. STNA 8 reaffirmed her statement she made on 05/19/2024. STNA 8 stated she and STNA 9 went to R11's room to put him to bed and change his shirt. She said they were going to use the Hoyer lift to help R11 from his chair onto his bed. STNA 8 stated she had taken hold of R11's shirt and was trying to help STNA 9 undress him, and the resident was moving his arms because he sometimes became slightly agitated. She stated STNA 9 struck R11 multiple times on the left upper arm. STNA 8 further stated during that time, STNA 10 entered R11's room and observed STNA 9 grabbing R11's wrist with her hand and placing his left arm behind her back to prevent R11 from striking at her further with his left hand. An attempt to contact STNA 10 by telephone on 05/30/2024 at 1:24 PM, resulted in no answer and a voicemail message being left for the STNA. A second attempt to contact STNA 10 by telephone on 05/30/2024 at 8:11 PM, resulted in no answer and a voicemail message again being left for STNA 10. No return phone call was received by the State Survey Agency (SSA) Surveyor. An attempt to contact STNA 9 by telephone on 05/29/2024 at 6:11 PM, resulted in no answer and a voicemail message being left for the STNA. A second attempt to contact STNA 9 by telephone on 05/30/2024 at 8:47 PM, resulted in no answer again and a voicemail message being left for the STNA. No return phone call was received by the SSA Surveyor. During an interview with the Director of Nursing (DON) on 05/30/2024 at 3:25 PM, he stated he was was concerned STNA 20 did not report the suspected abuse. He stated the facility provided education after any abuse allegation and she should have reported her suspicions. He stated if the suspected abuse was reported, the facility would have investigated. He stated if that abuse had been reported it could have possibly prevented the abuse of R11; however, that was just speculation. The DON stated anytime abuse was suspected and not reported, it created the potential for abuse by the staff member to occur again. He stated he had not had any negative reports about STNA 9's work or had any complaints about the STNA being rough or verbally abusive with residents. During an interview with the Administrator on 05/30/2024 at 10:25 AM and 10:35 AM, she stated it was unacceptable for STNA 20 not to have reported the suspected abuse she witnessed. The Administrator stated staff were provided training on reporting abuse and knew if suspected abuse was not reported the staff member could be held responsible. She stated the suspected abuse should have been reported by STNA 20 and the STNA has received a written reprimand on the event. The Administrator stated if the suspected abuse of R24 had been reported, the incident of abuse of R11 could have been prevented. She stated she was contacted by STNA 8 on 05/19/2024 at about 10:15 PM, concerning the allegation of witnessed abuse of R11. The Administrator stated after speaking with STNA 8, she contacted the police on 05/19/2024 at 10:45 PM to report the alleged abuse incident. She stated she then contacted the DON, Nurse Supervisor, and Shift Key (the staffing agency who employed STNA 9) notifying them of the alleged abuse. The Administrator stated she began an initial investigation through telephone conversations with staff and began a formal investigation the following morning. She stated she did not condone any abuse by any staff member at the facility whether it was the facility's employee or an employee hired through an agency. She further stated she believed STNA 9 acted outside of the facility's policies and procedures.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure its staff implemented the facility's abuse policy regarding reporting allegations of physical abuse for one of 39 sampled residents, (R) 24. State tested Nurse Aide (STNA) 20, during the first week of May 2024 (exact date unknown), observed STNA 9 being rough when providing care for R24. Review of the facility's abuse policy dated 11/01/2023, revealed employees must always report abuse or suspicion of abuse immediately to the Administrator or designee. STNA 20 failed to report the allegation of abuse to the Administrator or designee, and STNA 9 continued to work providing care to facility residents. As a result of STNA 20's failure to report the abuse allegation as per facility policy, STNA 9 was allowed to hit R11 on 05/19/2024, repeatedly with her fist in the resident's left upper arm and verbally abuse him during provision of care. The incident resulted in R11 sustaining a large bruise to the left upper arm. Refer to F600. The facility's failure to ensure its staff implemented its policies related to abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 05/31/2024 at 42 CFR 483.12 Freedom From Abuse, Neglect, and Exploitation (F607) at the Highest Scope and Severity (S/S) of a J, substandard quality of Care (SQC) was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F607). The Immediate Jeopardy was determined to exist on 05/19/2024. The facility was notified of Immediate Jeopardy on 05/31/2024. An acceptable Immediate Jeopardy Removal Plan was received on 06/06/2024, which alleged removal of the Immediate Jeopardy on 05/19/2024. The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 06/06/2024, prior to exit on 06/06/2024. Non-compliance remained in the areas of 42 CFR 483.12 Free from Abuse, Neglect, and Exploitation (F607) at a Scope and Severity (S/S) of a D; while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, dated 11/01/2023, revealed in the internal reporting area, Employees must always report any 'abuse' or suspicion of 'abuse' immediately to the Administrator or designee. ** Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law. Review of the facility's, Resident Rights policy dated 11/01/2023, revealed all residents were to be treated equally regardless of race, age, religion, physical or mental disability, or socioeconomic status. The policy also revealed the facility was to ensure all direct care and indirect care staff members, including volunteers and contractors, were educated on the rights of residents and on the facility's responsibility to properly care for its residents. Review of the facility's, Certified Nurse Assistant Job Description revised 2019, revealed the Certified Nurse Assistant ([CNA] the term used by the facility for its State tested Nurse Aides [STNA]) duties included reporting any allegation of abuse, neglect, exploitation or misappropriation of resident property per facility policy. 1. Review of R24's clinical record revealed the facility admitted R24 on 08/16/2008, with admitting diagnosis of Parkinson's disease without dyskinesia (involuntary, erratic, movements of the face, arms, limbs, and trunk), without mention of fluctuations, dysphagia (impairment of speech production), oropharyngeal phase, and depression unspecified. Review of R24's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) date of 04/19/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) which indicated severe cognitive impairment. Review of the work schedule for STNA 9 for the month of May 2024, revealed she had been scheduled to work 05/01/2024-05/03/2024, 05/05/2024-05/06/2024, 05/09/2024-05/10/2024, 05/15/2024-05/16/2024, and 05/19/2024. In an interview on 05/30/2024 at 1:00 PM, STNA 20 stated there had been one incident where she and STNA 9 were providing care for R24. She stated during the course of transferring R24 with the Hoyer lift, STNA 9 became rough with R24. The STNA stated she thought to herself, Don't be rough with her, she is my girl. She said, I guess I should have said something then, that was on me. I guess after hearing about the incident with STNA 9 and R11, I should have said something. 2. Review of R11's clinical record revealed the facility admitted him on 11/03/2023, with diagnoses which included cerebral infraction with hemiparesis/hemiplegia (partial weakness/complete paralysis) affecting his right dominant side. Review of R11's Admission MDS Assessment with with an ARD of 11/15/2023, revealed the facility assessed the resident to have a BIMS score of 99, indicating the resident was severely cognitively impaired and the interview was not completed. Review of R11's Progress Note dated 05/19/2024 at 10:42 PM revealed STNA 8 witnessed STNA 9 punch R11 in the left arm three to four times with her closed fist while she (STNA 9) reprimanded R11 for hitting her. Review of R11's Wound Evaluation and Management Summary under the miscellaneous tag in the medical record dated 05/22/2024, revealed R11 had a left upper extremity contusion (bruise). Review of R11's Weekly Wound assessment dated [DATE] revealed the wound site on the left upper are measured 8.0 centimeters (cm) by 6.0 cm. Further review of the Assessment revealed R11's left bicep (large muscle on the front of the upper arm) area was faded blue in color and non-tender to touch. Review of the facility's Initial Report dated 05/19/2024 at 11:30 PM, and Final Report/5 Day Follow-Up investigation document dated 05/23/2024, revealed STNA 8 witnessed STNA 9 punch R11's left arm/bicep while STNA 9 was attempting to remove the resident's shirt for evening care. Continued review of the documentation revealed STNA 8 reported STNA 9 told R11, I told you not to hit me. I hit harder than you and Don't hit women. Further review revealed STNA 9 grabbed the resident's wrist and placed the resident's arm behind her (STNA 9's) back. STNA 10 entered the room and observed R11's arm being restrained and heard STNA 9 making the statement, I told you not to hit me. I hit harder than you and Don't hit women. Further review of the Final Report/5 Day Follow-Up revealed the allegation of abuse had been VERIFIED by the Administrator. In interview on 05/30/2024 at 3:25 PM, the Director of Nursing (DON) stated it concerned him that STNA 20 had not reported the suspected abuse of R24. The DON stated if the STNA had reported the suspected abuse it could have potentially prevented the abuse of R11; however, that was just speculation. In an additional interview on 05/31/2024 at 11:51 AM, the DON stated he expected all employees to follow the facility's policy and report suspected abuse immediately, even if they were not sure about the incident. The DON stated the facility was always providing training for staff to identify abuse and to report suspected abuse promptly. In interview on 05/31/2024 at 12:47 PM, the Administrator stated the facility provided written and video education through Google Classroom and other formats. She stated scenarios were also provided where staff interacted and role played signifying the importance of recognizing and reporting abuse as per the facility policy. The Administrator stated her expectation was for every staff member to report abuse, even if they were not sure about it. She stated, That is why we investigate all reports of abuse. The Administrator stated if an employee was in a situation where they suspected abuse and did not report it, her expectation was for that employee to be held as responsible as the individual who might have committed the abuse.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure residents' food was served in a safe manner, and ensure all staff practiced proper hand hygiene procedures during the supper meal service on 05/28/2024. Observation of the supper meal on 05/28/2024, revealed State tested Nurse Aide (STNA)7 failed to wash her hands with soap and water, dry her hands thoroughly with a single-use towel, and turn off the faucet with a clean towel while serving residents' supper meal trays. The findings include: Review of the facility's policy titled, Hand Hygiene, implemented 11/08/2022, revealed, Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub [ABHR]. Continued review revealed Hand hygiene technique when using soap and water: Wet hands with water. Apply to hands the amount of soap recommended by the manufacturer. Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hand and fingers. Rinse hands with water. Dry thoroughly with a single-use towel. Use clean towel to turn off the faucet. Observation on 05/28/2024 at 5:15 PM, in the Walnut Unit Dining Room, revealed STNA 7 was waiting for residents' meal trays to serve. Continued observation revealed STNA 7 reached over the kitchenette counter towards the sink and turned on the water with her hands, then reached her hands into the sink and rinsed them off with water, without using soap. Further observation revealed STNA 7 then turned off the water with her bare hand, and proceeded to shake her hands dry without using a paper towel. Additionally, observation revealed the STNA did not use hand sanitizer after she rinsed her hands. In an interview with STNA 7, on 05/31/2024 at 3:56 PM, she stated the procedure for passing residents' meal trays was: first to wash her hands with soap and water for 15 to 30 seconds; and then turn the faucet off with a paper towel. She stated she just rinsed off her hands with water, turned off the faucet with her bare hand and then used the sanitizer after she rinsed her hands off, while waiting for the dinner trays. In an interview with Staff Development Licensed Practical Nurse (LPN) 2 on 05/30/2024 at 2:45 PM, she stated she monitored staffs' hand hygiene: as to how long they washed and dried their hands; when their hands were dry, turning the faucet off with a paper towel; performing proper hand washing technique; if ABHR was used to sanitize hands between trays; and after every third tray, if hands were washed with soap and water for infection control purposes to prevent cross contamination. She stated she had observed staff rinse with water, wave hands to dry, and not use soap or a towel to dry hands in the past, and had also observed staff touch their clothing after they washed their hands. In an interview with the Administrator on 05/30/2024 at 9:35 AM, she stated food was served restaurant style to the residents. She stated her expectation for staff at meals was for them to perform proper hand hygiene before service with soap and water; use hand sanitizer between each tray; and to wash their hands with soap and water after every third tray.

Based on interview, record review, review of the facility's nursing assistant (State Registered Nurse Assistant/SRNA) job description and review of the facility's policy, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of twenty-six (26) sampled residents (Resident #81). The facility's assessed and care planned Resident #81 to require the extensive assistance of two (2) staff for transfers and bed mobility. However, on 04/17/2022, State Registered Nurse Aide (SRNA) #14 attempted to transfer Resident #81 from a chair to the bed, without assistance from another staff member. The transfer was unsuccessful, resulting in a fall. Three (3) days later, Resident #81 complained of severe pain and underwent imaging three to the right ankle that resulted in a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility's policy titled, Comprehensive Care Plans, last reviewed 11/30/2021, revealed the facility must develop and implement a comprehensive person-centered care plan (CCP) for each resident, consistent with residents' rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the resident's comprehensive assessment. Further review revealed that the care planning process would include an assessment of the resident's strengths and needs and incorporate the resident's personal and cultural preferences in developing goals of care. Additional review revealed that qualified staff responsible for carrying out interventions specified in the care plan would be notified of their roles and responsibilities for carrying out the interventions, initially and when changes were made. Review of the facility's policy titled, Nursing Care Plan, (Nursing Assistant also known as SRNA), undated, revealed each resident would have a KARDEX, consisting of specific information required to meet his/her individual needs. Further review revealed the KARDEX was an essential tool, used for communicating information from the nursing care plan to the nursing assistants and the other staff. It also stated the information from this KARDEX was used to set up tasks in the Point of Care (POC), where staff would document care given for each resident, as care was provided. Continued review revealed the nursing assistant shall review and familiarize themselves with each resident's KARDEX and tasks in the POC. The policy stated the expectation that nursing assistants would follow the policies and procedures of the facility. Review of the State Registered Nurse Assistant's (SRNA) Job Description, undated, revealed that an essential job function of nursing assistants was to deliver care as described on each resident's Nursing Assistant Care Plan (KARDEX) and as directed per the nurse aide training standards. Review of Resident #81's electronic medical record (EMR) revealed the facility admitted the resident, on 08/16/2008, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #81's Quarterly Minimum Data Set (MDS) Assessment, dated 04/12/2022, revealed that he/she required total assistance of two (2) persons for transfers. Further review of the Quarterly MDS Assessment revealed that Resident #81 was only able to stabilize for surface-to-surface transfers with staff assistance. Review of Resident #81's Comprehensive Care Plan, initiated on 11/27/2020, effective on 04/17/2022, reflected a focus for Impaired Activities of Daily Living (ADL) function. Interventions included that he/she required the extensive assistance of two (2) staff members for transfers and bed mobility. Review of Resident #81's KARDEX, or Nursing Assistant Care Plan, dated 05/26/2022, revealed that the resident needed staff to give assistance with transfers. Review of the ADL functions, revealed that he/she currently required a mechanical lift with total assistance of two (2) staff with transfers. Review of Resident #81's EMR (electronic medical record) Progress Notes revealed he/she sustained an intercepted fall, on 04/17/2022, and subsequently experienced severe right ankle pain. Further review revealed an x-ray of the lower right leg and ankle was obtained on 04/17/2022 (negative for fracture); and, again on 04/20/2022 because of increased right ankle pain. The radiology report from the 04/20/2022 x-ray showed a non-displaced intra-articular medial tibia fracture. Interview with Resident #81, on 05/24/2022 at 5:08 PM, revealed some time back, an aide came to help him/her with a transfer to the bed from the chair. He/She stated the aide would not listen when he/she insisted that more help was needed. Resident #81 stated the aide attempted the transfer by herself; however, she could not complete the transfer. The resident stated the aide helped him/her to the floor. Resident #81 stated he/she had a non-displaced fracture in his/her lower right leg, so he/she did not have a cast. However, the resident stated he/she must now use a mechanical lift for transfers. Resident #81 stated he/she did not like to have to use the lift because it took longer, and he/she had to wait. An unsucessful attempt to call Registered Nurse (RN) #3, who had worked on 04/17/2022 when Resident #81 sustained the fall, was made on 05/26/2022 at 5:15 PM. A message was left requesting a return telephone call. However, RN #3 did not return the call. An unsucessful telephone call was make to SRNA #14, on 05/26/2022 at 5:44 PM. A message was left requesting a return telephone call. However SRNA #14 also did not return the call. Interview with Licensed Practical Nurse (LPN) #4, on 05/23/2022 at 4:07 PM, revealed staff was expected to provide resident care according to the resident's care plan. She stated the aides had the KARDEX to reference and were expected to use it to direct the care they gave to residents. Interview with SRNA #15, on 05/24/2022 at 5:24 PM, revealed the care plan was a guide for the residents' needs and care. SRNA #15 stated the aides used the KARDEX to find information for individual residents like diet, general preferences, or how to transfer the resident. Interview with Registered Nurse (RN) #1, on 05/25/2022 at 8:07 PM, revealed resident care should be guided by the care plan and the facility's policy. RN #1 stated the KARDEX gave instructions for care from the aides. Interview with SRNA #8, on 05/26/2022 at 8:15 AM, revealed care was guided by the resident's care plan or KARDEX. Interview with the Director of Nursing (DON), on 05/26/2022 at 3:47 PM, revealed she recalled the event of Resident #81's intercepted fall by SRNA #14 and had reviewed documentation of the investigation, close to the time of the occurrence. The DON stated the aide had failed to follow the care plan, specifically to transfer only with the assistance of two (2) staff members. The DON also stated aide staff members had all been retrained with using the KARDEX, and all had received retraining on transfers and mechanical lift use. Interview with the Administrator, on 05/26/2022 at 4:13 PM, revealed her expectation was that staff would provide care following best practices as outlined in the facility's policies.

Based on interview, record review, review of the facility's investigative report, review of the facility's job description, and review of the facility's policies, it was determined the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one (1) of twenty-six (26) sampled residents (Resident #81). According to Resident #81's Comprehensive Assessment, two (2) or more staff members were required to assist the resident for transfers and bed mobility. However, on 04/17/2022, Resident #81 sustained a fall when one (1) staff member, State Registered Nurse Aide (SRNA) #14 transferred the resident from a chair to the bed, with no assistance. Three (3) days later, Resident #81 complained of severe pain and underwent imaging to the right ankle that resulted in a diagnosis of a nondisplaced intra-articular fracture of the medial tibia. The findings include: Review of the facility's policy titled, Fall Process, undated, revealed prior to or within six (6) hours of admission, the resident's medical record was reviewed for fall risk and, if the risk existed, interventions were to be put in place upon admission. Further review revealed that fall risk assessments would be completed quarterly and the information gathered used to develop the plan of care. Continued review revealed that the resident's fall risk and fall risk plan of care would be discussed at the initial care conference within the week of admission. Review of the facility's policy titled, Nursing Assistant Care Plan, (nursing assistant also known as SRNA), undated, revealed each resident would have a KARDEX which would consist of specific information required to meet his/her individual needs. Further review revealed the KARDEX was an essential tool, used for communicating information from the nursing care plan to nursing assistants and other staff. Per the policy, the information from the KARDEX was used to set up tasks in the Point of Care (POC), where staff would document care given for each resident, as care was provided. Continued review revealed the nursing assistant shall review and familiarize themselves with each resident's KARDEX and task in the POC. Further review revealed the nursing assistant would follow the facility's policies and procedures. Review of the Certified Nurse Assistant (SRNA) Job Description, undated, revealed that an essential job function of nursing assistants was to deliver care as described on each resident's Nurse Assistant Care Plan and as directed per nurse aide training standards. Review of the facility's Investigative Report, dated 04/17/2022, revealed SRNA #14, alone, attempted to assist Resident #81 in transferring from the chair to the bed on 04/17/2022. The transfer could not be accomplished and resulted in Resident #81 being helped to the floor by SRNA #14. Further review revealed Resident #81's care plan and KARDEX stated the resident required the assistance of two (2) staff members with transfers. Review of Resident #81 medical record revealed the facility admitted the resident, on 08/16/2008, with diagnoses which included [CONDITION(S)], Type 2 Diabetes Mellitus, Unspecified Lack of Coordination, Other Reduced Mobility, Unspecified Muscle Weakness, and Contractures of the Right Knee and Bilateral Ankles. Review of Resident #81's Quarterly Minimum Data Set (MDS) Assessment, dated 04/12/2022, revealed the resident required the total assistance of two (2) persons for transfers. Further review of the MDS Assessment revealed Resident #81 was only able to stabilize for surface-to-surface transfers with staff assistance. In addition, the assessment revealed Resident #81's Brief Interview for Mental Status (BIMS) score was fifteen (15) of fifteen (15), indicating intact cognition. Review of Resident #81's Comprehensive Care Plan, initiated 11/27/2020, revealed a focus for Impaired Activities of Daily Living (ADL) Function. Interventions included that he/she required extensive assist of two (2) staff for transfers and bed mobility. Review of Resident #81's KARDEX, or Nursing Assistant Care Plan, dated 05/26/2022, revealed the resident needed staff assistance with transfers. Further review, of ADL functions, revealed the resident required a mechanical lift with total assistance of two (2) with transfers. Review of Resident #81's Progress Notes, in the Electronic Medical Record (EMR), revealed a Change of Condition and Physician Notification Note, dated 04/17/2022 at 9:53 AM, that detailed Resident #81's complaint of excruciating pain in his/her right ankle and pain to the left ankle. The note also described new orders received from Resident #81's Physician to obtain a stat (done immediately) x-ray of the right ankle, elevate both ankles, and apply ice to both ankles three (3) times a day for fifteen (15) minutes. Additional review of the Progress Notes revealed Resident #81 had sustained an intercepted fall and was at risk for falls due to [CONDITION(S)], lack of coordination, abnormal posture, unsteady on feet, visual loss, joint stiffness, anxiety, [CONDITION(S)], and knee contractures. Continued review revealed the Physician saw Resident #81 due to persistent pain and ordered repeat x-rays, on 04/20/2022, that showed a fracture to the right tibia. The Progress Notes stated Resident #81 was referred for an orthopedic consult. Review of Resident #81's Physician's Note, dated 04/20/2022 at 1:45 PM, revealed that Resident #81 sustained an intercepted fall, on 04/17/2022, and had continued severe right ankle pain. Further review revealed the Physician's suspicion of a fracture secondary to Resident #81's exquisite tenderness of his/her right lower leg and very debilitated condition since the fall. The Note revealed an order for a repeat x-ray of the right lower leg and ankle. Review of Resident #81's radiology reports from the x-rays of the right lower leg and ankle, dated 04/17/2022, revealed a negative result for fracture. Further review revealed the second images, dated 04/20/2022 at 3:25 PM, revealed a subtle, intra-articular fracture to the right medial tibial plateau. Review of the Orthopedic Consult Note, from the Orthopedic Physician's Assistant (PA), dated 04/22/2022, confirmed the resident had a right tibial fracture. Further review of the Note revealed Resident #81 had told the PA that he/she had sustained the injury a few days prior when an aide in his/her nursing facility had nearly dropped him/her while being transferred to bed. Continued review revealed the PA's decision for conservative management, which included Tylenol (a non-narcotic pain reliever) and ice for pain, nonweight bearing, and to return for reevaluation in four (4) to six (6) weeks. Interview with Resident #81, on 05/24/2022 at 5:08 PM, revealed that some time back, an aide came to help him/her with a transfer. The resident stated the aide would not listen when he/she insisted more help was needed. Resident #81 stated the aide attempted to transfer him/her from the chair to the bed by herself but could not, and in turn, helped him/her to the floor. Resident #81 stated the aide used a stuffed animal to support his/her injured leg while she got help. Additionally, the resident stated he/she had a non-displaced fracture in his/her lower leg, so he/she did not have a cast but, now must use a mechanical lift for transfers. Resident #81 stated he/she did not like having to use the mechanical lift because it took longer, and he/she had to wait. The State Survey Agency (SSA) Surveyor placed a telephone call on 05/26/2022 at 5:15 PM, to Registered Nurse (RN) #3, who had worked on 04/17/2022 when Resident #81 sustained the fall. A message was left requesting a return telephone call. However, RN #3 did not return the call. A message was left for SRNA #14, on 05/26/2022 at 5:44 PM, requesting a return telephone call. However SRNA #14 also did not return the call. SRNA #14 had provided care for Resident #81 when the fall occurred. Interview with Licensed Practical Nurse (LPN) #4, on 05/23/2022 at 4:07 PM, revealed staff was expected to provide resident care according to his/her care plan. She stated aides had the KARDEX to reference and were expected to use it to direct the care they provided to the residents. Interview with SRNA #15, on 05/24/2022 at 5:24 PM, revealed the care plan was a guide for overall resident needs and care. SRNA #15 and that the aides used the KARDEX to find information for individual residents related to diets, general preferences, or how to transfer the resident. Interview with SRNA #8, on 05/26/2022 at 8:15 AM, revealed care was guided by the resident's care plan or KARDEX. Interview with the Director of Nursing (DON), on 05/26/2022 at 3:47 PM, revealed she recalled the event of Resident #81's intercepted fall with SRNA #14 and reviewed the documentation of the investigation at that time. The DON stated the aide had failed to follow the care plan, specifically to transfer only with the assist of two (2) staff. The DON also stated the staff members had all been retrained with using the KARDEX, and all had received retraining on transfers and mechanical lift use. Interview with Administrator, on 05/26/2022 at 4:13 PM, revealed her expectation was that staff would provide care following best practices outlined in the facility's policies.

Based on observation, interview, review of the Centers for Disease Control and Prevention Infection Prevention during Blood Glucose Monitoring and Insulin Administration, and Environmental Cleaning Procedures: Best Practices for Environmental Cleaning in Healthcare Facilities, review of the manufacturer's instructions for use, review of Lippincott (2014) Manual of Nursing Practice 10th edition, and review of the facility's policies and procedures, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment. The facility also failed to help prevent and control the development and transmission of communicable diseases and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health's (Health Department) state guidelines for COVID-19. Observations, on 05/24/2022 before lunch, revealed the glucometer was not sanitized per policy. Observation, on 05/24/2022, revealed State Registered Nurse Aide (SRNA) #10, on the [NAME] Unit, touched the desk phone after doffing (removing) her personal protective equipment (PPE), without sanitizing or washing her hands. An additional observation, on 05/24/2022, during lunch, of SRNA #10, revealed she exited the room, doffed (removed) her PPE, and touched her uniform without sanitizing or washing her hands. Observation of the medication administration with vital signs performed, on 05/25/2022, revealed the blood pressure cuff and the pulse oximeter (measured oxygen saturation in the blood) were not sanitized between use on residents. The findings include: Review of the facility's policy titled, Hand Hygiene, dated 05/2019, revealed all staff would perform proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors. This applied to all staff working in all locations within the facility. Per the policy, hand hygiene was a general term for cleaning your hands by washing with soap and water or using alcohol based hand rub (ABHR). Review of the facility's reference book, Lippincott Manual of Nursing Practice, 10th Edition, 2014, page 1084, revealed gloves and gowns were removed and discarded prior to leaving the resident's room. Then, appropriate hand hygiene must be performed immediately with either soap and water or the use of ABHR. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment, revealed resident-care equipment could be a source of indirect transmission of pathogens. Per the policy, reusable resident-care equipment would be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Further review revealed that resident-care equipment was categorized based on the degree of risk for infection involved in the use of the equipment: critical items, semi-critical items and non-critical items. Continued review revealed that non-critical items came in contact with intact skin, but not mucous membranes and that these items required cleaning and disinfection with use of Environmental Protection Agency (EPA) registered disinfectants. Additional review revealed staff shall follow established infection control principles for cleaning and disinfecting reusable equipment, and each user was responsible for routine cleaning and disinfection of multi-resident items. The policy also defined reusable multiple-resident items as items that might be used multiple times for multiple residents with examples such as stethoscopes, blood pressure cuffs, feeding tube pumps, and oxygen concentrators. Review of the facility's policy titled, Blood Glucose Monitoring Device Disinfection, last reviewed 11/03/2021, revealed that blood glucose monitoring devices (glucometers) would be disinfected between each resident's use with a 1:10 bleach solution wipe, and staff should follow the manufacturers' recommendations for dry time between uses. Further review revealed the procedure included steps of: clean the meter after each person tested ; remove wipe from container; if wipe was very saturated (wet), squeeze or wring the wipe to remove some of the liquid; thoroughly wipe down the meter; and dispose of the used wipe in a trash container. Review of the CDC document, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html, revealed that using a blood glucose meter (glucometer) for more than one (1) person, without cleaning and disinfecting it between uses, was an unsafe practice. Further review revealed that whenever possible, blood glucose meters should be assigned to an individual person and not be shared. Continued review revealed if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per the manufacturer's instructions, to prevent carry-over of blood and infectious agents. The document stated, if the manufacturer did not specify how the device should be cleaned and disinfected, then it should not be shared. Review of the Evencare G2 Glucometer Care and Disinfection instructions, https://www.healthproductsforyou.com/p-[MEDICATION(S)]-evencare-g2-blood-glucose-monitoring-system.html, revealed that in order to disinfect the meter, the user must clean it with one (1) of the validated disinfecting wipes, which included Micro-Kill Bleach Germicidal Bleach Wipes. Further review revealed the user must wipe all external areas of the meter or lancing device including both front and back surfaces until visibly clean. Then, the surface of the meter was to remain wet at room temperature for the contact time listed on the wipe's directions for use. Continued review revealed the device should be wiped dry or allowed to air dry. Then, the user should wash hands with soap and water and dry thoroughly. Review of the Micro-Kill Bleach Germicidal Bleach Wipes label revealed the towelettes were saturated with a 1:10 bleach solution and that common uses for the wipes included disinfection of glucose meters, patient care equipment, point-of-care equipment, and hard non-porous healthcare surfaces. Review of the Micro-Kill Bleach Germicidal Bleach Wipe instructions revealed that the user must apply the pre-saturated towelette and wipe the desired surface to be disinfected and that a one (1) minute contact time was required to kill most viruses and bacteria, with the notable exception of [CONDITION(S)] spores, which required the most time at three (3) minutes of contact. Further review revealed the user should allow the surface to air dry. 1. Observation of State Registered Nurse Aide (SRNA) #10, on 05/24/2022 at 8:20 AM, on the [NAME] Unit, revealed SRNA #10 exited room [ROOM NUMBER] after doffing (removing) PPE, but did not wash hands or use hand sanitizer before touching the telephone at the nurses' desk. 2. Observation of State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) #1, on 05/24/2022 at 11:23 AM, revealed she was preparing to conduct bedside blood glucose testing for three (3) residents. After she gathered the glucometer and supplies, she initiated the preparation without washing or sanitizing hands. In the first resident's room, Resident #19, SRNA/KMA #1 placed the glucometer on the overbed table, obtained a lancet, prepared the resident's finger, placed the lancet in the glucometer, began to carry out the stick, then stopped and donned (put on) gloves. She then measured the resident's blood glucose, reported the result to the resident, then wiped the glucometer with one (1) alcohol square, discarded the square, placed the glucometer immediately back into the carrying tray, and placed the waste in a water cup serving as a portable temporary sharps container. SRNA/KMA #1 then moved immediately to Resident #70's room and then to Resident #60's room, where she used hand sanitizer and donned gloves. She then obtained the blood glucose sample with measurement. However, in both instances, she wiped the glucometer with one (1) alcohol square, placed the glucometer back into the carrying tray, and placed all the waste in the water cup. Interview with the Staff Development Coordinator (SDC), on 05/24/2022 at 1:25 PM, revealed SRNA/KMA #1 came to her and reported she might have made mistakes while being observed by the State Survey Agency (SSA) Surveyor during blood glucose fingerstick performance. The SDC stated she conducted re-education on the spot and completed the required check-off form for validation of skills. Interview with SRNA/KMA #1, on 05/24/2022 at 1:44 PM, revealed she had been an SRNA for many years but was nervous while being observed, which might have led her to making errors. She also stated hand sanitizing and glucometer disinfection were important to prevent cross contamination. 3. Observation of SRNA #10, on 05/24/2022 at 12:00 PM, revealed SRNA #10 doffed (removed) PPE in room [ROOM NUMBER]. SRNA #10 then left room [ROOM NUMBER] without performing hand hygiene, washing hands, or using hand sanitizer. Per the observation, SRNA #10 then touched her uniform top on both sides, used hand sanitizer near the kitchen, and washed her hands at the hand sink in the kitchen. Observation of SRNA #10 revealed she did not have hand sanitizer hanging around her neck. Interview with SRNA #11, on 05/26/2022 at 11:30 AM, revealed after removing PPE, staff must wash hands, dry hands, and then sanitize hands prior to going to another task to prevent the spread of germs between residents. Interview with Licensed Practical Nurse (LPN) #7, on 05/26/2022 at 11:32 AM, revealed Resident #162, in room [ROOM NUMBER], was under transmission-based precautions because the resident was not vaccinated against the COVID-19 virus. LPN #7 stated staff must wash and dry their hands, and sanitize hands after removal of PPE to prevent the spread of germs and prevent cross contamination. Interview with SRNA #10, on 05/26/2022 at 3:02 PM, revealed she had worked nights and a double shift when she was working on the day shift 05/24/2022. She stated she kept hand sanitizer hanging around her neck. Therefore, she stated, after she removed the PPE, she washed and sanitized her hands prior to touching other residents or items to prevent cross contamination. Interview with the Director of Nursing (DON)/Infection Control Preventionist, on 05/25/2022 at 3:40 PM, revealed after removing PPE, staff members must wash their hands. She stated staff members should not touch the phone or their uniforms until after their hands were washed. The DON stated going from dirty to clean would spread germs. 4. Observation of Registered Nurse (RN) #1, on 05/25/2022 at 7:24 AM, during medication administration for Resident #9, revealed he also took Resident #9's blood pressure, heart rate, and oxygen saturation level (pulse oximeter), using equipment from the rolling vital sign (VS) machine. After completing this, RN #1 rolled up the blood pressure cuff and placed it back on the VS machine, along with the pulse oximeter, without cleaning those multi-use items. RN #1 then went to Resident #9's Room, where he measured his/her blood pressure, heart rate, and oxygen level. Continued observation revealed RN #1 did not clean the blood pressure cuff or pulse oximeter. After completing this, RN #1 rolled up the blood pressure cuff and placed it back on the VS machine, along with the pulse oximeter, but did not clean or disinfect either of them. Interview with RN #1, on 05/25/2022 at 8:07 AM, revealed for multi-use equipment, such as blood pressure cuffs and oximeters, approved facility disinfectant wipes should be used to clean and disinfect between resident use. RN #1 stated to disinfect the glucometer, staff must use MicroKill wipes. Interview with the Director of Nursing (DON), on 05/25/2022 at 3:47 PM, revealed staff was expected to use approved disinfectant wipes on multi-use equipment between each resident use. Further interview revealed the expectation was that, for glucometers, staff must use Micro-Kill Bleach Germicidal Bleach Wipes to clean and disinfect them. Observation with her at that time revealed these wipes were not able to be located on the medication cart but were on the top shelf of a cabinet in the Medication Room. Interview with the Administrator, on 05/26/2022 at 4:13 PM, revealed her expectation was that staff would follow the facility's policies and best practices as outlined in the Lippincott Manual used as a reference for resident care. The Administrator stated the facility's policies and the Lippincott Manual included correct procedures for hand hygiene and cleaning multi-use equipment. She stated staff had been trained according to that expectation.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to handle kitchen equipment in a sanitary manner in the dish room. Observations, on 05/24/2022, of Utility Aide #1 revealed he touched the clean top and bottom covers for clean plates with contaminated ungloved hands. The findings include: Review of the facility's policy titled, Sanitation and Infection Prevention/Control: Hand Hygiene, dated 01/2022, revealed, under Disposable, that non-latex gloves must be worn when handling soiled dishware, clean utensils, dishes, and equipment. Per the policy, hands must be washed before putting on and after removing disposable gloves when working in the kitchen. Further, it stated disposable gloves must be changed and hands washed when the gloves were dirty and when moving from one task to another; for example, from handling dirty dishes to handling clean dishes. Observation of Utility Aide #1, on 05/24/2022 at 9:30 AM, revealed he was in the dish room and walked from the soiled side of the dishwasher, handled the soiled dishware, and then went back to the clean side. Further, at the clean side, after coming from the soiled side, he was handling the top and bottom covers for plates without washing his hands or donning gloves. Interview with Utility Aide #1, on 05/24/2022 at 9:30 AM, revealed he touched the soiled pots and pans then returned to the clean side without washing his hands. He stated he had received training on use of the dishwasher, including proper hand hygiene when working with both soiled and clean dishes. Further interview revealed if he did not wash his hands between using the soiled and clean side of the dishwasher and put on gloves, it could cause cross contamination. Interview with the Dietary Manager, on 05/26/2022 at 9:30 AM, revealed staff was trained to wash their hands after removal of gloves and to put on a new pair of gloves after their hands were dry. Further interview revealed staff not washing their hands and putting on new gloves between using the dirty and clean side of the dishwasher, could cause cross contamination by carrying bacteria from the dirty dishware to the clean dishware. Interview with the Director of Nursing/Infection Preventionist, on 05/25/2022 at 3:44 PM, revealed if a staff member did not wash their hands between using the dirty side and clean side of the dishwasher, it was cross contamination which could result in possible food-borne pathogens. Interview with the Administrator, on 05/25/2022 at 4:22 PM, revealed cross contamination with bacteria occurred when Utility Aide #1 touched the dirty side of the dishware and then touched the clean tops and bottoms for the plates. The Administrator stated the staff member should have washed his hands.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the Baseline Care Plan was developed and implemented to provide effective and person-centered care for one (1) of fifteen (15) sampled residents (Resident #2). Resident #2's Baseline Care Plan, initiated 01/23/2021, revealed the resident had pain with interventions to administer pain medications as directed; to assess pain after medication administration for effectiveness; and to notify the Physician if pain the medication was less than effective. However, the facility failed to administer medications as directed/ordered. Additionally, the facility also failed to ensure the resident's pain was assessed before and after administration of pain medication. Further, the facility failed to notify the Physician when the resident's pain medication was less than effective, as per the Care Plan. On Friday, 01/22/2021, the facility admitted Resident #2 from an Acute Care Hospital status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admitting Physician was not aware the facility needed paper prescriptions for [MEDICATION(S)] and Oxycodone to obtain the medications from the Pharmacy. The medications were never dispensed from the Pharmacy and were not administered as directed/per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 stated he/she was crying out for pain medication, as the pain was unbearable throughout the weekend. However, interview with the On-Call provider revealed, on 01/23/2021 and 01/24/2021, she was not notified that Resident #2 had pain or was not administered his/her ordered pain medications as directed per the Baseline Care Plan. (Refer to F- 697 and F-755). The facility's failure to have an effective system in place to ensure the Baseline Care Plan was implemented to provide effective and person-centered care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 02/10/2021 and was determined to exist on 01/22/2021. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/23/2021, with the facility alleging removal of the Immediate Jeopardy on 02/19/2021. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/19/2021, prior to exit on 02/25/2021, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Care Plan, dated 08/25/2020, revealed the initial Care Plan would ensure the resident received the necessary care and services that were consistent with his/her physical status and preferences at the time of admission. Additionally, the initial Care Plan would serve as a basis for providing care until the Comprehensive Resident Assessment and Care Plan were developed. Per policy, a licensed nurse conducting the admission process would receive the Admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Hospital Discharge Summary, dated 01/22/2021, revealed the resident was admitted to the hospital, on 01/20/2021, for a Right Sacroiliac Fusion. Per Summary, the resident's pain was controlled with pain medication. Additionally, the discharge plan included pain control with pain medication including Oxycodone 7.5/325 mg, every six (6) hours as needed (PRN); [MEDICATION(S)] 600 mg, four (4) times a day; and [MEDICATION(S)] Sulfate Extended Release (ER) 15 mg, every twelve (12) hours PRN. Review of Resident #2's closed medical record revealed the facility admitted the resident Friday, 01/22/2021 at 6:00 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident was discharged from the facility on 01/25/2021. There was no Admission Minimum Data Set (MDS) Assessment completed for Resident #2 due to the discharge date and short-stay. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed an order, dated 01/22/2021, for [MEDICATION(S)] Sulfate ER 15 mg, one (1) tablet orally, every twelve (12) hours PRN for pain. Further review revealed an order, dated 01/22/2021 for [MEDICATION(S)] 600 mg, one (1) tablet orally, four (4) times a day for pain. Review of Resident #2's Ancillary Admission Assessment, opened on 01/22/2021 at 6:00 PM, and closed on 01/23/2021 at 12:42 PM, revealed Resident #2 was alert and oriented to person, place and time. Additionally, the Assessment stated the resident communicated verbally, his/her speech was clear, and he/she was able to understand and be understood when speaking. Additional review of the Assessment, revealed the resident had a surgical wound to his/her right hip, with no exudate (drainage); the wound was dry, intact, and closed with glue. Further review of the Assessment revealed the resident had pain, which affected sleep and limited day-to-day activity. The resident rated his/her pain at 7/10, on a scale with zero (0) being the least amount of pain and ten (10) being the greatest amount of pain. Review of Resident #2's Controlled Drug Record (CDR), revealed the resident received [MEDICATION(S)] Sulfate ER (extended release) 15 mg, on 01/23/2021 at 1:15 AM, and, on 01/23/2021 at 8:30 PM, by Kentucky Medication Aide (KMA) #1. However, there was no documented evidence of a pain assessment prior to or after administration of the medication in order to evaluate if the medication was effective, as per the care plan. Additionally, [MEDICATION(S)] Sulfate ER 15 mg was signed out on the CDR, on 01/24/2021 at 1:30 PM, by KMA #1, with the pain scale rating of 7/10. Review of Resident #2's Pain Assessment, dated 01/24/2021 at 9:41 PM, by RN #1, revealed the resident had verbal complaints of 6/10 throbbing pain, multiple times a day, at 8:43 PM. Continued review revealed non-medical interventions such as relaxation, distraction, and change in position were implemented and provided relief. Further review revealed the [MEDICATION(S)] Sulfate ER 15 mg was signed out on the CDR, on 01/25/2021 at 8:15 AM, by LPN #2, with the pain scale rating of 10/10. However, there was no documented evidence the Physician was notified that the pain medication the resident received was less than effective. Record review revealed there was no documented evidence the Physician was notified that Resident #2's [MEDICATION(S)] or Oxycodone were not administered per orders/as directed. Review of Resident #2's Electronic Medication Administration Record (E-MAR), dated January 2021, revealed no evidence Oxycodone 7.5-325 mg, PRN every six (6) hours, or [MEDICATION(S)] 600 mg four (4) times a day were administered. Review of Resident #2's Baseline Care Plan, initiated 01/23/2021, revealed the resident had pain. The goal stated the resident would verbalize pain, indicate the location of pain and remain free from any unrelieved pain. Further review revealed interventions included but were not limited to administer pain medications as directed; assess pain after medication administration for effectiveness; notify the Physician if pain medication was less than effective. However, there was no evidence pain was assessed after the pain medication was administered on 01/23/2021 or, that the Physician was notified of continued pain, on 01/23/2021 and 01/24/2021. Further, there was no documented evidence Resident #2 received [MEDICATION(S)] or Oxycodone per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Resident #2, on 02/03/2021 at 10:40 AM, revealed while the resident resided at the facility, he/she did not receive his/her pain medications, [MEDICATION(S)] and Oxycodone as ordered/directed by the Physician. Additionally, the resident stated he/she asked several Nursing staff at the facility for help to get his/her [MEDICATION(S)] and Oxycodone because the pain medication he/she was receiving was less than effective, and he/she was in pain. However, Resident #2 stated he/she was told over and over again the medication was not available at the facility to administer. Interview with SRNA #4, on 02/03/2021 at 3:22 PM, revealed she was assigned to Resident #2, on 01/23/2021 from 2:00 PM until 6:00 PM, and, on 01/24/2021 from 2:00 PM until 6:00 PM. SRNA #4 stated Resident #2 verbalized he/she had pain in his/her lower extremities, on 01/23/2021 and 01/24/2021, and had facial grimacing. Continued interview revealed the resident kept asking for more pain medication; to speak with someone in charge who could get him/her pain medication; and to discharge from the facility because Resident he/she had pain medication at home. Further, SRNA #4 stated the resident frequently would self-propel in a wheelchair to the Nurses' Station, on 01/23/2021 and 01/24/2021, to talk to Licensed Practical Nurse (LPN) #6, Registered Nurse (RN) #2, and RN #1 about getting his/her pain medication. Interview with Agency LPN #5, on 02/03/2021 at 5:12 PM, revealed she had worked at the facility about a week. LPN #5 stated she was assigned to Resident #2, on 01/23/2021 which was her first day at the facility. She stated she did not receive an orientation related to the facility's policy and procedures and was not aware of the facility's policy related to Baseline Care Plans. However, she stated she was aware Resident #2 was prescribed [MEDICATION(S)] and Oxycodone for pain and was aware the resident was requesting his/her [MEDICATION(S)]. LPN #5 stated medication was not available at the facility to administer as directed/ordered, per the Baseline Care Plan. Interview with KMA #1, on 02/04/2021 at 3:50 PM, revealed she had worked at the facility fourteen (14) years. Per interview, she worked with Resident #2, on Saturday, 01/23/2021, and Sunday, 01/24/2021. Additional interview revealed she administered the resident his/her PRN [MEDICATION(S)] when he/she was in pain because his/her [MEDICATION(S)] and Oxycodone were not available as directed/ordered by the Physician. Continued interview revealed per her scope of practice, as a KMA, she was not able to assess a resident's pain before and after administration of pain medication. KMA #1 stated she recorded what the resident told her on the E-MAR and notified the Nurse. Per interview, she forgot to document the administration of [MEDICATION(S)] on the E-MAR on 01/23/2021. Continued interview revealed Resident #2 complained of ongoing pain over the weekend (01/23/2021 and 01/24/2021), and she reported the resident's pain complaints to LPN #5, RN #1, and RN #2. Interview with RN #2, on 02/03/2021 at 2:30 PM, revealed she had worked at the facility two (2) weeks. RN #2 stated she was in training with RN #1, on Sunday 01/24/2021, her third day of training, and was assigned to Resident #2. She stated on 01/24/2021, she was aware Resident #2 had complaints of pain and the resident's [MEDICATION(S)] and Oxycodone were not available to administer per Physicians orders as directed. Continued interview revealed she did not notify the On-Call provider that the resident had not received his/her pain medications as directed or the resident verbalized his/her pain management was less than effective. Further, she stated Resident #2 received [MEDICATION(S)] 15 mg during her shift, that was administered by KMA #1. However, RN #2 stated she did not complete a pain assessment before or after the administration of pain medication. Per RN #2, it was important for a resident's Baseline Care Plan to be followed to ensure the resident received the necessary care. Interview with RN #1, on 02/03/2021 at 4:20 PM revealed she had worked at the facility six (6) months. Per interview, she was assigned to Resident #2, on 01/24/2021. Continued interview revealed Resident #2 had asked staff several times, on 01/24/2021, why he/she was not receiving the prescribed [MEDICATION(S)] as directed and ordered by the Physician. Continued interview revealed RN #1 did a pain assessment with the daily Skilled Evaluation Assessment but, she did not complete a pain assessment prior to or after the administration of [MEDICATION(S)]. Further, RN #1 stated she did not notify the Physician the resident was suffering in pain. However, she stated it was the Nurse's responsibility to follow the resident's Baseline Care Plan, and she should have called the Physician related to Resident #2 not receiving pain medication as directed/ordered, and the resident's pain management not being effective without the [MEDICATION(S)] and Oxycodone. Per interview, it was important for residents to receive care per their Baseline Care Plan to ensure they received quality care. Interview with the Advanced Practice Registered Nurse, (APRN), on 02/05/2021 at 2:10 PM, revealed she was the On-Call provider for Saturday, 01/23/2021 and Sunday, 01/24/2021. Further interview revealed she did not receive any pages or calls from the facility over the weekend related to Resident #2, and she was not aware the resident did not receive his/her ordered pain medication as directed or that the resident had ineffective pain management. Interview with LPN #2, on 02/03/2021 at 1:45 PM, revealed she had worked at the facility seventeen (17) years. Additionally, she stated she was Resident #2's nurse, on 01/25/2021, from 6:00 AM until discharge, at approximately 11:00 AM. Per interview, Resident #2 requested to discharge from the facility, early on 01/25/2021, because he/she had received less than effective pain management while at the facility. She stated the resident said his/her pain was 10/10 because he/she had not received pain medication as ordered/directed by the Physician. Continued interview revealed LPN #2 assessed the resident's pain at that time to be 10/10 and administered [MEDICATION(S)] Sulfate ER 15 mg at 8:15 AM. However, the resident was requesting the prescribed [MEDICATION(S)] and Oxycodone, which were not available at the facility. Further, LPN #2 stated she waited to inform the Attending Physician of the above until she arrived on the Unit, on 01/25/2021 at approximately 10:15 AM. Interview with the Director of Nursing (DON), on 02/05/2021 at 11:25 AM, revealed she had worked at the facility in her current role for one (1) year. Additionally, she stated she expected the Baseline Care Plan to be followed by staff to ensure the resident received necessary individualized care. Per interview, and per Resident #2's Baseline Care plan, his/her pain medication should have been administered as directed/ordered by the Physician. Additionally, the DON stated pain assessments should have been documented on the E-MAR to determine the resident's pain level prior to and after the administration of medications. Further, she stated she expected Nurses to contact the provider for further direction if a resident did not receive pain medication as ordered and when their pain management was less than effective, per the Baseline Care Plan and as directed by the facility's policy. Interview with the Administrator, on 02/04/2021 at 9:50 AM, revealed he expected a resident's Baseline Care Plan to be followed by staff to ensure care needs were met and to limit the opportunity for negative outcomes. Additionally, he stated he expected ordered pain medication to be available to residents and administered per orders as directed by providers. Per interview, he expected pain to be assessed per standards of care and per the Baseline Care Plan. Further, he stated he would expect Nurses to notify providers if a resident had less than effective pain management. Further, the Administrator stated it was a healthcare provider's obligation to ensure a resident in pain received pain management, so the resident's pain was relieved. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/23/2021 alleging removal of the Immediate Jeopardy on 02/19/2021. Review of the AoC revealed the facility implemented the following: 1. On 02/02/2021, the Interdisciplinary Team (IDT) reviewed Resident #2's medical record. 2. A Clinical Admissions Evaluation would be completed on all new admissions with routine and as needed medication orders. 3.a. On 02/17/2021, the Clinical Coordinators reviewed all admissions and readmissions for the previous thirty (30) days related to pharmaceutical procedures, pain assessments, and care plans. b. Clinical Coordinators audited if pain medications were available for those residents noted with pain and orders for narcotic pain medications. c. Clinical Coordinators audited prescription availability for narcotic pain medications. d. Findings were reviewed with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). e. Education was provided as necessary, based on the review findings. f. Clinical Coordinators assured all residents with narcotic pain medication orders had appropriate medications available at the time of review. 4. Upon admission, the Admitting Nurse would verify all needed prescriptions had been sent to the facility. Additionally, the Admitting Nurse would notify the Physician if a written prescription was needed and would document notification in the resident's medical record. 5.a. Beginning on 02/17/2021, a list of all medications requiring a written prescription was added to all medication cart binders, by the Clinical Coordinators. b. Beginning on 02/17/2021, a list of controlled substances needing prescriptions was added to the Twenty-four (24) Hour Report sheet by the ADON and the DON. c. Beginning on 02/17/2021, a list of Emergency Stock Box medications was updated and placed at all Nursing Stations and in all medication cart binders, by the Clinical Coordinators. 6.a. On 02/18/2021, the Clinical Coordinators provided education to twenty-two (22) of thirty-nine (39) Licensed Practical Nurses (LPN), Registered Nurses (RN), and Kentucky Medication Aides (KMA), on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box. No employee would be permitted to work beyond 02/18/2021 without receiving education. b. New hire orientation, orientees, including agency contract staffing, would be educated on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box, by the ADON, DON, and Clinical Coordinators. 7. Beginning on 02/17/2021, a member of the Interdisciplinary Team (IDT) reviewed new admissions within twenty-four (24) hours, verifying medication orders, controlled substance availability, pain assessments, and pain care plans for accuracy. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the ADON would validate the review Monday through Friday. 8. Beginning on 02/17/2021, a member of the IDT audited all new admissions within twenty-four (24) hours for medication orders, medication order verifications of controlled substances for availability on hand and/or in the Emergency Stock Box. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the DON would validate the review Monday thru Friday. 9. Beginning on 02/17/2021, during the Monday through Friday Clinical Meetings, the IDT reviewed all Twenty-four (24) Hour Report sheets monitoring controlled substances awaiting arrival related to the need for written prescription and verifying timely medication arrival. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the ADON would validate the review Monday thru Friday. 10. On 02/03/2021, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held, and on 02/10/2021, a monthly QAPI meeting was conducted to discuss the action plan related to the identified deficiency(s). 11. On 02/17/2021, a QAPI Performance Improvement Project (PIP) was implemented to review findings with ongoing monitoring. 12. Upon admission, Resident #2 was given a summary of his/her Baseline Care Plan, which was documented in Resident #2's medical record. 13. On 02/01/2021, the IDT, consisting of the DON, ADON, Clinic Coordinators, and Minimum Data Set (MDS) Coordinators, reviewed Resident #2's medical records, which included orders, medication administration record, and assessments for pain management and accuracy. 14. A Clinical Outcomes Management Systems (COMS) Clinical Admissions Evaluation would be completed for all new admissions with routine and as needed medication orders. 15.a. On 02/17/2021, the Clinical Coordinators reviewed all new admissions and readmissions for the previous thirty (30) days for a COMS Pain Assessment, noting pain, and a corresponding pain care plan. b. On 02/17/2021, the Clinical Coordinators audited if controlled pain medication was noted as not available for those residents with orders for narcotic pain medications. Following any narcotic pain medication noted as not available, the Clinical Coordinators determined if it was related to prescription availability. For all noted concerns during the review, the Clinical Coordinators ensured all residents with narcotic pain medication orders had appropriate medication available at the time of the review. c. Findings of the review were reviewed with the DON and ADON. d. On 02/17/2021, the Clinical Coordinators provided education to twenty-two (22) of thirty-nine (39) LPN's, RN's, and KMA's, on COMS Pain Assessment, noting pain and corresponding care plan. No employee was permitted to work beyond 02/18/2021 without receiving education. 16. On 02/17/2021, revisions to pain management guidelines were reviewed. Revisions to pain management included: 1. Licensed Nurses would conduct pain assessments on admission and document findings in the COMS Admission Evaluation and Ancillary Admissions Assessment. 2. A pain-focused care plan would be initiated in the Baseline Care Plan if pain was noted in the COMS Admission Evaluation and Ancillary Admissions Assessment. 3. The Emergency Stock Box would be utilized for pain management medications when an ordered medication was unavailable. 17. Beginning on 02/17/2021, the IDT, including the Clinical Coordinators, Social Service Department (SSD), and MDS Nurses reviewed the previous twenty-four (24) hour Nurse charting for appropriate notification and intervention on new behaviors, risk management incidents, and Situation, Background, Assessment, Recommendation (SBAR), daily Monday through Friday. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the DON would validate the review Monday through Friday, with the weekend review on Monday, for a minimum of one (1) month with no omissions. 18. Beginning on 02/17/2021, the IDT, consisting of DON, ADON, Clinical Coordinators, and MDS Nurses would audit all new admission Baseline Care Plans and COMS Admission Evaluation validating nursing assessments for pain, implementation of a pain care plan, pain management orders in place, and medication administration records, within twenty-four (24) hours of admission. Additionally, the weekend Clinical Coordinator would review new admissions, within twenty-four (24) hours of admission, on Saturdays and Sundays. Further, the IDT would perform a review of the audit daily, Monday through Friday, during the Clinical Meeting with the weekend review validated during the Monday Clinical Meeting. 19.a. On 02/17/2021, the Clinical Coordinators reviewed all new admissions and readmissions for the previous thirty (30) days for COMS Pain Assessments, noting pain and a corresponding pain care plan. b. On 02/17/2021, Clinical Coordinators audited if controlled pain medications were noted as not available for those residents noted with pain, and with orders for narcotic pain medication. For all noted concerns during the review, the Clinical Coordinators ensured all residents with narcotic pain medication orders had appropriate medication available at the time of the review. c. Findings of the review were shared with the DON and ADON. d. On 02/17/2021, education was provided to twenty-two (22) of thirty-nine (39) LPN's, RN's, and KMA's on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box. No employee was permitted to work beyond 02/18/2021 without receiving education. Clinical Coordinators were responsible for providing in-service education beyond 02/18/2021, prior to any employee working. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of a document titled Resident #2's Medical Record, revealed the DON, ADON, MDS Nurses, and Clinical Coordinators (all IDT members) signed the document, on 02/01/2021, stating they reviewed Resident #2's Assessment, Progress Notes, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. Record review for sampled residents, revealed residents admitted within the last thirty (30) days had Clinical Admission Evaluations, including pain assessment. The Admission Report, dated 01/25/2021 through 01/31/2021, and 02/01/2021 to 02/23/2021, noted twenty-seven (27) new admissions. Review of the thirty (30) day New Resident Admission Audit revealed thirty-three (33) residents were audited, and four (4) residents had narcotic pain medication which was not available. 3.a-f. Review of the thirty (30) day New Resident Admission Audit revealed thirty-three (33) residents were audited for a pain care plan, COMS Pain Assessment, pain on admission, narcotic (NARC) pain medication administration, medications marked N/A, and prescription (script) not available. Interview with the Clinical Coordinators, on 02/25/2021 at 3:50 PM, revealed they completed the thirty (30) day New Resident Admission Audit. The audit revealed three (3) additional residents did not have narcotic pain medication available, and they notified the DON of the findings. Interview with the DON, on 02/25/2021 at 4:45 PM, revealed the audit identified medication availability issues with only two (2) residents; however, those two (2) issues were specific to accessing the Emergency Stock box. The medication for those residents was available in the facility; however, the nurses did not follow proper procedure for accessing the Emergency Stock Box to obtain medications for the residents. The DON stated Nursing staff received education on the Emergency Stock Box procedures. 4. Interview with the DON, on 02/25/2021 at 4:45 PM, revealed an Admission Checklist and audit were developed for the Admitting Nurse to utilize for controlled substances requiring a written script and to notify the Physician if a written prescription was needed when verifying medication. Interview with the MDS Coordinators, on 02/25/2021 at 3:35 PM, revealed documentation of notification to Physicians when verifying medications was in the resident's medical record and the Twenty-four (24) Hour Report sheet. Review of the Admission Checklist included verification of controlled medication prescriptions, which was answered yes or no. If answered no, it asked if the Physician was notified. Review of the document Obtaining Pharmaceuticals New Admission, (no date), revealed it listed step criteria for the Admitting Nurse to include: 1) the Admitting Nurse would verify with the Discharging Nurse (from the other facility) if the resident would be discharging with controlled substances requiring a written prescription; 2) the Admitting Nurse would request all prescriptions be sent with discharge paperwork; 3) a list of all medications requiring a prescription had been added to all medication cart binders; 4) if a needed prescription was not in a new resident's discharge packet, the Admitting Nurse would notify the Physician a written prescription was needed when verifying medications; 5) controlled substances needing prescriptions had been added to all Twenty-four (24) Hour Report sheets; and 6) the current list of Emergency Box Medications was available at all nursing stations and all medication cart binders. 5.a. Interview with the Clinical Coordinators, on 02/25/2021 at 3:50 PM, revealed on 02/17/2021, they placed a list of all medications requiring a prescription and a list of Emergency Stock Box medications to all medication cart binders and at the Nurses' Stations. b. Interview with the ADON, on 02/25/2021 at 3:50 PM, revealed she and the DON added controlled substances needing prescriptions to the Twenty-four (24) Hour Report sheet on 02/17/2021. c. Interview with the Clinical Coordinators, on 02/25/2021 at 3:50 PM, revealed on 02/17/2021, they placed a list of all medications requiring a prescription and a list of Emergency Stock Box medications to all medication cart binders and at the Nurses' Stations. 6.a. Interviews with KMA #1, on 02/25/2021 at 3:00 PM; LPN #11 and LPN #12, on 02/25/2021 at 3:10 PM; MDS Coordinator #1 and MDS Coordinator #2, on 02/25/2021 at 3:35 PM; RN #6, RN #5, and LPN #13, on 02/25/2021 at 3:50 PM, revealed they received education related to obtaining pharmaceuticals, obtaining Physician's scripts, and the process of pulling a controlled substance from the Emergency Stock Box. Review of the education audit sheets, on 02/18/2021, revealed the Clinical Coordinators provided education to twenty-two (22) of thirty-nine (39) LPN's, RN's, and KMA's on obtaining pharmaceuticals, obtaining Physician's scripts, and the process of pulling a controlled substance from the Emergency Stock Box. b. Interview with Human Resources (HR), on 02/25/2021 at 4:25 PM, revealed the New Hire Orientation process included education on obtaining pharmaceuticals, obtaining Physician's scripts, and the process of pulling a controlled substance from the Emergency Stock Box. Review of the New Hire Orientation packet revealed orientation provided Provisions of Quality of Care, Baseline Care Plan, Nursing Initial Care Plan, Medications Controlled Drugs, Obtaining Pharmaceuticals for New Admissions, Pain Management Guidelines, and Emergency Box Stock List trainings. Review of the document Obtaining Pharmaceuticals for New Admission, (no date), revealed it listed step criteria for the Admitting Nurse to include: 1) the Admitting Nurse would verify with the Discharging Nurse (from the other facility) if the resident would be discharging with controlled substances requiring written prescriptions; 2) the Admitting Nurse would request all prescriptions be sent with discharge paperwork; 3) a list of all medications requiring a prescription had been added to all medication cart binders; 4) if a needed prescription was not in a new resident's discharge packet, the Admitting Nurse would notify the Physician a written prescription was needed when verifying medications; 5) controlled substances needing prescriptions had been added to all [TRUNCATED]

Based on interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services' (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to have an effective system to review and develop the Comprehensive Care Plan for one (1) of fifteen (15) sampled residents (Resident #1) when the resident exhibited elopement risk behaviors. The facility admitted Resident #1 on 04/30/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had a Durable Power of Attorney, who stated the resident was not safe to leave the facility unsupervised. The Physician wrote an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented evidence the facility developed a Comprehensive Care Plan (CCP) to include this incident or added interventions to increase monitoring and supervision to prevent or decrease the risk for further occurrence. Additionally, during the summer of 2020 (exact date unknown), the resident was outside unsupervised and was observed driving his/her electric wheelchair behind cars, going in the opposite direction of traffic. The facility added a tall flag to the back of the resident's electric wheelchair to ensure the resident would be visible. However, there was no documented evidence the CCP was developed to include the incident or staff implemented an intervention to increase monitoring or supervision of the resident after this incident. In addition, the CCP was not developed to include interventions to prevent or reduce further occurrences. Further, on 01/26/2021, around 3:00 PM, the facility notified Resident #1 of a room change. Resident #1 verbalized to Licensed Practical Nurse (LPN) #1 he/she would go home and leave the facility if he/she had to change rooms. The LPN directed the resident to talk to the Administrator. However, the LPN did not develop the CCP to include the resident's statement that he/she was going to leave and go home, nor did the facility include an intervention to increase monitoring or supervision to prevent elopement. Review of the facility's video footage revealed, on 01/26/2021 at 4:24 PM, Resident #1 exited the facility without staff knowledge. At 4:26 PM, the resident exited the facility's driveway and entered the roadway in his/her electric wheelchair. The resident's daughter notified the facility the resident was at a Walmart, approximately 0.8 miles away, and she returned the resident to the facility at approximately 5:07 PM. (Refer to F-689) The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 02/10/2021 and determined to exist on 01/21/2021. The facility provided an acceptable Allegation of Compliance (AoC) on 02/23/2021, with the facility alleging removal of the Immediate Jeopardy on 02/19/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 02/19/2021, prior to exit on 02/25/2021, with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Care Plan, dated 10/15/2018, revealed the Comprehensive Care Plan was a resident specific plan of care based on information gathered through the Resident Assessment Instrument (RAI) process as well as ancillary assessments and evaluations. Additionally, the CCP was prepared by an interdisciplinary team (IDT) of health care professionals and would be developed to identify which discipline(s) would be responsible to carry out the approaches and interventions. Per policy, the CCP was designed to maintain the resident's current status or assist the resident to attain his/her highest potential while respecting the resident's rights and choices. Further, personnel on all shifts had access to the CCP via the Electronic Health Record (EHR), and it was their responsibility to report changes in the resident's status that could affect the accuracy of the CCP. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2017, revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The RAI Manual stated the care plan must be reviewed and revised on an ongoing basis to reflect changes in the resident and the care the resident received. Review of Resident #1's Medical Record revealed the facility admitted the resident, on 04/30/2018, with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's CCP, initiated on 07/25/2018, revealed the resident's representative and/or the resident expressed a desire for continued placement to remain at the long-term care (LTC) facility; there were no plans for discharge. Additionally, the resident would sometimes get frustrated and say he/she was going home, but understood he/she was unable to provide self-care. The goal was the resident would demonstrate understanding of LTC placement. Further review revealed interventions included but were not limited to assess preferences regularly regarding LTC placement and refer to outside agency as needed, if preferences changed (i.e. desired to speak to someone about living in the community); encourage family to bring familiar items from home to help create a home-like environment; provide resident and/or representative and Physician education and care plan meeting notifications; provide opportunity to build relationships with others residing in the facility though activity programs and social interaction; and provide opportunity to vent, voice concerns, or ask questions. However, additional review of the CCP revealed there was no documented evidence the CCP was developed related to the resident's risks for elopement to include interventions to prevent or reduce occurrences. Review of Resident #1's Progress Note, dated 09/22/2019 at 10:48 AM, revealed the resident was observed driving his/her scooter into a grassy, wooded area surrounding the facility; The resident was not able to be redirected. Additional review of Resident #1's Progress Note, dated 09/22/2019 at 10:50 AM, revealed the resident was observed outside, unsupervised, riding his/her scooter in a grassy area along the tree line down to the end by the roadway. Further review revealed when staff attempted to redirect the resident to drive his/her scooter on the pavement in the parking lot, he/she refused. The resident responded to staff's request and told them, Get the hell away from me; I know how to drive this thing. Continued review revealed the resident stated, I'm looking for a rabbit or a squirrel or something. Record review revealed no documented evidence the facility assessed Resident #1 for the behavior of driving his/her scooter into a grassy, wooded area by the roadway. In addition, there was no documented evidence the facility developed the CCP to include interventions to prevent or reduce further occurrences. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no documented evidence the facility developed the CCP to include the ordered intervention to increase supervision and monitoring to prevent or reduce further occurrences. Interview with the Maintenance Manager, on 02/08/2021 at 8:10 AM, revealed as he was leaving the facility during the summer of 2020 (exact date unknown), he observed Resident #1 riding his/her electric wheelchair along the cars going the opposite direction the cars should go. Additionally, the resident's electric wheelchair was so low to the ground the resident was barely visible and there were no staff in the parking lot supervising the resident. Continued interview revealed the incident was discussed the next morning in Clinical Meeting with the interdisciplinary team (IDT). Further interview revealed it was decided a tall flag would be added to the back of the resident's electric wheelchair in a proactive approach to keep the resident safe. However, there was no documented evidence of the parking lot incident. In addition, there was no documented evidence the facility developed the CCP to include interventions to increase supervision and monitoring and to prevent or reduce further occurrences. Resident #1's Quarterly Minimum Data Set Assessment, dated 12/16/2020, revealed the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating intact cognition. Continued review of the Assessment revealed the facility assessed the resident to require supervision with bed mobility; required limited assistance of one (1) staff with ambulation; and, required supervision with setup toileting. The Assessment stated the resident was not steady, but was able to stabilize without staff assistance between surfaces, walked with a walker, and used a wheelchair. Review of Resident #1's Progress Note, dated 01/26/2021 at 2:22 PM, completed by Social Services, revealed the family was notified of the need for Resident #1's room relocation due to facility Covid-19 cohorting infection control protocol. Interview with State Registered Nurse Aide (SRNA) #1, on 02/01/2021 at 4:13 PM, who was assigned to the Hickory Unit, on 01/26/2021, revealed on 01/26/2021, between 3:00 PM and 4:00 PM, Resident #1 came out of his/her room on Hickory Unit and was upset related to his/her room changing related to COVID cohorting. Per interview, she heard the resident talking to Licensed Practical Nurse (LPN) #1 who directed the resident to talk to the Administrator. Interview with LPN #1, on 02/01/2021 at 4:30 PM, who was assigned to the Hickory Unit on 01/26/2021, revealed on 01/26/2021 around 4:00 PM, the resident realized he/she was moving to another room and became upset. LPN #1 stated the resident came out of his/her room and told her he/she did not want to move to another room, and if he/she had to change rooms, he/she was going to leave the facility. However, LPN #1 stated she did not develop the CCP to include an intervention to increase supervision or monitoring to prevent or reduce the resident's risk for elopement. Review of Resident #1' Progress Note, dated 01/26/2021 at 4:30 PM, completed by LPN #1, revealed the resident was seen in parking lot on his/her scooter without supervision. Additional review of Resident #1's Progress Note, dated 01/26/2021 at 4:35 PM, completed by LPN #1, revealed she spoke with the resident's spouse who informed her the resident was meeting him/her at Walmart. Further review of Resident #1's Progress Note, dated 01/26/2021 at 5:10 PM, completed by LPN #1, revealed the resident returned to the facility with family. Observation and interview with Resident #1, on 02/03/2021 at 3:05 PM, revealed the resident was hard of hearing, was wearing Oxygen per nasal cannula, and had generalized [CONDITION(S)]. Additionally, the resident stated he/she left the faciity on [DATE] because he/she was mad about having to change rooms, and he wanted to leave the facility. Further, the resident stated he/she told everyone he/she was mad and was going to leave. Continued interview with SRNA #1, on 02/01/2021 at 4:13 PM, who was assigned to the Hickory Unit, on 01/26/2021, revealed the resident would tell staff he/she was going outside and would go outside unsupervised on his/her electric wheelchair. Additionally, she stated the CCP did not reflect the resident was at risk for elopement, and she was not aware the resident required supervision when outside. Interview with LPN #1, on 02/01/2021 at 4:30 PM, revealed Resident #1 often would make statements to her about leaving the facility to go to get food. Per interview, the resident was also known to go outside, on his/her electric wheelchair, on the walks and in the parking lot to watch birds and to get some sun. Additionally, she stated she knew the resident had a few unsafe incidents on his/her electric wheelchair when he/she was outside. However, she stated she did not develop the resident's CCP to reflect the resident's behavior patterns or interventions to increase supervision/monitoring to prevent/reduce the risks for elopement because she never thought the resident would have left the facility. However, after the 01/26/2021 elopement, she identified the resident's history of statements he/she was leaving the facility and the resident's patterned behaviors of riding around outside on his/her electric wheelchair as Elopement Risks. Further, LPN #1 stated the resident's CCP should have been developed to reflect the statements and with interventions to increase supervision and monitoring to reduce the risk of, or prevent elopement. She stated it was important for the CCP to be person-centered and include individualized risks and interventions to ensure the residents were safe and happy. Interview with the Social Worker, on 02/02/2021 at 10:38 AM, revealed Resident #1 had told her before in conversation that he/she was leaving to go home. Additionally, LPN #1 stated the resident had also made statements that he/she was leaving the facility to go get food. Further, she stated she was aware of incidents in 2019 and 2020 where the resident demonstrated elopement risk behaviors on his/her electric wheelchair outside the facility. However, the resident continued to go outside unsupervised and the CCP had not been developed to include increased supervision and monitoring to prevent or decrease further occurrences. The LPN stated it was important to develop the CCP to include individualized risks and interventions to ensure all staff had that information and to ensure resident safety. Telephone interview with Resident #1's Physician, on 02/03/2021 at 9:39 AM, revealed she did not recall why Resident #1 was initially ordered not to be outside without supervision on 09/22/2019; it could have been requested by a nurse. She stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed the Physician expected the facility staff to have knowledge of the resident's behaviors and habits and to ensure they were aware of the resident's location. In addition, the Physician stated she expected staff not to allow the resident to leave the facility unassisted and without staff's knowledge to ensure Resident #1's safety. Interview with Minimum Data Set Nurse (MDS) #1 and MDS #2, on 02/04/2021 at 11:00 AM, revealed they had worked at the facility for fourteen (14) years. Additionally, they stated they developed and revised the CCP, using the MDS Assessments, and the direct care nurses revised the CCP between MDS Assessments for changes in a resident's status. Per interview, they were not aware of Resident #1's statement related to wanting to leave the facility and were not aware of any incidents where the resident demonstrated elopement risk behaviors. Further, they stated they were not aware the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the supervision order and the behaviors, such as the incident in 2019 and 2020 where the resident was outside on his/her electric wheelchair near the road (unusual behavior for the resident), should have been included on the resident's CCP per policy. MDS #1 and MDS #2 stated Resident #1's CCP should have been revised at the time of the order and incidents, to include interventions to increase supervision and monitoring to prevent reoccurrence. Further, they stated the CCP should be an accurate reflection of individualized resident-centered care needs to ensure quality care and safety. Interview with the Director of Nursing (DON), on 02/02/2021 at 1:20 PM, revealed the MDS Nurse was responsible to develop and revise the CCP with the MDS Assessment, and the direct care nurses were responsible to develop and implement the CCP with any changes in a resident's status, behaviors, or new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated when Resident #1 stated he/she was going to leave the facility, the Care Plan should have updated to include supervision and monitoring interventions to be implemented to prevent risk for elopement. Further interview with the DON revealed Resident #1's CCP should have included Risk for Elopement with specific interventions to guide staff when the resident made statements he/she was leaving the facility or had behaviors that indicated an elopement risk. Interview with the Administrator, on 02/04/2021 at 9:50 AM, revealed the MDS Nurse was responsible for developing and revising the CCP with the MDS Assessments, and all nurses were responsible for updating/revising the care plan with new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, he stated the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview revealed Resident #1's CCP should have been revised after the incident in September 2019 and after the occurrence during the summer of 2020, when Resident #1 was outside on his/her electric wheelchair unsupervised by staff. Further, he stated LPN #1 should have reported the resident's statement he/she was going to leave the facility, and all these things required the CCP to be developed and interventions to be implemented with the involvement of the whole interdisciplinary team. Further, the Administrator stated if he had been informed of Resident #1's statement, it would have triggered implementation of interventions of increased supervision and monitoring to reduce the risk or prevent elopement. The facility provided an acceptable credible Allegation of Compliance (AoC), on 02/23/2021 that alleged removal of the Immediate Jeopardy (IJ), on 02/19/2021. Review of the AoC revealed the facility implemented the following: 1. On 01/26/2021, the facility initiated a Code 10. Resident #1 was located and returned to the facility with no injuries or harm. 2. On 01/26/2021, upon returning to the facility, the nurse assessed Resident #1 with no noted concerns. Resident #1 was placed on one-to-one (1:1) care. 3. On 01/26/2021, the facility made reports/notifications to the Office of Inspector General (OIG), Adult Protective Services (APS), the Ombudsman, the Police Department, the Medical Director (MD), and Resident #1's Family/Guardian. 4. On 01/26/2021, Resident #1's electric wheelchair was removed from the facility. 5. On 01/26/2021, an investigation was initiated by the Administrator and Director of Nursing. a. The Administrator reviewed the facility's camera footage and analyzed the path of egress of Resident #1. b. The DON reviewed Resident #1's Elopement Nursing Assessment. c. The DON updated Resident #1's care plan to address his/her elopement risk. d. On 01/26/2021, education was initiated for nursing staff on Elopement Procedure Code 10, Wandering Resident, and Accident and Supervision by the Clinical Coordinator, Environmental Service Manager, Dining Manager, and Human Resources (HR) Manager. e. Witness statements were obtained from employees and Resident #1. 6. On 01/27/2021, the Minimum Data Set (MDS) Coordinators reviewed all residents' Section E of the Minimum Data Set (MDS) Assessment and associated Care Area Assessments (CAA) for accuracy. Additionally, care plans were reviewed and updated as necessary to ensure the finding of the review. 7. On 02/01/2021, all residents with current orders for a Roam Alert bracelet were re-evaluated by the Clinical Coordinators using an assessment tool. 8. On 01/29/2021, key pads were installed on the main elevator in C Building and the elevator in the Personal Care facility, limiting ability to use the elevators without a code. Additionally, the main entrance therapy door was locked at all times via key. 9. On 01/27/2021, the (DON) and the Administrator reviewed the following guidelines: a. Comprehensive Care Plan b. Code 10 c. Accident and supervision d. Elopement and wandering resident e. Review of elopement drill procedure f. Code 10 drill document was created g. Resident Right policy and procedure h. Abuse and Reporting policy and procedure. 10. Beginning on 02/18/2021, a new white board process to review residents at risk for elopement, was added to the Clinical Meeting, which occurred daily, Monday through Friday. The attending the meeting included but not limited to Clinical Coordinators, MDS Coordinators, ADON, DON, Therapy, and Social Services 11. Beginning on 01/26/2021, Clinical Coordinators and the Assistant Director of Nursing (ADON) educated seventy-seven (77) of ninety-one (91) Nursing staff on Elopement and Wandering, Accident and Supervision, Care Plan Updates and Code 10 Procedure. No staff member could work beyond 02/18/2021 without receiving the in-service education by a Clinical Coordinator. 12. Beginning on 01/26/2021, Clinical Coordinators, the ADON, the Dining Manager, the Therapy Manager, the Environmental Service Manager, and the HR Manager, educated one hundred forty-five (145) of one hundred seventy-three (173) staff members on the Code 10 Procedure. No staff member could work beyond 02/18/2021 without receiving the in-service education by the Clinical Coordinator. 13. The HR Manager would conduct new hire orientation to include agency and contract staffing for Wandering Elopement and Code 10 Procedures with a posttest. 14. Beginning on 02/17/2021, the Administrator initiated weekly Elopement Drills. 15. Beginning on 02/17/2021, the ADON and Clinical Coordinators reviewed new admissions for elopement risk and ensured appropriate Care Plans were in place within twenty-four (24) hours of admission. The weekend Clinical Coordinator would review new admissions within twenty-four (24) hours of admission on Saturday and Sunday. The DON would validate the review Monday through Friday and the weekend on Monday. 16. Beginning on 02/17/2021, the Clinical Coordinator, Social Service Director, and the MDS Coordinators, would review the previous twenty-four (24) hour nurse charting for appropriate notification interventions, daily Monday through Friday, with the weekends being reviewed on Monday. The ADON would validate the review Monday through Friday and the weekend on Monday. 17. On 02/03/2021, an Ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held, and on 02/10/2021, a monthly QAPI meeting was held to discuss the action plan. The committee members included the Social worker, MDS Coordinator, Clinical Coordinators, ADON, DON and Administrator. 18. On 02/17/2021, a QAPI Performance Improvement Plan (PIP) was implemented to review findings. 19. On 01/29/2021, the MDS Coordinators audited all residents' physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 20. Beginning on 01/27/2021, during the morning Clinical Meeting, the Social Service Manager and the MDS Coordinators would review all behavior notes from the previous day. 21. Beginning on 01/26/2021, daily the Charge Nurse assigned to each neighborhood, the Nurse Supervisors in the evenings, and Clinical Coordinators would conduct ongoing monitoring of interventions and development of the care plan including observations and record review through daily rounds, and the morning Clinical Meeting. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the Code 10 checklist, dated 01/26/2021, revealed all ten (10) neighborhoods at the facility with four (4) post/areas outside that staff reported to during a CODE 10 procedure participated in the Code 10 announced for Resident #1. Review of Resident #1's medical record revealed a Progress Note, dated 01/26/2021 at 4:30 PM, by LPN #1, which stated Resident #1 was seen in the parking lot on his/her electric wheelchair without supervision; a Code 10 was called immediately per protocol and staff responded. Interview with the Administrator, on 02/25/2021 at 5:00 PM, revealed he directed a Code 10, on 01/26/2021, when he was made aware Resident #1 had left the facility. Interview with LPN #1, on 02/01/2021 at 4:30 PM and SRNA #1, on 02/01/2021 at 4:13 PM, revealed they heard the overhead Code 10 announcement for Resident #1, on 01/26/2021, and followed the facility's protocol. 2. Review of Resident #1's medical record revealed a Progress Note, dated 01/26/2021 at 5:15 PM, by LPN #1, which revealed Resident #1 was returned to the facility at 5:07 PM by his/her family. The resident was alert and oriented, and per the assessment, the resident was at baseline with no injuries noted. One-on-one (1:1) monitoring was provided for Resident #1 for approximately two (2) hours; then fifteen minute checks were initiated. Interview with LPN #1, on 02/01/2021 at 4:30 PM, revealed when Resident #1 returned to the facility, he/she was in no acute distress. In addition, she stated she sat with Resident #1 for approximately two (2) hours once he/she returned to the facility to ensure the resident's safety. 3. Review of the Long Term Care Self-Reported Incident Form, dated 01/26/2021, signed by the Administer, revealed the Office of Inspector General (OIG), the Physician, the resident's family, the Department of Community Based Services (DCBS), local law enforcement, and the Ombudsman were notified of a missing resident/elopement had occurred, on 01/26/2021 involving Resident #1. 4. Review of Resident #1's medical record revealed a Progress Note, dated 01/29/2021 at 12:12 PM, by Social Services, revealed Resident #1's Durable Power of Attorney (DPOA) stated she had the resident's electric wheelchair, and the resident could not have it back at the facility. 5. a. Review of the facility's document, Administrative Review of Facility Camera System, undated, revealed the Administrator reviewed the facility's camera footage to assist with analyzing the path of egress Resident #1 took to elope. The receiving drop camera (1st floor receiving) noted Resident #1 on camera, at 4:23 PM, approaching the service/employee entrance. The outside camera noted the resident on camera, at 4:24 PM, exiting the facility. The therapy drop camera (main entrance view) noted Resident #1 on camera exiting the driveway and turning eastward. Resident #1 stopped prior to entering the roadway, and waited for a red car to pass on the opposite side of the street and waited on a second white car on the same side of the street, closest to the resident, to pass prior to entering the roadway at 4:27 PM. b. Review of Resident #1's medical record revealed a Nursing Elopement Assessment, dated 01/26/2021 at 5:50 PM, completed by the DON. Additional review revealed the resident had Actual and Potential Elopement Risk Behaviors; however, the resident refused to have a Roam Alert bracelet applied. c. Review of Resident #1's medical record revealed, on 01/26/2021, the DON reviewed and updated the resident's Care Plan to include Elopement Risk related to history of elopement. The goal was the resident would safely travel throughout the facility with assistive devices. Interventions included but were not limited to maintain a safe environment and structure routine and staff supervision when outside. d. Review of an education sign in sheet, Accidents and Supervision, dated 01/26/2021, revealed forty-six (46) staff signed they received training on Elopement Procedure Code 10, Wandering Resident, and Accident and Supervision. Interview with the EMS (Environmental Service Manager), on 02/25/2021, revealed the DON provided him with education, on 01/26/2021, on what to do in case of an elopement and residents at risk for elopement. Additionally, he received a packet of information which included the facility's policy and procedures on Elopement Procedure Code 10, Wandering Resident, and Accident and Supervision. Continued interview revealed he was also informed later that the facility had installed key pads to elevators and the therapy gym door was to be locked at all times. Further, he provided training to all current EMS staff and would be training all new EMS employees on the same material. Interview with the Clinical Coordinators, on 02/25/2021 at 3:50 PM, and the Environmental Service Manager, on 02/25/2021 at 4:15 PM, revealed they initiated immediate education, on 01/26/2021, to all employees related to the Elopement Procedure Code-10, Wandering Resident, and Accidents and Supervision. Interview with SRNA #6, on 02/25/2021 at 3:00 PM; SRNA #7, on 02/25/2021 at 3:00 PM; SRNA #18 and Kentucky Medication Aide (KMA) #2, on 02/25/2021 at 3:00 PM, revealed they were provided training, by a Clinical Coordinator, on Elopement/Wandering, Accidents and Supervision, and Code 10 procedure, after Resident #1's elopement, on 01/26/2021. Interview with the ADON and Clinical Coordinators, on 02/25/2021 at 3:50 PM, revealed current, new and agency nurses would be educated on Wandering behaviors, Code-10, Pain and Care Plans. e. Review of a witness statement with Resident #1, dated 01/26/2021, by the DON, revealed the resident left the facility to go to Walmart because he/she upset, The resident stated, Where's there's a will, there's a way. Further, when asked to apply a roam alarm bracelet the resident stated, Oh no you're not, you must be afraid I'm going to escape again. Interview with LPN #1 on 02/01/2021 at 4:30 PM revealed the Administrator spoke with the resident about the move to the Walnut Unit. Interview with Central Supply, on 02/01/2021 at 3:28 PM revealed the Administrator reported Resident #1 was on the road. He picked her up in a car and they went to the shopping center to search for Resident #1. Staff went to Walmart and observed resident #1 exiting Walmart on his/her electric wheelchair and get into his/her daughter's car around 5:00 PM. Resident #1's daughter returned the resident to the facility at approximately 5:10 PM. Interview with Dietary #2, on 02/02/2021 at 2:50 PM revealed he looked out the window and saw Resident #1 on his electric wheelchair at the end of the driveway. He heard a Code 10 announced over the intercom. 6. Review of a document titled MDS Review Log, with no date, revealed all residents were reviewed related to section E of the MDS Assessment, and care plans were also reviewed and updated as necessary to reflect the findings. Review of the Daily Census Report, dated 01/27/2021, revealed the facility had one hundred ten (110) active residents. Interview with MDS Coordinator #1 and MDS Coordinator #2, on 02/25/2021 at 3:35 PM, revealed on 01/27/2021 they completed an audit of all residents' MDS Assessment, section E, for accuracy and ensured the care plans were reviewed and revised as necessary. 7. Review of an Order Listing Report, dated 02/01/2021 through 02/28/2021, revealed twenty-three ( [TRUNCATED]

Based on observation, interview, record review, review of the facility's policies, review of the facility's investigation, and review of a National Oceanic and Atmospheric Administration (NOAA) weather document, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for one (1) of fifteen (15) sampled residents (Resident #1). The facility admitted Resident #1, on 04/30/2018, with multiple diagnoses to include Anxiety Disorder and Major Depressive Disorder. The resident had a Durable Power of Attorney, who stated the resident was not safe to leave the facility unsupervised. The Physician wrote an order for the resident not to be outside without supervision, after an incident, on 09/22/2019, related to being outside on his/her electric wheelchair near the road. Additionally, during the summer of 2020 (exact date unknown), the resident was outside unsupervised and was observed driving his/her electric wheelchair behind cars, going in the opposite direction of traffic. However, there was no documented evidence the facility identified the need to increase monitoring of the resident, nor the need to complete an elopement risk assessment after these incidents. In addition, the Comprehensive Care Plan was not developed to include interventions to prevent further occurrences. On 01/26/2021 around 3:00 PM, the facility notified Resident #1 of a room change. Resident #1 verbalized to Licensed Practical Nurse (LPN) #1 that he/she would go home and leave the facility if he/she had to change rooms. The LPN directed the resident to talk to the Administrator. However, the LPN did not notify Administrative staff of the resident's statement that he/she was going to leave and go home. Review of the facility's video footage revealed, on 01/26/2021 at 4:24 PM, Resident #1 exited the facility without staff knowledge. At 4:26 PM, the resident exited the facility's driveway and entered the roadway in his/her electric wheelchair. The resident's daughter notified the facility the resident was at a Walmart, approximately 0.8 miles away. The resident's daughter returned the resident to the facility at approximately 5:07 PM. (Refer to F-656) The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 02/10/2021 and was determined to exist on 01/21/2021. The facility provided an acceptable Allegation of Compliance (AoC) on 02/23/2021, with the facility alleging removal of the Immediate Jeopardy on 02/19/2021. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 02/19/2021, prior to exit on 02/25/2021, with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Wandering Resident/Elopement Risk Assessment, revised 10/15/2018, revealed wandering was defined as movement about an area without a fixed goal, and elopement was defined as slipping away secretly, running away, or leaving without accompaniment or knowledge of staff. Further, residents should be evaluated for elopement risk at admission with each Omnibus Budget Reconciliation Act (OBRA) assessment (quarterly, annual or significant change) and any time a new wandering or exit seeking behavior was exhibited. Per assessment, each resident's level of supervision and/or specific Care Plan interventions would be assessed based on his/her history and observed behaviors. Additional review revealed for observed behaviors an Elopement Assessment should be immediately completed (located in the Electronic Health Record {EHR}) and the Care Plan be updated as appropriate, with interventions such as addition of a Roam Alert bracelet (a device which triggered an alert when a protected resident approached a monitored exit), fifteen (15) minute checks, or other personalized interventions; Social Services would be notified which could prompt additional action such as a psychiatrist or psychologist referral or significant change assessment. The Elopement Assessment described the steps to take depending on the results of the Assessment. Review of the EHR, Elopement Assessment, under the Section titled Actual Elopement Risk Behaviors, revealed if one (1) or more of the following behaviors were observed a Roam Alert bracelet was required to be applied to the resident. These behaviors included: the resident followed people out of exits; had the potential to learn door codes; opened exit doors; was observant of staff and would attempt to exit if not monitored; hovered at exits; or was a new admit with a history of wandering from home or another setting. Additional review of the Assessment, under the Section titled, Potential Elopement Risk Behaviors, revealed if one (1) or more of the following behaviors were observed a Roam Alert bracelet might be required. These behaviors included: the resident was resistant to care or direction; hid from staff; packed belongings; was on psychoactive medication due to agitation/mood disturbance; or wandered aimlessly. Review of the facility's policy titled, Accidents and Supervision, reviewed 08/25/2020, revealed each resident would receive adequate supervision and assistive devices to prevent accidents which included 1) identifying hazards and risk; 2) evaluating and analyzing hazards and risk; 3) implementing interventions to reduce hazards and risk; and 4) monitoring for effectiveness and modifying interventions when necessary. Additionally, the facility would use a systematic approach to address resident risk and hazards including all staff observing and identifying potential hazards. This information would be documented and communicated across all disciplines. Per policy, evaluation and analysis of data to identify specific hazards and risks to develop target interventions was a facility centered and resident directed approach, based on the severity of the hazard and immediacy of the risk. Continued review revealed implementation of interventions included 1) communicating the intervention to all relevant staff; 2) assigning responsibility; 3) providing needed training; 4) documenting interventions (plan of action in care plan for individual resident); and, 5) ensure the intervention was put into action. Further, modification and monitoring was utilized to evaluate the effectiveness of interventions by ensuring interventions were implemented correctly and consistently, evaluating the effectiveness, and modifying as needed. Review of Resident #1's medical record revealed the facility admitted the resident, on 04/30/2018, with multiple diagnoses to include Anxiety Disorder and Major Depressive Disorder. The resident had a Durable Power of Attorney (DPOA). Review of Resident #1's DPOA document, dated 07/11/1994, revealed the resident designated his/her spouse as a health care surrogate and his/her daughter, if his/her spouse refused or was not able to act for the resident. Further review revealed the resident appointed his/her daughter to take charge of, manage, and control all business limited to financial affairs. The resident's daughter was his/her health care surrogate. Review of Resident #1's Comprehensive Care Plan (CCP), initiated on 07/25/2018, revealed the resident's representative and/or the resident expressed a desire for continued placement to remain at the long-term care (LTC) facility; there were no plans for discharge. Additionally, the resident would sometimes get frustrated and say he/she was going home, but understood he/she was unable to provide self-care. The goal was the resident would demonstrate understanding of LTC placement. Further review revealed interventions included to assess the resident's preferences regularly regarding LTC placement and refer to an outside agency as needed, if preferences changed (i.e. desired to speak to someone about living in the community); attempt to develop rapport and trust through regular visitation; coordinate a compatible roommate whenever possible or when a semi-private room was needed; discuss LTC placement with the resident and/or representative; encourage and facilitate family visits to assist with adjustment; encourage family to bring familiar items from home to help create a home-like environment; provide the resident and/or representative and physician education and care plan meeting notifications; provide opportunity to build relationships with others residing in the facility through activity programs and social interaction; and provide opportunity to vent, voice concerns, or ask questions. However, additional review revealed there was no evidence the CCP was developed related to risks for elopement to include interventions to prevent or reduce occurrences. Review of Resident #1's Progress Note, dated 09/22/2019 at 10:48 AM, revealed the resident was observed driving his/her scooter into a grassy, wooded area surrounding the facility, and the resident was not able to be redirected. Additionally, the family and the Administrator were notified. Additional review of Resident #1's Progress Notes, dated 09/22/2019 at 10:50 AM, revealed the resident was observed riding his/her scooter in a grassy area along the tree line down by the roadway. The resident then got back on the driveway and returned to the building. Further review revealed staff attempted to redirect the resident to drive his/her scooter on the pavement in the parking lot; however, the resident refused and stated, Get the hell away from me; I know how to drive this thing. When the resident was asked why he/she was driving in the grass, the resident stated, I'm looking for a rabbit or a squirrel or something. Further, the resident's spouse was called, and the resident returned to the building. Further review of Resident #1's Progress Note, dated 09/22/2019 at 12:42 PM, revealed the resident returned to the building and stated he/she was okay. Per the note, the resident's spouse came to the facility to stay with the resident a while. Further, the resident's spouse stated the resident was mad this morning and asked the spouse to sign him/her out of the facility, and the spouse refused. However, there was no documented evidence the facility assessed Resident #1 for the behavior of driving his/her scooter into a grassy, wooded area by the roadway or stating he/she wanted to sign out of the facility. In addition, there was no evidence the CCP was developed to include interventions to prevent or reduce further occurrences. Review of Physician's Orders for Resident #1, revealed an order, dated 09/29/2019, and revised most currently on 01/12/2021, stating the resident was not allowed outside without supervision, every day and night shift. However, there was no documented evidence the CCP was developed to include the ordered intervention to prevent or reduce further occurrences. Interview with the Maintenance Manager, on 02/08/2021 at 8:10 AM, revealed he had worked at the facility twenty-five (25) years. Per interview, as he was leaving the facility during the summer of 2020 (exact date unknown), he drove around the end of the parking lot row, and Resident #1 was riding his/her electric wheelchair along the cars going the opposite direction the cars should go. Additionally, he stated the resident's electric wheelchair was so low to the ground the resident was barely visible, and there was no staff in the parking lot supervising the resident. Continued interview revealed he did not immediately report the incident or provide a written statement about the incident, but the incident was discussed the next morning in Clinical Meeting with the interdisciplinary team (IDT). Further, he stated the IDT team discussed if the resident was going to continue to ride his/her electric wheelchair in the parking lot, he/she needed to be visible. The Maintenance Manager stated it was decided a tall flag would be added to the back of the resident's electric wheelchair in a proactive approach to keep the resident safe. However, there was no documented evidence of the parking lot incident or that Resident #1 was assessed for the behavior of driving his/her electric wheelchair unsupervised in the parking lot. In addition, there was no documented evidence the CCP was developed to include interventions to prevent or reduce further occurrences. Review of Resident #1's OBRA Ancillary Assessments, revealed the resident had an assessment completed on 03/09/2021, by Minimum Data Set Nurse (MDS) #2; MDS #1 completed assessments on 05/22/2020, 08/21/2020, 11/20/2020, and 12/16/2020. However, all Assessments, Section Elopement Risk, noted Resident #1 had No Actual Elopement Risk Behaviors Assessed and one (1) Potential Elopement Risk Behaviors: on psychoactive medication due to agitation/mood disturbance. Further, the Documented Assessment and Decision noted no wandering, exit seeking, or attempts to elope at that time. Review of Resident #1's Quarterly Minimum Data Set Assessment, dated 12/16/2020, revealed the resident had adequate hearing, vision, and speech and was able to make himself/herself understood and understood others. Per the Assessment, the resident had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating intact cognition. Additionally, behaviors or wandering was not present. Continued review of the Assessment revealed the resident was assessed to require supervision with bed mobility; was independent with transfers; limited assistance of one (1) staff with ambulation; independent with locomotion on and off unit. The Assessment stated the resident was not steady, but was able to stabilize without staff assistance between surfaces, walked with a walker, and used a wheelchair. Further, the resident did not have an elopement wander alarm. Review of Resident #1's Progress Notes, dated 01/26/2021 at 2:22 PM, completed by Social Services, revealed the family was notified of relocation due to the facility's COVID-19 cohorting infection control protocol. Interview with State Registered Nurse Aide (SRNA) #1, on 02/01/2021 at 4:13 PM, who was assigned to the Hickory Unit, on 01/26/2021, revealed, on 01/26/2021, between 3:00 PM and 4:00 PM, Resident #1 came out of his/her room on the Hickory Unit and was upset related to his/her room change because of COVID cohorting. Per interview, she heard the resident talking to Licensed Practical Nurse (LPN) #1 who directed the resident to talk to the Administrator. Continued interview revealed she was not aware the resident had stated he/she was going to leave the facility. Additionally, she stated she saw the resident on the Walnut Unit at approximately 4:00 PM, talking to the Administrator. Interview with Licensed Practical Nurse (LPN) #1, on 02/01/2021 at 4:30 PM, who was assigned to the Hickory Unit on 01/26/2021, revealed around 4:00 PM, Resident #1, realized he/she was changing rooms and became upset. Per interview, the resident came out of his/her room on the Hickory Unit and told her he/she did not want to change rooms, and if he/she had to change rooms, he/she was going to leave the facility. Continued interview revealed the Administrator was on the Hickory Unit and talked with the resident about why the move to the Walnut Unit was occurring, and the move was temporary. Additional interview revealed after the resident spoke with the Administrator, LPN #1 saw the resident go back in his/her room on the Hickory Unit and then left the room on his/her electric wheelchair. Per interview, she was administering residents' medications on two (2) units (Hickory and Walnut) because the EHR had not been updated with room changes made that day, and the units were chaos. LPN #1 stated she could not find Resident #1 on either unit (Hickory or Walnut) to administer his/her medications. She stated she asked the Administrator if he knew where the resident was located, and she was told by the Administrator that Resident #1 was in the hallway, on his/her cell phone, looking out the window between the Walnut and Willow Units. The LPN stated she went to that location, administered Resident #1's medications, and returned to the Hickory Unit where she heard CODE 10 for Resident #1 called; it was approximately 4:30 PM. Continued interview revealed the last time she saw Resident #1 was when she administered his/her medication. Review of Resident #1's Progress Note, dated 01/26/2021 at 4:30 PM, completed by LPN #1, revealed the resident was seen in the parking lot on his/her scooter, without supervision. Code 10 was called immediately per protocol and staff responded. Additional review of Resident #1's Progress Note, dated 01/26/2021 at 4:35 PM, completed by LPN #1, revealed she spoke with the resident's spouse who informed her the resident was meeting him/her at Walmart. LPN #1 stated she called to notify the resident's spouse and see if he/she knew where the resident had gone or if he/she had heard from the resident. Further review of Resident #1's Progress Note, dated 01/26/2021 at 5:10 PM, completed by LPN #1, revealed the resident returned to the facility with family. Review of the NOAA's weather document titled, Local Climatological Data, Hourly Observations, January 2021 for the facility's geographical area revealed, on 01/26/2021 between 4:11 PM and 5:08 PM, the weather was mostly cloudy with light rain. In addition, the temperature had a range of forty-three (43) to forty-four (44) degrees Fahrenheit with winds between ten (10) and fifteen (15) miles per hour. Review of the Long Term Care Facility-Self Report Incident Form, Initial Report, dated 01/26/2021 at 6:28 PM, revealed an incident, missing resident/elopement occurred on 01/26/2021 involving Resident #1. Additionally, the Medical Director, family, Department of Community Based Services (DCBS), law enforcement, and the Ombudsman were notified. Per the report, Resident #1 exited the facility via a service entrance at approximately 4:30 PM. Staff in the Second Floor Break Room witnessed Resident #1 driving down the facility driveway on a motorized scooter. Further review revealed staff alerted the Administrator, and a CODE 10 was announced immediately. The report stated the resident contacted his/her spouse and said he/she was going to Walmart, then home, and was discharging from the facility. Continued review revealed the resident drove his/her scooter to Walmart and was returned to the facility by his/her daughter at 5:10 PM. Per report, the resident attempted to self-discharge and did not want to reside at the facility. Review of Resident #1's Progress Note, dated 01/27/2021 at 10:54 AM, documented by the Social Worker revealed the resident had a history of saying he/she would just go home when things did not go the way he/she wanted them to go. Review of Resident #1's Progress Note, dated 01/29/2021 at 2:57 PM (three {3}) days after the resident eloped from the facility), late entry for 01/26/2021 at 5:15 PM, completed by LPN #1, revealed a Code 10 was called at 4:29 PM. Resident #1 was noted to exit the facility, leave the premises, and return to the facility at 5:07 PM per his/her family. Continued review revealed the resident was verbal and alert and oriented to person, place, time, and situation. Additionally, the resident's lungs had wheezes in the upper lobes, and the resident required two (2) liters of oxygen via nasal cannula. There were no visible injuries noted, and the resident stated he/she had no injuries and denied pain or discomfort. Further, one on one (1:1) supervision was provided for approximately two (2) hours, and then, fifteen (15) minute checks were initiated. Continued review revealed an Elopement Assessment was completed, and the resident refused a wander guard (a device used to prevent elopement by alarming when the resident exited the facility). Observation of the elopement route, on 02/02/2021, revealed Resident #1 drove his/her electric wheelchair to the front lobby area and after taking the elevator from the first floor to the second floor, navigated from the elevator through two (2) hallways to a service elevator. After taking the service elevator from the second floor to the first floor, the resident would have navigated through a short hallway and out an employee/service exit door at the rear of the facility. Per observation, the resident would have exited the facility into a paved service area beside a dumpster. Then, the resident would have continued to drive his/her electric wheelchair through the employee parking lot, down the facility driveway, passing the front parking lot, turning left, crossing a lane of traffic, onto a busy two (2) lane road with no sidewalks. Further, driving the path the resident took from exiting the building, leaving the property, and going to Walmart revealed he/she traveled 0.8 miles from the facility's entrance. Review of the facility's video footage revealed Resident #1, on 01/26/2021 at 4:22 PM, at the second floor, operating an elevator. Then at 4:23 PM, the resident was on the first floor, approaching the employee/service entrance. Next, the resident was exiting the facility, into the rear delivery area, at 4:24 PM. Additionally, the resident was seen exiting the facility driveway, at 4:26 PM, turning left entering onto a busy two (2) lane road without a sidewalk. Lastly, the video footage showed the resident stopped prior to entering the roadway and allowed two cars to pass prior to entering the roadway at 4:27 PM. Further, the footage revealed, at 4:47 PM, the Police arrived at the facility, and at 5:07 PM, Resident #1 returned to the facility via his/her daughter's vehicle and walked back into facility. Observation and interview with Resident #1, on 02/03/2021 at 3:05 PM revealed the resident was hard of hearing, was wearing Oxygen per nasal cannula, and had generalized [CONDITION(S)]. Additionally, the resident stated he/she left the facility, on 01/26/2021, because he/she was very mad about having to change rooms, and he/she wanted to leave the facility. Per interview, the resident stated he/she told everyone he/she was mad and was going to leave but did not know where he/she was going when he/she left the facility. Continued interview revealed the resident ended up at Walmart and called his/her daughter to come and get him/her. Continued interview revealed the resident's daughter brought the resident back to the facility, and the resident was still upset he/she had to change rooms. Resident #1 stated his/her room was a mess, and the resident did not know if he/she could get it back in order. Further observation revealed the resident's personal belongings such as clothing, picture frames, and shoes were scattered across the top of the bed. Interview with Central Supply Clerk, on 02/01/2021 at 3:28 PM, revealed she had worked at the facility nineteen (19) years. Additionally, on 01/26/2021 at approximately 4:30 PM, she was in the Second Floor Break Room, glanced out the window that overlooked the front parking lot and driveway, and saw Resident #1 in his/her electric wheelchair at the end of the facility's driveway, sitting at the edge of the road. Per interview, she called the Director of Nursing (DON) who did not answer, so she called the Administrator and reported the Resident #1 was on the road. Per interview, she ran out of the facility, across the parking lot, down the driveway, across the road, and to the shopping center entrance but never saw Resident #1. Further, she stated she got in a car with the Administrative Assistant when she got to the shopping center entrance, and they continued their search for the resident. Continued interview revealed a family member of Resident #1 had called the facility and stated the resident was at Walmart, and she was going to get him/her. Per interview, staff went to Walmart and observed the resident exit Walmart on his/her electric wheelchair and got into his/her daughter's car around 5:00 PM. Per interview, the resident's daughter returned the resident to the facility at approximately 5:10 PM. Interview with the Administrative Assistant, on 02/01/2021 at 3:48 PM, revealed she had worked at the facility fourteen (14) years. Additionally, on 01/26/2021 around 4:30 PM, she stated she was in the front lobby on the first floor of the facility, and the receptionist alerted her Resident #1 had driven off facility property in his/her electric wheelchair. Per interview, she notified the DON, who was also in the front lobby on the first floor. The Administrative Assistant stated she and the DON ran into the parking lot but could not see the resident, so she came back into the facility and got her car keys. Additional interview revealed drove toward the shopping center, because the DON had talked to someone at the facility who knew the resident was going to Walmart, and then home. Continued interview revealed she drove around the building to see if she could see Resident #1 in the parking lot. The Assistant Administrator stated she drove to various other restaurants and stores in the area looking for the resident; however, she could not find the resident. Further, she returned to Walmart, saw Resident #1 on his/her electric wheelchair exit Walmart and get into the family car that had come for the resident. The Administrative Assistant stated the resident had no obvious injuries but was out of breath. Interview with Dietary Worker #1, on 02/01/2021 at 4:00 PM, revealed he had worked at the facility twenty-nine (29) years. Per interview, on 01/26/2021 at 4:30 PM, he was in the Second Floor Break Room and looked out the window to see Resident #1 going toward the road in his/her electric wheelchair. Continued interview revealed Resident #1 was known to go outside the facility and ride around, but he was not aware the resident required supervision when outside. However, this time the resident pulled out of the driveway onto the road. Additionally, he stated the Central Supply Clerk was in the break room, and he asked her to call a Code 10 and the Administrator. Per interview, he watched Resident #1 turn left out of parking lot, onto the road, and up the hill toward the shopping center. Interview with the Physical Therapy Aide (PTA), on 02/01/2021 at 5:00 PM, revealed she had worked at the facility eighteen (18) years. Per interview, on 01/26/2021 at 4:28 PM, she was at a second floor window in the facility that overlooked the front parking lot, and an orange flag caught her eye. Continued interview revealed she quickly realized it was Resident #1, who was allowed to be outside (she was not aware the resident had an order to be supervised when outside) and had an orange flag on the back of his/her electric wheelchair; however, Resident #1 was driving very fast and was at the at the end of the driveway. Additionally, she stated the resident paused briefly for traffic at the end of the driveway, then crossed a lane of traffic and turned left onto the busy two (2) lane road. Further, the PTA immediately called the front desk on her cell phone and alerted the receptionist to call a CODE 10 for Resident #1. Interview with Dietary Worker #2, on 02/02/2021 at 2:50 PM, revealed he had worked at the facility for four (4) months. Per interview, on 01/26/2021 around 4:30 PM, he was in the Second Floor Break Room with Dietary Worker #1 and the Central Supply Clerk. He stated he looked out the window and saw Resident #1 on his/her electric wheelchair at the end of the driveway; the Central Supply Clerk noticed the resident too and was calling the front lobby. Additionally, he stated he saw the resident making a left turn off the facility property, onto the road. Continued interview with LPN #1, on 02/01/2021 at 4:30 PM, revealed the resident often would make statements to her about leaving the facility. Per interview, the resident was also known to go outside, on his/her electric wheelchair on the sidewalks and in the parking lot to watch birds and to get some sun. However she never documented the resident's statements or behaviors. She further stated she did not develop the resident's CCP to reflect the resident's behavior patterns, report the statements to Administrative staff or the Social Worker, or complete an Elopement Assessment because she thought the resident was joking and was oriented. Continued interview revealed the resident had an incident during the summer of 2020 (exact date unknown) where he/she was observed by a staff member in-between cars, and over the summer the resident had to have someone with him/her when outside. However since then, the resident would just let staff know he/she was going outside. She stated the resident did not require supervision when outside. Additionally, she stated she never thought the resident would leave the facility. However, after the 01/26/2021 elopement, she identified the resident's history of statements he/she was leaving the facility and the resident's patterned behaviors of riding around outside on his/her electric wheelchair as Elopement Risks. She stated she should have documented the behaviors, developed the care plan to reflect the statements, reported the statements to the Social Worker and Administration and completed an Elopement Assessment to determine what intervention was appropriate to ensure supervision and monitoring for the resident. Further interview revealed that she, the Administrator, and the DON knew the resident was upset, on 01/26/2021, and Resident #1 made the statement he/she wanted to leave the facility. LPN #1 stated there was not enough supervision and monitoring because the resident exited the facility without anyone knowing. She stated she should have immediately initiated increased supervision and monitoring of the resident when he/she made the statement he/she was going to leave the facility, as per facility policy. Interview with the Social Worker, on 02/02/2021 at 10:38 AM, revealed Resident #1 had told her before in conversation that he/she was leaving to go home. LPN #1 stated the resident had told her the resident had also made statements that he/she was leaving the facility to go get food. Continued interview revealed, in 2018, she developed Resident #1's CCP related to placement at the long-term care (LTC) facility to include the resident would get frustrated and would say he/she was going home, but understood he/she was not able to provide care for himself/herself. However, she was not aware the statements of wanting to leave the facility were ongoing patterned statements/behaviors. Per interview, nursing should have implemented increased supervision and monitoring when the resident made statements he/she was leaving the facility and developed the CCP to include those continued behaviors/statements. The Social Worker stated she was aware the resident was outside a lot and liked to sun on the walks. However, she stated the resident had a history of unsafe behavior while outside on his/her electric wheelchair. Per interview, Resident #1 had an unsafe driving incident looking for an animal in the grass near the road in 2019 and again in the parking lot between cars, on his electric wheelchair during the summer of 2020. The Social Worker stated since those incidents, the resident was encouraged to stay to the walks, to be supervised by staff when outside, and a flag was added to his/her electric wheelchair so the resident could be more visible when outside. However, she stated the resident continued to go outside unsupervised, and the CCP was not developed to include those incidents or interventions for increased supervision and monitoring to prevent or decrease further occurrences. Telephone interview with Resident #1's Physician, on 02/03/2021 at 9:39 AM, revealed she did not recall why Resident #1 was initially ordered not to be outside without supervision on 09/29/2021, other than it would have been r [TRUNCATED]

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure pain management was provided to residents who required such services. The facility failed to ensure pain medication was available to the resident per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On Friday, 01/22/2021, the facility admitted Resident #2 from an Acute Care Hospital, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, the resident's discharge medication and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Physician was not aware the facility needed written prescriptions for [MEDICATION(S)] and Oxycodone, to obtain the medications from the Pharmacy. On admission, the facility assessed the resident as having pain, at seven on a scale from one (1) to ten (10), with ten (10) being the most severe. Interviews with staff, both licensed nurses and State Registered Nurse Aides (SRNA) revealed the resident complained of pain and asked for pain medication throughout the weekend. Registered Nurse (RN) #1 stated on Sunday, 01/24/2021, the resident suffered in pain, and she assessed the resident to have throbbing pain multiple times a day. On Monday, 01/25/2021, the facility assessed the resident to have 10/10 pain. Interview with the On-Call Physician revealed she was not notified Resident #2 was in pain or needed prescriptions for pain medications on either 01/23/2021 or 01/24/2021. Resident #2 should have received [MEDICATION(S)] 600 mg four (4) times a day and Oxycodone PRN for pain. However, these medications were not delivered, as the facility failed to ensure prescriptions were provided to the Pharmacy. Resident #2, revealed on admission on 01/22/2021, his/her pain was 7/10 and quickly increased to 10/10 when he/she did not get pain medication as ordered by the Physician. The resident stated he/she was crying out for pain medication, as the pain was unbearable; the pain medication he/she was receiving was ineffective. (Refer to F- 655 and F-755). The facility's failure to have an effective system in place to ensure pain management was provided to residents who required such services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 02/10/2021 and were determined to exist on 01/22/2021. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/23/2021, with the facility alleging removal of the Immediate Jeopardy on 02/19/2021. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/19/2021, prior to exit on 02/25/2021, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Pain Management Guidelines, revised 08/25/2020, revealed each resident would have a treatment plan established to treat/manage his/her pain. Additionally, a licensed nurse should conduct pain assessments and reassessments. The policy stated the resident would be reassessed every other day for the first eight (8) days from the admitted and with each scheduled Minimum Data Set (MDS) Assessment as indicated. Per policy, when possible, upon Physician consultation/order, a resident experiencing chronic pain would have a routine medication scheduled. In addition, the policy stated a review of the resident's current pain medication regimen should be conducted if the resident indicated or behaved in a manner which indicated he/she had pain, with the Attending Physician consulted as indicated. Further, per policy, when a PRN pain medication was administered, the nurse would document specific complaints given by the resident, or symptoms/actions observed by the Nurse in the Electronic Health Record (EHR) via the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled, Orders Including Medication Orders, revised 10/20/2019, revealed the lawfully authorized prescriber of medications would be contacted for directions when delivery of a medication was delayed or the medication was not available. Further review revealed the Pharmacy and EHR were integrated and orders entered into the EHR would be visible to the Pharmacy. Interview with the Director of Nursing (DON), on 02/05/2021 at 11:25 AM, revealed staff was to utilize the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, she stated staff was to reassess the resident's pain level after administration of the medication for effectiveness and document Effective or Ineffective on the E-MAR. Review of Resident #2's Hospital Discharge Summary, dated 01/22/2021, revealed the resident was admitted to the hospital, on 01/20/2021, for Right Sacroiliac Fusion surgery. Per the Summary, the resident's pain was controlled with pain medication. Additionally, the discharge plan included pain control with pain medication including Oxycodone 7.5/325 mg, every six (6) hours PRN; [MEDICATION(S)] 600 mg, four (4) times a day; and [MEDICATION(S)] Sulfate Extended Release (ER) 15 mg, every twelve (12) hours. Review of Resident #2's closed medical record revealed the facility admitted the resident, on Friday, 01/22/2021 at 6:00 PM, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #2 was discharged on [DATE]. There was no Admission Minimum Data Set (MDS) Assessment completed for Resident #2 due to the discharge date . Review of Resident #2's Ancillary Admission Assessment, opened on 01/22/2021 at 6:00 PM, and closed on 01/23/2021 at 12:42 PM, completed by Licensed Practical Nurse (LPN) #6, revealed Resident #2 was alert and oriented, to person, place and time. Additionally, the resident communicated verbally, his/her speech was clear, and he/she was able to understand and be understood when speaking. Additional review of the Assessment, revealed the resident had a surgical wound to his/her right hip, with no exudate (drainage); the wound was dry and intact and closed with glue. Further review of the Assessment revealed the resident had pain, which affected sleep and limited day-to-day activity. Per Assessment, Resident #2 rated his/her pain at 7/10. Review of Resident #2's Progress Note, dated 01/22/2021 at 6:00 PM, by Agency Licensed Practical Nurse (LPN) #6, revealed the Admitting Physician approved the resident's medication. Review of Resident #2's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed an order, dated 01/22/2021, for [MEDICATION(S)] Sulfate ER (extended-release) 15 mg, one (1) tablet orally, every twelve (12) hours PRN for pain. Further review revealed an order, dated 01/22/2021, for [MEDICATION(S)] 600 mg, one (1) tablet orally, four (4) times a day for pain. Review of Resident #2's Baseline Care Plan, initiated on 01/23/2021 by LPN #6, revealed the resident had pain. The goal stated the resident would verbalize pain, indicate the location of pain and remain free form any unrelieved pain. Interventions included but were not limited to administer pain medications as directed; assess pain after medication administration for effectiveness; notify the Physician if pain medication was less than effective. However, there was no documented evidence the resident's pain was assessed after pain medication administration, on 01/23/2021, or that the Physician was notified of continued pain, on 01/23/2021 and 01/24/2021. Further, there was no documented evidence the resident received [MEDICATION(S)] or Oxycodone per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #2's Progress Notes, dated 01/23/2021 at 7:29 AM; 01/23/2021 at 5:23 PM; 01/23/2021 at 9:21 PM; 01/24/ at 7:48 AM, and 01/24/2021 at 11:30 AM, revealed the facility was waiting on Resident #2's [MEDICATION(S)] 600 mg ( which was to be administered four (4) times a day for pain) from the Pharmacy. Continued review of a Progress Note, dated 01/24/2021 at 3:54 PM, by Registered Nurse (RN) #2, revealed she had been alerted by the Pharmacy that Resident #2's [MEDICATION(S)] order was rejected. In addition, the note stated the Pharmacy was called for clarification, a voice mail was left, and RN #2 was awaiting a return call from the Pharmacy. Review of a Progress Note, dated 01/24/2021 at 3:57 PM, by RN #2, revealed the Pharmacy stated a paper prescription was required from the Physician, and the Physician would be notified. However, there was no documented evidence the Physician was notified of the required written prescriptions for pain medication on 01/22/2021, 01/23/2021, 01/24/2021, or 01/25/2021. Also, there was no documented evidence the Physician or Pharmacy were notified related to the delay on receiving Oxycodone from the Pharmacy. Review of the Controlled Drug Record (CDR) revealed [MEDICATION(S)] Sulfate ER 15 mg was received by the Pharmacy, on 01/22/2021 at 8:06 PM. Additionally, it was signed out on the CDR, on 01/23/2021 at 1:15 AM, and, on 01/23/2021 at 8:30 PM for Resident #2, by Kentucky Medication Aide (KMA) #1. However, the medication was not documented as administered on the E-MAR. There was no documented evidence on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of the E-MAR, revealed no documented evidence Oxycodone 7.5-325 mg, PRN every six (6) hours, or [MEDICATION(S)] 600 mg four (4) times a day were administered on 01/22/2021, 01/23/2021, 01/24/2021 or 01/25/2021. Review of Resident #2's Skilled Evaluation, dated 01/23/2021 at 8:00 AM, by Agency LPN #2, revealed the resident had no indicators of pain. Additional review of Resident #2's Skilled Evaluation, dated 01/23/2021 at 10:56 PM, by Agency LPN #6, revealed the resident had no indicators of pain. Further review of Resident #2's Skilled Evaluation, dated 01/24/2021 at 9:41 PM, by RN #1, revealed the resident had verbal complaints of 6/10 throbbing pain, multiple times a day. Per RN #1's assessment, non-medical interventions such as relaxation, distraction and change in position were implemented. Additional review of the CDR revealed [MEDICATION(S)] Sulfate ER 15 mg was signed out, on 01/24/2021 at 1:30 PM, by KMA #1, the pain scale rating was 7/10; the medication was recorded as Effective. Further review revealed [MEDICATION(S)] Sulfate ER 15 mg was signed out, on 01/25/2021 at 8:15 AM, by LPN #2, the pain scale rating was 10/10; the medication was recorded as Effective. Review of Resident #2's Unit Twenty-four (24) Hour Report sheet, dated 01/23/2021, noted the nurse was Agency LPN #5. Additional review of the Report sheet, revealed Resident #2 had no paper prescription for [MEDICATION(S)] and needed this from the Medical Director. Further review revealed the Twenty-four (24) Hour Report sheet, dated 01/24/2021, noted the nurse was RN #1. There was no documented evidence Resident #2 needed prescriptions for pain medication. Review of Resident #2's Unit Physician Rounding Sheet, dated 01/25/2021, revealed the reason Resident #2 would be seen was routine. Review of Resident #2's, Physician's History and Physical (H&P), dated 01/25/2021, completed by the resident's Attending Physician, revealed the resident was admitted for acute Skilled Nursing Facility (SNF) rehabilitation status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, it stated the resident moved all extremities and the incision with staples, on the resident's right back were okay. Per the H&P, the resident's pain was controlled with the current management of Oxycodone 7.5-325 mg, [MEDICATION(S)] Sulfate ER 15 mg, and [MEDICATION(S)] 600 mg. Further, it stated upon assessment, the resident informed the Physician he/she had bad [CONDITION(S)], had not received any pain medication while at the facility, and was discharging home because he/she had pain medication at home. Continued review revealed the resident chose to discharge from the facility on 01/25/ . Interview with Resident #2, on 02/03/2021 at 10:40 AM, revealed while the resident resided at the facility, he/she did not receive [MEDICATION(S)] and Oxycodone. Additionally, the resident stated he/she asked several nursing staff at the facility for help to get his/her [MEDICATION(S)] and Oxycodone because the pain medication he/she was receiving was less than effective. However, the resident stated he/she was told over and over again the Physician had been notified, and the facility was waiting on Pharmacy to deliver the medications. Per interview, the resident stated he/she even asked if his/her daughter could bring medications from home since the facility did not have his/her medication available, but that request was denied. Further, the resident stated on admission, on 01/22/2021, his/her pain was 7/10 and quickly increased to 10/10 when the medication he/she had taken at the hospital wore off. Resident #2 stated then he/she did not get pain medication as ordered by the Physician. The resident stated he/she was crying out and begging for pain medication, as the pain was unbearable and was not controlled. Record review revealed Agency Licensed Practical Nurse (LPN) #6, was Resident #2's admitting nurse, on 01/22/2021 at 6:00 PM. However, LPN #6 was not available for interview after several telephone messages were left for the nurse to return a call to the State Survey Agency (SSA) Surveyor. Interview with the Admitting Physician, on 02/06/2021 at 3:30 PM, revealed, on 01/22/2021, she received a call from a facility Nurse to verify Resident #2's hospital discharge medications. Additionally, she stated she discussed with the Nurse (she cannot recall the name of the Nurse) the resident had chronic pain and used opioids, and she recommended for the Nurse to contact the pain specialist related to the orders for pain medication to ensure they were appropriate. She stated she did not hear back from the Nurse to see if she had contacted the pain specialist and she did not follow-up with the Nurse to see if this happened. Per interview, she was told a paper prescription was needed to be sent related the resident's [MEDICATION(S)] Sulfate ER. The Physician stated she sent the prescription straight to the Pharmacy; however, she was not informed that prescriptions were needed for the [MEDICATION(S)] and/or Oxycodone. Further, the Physician stated she expected Nursing staff to notify her if a resident's pain medication was not available for administration. She stated the dose of [MEDICATION(S)] that Resident #2 was prescribed was a dose the resident had been on for a while, and without the medication, the resident had the potential to experience withdrawal symptoms and increased pain. Interview with SRNA #4, on 02/03/2021 at 3:22 PM, revealed she had worked at the facility eight (8) years. Per interview, she was assigned to Resident #2, on 01/23/2021 from 2:00 PM until 6:00 PM, and on 01/24/2021 from 2:00 PM until 6:00 PM. SRNA #4 stated Resident #2 verbalized pain in his/her lower extremities and had facial grimacing. The resident told her his/her legs were killing him/her. Continued interview revealed the resident kept asking for pain medication; to speak with someone in charge who could get him/her pain medication; and to discharge from the facility because he/she had pain medication at home. Per interview, on 01/23/2021 and 01/24/2021, Resident #2 would frequently self-propel in a wheelchair to the Nurses' Station to talk with LPN #6, RN #2, and RN #1 about his/her pain medication. Per interview, SRNA #4 stated she tried non-medicinal interventions such as repositioning, distraction, and warm blankets; however, none were effective. She stated the resident continued to verbalize pain, request pain medication, and beg to go home. Further, SRNA #4 reported the resident's pain to Agency LPN #6, RN #2, and RN #1 several times; but, she was uncertain if the Resident #2 ever received his/her pain medication. Interview with Agency LPN # 5, on 02/03/2021 on 5:12 PM, revealed she had worked at the facility about a week. Per interview, she was assigned to Resident #2, on 01/23/2021. The LPN stated 01/23/2021 was her first day at the facility, and she did not receive an orientation related to the facility's policies and procedures. Continued interview revealed she was not aware of the facility's policy related to pain management or medication administration. Additionally, she stated she was not aware Resident #2 was in pain; however, she was aware the resident was requesting his/her [MEDICATION(S)], and it was not available at the facility. Continued interview revealed she called the Pharmacy and asked about Resident #2's [MEDICATION(S)] and was informed the Pharmacy needed an order and a prescription from the Physician. Further, the LPN stated she did not notify a supervising nurse or contact the On-Call Physician; she wrote, on the Twenty-four (24) Hour Report that the resident needed a prescription for [MEDICATION(S)] and also added the resident to the Monday, 01/25/2021, Physicians Clinic List (a list of residents the Physician would see during rounds). Further interview revealed when she reviewed Resident #2's medical record, the resident did not have any diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, it was important for residents to receive pain medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with KMA (Kentucky Medication Aide) #1, on 02/04/2021 at 3:50 PM, revealed she had worked at the facility fourteen (14) years. Per interview, she worked with Resident #2, on Saturday, 01/23/2021, and Sunday, 01/24/2021. Continued interview revealed the resident complained of pain on Sunday and had questions about his/her pain medications. She stated Resident #2 told her he/she was not getting his/her prescribed [MEDICATION(S)] or Oyxcodone, and the pain medication he/she was receiving was less than effective. Additionally, she stated the resident reported he/she had not received all his/her pain medications. The KMA stated she reported Resident #2's complaints to RN #1 and RN #2. Further, she stated it was important for residents to get their pain medication to ensure they were not in pain. Interview with RN #2, on 02/03/2021 at 2:30 PM, revealed she had worked at the facility two (2) weeks. Additionally, RN #2 stated she was in training with RN #1, and on Sunday 01/24/2021 was her third day of training and she was assigned to Resident #2. Per interview, pain management was briefly discussed with her by her orientating nurse, RN #2. Continued interview revealed pain assessments were documented in Assessments in the EHR and on the E-MAR. RN #2 stated during her orientation she was not trained adequately on the admission of a new resident and how to ensure medications were obtained from Pharmacy, but she had accidentally figured it out. Further interview revealed, on 01/24/2021, Resident #2 had no complaints of pain at the beginning of the day; however, toward the end of the day, in the evening, he/she complained of pain and voiced concerns with his/her medications ([MEDICATION(S)] and Oxycodone) not arriving to the facility. Per interview, RN #2, called the Pharmacy and was informed a paper prescription was required from the Physician for the [MEDICATION(S)] before they could dispense the medication. RN #2 stated she did not inquire about the resident's Oxycodone. Per interview, RN #2 did not have access to log onto the Physician's messaging system to notify the On-Call APRN (Advanced Practice Registered Nurse) that Resident #2 needed a paper prescription. She stated she informed RN #1 of the Pharmacy's request and was under the impression RN #1 contacted the On-Call APRN for the paper prescription. Per interview, Resident #2 received [MEDICATION(S)] 15 mg during her shift. RN #2 stated it was important for residents to receive pain medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN #1, on 02/03/2021 at 4:20 PM, revealed she had worked at the facility six (6) months. Per interview, she was assigned to Resident #2, on 01/24/2021. Continued interview revealed Resident #2 was alert, oriented, and able to express his/her needs. Additionally, she stated Resident #2 had asked staff several times, on 01/24/2021, why he/she was not receiving the prescribed [MEDICATION(S)] because the pain medication he/she was receiving was less than effective. She stated Resident #2 told her that he/she had not received the [MEDICATION(S)] since admission to the facility and was suffering with terrible pain. RN #1 stated she explained to the resident he/she was a new admission, and the medication had just not arrived from the Pharmacy yet. Per interview, RN #1 was not aware of why the pain medications were delayed from the Pharmacy, and she administered the resident's [MEDICATION(S)] Sulfate ER. Continued interview revealed that RN #2 made a call to Pharmacy inquiring about the [MEDICATION(S)], and it was her (RN #1) understanding the Pharmacy could not send the [MEDICATION(S)]. However, she did not call the Pharmacy to clarify why the medication was not available or notify the physician of the resident's pain. Further, RN #1 stated nurses were responsible to advocate for residents, and she should have called the Pharmacy and the Physician related to the delay in pain medication and the resident's increased pain, per the facility policy. RN #1 stated it was important for residents to receive pain medication per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #2, on 02/03/2021 at 1:45 PM, revealed she had worked at the facility seventeen (17) years. Additionally, she stated she was Resident #2's nurse, on 01/25/2021 from 6:00 AM until discharge, at approximately 11:00 AM. Per interview, Resident #2 requested to discharge from the facility early on 01/25/2021, because he/she had not received any pain medication while at the facility, and his/her pain was 10/10. Continued interview revealed LPN #2 administered [MEDICATION(S)] Sulfate ER 15 mg when the resident stated he/she was in pain. However, the resident was requesting the prescribed [MEDICATION(S)] and Oxycodone, which were not available at the facility. Per interview, the LPN told Resident #2, the facility was working on getting the [MEDICATION(S)] and Oxycodone, and she would talk to the Physician. LPN #2 stated Resident #2 was also concerned he/she had to request the [MEDICATION(S)] Sulfate ER; he/she had always taken the medication scheduled every twelve (12) hours. LPN #2 stated she advised the resident he/she would have to request the [MEDICATION(S)] because the order was written as PRN (as needed). Interview with the contracted Pharmacy's Pharmacist and Ordering Manager, on 02/03/2021 at 2:50 PM, revealed review of Resident #2's profile showed the Pharmacy did not receive an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore, the medications were never dispensed from the Pharmacy to the facility. Additionally, the Pharmacist stated the only reason Resident #2's [MEDICATION(S)] Sulfate ER 15 mg every twelve (12) hours was dispensed to the facility on [DATE] was the Pharmacy had received a paper prescription from the Admitting Physician. Further, the Pharmacist stated the Pharmacy had no documented evidence of communication from the facility about the need for the medications. Further interview revealed, Resident #2 would have noticed increased pain and withdrawal symptoms from not taking his/her prescribed [MEDICATION(S)] 600 mg four (4) times a day. Continued interview revealed [MEDICATION(S)] was a drug that would require titration to the prescribed dose to ensure therapeutic results, and the resident should not have gone without the medication without additional pain management in place. Interview with the Advanced Practice Registered Nurse (APRN), on 02/05/2021 at 2:10 PM, revealed she was the On-Call provider, for Saturday, 01/23/2021, and Sunday, 01/24/2021. Further interview revealed she did not receive any pages or calls from the facility over the weekend related to Resident #2. The APRN stated she was not aware the resident did not receive his/her ordered pain medication. Interview with Resident #2's Attending Physician, on 02/03/2021 at 10:30 AM, revealed she was not aware Resident #2 did not receive his/her prescribed medications, [MEDICATION(S)] or Oxycodone until Monday, 01/25/2021, when the resident informed her he/she had not received the medication over the weekend and since admission to the facility. She stated Resident #2 requested to be discharged from the facility, on 01/25/2021. The Physician stated when she saw the resident on Monday, he/she was in pain, was very angry, and said he/she had not received any pain medication since admission. However, she stated she did not specifically ask the resident his/her pain level. She stated she would have expected to be notified of any issues with the resident's pain; but, she was not notified by the facility over the weekend with any issues related to the resident's pain medications or pain management. Further, she stated she expected the resident's pain medications to be available at the facility and administered per orders. Per interview, the Physician stated it was important residents received ordered pain medication to ensure the best care and pain management was provided to them. Interview with the Director of Nursing (DON), on 02/05/2021 at 11:25 AM, revealed she had been in her position at the facility for one (1) year. Additionally, she stated she expected staff to administer pain medications as ordered and document administration of pain medication on the MAR, as well as perform pain assessments to determine pain levels prior to and after the administration of medications and document these levels on the MAR. Per interview, she also expected staff to thoroughly assess a resident's pain when a resident verbalized pain or had signs or symptoms of pain. Additionally, the DON stated it was the Nurse's responsibility to ensure medications were verified with the Admitting Physician and necessary paper/hard copy prescriptions were obtained and sent to Pharmacy. Per interview, after admission, it was also the Nurse's responsibility to contact the On-Call provider for necessary paper prescriptions. Further, she stated she expected nursing staff to contact the Physician for directions when delivery of a medication was delayed or the medication was not available, as directed in the facility's policy. The DON stated she was not aware, until Monday, 01/25/2021, that Resident #2 did not receive his/her [MEDICATION(S)] or Oxycodone. Continued interview revealed it was important for residents to receive their prescribed pain medications to ensure optimal pain management. Interview with the Administrator, on 02/04/2021 at 9:50 AM, revealed he expected residents with pain to have pain management per standards of practice; pain should be assessed and documented when noted. Continued interview revealed he expected pain medication to be administered per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, he expected Nursing staff to attempt to acquire necessary paper prescriptions from providers for ordered pain medication and to notify providers with unrelieved pain or if the delivery of pain medication was delayed. Further, the Administrator stated it was a healthcare provider's obligation to ensure a resident in pain received pain medication to relieve the resident's pain. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/23/2021 alleging removal of the Immediate Jeopardy on 02/19/2021. Review of the AoC revealed the facility implemented the following: 1. On 02/02/2021, the Interdisciplinary Team (IDT) reviewed Resident #2's medical record. 2. A Clinical Admissions Evaluation would be completed on all new admissions with routine and as needed medication orders. 3.a. On 02/17/2021, the Clinical Coordinators reviewed all admissions and readmissions for the previous thirty (30) days related to pharmaceutical procedures, pain assessments, and care plans. b. Clinical Coordinators audited if pain medications were available for those residents noted with pain and orders for narcotic pain medications. c. Clinical Coordinators audited prescription availability for narcotic pain medications. d. Findings were reviewed with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). e. Education was provided as necessary, based on the review findings. f. Clinical Coordinators assured all residents with narcotic pain medication orders had appropriate medications available at the time of review. 4. Upon admission, the Admitting Nurse would verify all needed prescriptions had been sent to the facility. Additionally, the Admitting Nurse would notify the Physician if a written prescription was needed and would document notification in the resident's medical record. 5.a. Beginning on 02/17/2021, a list of all medications requiring a written prescription was added to all medication cart binders, by the Clinical Coordinators. b. Beginning on 02/17/2021, a list of controlled substances needing prescriptions was added to the Twenty-four (24) Hour Report sheet by the ADON and the DON. c. Beginning on 02/17/2021, a list of Emergency Stock Box medications was updated and placed at all Nursing Stations and in all medication cart binders, by the Clinical Coordinators. 6.a. On 02/18/2021, the Clinical Coordinators provided education to twenty-two (22) of thirty-nine (39) Licensed Practical Nurses (LPN), Registered Nurses (RN), and Kentucky Medication Aides (KMA), on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box. No employee would be permitted to work beyond 02/18/2021 without receiving education. b. New hire orientation, orientees, including agency contract staffing, would be educated on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box, by the ADON, DON, and Clinical Coordinators. 7. Beginning on 02/17/2021, a member of the Interdisciplinary Team (IDT) reviewed new admissions within twenty-four (24) hours, verifying medication orders, controlled substance availability, pain assessments, and pain care plans for accuracy. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the ADON would validate the review Monday through Friday. <

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure an effective system was in place to obtain Pharmaceutical services, per Physician's orders, to meet the needs of each resident for one (1) of fifteen (15) sampled residents (Resident #2). The facility failed to ensure pain medication was obtained from the Pharmacy for Resident #2. The facility admitted Resident #2 on Friday, 01/22/2021 at 6:00 PM, with diagnoses that included Status Post Fusion Spine/Sacral Region, Intervertebral Disc Degeneration/Lumbar Region, Cervical Disc Degeneration, Opioid Use, and Right Hip Pain. According to the Hospital Discharge records, dated 01/22/2021, the discharge plan included pain control, and the discharge pain medications, to be taken orally, included Oxycodone, [MEDICATION(S)], and [MEDICATION(S)]. Agency Licensed Practical Nurse (LPN) #6, verified the resident's orders with the Admitting Physician and entered Resident #2's hospital discharge orders for medications into the Electronic Health Record (EHR). However, interview with the Pharmacist revealed paper/hard copy prescriptions for [MEDICATION(S)] and Oxycodone were not received from the facility; therefore, Pharmacy did not dispense the pain medications. Interview with the Admitting Physician, the On-Call Advanced Practice Registered Nurse (APRN), and the Attending Physician revealed they were not notified that Resident #2 required paper prescriptions to receive [MEDICATION(S)] and Oxycodone on 01/22/2021, 01/23/2021, or 01/24/2021. Resident #2 reported ineffective pain relief with significant pain during his/her three (3) day stay at the facility. (Refer to F-655 and F-697) The facility's failure to have an effective system in place to ensure the resident's pain medications were available per Physician's Orders has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 02/10/2021 and were determined to exist on 01/22/2021. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/23/2021, with the facility alleging removal of the Immediate Jeopardy on 02/19/2021. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on 02/19/2021, prior to exit on 02/25/2021, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Orders Including Medication Orders, revised 10/20/2019, revealed medications were administered and verified from orders of a person lawfully authorized to prescribe medications. Additionally, the prescriber would be contacted for directions when delivery of a medication was delayed or the medication was not available. Continued review revealed the Pharmacy and EHR were integrated and orders entered into the EHR would be visible to the Pharmacy. Further, the policy stated a Nurse Manager would run a daily report of all new, revised, or discontinued orders from any source, to review in the Clinical Meeting. Review of the facility's policy titled, Provider Pharmacy Requirements, undated, revealed regular and reliable Pharmaceutical services would be available to provide residents with prescription medications. Further, the policy stated Pharmacy services included but were not limited to providing routine and timely Pharmacy services six (6) days a week and emergency Pharmacy services twenty-four (24) hours per day, seven (7) days per week. Review of Resident #2's Hospital Discharge Summary, dated 01/22/2021, revealed the resident was admitted to the hospital, on 01/20/2021, for Right Sacroiliac Fusion surgery. Continued review revealed the resident's pain was controlled with pain medication. Additionally, the discharge plan included pain control with pain medications including Oxycodone (a narcotic pain reliever) 7.5/325 mg, every six (6) hours PRN; [MEDICATION(S)] (a controlled pain reliever for nerve pain) 600 mg, four (4) times a day; and [MEDICATION(S)] Sulfate Extended Release (ER) (a narcotic opioid pain reliever) 15 mg, every twelve (12) hours. Review of Resident #2's closed medical record revealed the facility admitted the resident on Friday, 01/22/2021 at 6:00 PM, with diagnoses to include Status Post Fusion Spine/Sacral Region, Type II Diabetes, [CONDITION(S)], Intervertebral Disc Degeneration/Lumbar Region, Cervical Disc Degeneration, Opioid Use, and Right Hip Pain. Further review of the record revealed Resident #2 was discharged from the facility on 01/25/2021. Review of Resident #2's Progress Note, dated 01/22/2021 at 6:00 PM, by Agency Licensed Practical Nurse (LPN) #6, revealed she verified Resident #2's medication orders, and the Admitting Physician approved the resident's medications. The admission pain medications approved, from the Physician's Orders, were Oxycodone 7.5/325 milligrams (mg) every six (6) hours as needed; [MEDICATION(S)] 600 mg four (4) times per day; and [MEDICATION(S)] ER 15 mg every twelve (12) hours as needed (PRN). Additional review of Resident #2's Progress Notes, dated 01/23/2021 at 7:29 AM; 01/23/2021 at 5:23 PM; 01/23/2021 at 9:21 PM; 01/24/ at 7:48 AM, and 01/24/2021 at 11:30 AM, revealed the facility was waiting on and had not received from the Pharmacy Resident #2's [MEDICATION(S)] 600 mg, four (4) times a day for pain. Review of Resident #2's Progress Note, dated 01/24/2021 at 3:54 PM, by Registered Nurse (RN) #2, revealed Resident #2's [MEDICATION(S)] 600 mg, four (4) times a day for pain, had alerted that the order was rejected. Continued review revealed the Pharmacy was called for clarification, a voice mail was left, and RN #2 was awaiting a return call from the Pharmacy. Review of a Progress Note, dated 01/24/2021 at 3:57 PM, by RN #2, revealed the Pharmacy stated a paper (hard copy) prescription was required from the Physician, and the Physician would be notified. However, there was no documented evidence the Physician was notified of the required paper prescriptions for the pain medication on 01/22/2021, 01/23/2021, or 01/24/2021. Record review revealed no documented evidence the Physician or Pharmacy were notified related to Resident #2's need for his/her pain medications. Interview with RN #2, on 02/03/2021 at 2:30 PM, revealed she had worked at the facility two (2) weeks. Additionally, RN #2 stated she was in training with RN #1, on Sunday, 01/24/2021, and was assigned to Resident #2. The RN stated she did not know how to ensure medications were obtained from the Pharmacy, but she called the Pharmacy and was informed a paper prescription was required from the Physician for the [MEDICATION(S)] before they could dispense the medication. Per interview, RN #2 stated she did not have access to log onto the Physician's messaging system to notify the On-Call APRN (Advanced Practice Registered Nurse) that Resident #2 needed a paper prescription. She informed RN #1 of the Pharmacy's request and was under the impression RN #1 contacted the On-Call APRN for this. Review of the Electronic Medication Administration Record (E-MAR) revealed no documented evidence Oxycodone 7.5-325 mg, PRN every six (6) hours, or [MEDICATION(S)] 600 mg four (4) times a day were administered on 01/22/2021, 01/23/2021, 01/24/2021 or 01/25/2021. Review of Resident #2's Unit Twenty-four (24) Hour Report sheet, dated 01/23/2021, noted Resident #2's Nurse was Agency LPN #5. Additional review of the Report sheet revealed Resident #2 did not have a paper prescription for [MEDICATION(S)] and needed one from the Medical Director (MD). Further review of the Twenty-four (24) Hour Report sheet, dated 01/24/2021, revealed the resident's Nurse was RN #1. Continued review revealed there was no documented evidence on the Report sheet that resident #2 still needed paper prescriptions for his/her pain medications. Review of Resident #2's Unit Physician Rounding Sheet, dated 01/25/2021, revealed the reason Resident #2 needed to be seen by the Physician was routine. There was no documented evidence Resident #2 needed paper prescriptions for [MEDICATION(S)] or Oxycodone. Interview with Resident #2, on 02/03/2021 at 10:40 AM, revealed while the he/she resided at the facility, he/she did not receive [MEDICATION(S)] and Oxycodone. Additionally, the resident stated he/she asked several nursing staff at the facility for help to get his/her [MEDICATION(S)] and Oxycodone and was told over and over again the Physician had been notified, and the facility was waiting on Pharmacy to deliver the medication. The resident stated he/she was crying out and begging for pain medication, as the pain was unbearable and was not controlled. Record review revealed Agency Licensed Practical Nurse (LPN) #6 was Resident #2's Admitting Nurse, on 01/22/2021 at 6:00 PM. However, LPN #6 was not available for interview after several telephone messages were left for the Nurse to return a call to the State Survey Agency (SSA) Surveyor. Interview with the Admitting Physician, on 02/06/2021 at 3:30 PM, revealed, on 01/22/2021, she received a call from a facility Nurse to verify Resident #2's hospital discharge medications. Additionally, she stated she was told by the Nurse, a paper prescription was needed for [MEDICATION(S)] Sulfate ER, and she sent this straight to the Pharmacy. The Physician stated she was not informed that a paper prescription was also needed for [MEDICATION(S)] and/or Oxycodone. She stated she expected Nursing staff to notify her if a resident's pain medication was not available for administration. Interview with Agency LPN # 5, on 02/03/2021 at 5:12 PM, revealed she had worked at the facility one (1) week. Per interview, 01/23/2021 was her first day at the facility, and she did not receive an orientation related to the facility's policies and procedures. Continued interview revealed she was not aware the facility's policy related to medication administration/obtaining medication from the Pharmacy. Additionally, she stated Resident #2 was requesting his/her [MEDICATION(S)], but the medication was not available at the facility. The LPN stated she called the Pharmacy, asked about Resident #2's [MEDICATION(S)]'s delay in delivery, and was informed the Pharmacy needed an order with a paper prescription from the Physician. Further, the LPN stated she did not notify a Supervising Nurse or contact the On-Call Physician. She stated she wrote on the Twenty-four (24) Hour Report that Resident #2 needed a paper prescription for [MEDICATION(S)] and also added the resident to the Monday, 01/25/2021 Physicians Clinic list (a list of residents the Physician would see during rounds). Further interview revealed it was important for the facility to have a process in place to ensure residents received their ordered pain medications to ensure their pain was managed and residents did not have adverse outcomes such as increased pain. Interview with the Advanced Practice Registered Nurse (APRN), on 02/05/2021 at 2:10 PM, revealed she was the On-Call provider, for Saturday, 01/23/2021, and Sunday, 01/24/2021. Additional interview revealed she did not receive any pages or calls from the facility over the weekend related to Resident #2, and she was not aware the resident did not receive his/her ordered pain medication. Further, she stated she expected Nursing staff to notify her if a resident's pain medication was not available or had delayed receipt from Pharmacy. Interview with RN #1, on 02/03/2021 at 4:20 PM, revealed she had worked at the facility six (6) months and was assigned to Resident #2, on 01/24/2021. Continued interview revealed the Admitting Nurse should ensure controlled medications had required Physician paper prescriptions on admission. Per interview, if these paper prescriptions were needed, the Physician should be notified immediately to ensure the resident's pain medications were available timely after admission. Additionally, she stated the Admitting Nurse would verify Physician orders and enter them into the EHR where the orders automatically transmitted to the Pharmacy, and paper prescriptions for controlled medications would be faxed to the Pharmacy. Per interview, if the Pharmacy had questions, they would contact the facility Nursing staff to request paper prescriptions if needed. Then, she stated the Physician would be contacted by Nursing staff, and the Physician would fax the paper prescriptions to the Pharmacy. RN #1 stated if there was any delay in a resident's pain medication arriving at the facility from the Pharmacy, Nurses would call the Pharmacy to determine the reason for the delay, and notify the Physician, as per the facility's policy. However, additional interview with RN #1, on 02/03/2021 at 4:20 PM, revealed Resident #2 had asked staff several times, on 01/24/2021, why he/she was not receiving the prescribed [MEDICATION(S)]; he/she had not received the [MEDICATION(S)] since admission to the facility and he/she was in terrible pain; and the resident was suffering in pain. Per interview, RN #1 was not aware why the pain medications were delayed from the Pharmacy. However, she stated she did not call the Pharmacy to clarify why the medication was not available or notify the Physician of the delay in receipt of the pain medications from Pharmacy, in violation of the facility's policy. Further interview revealed she should have called the Pharmacy and the Physician related to the delay in receipt of Resident #2's pain medications. Per interview, RN #1 stated it was important for the facility to ensure their protocol to ensure a resident's pain medication was obtained from the Pharmacy to ensure the resident was provided pain management, did not have an increase in pain, and to ensure quality of care and life. Interview with the contracted Pharmacy's Pharmacist and Ordering Manager, on 02/03/2021 at 2:50 PM, revealed review of Resident #2's profile showed the Pharmacy did not receive an order for [MEDICATION(S)] 600 mg four (4) times a day for pain or Oxycodone 7.5-325 mg every six (6) hours for pain. Therefore, the medications were never dispensed from the Pharmacy to the facility. Additionally, the Pharmacist stated the Pharmacy had no evidence of communication from the facility about the need for the medications. Further interview revealed when a resident was admitted to the facility, orders were entered into the EHR, but controlled medication orders would not transmit to the Pharmacy through the EHR. Therefore, the Pharmacist stated controlled medication orders would need to be printed and faxed to the Pharmacy and entered into the resident's profile by the Pharmacy. Interview with Resident #2's Attending Physician, on 02/03/2021 at 10:30 AM, revealed she was not aware Resident #2 did not receive his/her prescribed medications, [MEDICATION(S)] or Oxycodone until Monday 01/25/2021. She stated when she saw the resident on Monday, he/she was in pain, was very angry, and said he/she had not received any pain medication since admission. Per interview, she expected to be notified of any issues with the resident's pain medication not being available from the Pharmacy; but, she was not notified by the facility over the weekend with any issues related to Resident #2's pain medication. Further, the Physician stated she expected a resident's pain medications to be available timely after admission, and administered per orders. Per interview, it was important residents received ordered pain medication to ensure the best care and pain management. Interview with the Director of Nursing (DON), on 02/05/2021 at 11:25 AM, revealed she had worked at the facility in her current role for one (1) year. Additionally, she stated she expected pain medication to be available to residents timely after admission to the facility. Additionally, she stated it was the Nurse's responsibility to ensure medications were verified with the Admitting Physician and necessary paper prescriptions were obtained and sent to Pharmacy. Per interview, after admission, it was also the Nurse's responsibility to contact the On-Call provider for necessary scripts. Further, she stated she expected the Nursing staff to contact the Physician for directions when delivery of a medication was delayed or the medication was not available. Continued interview revealed it was important for the facility to have processes in place to ensure residents received their prescribed pain medications to ensure pain management and resident comfort. Interview with the Administrator, on 02/04/2021 at 9:50 AM, revealed he expected residents with pain to receive pain medication per Physician's Orders. Additionally, he expected ordered pain medication to be available to residents as soon as possible after admission to the facility. Per interview, he expected Nursing staff to attempt to acquire necessary paper prescriptions from providers for ordered pain medication and to notify providers with a resident's unrelieved pain or if the delivery of pain medication was delayed. The facility provided an acceptable credible Allegation of Compliance (AoC) on 02/23/2021 alleging removal of the Immediate Jeopardy on 02/19/2021. Review of the AoC revealed the facility implemented the following: 1. On 02/02/2021, the Interdisciplinary Team (IDT) reviewed Resident #2's medical record. 2. A Clinical Admissions Evaluation would be completed on all new admissions with routine and as needed medication orders. 3.a. On 02/17/2021, the Clinical Coordinators reviewed all admissions and readmissions for the previous thirty (30) days related to pharmaceutical procedures, pain assessments, and care plans. b. Clinical Coordinators audited if pain medications were available for those residents noted with pain and orders for narcotic pain medications. c. Clinical Coordinators audited prescription availability for narcotic pain medications. d. Findings were reviewed with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). e. Education was provided as necessary, based on the review findings. f. Clinical Coordinators assured all residents with narcotic pain medication orders had appropriate medications available at the time of review. 4. Upon admission, the Admitting Nurse would verify all needed prescriptions had been sent to the facility. Additionally, the Admitting Nurse would notify the Physician if a written prescription was needed and would document notification in the resident's medical record. 5.a. Beginning on 02/17/2021, a list of all medications requiring a written prescription was added to all medication cart binders, by the Clinical Coordinators. b. Beginning on 02/17/2021, a list of controlled substances needing prescriptions was added to the Twenty-four (24) Hour Report sheet by the ADON and the DON. c. Beginning on 02/17/2021, a list of Emergency Stock Box medications was updated and placed at all Nursing Stations and in all medication cart binders, by the Clinical Coordinators. 6.a. On 02/18/2021, the Clinical Coordinators provided education to twenty-two (22) of thirty-nine (39) Licensed Practical Nurses (LPN), Registered Nurses (RN), and Kentucky Medication Aides (KMA), on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box. No employee would be permitted to work beyond 02/18/2021 without receiving education. b. New hire orientation, orientees, including agency contract staffing, would be educated on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box, by the ADON, DON, and Clinical Coordinators. 7. Beginning on 02/17/2021, a member of the Interdisciplinary Team (IDT) reviewed new admissions within twenty-four (24) hours, verifying medication orders, controlled substance availability, pain assessments, and pain care plans for accuracy. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the ADON would validate the review Monday through Friday. 8. Beginning on 02/17/2021, a member of the IDT audited all new admissions within twenty-four (24) hours for medication orders, medication order verifications of controlled substances for availability on hand and/or in the Emergency Stock Box. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the DON would validate the review Monday thru Friday. 9. Beginning on 02/17/2021, during the Monday through Friday Clinical Meetings, the IDT reviewed all Twenty-four (24) Hour Report sheets monitoring controlled substances awaiting arrival related to the need for written prescription and verifying timely medication arrival. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the ADON would validate the review Monday thru Friday. 10. On 02/03/2021, an Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held, and on 02/10/2021, a monthly QAPI meeting was conducted to discuss the action plan related to the identified deficiency(s). 11. On 02/17/2021, a QAPI Performance Improvement Project (PIP) was implemented to review findings with ongoing monitoring. 12. Upon admission, Resident #2 was given a summary of his/her Baseline Care Plan, which was documented in Resident #2's medical record. 13. On 02/01/2021, the IDT, consisting of the DON, ADON, Clinic Coordinators, and Minimum Data Set (MDS) Coordinators, reviewed Resident #2's medical records, which included orders, medication administration record, and assessments for pain management and accuracy. 14. A Clinical Outcomes Management Systems (COMS) Clinical Admissions Evaluation would be completed for all new admissions with routine and as needed medication orders. 15.a. On 02/17/2021, the Clinical Coordinators reviewed all new admissions and readmissions for the previous thirty (30) days for a COMS Pain Assessment, noting pain, and a corresponding pain care plan. b. On 02/17/2021, the Clinical Coordinators audited if controlled pain medication was noted as not available for those residents with orders for narcotic pain medications. Following any narcotic pain medication noted as not available, the Clinical Coordinators determined if it was related to prescription availability. For all noted concerns during the review, the Clinical Coordinators ensured all residents with narcotic pain medication orders had appropriate medication available at the time of the review. c. Findings of the review were reviewed with the DON and ADON. d. On 02/17/2021, the Clinical Coordinators provided education to twenty-two (22) of thirty-nine (39) LPN's, RN's, and KMA's, on COMS Pain Assessment, noting pain and corresponding care plan. No employee was permitted to work beyond 02/18/2021 without receiving education. 16. On 02/17/2021, revisions to pain management guidelines were reviewed. Revisions to pain management included: 1. Licensed Nurses would conduct pain assessments on admission and document findings in the COMS Admission Evaluation and Ancillary Admissions Assessment. 2. A pain-focused care plan would be initiated in the Baseline Care Plan if pain was noted in the COMS Admission Evaluation and Ancillary Admissions Assessment. 3. The Emergency Stock Box would be utilized for pain management medications when an ordered medication was unavailable. 17. Beginning on 02/17/2021, the IDT, including the Clinical Coordinators, Social Service Department (SSD), and MDS Nurses reviewed the previous twenty-four (24) hour Nurse charting for appropriate notification and intervention on new behaviors, risk management incidents, and Situation, Background, Assessment, Recommendation (SBAR), daily Monday through Friday. Additionally, the weekend Clinical Coordinator completed the same process on Saturdays and Sundays. Further, the DON would validate the review Monday through Friday, with the weekend review on Monday, for a minimum of one (1) month with no omissions. 18. Beginning on 02/17/2021, the IDT, consisting of DON, ADON, Clinical Coordinators, and MDS Nurses would audit all new admission Baseline Care Plans and COMS Admission Evaluation validating nursing assessments for pain, implementation of a pain care plan, pain management orders in place, and medication administration records, within twenty-four (24) hours of admission. Additionally, the weekend Clinical Coordinator would review new admissions, within twenty-four (24) hours of admission, on Saturdays and Sundays. Further, the IDT would perform a review of the audit daily, Monday through Friday, during the Clinical Meeting with the weekend review validated during the Monday Clinical Meeting. 19.a. On 02/17/2021, the Clinical Coordinators reviewed all new admissions and readmissions for the previous thirty (30) days for COMS Pain Assessments, noting pain and a corresponding pain care plan. b. On 02/17/2021, Clinical Coordinators audited if controlled pain medications were noted as not available for those residents noted with pain, and with orders for narcotic pain medication. For all noted concerns during the review, the Clinical Coordinators ensured all residents with narcotic pain medication orders had appropriate medication available at the time of the review. c. Findings of the review were shared with the DON and ADON. d. On 02/17/2021, education was provided to twenty-two (22) of thirty-nine (39) LPN's, RN's, and KMA's on obtaining pharmaceuticals, obtaining a Physician's written prescription, and the process of pulling a controlled substance from the Emergency Stock Box. No employee was permitted to work beyond 02/18/2021 without receiving education. Clinical Coordinators were responsible for providing in-service education beyond 02/18/2021, prior to any employee working. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of a document titled Resident #2's Medical Record, revealed the DON, ADON, MDS Nurses, and Clinical Coordinators (all IDT members) signed the document, on 02/01/2021, stating they reviewed Resident #2's Assessment, Progress Notes, Physician's Orders, Medication Administration Record, Care Plan, and Controlled Drug Records. 2. Record review for sampled residents, revealed residents admitted within the last thirty (30) days had Clinical Admission Evaluations, including pain assessment. The Admission Report, dated 01/25/2021 through 01/31/2021, and 02/01/2021 to 02/23/2021, noted twenty-seven (27) new admissions. Review of the thirty (30) day New Resident Admission Audit revealed thirty-three (33) residents were audited, and four (4) residents had narcotic pain medication which was not available. 3.a-f. Review of the thirty (30) day New Resident Admission Audit revealed thirty-three (33) residents were audited for a pain care plan, COMS Pain Assessment, pain on admission, narcotic (NARC) pain medication administration, medications marked N/A, and prescription (script) not available. Interview with the Clinical Coordinators, on 02/25/2021 at 3:50 PM, revealed they completed the thirty (30) day New Resident Admission Audit. The audit revealed three (3) additional residents did not have narcotic pain medication available, and they notified the DON of the findings. Interview with the DON, on 02/25/2021 at 4:45 PM, revealed the audit identified medication availability issues with only two (2) residents; however, those two (2) issues were specific to accessing the Emergency Stock box. The medication for those residents was available in the facility; however, the nurses did not follow proper procedure for accessing the Emergency Stock Box to obtain medications for the residents. The DON stated Nursing staff received education on the Emergency Stock Box procedures. 4. Interview with the DON, on 02/25/2021 at 4:45 PM, revealed an Admission Checklist and audit were developed for the Admitting Nurse to utilize for controlled substances requiring a written script and to notify the Physician if a written prescription was needed when verifying medication. Interview with the MDS Coordinators, on 02/25/2021 at 3:35 PM, revealed documentation of notification to Physicians when verifying medications was in the resident's medical record and the Twenty-four (24) Hour Report sheet. Review of the Admission Checklist included verification of controlled medication prescriptions, which was answered yes or no. If answered no, it asked if the Physician was notified. Review of the document Obtaining Pharmaceuticals New Admission, (no date), revealed it listed step criteria for the Admitting Nurse to include: 1) the Admitting Nurse would verify with the Discharging Nurse (from the other facility) if the resident would be discharging with controlled substances requiring a written prescription; 2) the Admitting Nurse would request all prescriptions be sent with discharge paperwork; 3) a list of all medications requiring a prescription had been added to all medication cart binders; 4) if a needed prescription was not in a new resident's discharge packet, the Admitting Nurse would notify the Physician a written prescription was needed when verifying medications; 5) controlled substances needing prescriptions had been added to all Twenty-four (24) Hour Report sheets; and 6) the current list of Emergency Box Medications was available at all nursing stations and all medication cart binders. 5.a. Interview with the Clinical Coordinators, on 02/25/2021 at 3:50 PM, revealed on 02/17/2021, they placed a list of all medications requiring a prescription and a list of Emergency Stock Box medications to all medication cart binders and at the Nurses' Stations. b. Interview with the ADON, on 02/25/2021 at 3:50 PM, revealed she and the DON added controlled substances needing prescriptions to the Twenty-four (24) Hour Report sheet on 02/17/2021. c. Interview with the Clinical Coordinators, on 02/25/2021 at 3:50 PM, revealed on 02/17/2021, they placed a list of all medications requiring a prescription and a list of Emergency Stock Box medications to all medication cart binders and at the Nurses' Stations. 6.a. Interviews with KMA #1, on 02/25/2021 at 3:00 PM; LPN #11 and LPN #12, on 02/25/2021 at 3:10 PM; MDS Coordinator #1 and MDS Coordinator #2, on 02/25/2021 at 3:35 PM; RN #6, RN #5, and LPN #13, on 02/25/2021 at 3:50 PM, revealed they received education related to obtaining pharmaceuticals, obtaining Physician's scripts, and the process of pulling a controlled substance from the Emergency Stock Box. Review of the education audit sheets, on 02/18/2021, revealed the Clinical Coordinators provided education to twenty-two (22) of thirty-nine (39) LPN's, RN's, and KMA's on obtaining pharmaceuticals, obtaining Physician's scripts, and the process of pulling a controlled substance from the Emergency Stock Box. b. Interview with Human Resources (HR), on 02/25/2021 at 4:25 PM, revealed the New Hire Orientation process included education on obtaining pharmaceuticals, obtaining Physician's scripts, and the process of pulling a controlled substance from the Emergency Stock Box. Review of the New Hire Orientation packet revealed orientation provided Provisions of Quality of Care, Baseline Care Plan, Nursing Initial Care Plan, Medications Controlled Drugs, Obtaining Pharmaceuticals for New Admissions, Pain Management Guidelines, and Emergency Box Stock List trainings. Review of the document Obtaining Pharmaceuticals for New Admission, (no date), revealed it listed step criteria for the Admitting Nurse to include: 1) the Admittin [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19 for three (3) out of fifteen (15) sampled residents (Resident #9, Resident #13, and Resident #14). Observations on 02/23/2021 at 11:40 AM, revealed State Registered Nursing Assistant (SRNA) #10, on the [NAME] Unit, wearing her surgical mask below her nose. Additional observations, on 02/25/2021 at 3:00 PM, revealed Resident #9 on the Dogwood Unit; Resident #13 and Resident #14 on the Maple Unit were in isolation. However, there were no red biohazard bags being used for the discarding of contaminated disposable medical equipment. Furthermore, observations on 02/23/2021 at 12:13 PM, revealed Dietary Aide (DA) #3, on the Magnolia Unit, plating dessert with improper hand hygiene and without gloves. The findings include: Review of the facility's policy, Infection Control Guidelines, dated 01/17/2017 and reviewed 08/25/2020, revealed staff would use Personal Protective Equipment (PPE) according to established facility policy governing the use of PPE. Additional review revealed all contaminated disposable items would be discarded in a waste receptacle lined with a red plastic biohazard bag. Further review revealed Standard/Universal Precautions would be employed by all personnel for all residents. The facility staff would apply transmission-based precautions, in addition to standard precautions, to residents who were known or suspected to be infected with certain infectious agents requiring additional controls to prevent transmission. Continued review revealed the purpose of the policy was to ensure the facility took appropriate precaution to prevent transmissions of infectious agents. The facility would use the standard approach, as defined by the Centers for Disease Control (CDC), for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of PPE to be used. Review of CDC Infection Control Guidelines, updated 02/18/ 1, revealed Masks should completely cover the nose and mouth and fit snugly against the sides of face without gaps. Review of the facility's policy, Infection Control Guidelines, dated 01/17/2017 and reviewed 08/25/2020, revealed staff would wash their hands after handling contaminated objects, and before and after donning gloves. 1. Review of Resident #9's medical record revealed, he/she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review revealed the resident was diagnosed , on 02/09/2021 with COVID-19. Continued review revealed the resident had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the resident had a Care Plan, initiated on date 02/09/2021, for Infection related to COVID-19 Precautions. The goal was will remain free from COVID-19. The interventions included but were not limited to: I need staff to encourage me to follow social distancing guidelines; I need staff to encourage me to not touch my face; I need staff to monitor labs as directed; I need staff to remind/help me wash my hands several times a day; Staff will monitor for signs/symptoms of COVID-19 daily. Observation on 02/24/21, at 10:58 AM, on the Dogwood Unit of Resident #9's room, revealed Resident #9 was in isolation under Contact precautions. Additional observations revealed the trash receptacle was located inside the door, and was being used for the disposal of contaminated PPE. However, the receptacle was lined with a clear plastic liner, not a red biohazard bag. 2. Review of Resident #13's medical record revealed, he/she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident had a care plan, initiated on date 02/11/2021, for Infection related to VRE/UTI precautions. The goal was, will have no adverse effects from antibiotic use and will be free of signs/symptoms of infection. The interventions included but were not limited to: I need staff to observe Contact Precautions; I need staff to administer medications as ordered by the physician and observe for side effects and effectiveness; I need staff to assess/document vital signs and notify physician of significant abnormalities; I need staff to encourage adequate fluid intake. Observation on 02/24/2021, at 10:25 AM, on the Maple Unit revealed Resident #13 was in isolation; however, trash receptacles inside the room had clear plastic trash bags liners and not red biohazard bags. 3. Review of Resident #14's medical record revealed, he/she was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] (antibiotic) tablet 500 mg (milligrams) 1 tablet by mouth every 8 hours for C-diff until 03/11/2021. Further review revealed the resident had a care plan, initiated on date 02/24/2021, for Infection related to C-diff. The goal was will have no adverse effects from antibiotic use and will be free of signs/symptoms of infection. The interventions included but were not limited to: I need staff to observe Contact Precautions; I need staff to administer medications as ordered by the physician and observe for side effects and effectiveness; I need staff to assess/document vital signs and notify physician of significant abnormalities; I need staff to encourage adequate fluid intake. Observation on 02/24/2021, at 10:25 AM, on the Maple Unit revealed Resident #14 was in isolation. However, trash receptacles inside the room had clear plastic trash bags liners and not red biohazard bags. Interview with Registered Nurse (RN) #4, on 02/24/2021 at 10:25 AM, revealed she worked on the Maple Unit. Further interview revealed she had received IC training which included signs and symptoms of COVID-19, types of isolation, use of PPE, and hand hygiene. RN #4 stated that wearing PPE and hand hygiene was important to prevent the spread of infection. Interview with State Registered Nurse Aide (SRNA) #11 on 02/24/2021 at 10:40 AM, revealed she worked on the Maple Unit. SRNA #11 stated she had received IC training which included signs and symptoms of COVID-19, types of isolation, use and disposal of PPE, and hand hygiene. Per interview, contaminated PPE was disposed of in trash receptacles in side the isolation rooms. The SRNA stated red biohazard bags should be used in all isolation rooms to decrease the potential for exposure and spread of infection. Interview with SRNA #12 on 02/24/2021 at 10:45 AM, revealed she worked on the Maple Unit. Per interview, she had received IC training which included signs and symptoms of COVID-19, types of isolation, use and disposal of PPE, and hand hygiene. SRNA #12 stated contaminated PPE was disposed of in trash receptacles in side isolation rooms. Further interview revealed red biohazard bags should be used in all isolation rooms to decrease the potential for exposure and spread of infection. Interview with Licensed Practical Nurse (LPN) #10, on 02/25/2021 at 8:45 AM, revealed she worked on the Maple Unit. Per interview, she had received IC training which included signs and symptoms of COVID-19, types of isolation, use and disposal of PPE, and hand hygiene. Per interview, red biohazard bags were not used for residents in isolation. However, red bags should be used to decrease exposure of contacting infectious diseases. Additional interview revealed an ample supply of red biohazard bags was available, and while they should use them, they just don't. Further, it was important to use red biohazard bags to ensure staff separate soiled infectious linen and trash from non-infections linen and trash. 4. Observation, on 02/23/2021 at 11:35 AM, of the [NAME] Unit (Short Term Care/Quarantine) revealed all rooms with PPE carts had regular trash receptacles with clear bags in them inside the doorway of the room. Further observation revealed no red biohazard bags in use. Interview with LPN #2, on 02/23/2021 at 11:40 AM, on the [NAME] Unit, revealed that all residents had potential exposure to COVID-19. Additionally, dedicated PPE should be worn at all times. Further, PPE should be worn appropriately per facility policy and training. LPN #2 further stated there was a trash receptacle lined with a red biohazard bag located in the hallway outside of room [ROOM NUMBER], but all other rooms had a clear trash receptacle liner. LPN #2 stated it was important to use red biohazard bags to ensure staff separated soiled infectious trash to prevent the spread of infection. 5. Observation, on 02/23/2021 at 11:45 AM, of the [NAME] Unit (Short Term Care/Quarantine) revealed State Registered Nurses Aide (SRNA) #10, with her surgical mask below her nose. The SRNA was standing by the food service line during lunch meal service. Interview with SRNA #10, on 02/23/2021 at 11:45 AM, revealed she has worked at facility on and off for one (1) year as an Agency SRNA. SRNA #10 further stated she had received IC training from the facility during orientation, which included how to wear PPE appropriately. SRNA #10 stated, My mask is too big and slips off my nose. SRNA #10 stated wearing PPE appropriately was important to prevent the spread of infection. Interview with LPN #2, on 02/23/2021 at 11:40 AM, on the [NAME] Unit, revealed that all residents had potential exposure to COVID-19. Additionally, dedicated PPE should be worn at all times. Further, PPE should be worn appropriately, per facility policy and training. 6. Observation on 02/23/2021, at 12:10 PM, on the Magnolia Unit, revealed Dietary Aide (DA) #3, plated a bowl of dessert for a resident without first washing his hands, or donning gloves. Further observation revealed DA #3 did not wash his hands prior to donning gloves to plate another dish. Interview with DA #3, on 02/23/2021 at 12:13 PM, revealed he has worked at the facility in the past, but has been back at the current position as a DA for two (2) months. DA #3 stated he received Infection Control training upon hire. Further interview with DA #3 revealed he served food on all units in the facility. DA #3 stated that he has been trained to wash his hands and wear gloves when plating trays and serving food. The DA stated, I normally wear gloves, but forgot to do it just then. DA #3 further stated that wearing PPE and following proper hand hygiene was important to prevent the spread of infection. Interview with Laundry Aides (LA) #1, and #2, on 02/25/2021 at 9:20 AM, revealed laundry staff picked up linens from the soiled utility rooms on all units. Per interview, red biohazard bags used to dispose of contaminated disposable equipment, had not been seen for a week or two (2). However, they had been trained that residents in isolation would have red biohazard bags in trash receptacles to alert staff that the resident had an infectious illness. Per interview, however, recently all the bags were clear, tied at the top, were placed in linen carts in the soiled utility room located on each unit. Interview with Director of Nursing (DON), on 02/25/2021 at 9:15 AM, revealed she expected biohazard bags to be used for all residents in isolation for contaminated disposable items. Per interview, the DON stated the facility had had no issues with procuring red biohazard bags; they were available for use on all the units. Additionally, she stated biohazard bags were used to dispose of contaminated items, to alert staff to handle the contaminated disposable items properly, and to dispose of red biohazard bags accordingly; in the biohazard bin in the soiled utility room. Interview with the Director of Nursing (DON), on 02/24/2021 at 3:10 PM, revealed she expected staff to wear all appropriate PPE properly, per CDC guidelines and facility policy, to prevent the spread of infectious disease such as COVID-19. Further interview with the Director of Nursing (DON), revealed that she expected staff to use proper hand hygiene techniques routinely, before and after each resident care; before and after each medication pass; at meal service, and when visible soiled. Interview with the Administrator, on 02/24/2021 at 12:20 PM, revealed he expected Infection Control guidelines to be maintained at all times in the facility, to decrease to potential spread of infection.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to provide care in accordance with each resident's individualized care plan related to Mood and Behaviors for one (1) of eight (8) sampled residents (Resident #1). The facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. According to the Comprehensive Care Plans (CCP) dated [DATE], [DATE], and [DATE], Resident #1 was to be provided one to one (1:1) care as needed or directed by the supervisor or management to decrease the potential for the resident to harm self or others. Interviews revealed, on [DATE] from 2:00 PM to 4:00 PM, Resident #1 was exhibiting yelling out behaviors which progressed to behaviors including sliding down in his/her chair and bumping his/her wheelchair into other residents. Further interview revealed staff did not implement the facility's assessed care plan interventions to address the resident's displayed behaviors. Interviews revealed after two (2) hours of Resident #1's acting out behaviors, around 4:00 PM, staff moved the resident from the common area to his/her room and left the resident alone. At 5:00 PM, State Registered Nurse Aide (SRNA) #9 found Resident #1 seated on the floor in front of the wheelchair. His/her shirt was caught on the wheelchair arm and was pulled tight around the resident's neck. The resident was non-responsive with no visible signs of life. The facility's failure to implement Resident #1's assessed care plan interventions related to Mood and Behavior caused or is likely to cause serious injury, harm, impairment, or death to the resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable credible Allegation of Compliance (AoC) was received on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Care Plan, dated [DATE], revealed the Comprehensive Care Plan (CCP) was a resident specific plan of care based on information gathered through the Resident Assessment Instrument (RAI) process as well as ancillary assessments and evaluations. Additionally, the CCP was prepared by an interdisciplinary team of health care professionals and would be developed to identify which discipline(s) would be responsible to carry out the approaches and interventions. Per policy, the CCP was designed to maintain the resident's current status or assist the resident to attain his/her highest potential while respecting the resident's rights and choices. Further, personnel on all shifts had access to the CCP via the Electronic Medical Record (EMR), and it was their responsibility to report changes in the resident's status that could affect the accuracy of the CCP. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the CCP must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written CCP. Continued review revealed the CCP was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a CCP based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. Further review revealed, a well developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized CCP as appropriate and necessary. Review of Resident #1's medical record revealed the facility admitted the resident, on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's CCP, revised [DATE], revealed the resident was developmentally challenged and childlike as evidence by temper tantrums, crying, hitting/kicking staff and residents, wrapping the call light around his/her neck, sliding out of the chair, yelling/screaming, throwing self on the floor, abusive language, and threatening staff. The goal stated there would be no exacerbation of symptoms, and the resident would not harm self or others. The interventions included (one to one) 1:1 supervision as needed; assess and address factors that may be contributing to agitation; offer pleasant diversions, structured activities, food, conversation, and television; give boxes to pull apart when agitated; give Lego blocks; give stuffed animals and blankets; reassurance and praise; take to room when throwing things; modify environment (adjust air, temperature, noise level, dim lights); notify nurse and physician immediately of harmful behaviors; and re-approach later when agitated. Additional review of Resident #1's CCP, revised [DATE], revealed Resident #1 had potential to have poor impulse control and physical behaviors directed towards others. Specifically, he/she would hit other residents, hit staff, and kick. The goal stated the resident would have no physical behaviors. The interventions included, assess and address needs; provide one-to-one (1:1) care as needed or directed by the charge nurse to decrease the potential for the resident to harm self or others; modify the environment (comfortable temperature, quiet surroundings, dim light) to help deescalate behaviors; give positive feedback; analyze triggers surrounding behaviors, and document findings. Further review of Resident #1's CCP, revised on [DATE], revealed Psychoactive/[MEDICAL CONDITION] Drug Use related to [DIAGNOSES REDACTED]. The goal stated the resident would remain free from any adverse drug reaction from use of these medications, improve mood stability and decrease hostility to others, and decrease throwing things. The interventions included, ensure safety when he/she wished to throw self on floor; provide boxes to break down; provide Lego blocks, stuffed animals, and blanket; provide one-to-one care (1:1) as directed by supervisor/management for behaviors; and give medications as directed. Further review of Resident #1's medical record revealed there was no documented evidence, on [DATE], that Resident #1 was provided CCP interventions to decrease the potential for the resident to harm himself/herself or others, including one-to-one (1:1) care. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 as rarely/never making himself/herself understood or understanding others. Additional review revealed the resident had severely impaired cognitive skills for daily decision making. Further review revealed the facility assessed the resident as having behavioral symptoms that were verbally directed towards others and other behaviors not directed towards others four (4) to six (6) days per week, but less than daily. Review of the Progress Notes, dated [DATE] at 4:30 PM, completed by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was yelling in the dining room and bumping into other residents with his/her wheelchair. Additionally, the action taken was the resident was taken to his/her room. Further, the resident's response was he/she was not able to be redirected. Additional review of Progress Notes, dated [DATE] at 5:00 PM, completed by LPN #4, revealed Resident #1 was found to be non-responsive with no audible or visible signs of life. Continued review revealed staff was unable to obtain his/her blood pressure, auscultate an apical pulse, or palpate any peripheral pulses. Per review, respirations were nonexistent, pupils were non-reactive to light, and pupils were fixed and dilated. Further review of Progress Notes, dated [DATE] at 5:14 PM, completed by LPN #4, revealed the on-call doctor was notified of the above findings. Pronouncement of death was made via telephone with an order received to release the resident's remains to the funeral home of choice. Review of the Medication Administration Record [REDACTED]. Further review of the MAR, revealed no documented evidence the resident received his/her as needed (PRN) [MEDICATION NAME] one (1) mg, on [DATE]. Interview with LPN #1, on [DATE] at 1:10 PM, revealed, on [DATE] at approximately 2:00 PM, Resident #1 began to have a behavioral outburst and was yelling while in the common area. She stated she moved the resident around in the common area while she provided care to other residents. Per LPN #1, at approximately 4:00 PM, the resident remained in the common area and was now bumping his/her wheelchair into another resident. Additional interview revealed she moved the resident away from the other resident and repositioned Resident #1 in his/her wheelchair because he/she was sliding down. LPN #1 stated she also assisted the resident in moving his/her legs off the wheelchair foot pedals so he/she could rest his/her feet on the floor. However, she stated she did not identify the need to implement a care-planned intervention to decrease the potential for the resident to harm himself/herself, including one-to-one (1:1) care. Continued interview with LPN #1 revealed she left the unit after assisting Resident #1, for fifteen (15) minutes, leaving SRNA #8 and SRNA #9 on the hallway without a licensed nurse. She stated when she returned to the unit at approximately 4:15 PM, she asked agency SRNA # 8 and SRNA #9 why Resident #1 was in his/her room, and both responded that the resident had continued to yell. LPN #1 stated she saw the resident sitting in his/her wheelchair in the room with the door open and the resident continued to yell. The LPN stated, at that time, she did not identify the need to implement a care planned intervention to decrease the potential for the resident to harm himself/herself, including one-to-one (1:1) care. Continued interview with LPN #1 revealed, on [DATE] at approximately 4:30 PM, SRNA #9 left the unit to go on break. At that time, she and agency SRNA #8 entered into another resident's room and closed the door to provide care. LPN #1 stated it was common practice to have one (1) SRNA and one (1) nurse on the unit during breaks to provide care and supervision to all residents. Continued interview revealed LPN #1 and SRNA #8 provided care to the other residents for twenty (20) minutes, and during that time, there was no other staff on the unit providing supervision to residents. LPN #1 stated when she came out of the other resident's room, where she had been providing care with SRNA #8, she no longer heard Resident #1 yelling. Per interview, LPN #1 immediately responded and went to Resident #1's room where the resident was found seated on the floor in front of his/her wheelchair with the neck of the shirt pulled tight around the resident's neck. Resident #1 was not breathing or responsive. LPN #1 stated she panicked and cut the shirt off Resident #1, laid him/her flat on the floor, and began chest compressions. Continued interview with LPN #1, revealed nursing staff used the CCP as a guide to know how to provide adequate care to each resident based upon specific care needs; however, she did not identify the necessity to provide one-to-one (1:1) care to Resident #1, on [DATE]. Per interview, LPN #1 stated, Resident #1 was having baseline behaviors and was with the nursing staff unless they were providing care to another resident, which was adequate supervision. Further, she stated it was important to provide adequate supervision per the care plan to ensure necessary care to residents and to ensure their safety. Telephone interview with Agency SRNA #8, on [DATE] at 3:10 PM, revealed she used the CCP to know how to provide care for residents with behaviors and relied on regular facility staff to direct her as necessary on how to provide care for residents with behaviors. Per interview, SRNA #8 revealed it was important to follow the care plan to ensure residents' needs were met, and they were supervised and safe. Continued interview with Agency SRNA #8, revealed, on [DATE] at 4:00 PM, she asked SRNA #9 to identify an intervention for Resident #1, since he/she had been yelling since 2:00 PM and LPN #1 was not on the unit. Per interview, SRNA #9 agreed assisting Resident #1 to his/her room to watch cartoons as an appropriate intervention. SRNA #8 stated she assisted the resident to his/her room, left Resident #1 in front of the television, and pulled the door together. SRNA #8 stated she continued to hear Resident #1 yell and scream from his/her room until she left the unit for break, at approximately 4:05 PM. Continued interview with Agency SRNA #8, revealed, on [DATE] at approximately 4:35 PM, she returned to the unit, and Resident #1 was still in his/her room and was heard yelling and screaming. However, SRNA #8 and LPN #1 entered another resident's room at approximately 4:40 PM, and closed the door to provide care. Per interview, SRNA #8 did not discuss Resident #1's continued yelling out behaviors with LPN #1 or attempt to implement an additional intervention, even though the resident continued to yell and scream in his/her room. Continued interview with Agency SRNA #8, revealed, on [DATE] at approximately 5:00 PM, SRNA #9 reported to LPN #1 there was an emergency with Resident #1. Per interview, when she entered Resident #1's room, it appeared the resident had slid down out of the chair into the floor, but his/her shirt was caught on the wheelchair arm and was wrapped tightly around his/her neck. She stated the resident was obviously dead. Telephone interview with LPN #4, on [DATE] at 3:00 PM, revealed she was the Supervisor Nurse, on [DATE] for the 2:00 PM to 10:00 PM shift, and was not aware of Resident #1's behaviors until after 5:00 PM. Per interview, LPN #4 stated it was important for residents to receive adequate supervision, to meet their specific needs as outlined in the CCP, to ensure their safety. Interview with SRNA #9, on [DATE] at 4:40 PM, revealed she used the CCP to know how to provide care for residents with behaviors, and it was important to frequently check on residents with behaviors to meet their needs and ensure their safety. She stated it was normal for Resident #1 to stay in the common areas of the unit because staff frequently interacted with him/her because of the resident's behaviors. Per interview, Resident #1 was yelling and bumping into other residents with the wheelchair, in the common area, on [DATE] between 2:00 PM and 4:30 PM. Continued interview with SRNA #9, revealed, on [DATE] at approximately 5:00 PM, when she returned to the unit after a thirty (30) minute break, Resident #1 was no longer in the common area of the unit, and she did not hear the resident yelling. Per interview, she immediately went to Resident #1's room to check on him/her, and she saw the resident sitting on the floor in front of the wheelchair, the resident's shirt was caught on the back of the wheelchair arm and the neck of the shirt was tight around the resident's neck, the resident was non-responsive. Further SRNA #9 stated she immediately went to LPN #1 and informed her of the emergency with Resident #1. SRNA #9 stated SRNA #8 never asked her if it was an appropriate intervention to place the resident in his/her room because he/she was yelling in the common area. Interview with the Director of Nursing (DON), on [DATE] at 1:33 PM, revealed nursing staff were instructed during orientation and throughout the year on how to provide supervision and safe care per the CCP. Per interview, on [DATE], she was informed staff did not visualize Resident #1 for thirty (30) minutes, while providing care to another resident, and then the resident was found unresponsive in his/her room. Continued interview revealed she was not informed of Resident #1's behaviors or attempted interventions until after the resident's death. Further, she stated she expected residents to be provided adequate supervision at all times and nursing staff were to implement behavior interventions per the CCP to ensure quality care and safe care for all residents. Interview with the Administrator, on [DATE] at 2:45 PM, revealed staff should always be available to meet resident needs, and residents should be provided care per their CCP. Continued interview revealed this was important to ensure residents achieved the best possible outcomes. Additionally, he stated all residents should be provided adequate supervision and a safe environment. Further, he stated nursing staff were expected to be knowledgeable about the care of residents, including their behavioral health status and where to reference, if they required information regarding the care of a resident (care plan). However, he continued, Resident #1 should not have been provided one-to-one (1:1) care per the CCP, on [DATE], because moving the resident to his/her room alone, when having behaviors, was appropriate and had been effective in the past. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. Review of the AoC revealed the facility implemented the following: 1. The Administrator conducted a review/update of all facility policies and procedures between [DATE] and [DATE]. All updates were documented on a log for review at the ad hoc QAPI meeting on [DATE]. 2. The Administrator and DON developed and executed new facility operational guidelines including: Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response on [DATE]-[DATE]. 3. The Administrator and DON updated the facility's Emergency Code Announcement in the Disaster Preparedness Manual from the announcement of code blue to the announcement of Nurse Stat on [DATE]. Nurse Stat announcement is now the facility's universal nurse emergency announcement including but not limited to cardiopulmonary events requiring appropriate nursing staff response with the emergency code book and crash carts for all facility emergencies. 4. On [DATE] the Administrator educated the leadership team. Those included were the DON, Clinical Coordinators, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator on Walking Shift Report and Room Rounds. 5. The Admissions Director, both Social Services Managers, DON, Clinical Coordinator, and MDS Coordinator were educated in Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat announcement on [DATE] by the Administrator. 6. An Emergency Code Binder was created on [DATE] as the primary source for obtaining resident code status in the event it was needed. Policies including Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response have all been updated to include responsibilities associated with updating and maintaining the Emergency Code Binders on each neighborhood. The binders are stored at each neighborhood nursing station with the code status of each resident residing on that neighborhood. Mock emergency response drills to be conducted two (2) times per day to ensure compliance with the facility's new process. Each binder is brought to every emergency announcement of Nurse Stat. 7. On [DATE], the Facility's Clinical Coordinator developed a care plan focus category titled Advance Directives for utilization in the point click care resident electronic medical record. The Advanced Directives Care Plan will be utilized in all resident comprehensive care plans and SRNA care plans. 8. On [DATE] and [DATE], the MDS Coordinator and Clinical Coordinators reviewed and updated all residents' care plans. The finding of the care plan audit was documented on an audit log noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Charge Nurse, Clinical Coordinators and Social Services Managers are responsible for on-going resident care plan updates. 9. The Admissions Director and Social Service Managers provided in-service education to nursing staff on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat code announcement with post test given between [DATE] through [DATE] with eighty-three (83) out of one-hundred three (103) nursing staff which included licensed nurses, State Registered Nurse Aides (SRNA) and KMA that were educated. No nursing staff member was permitted to work beyond [DATE] without first receiving in-service education covering Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat code announcement with posttest given. 10. The DON, Clinical Coordinators and MDS Coordinators will perform a mock code Nurse Stat daily starting [DATE] on first and second shifts (facility deploys 12 hour nurse rotations) until substantial compliance is achieved. Once substantial compliance is achieved, daily mock code Nurse Stat per shift will continue for one month and then weekly thereafter on a continual basis or until advised by the QAPI committee. The Mock Code Evaluation Checklist will be used as a quality assurance instrument with all areas of improvement noted and corrected immediately on the spot and reported at the following QAPI committee meeting. 11. The Clinical Coordinator conducted a new Facility Assessment in abaQIS (the facility's Electronic Record System) on [DATE]. Results of the facility's assessment will be presented during the ad hoc QAPI meeting on [DATE]. Recommendations made by the QAPI committee will be implemented immediately. 12. The Human Resources Manager audited all nursing personnel files between [DATE] and [DATE] to include: verification of credentials and evidence of verification prior to hire for CPR certification (as appropriate), licensure, TB ([MEDICAL CONDITION]) testing and background checks. 13. In-Service Education was conducted on [DATE] by the DON, Clinical Coordinators, and MDS Coordinators provided to twenty-nine (29) of thirty-four (34) licensed nursing staff with no staff member permitted to work without first receiving education. The education was on Baseline Care Plans, Care Plan Policy and Behavior Documentation with emphasis training for the Charge Nurses related to implementing care plan interventions and discretion to implement one on one care as needed and per the physician's orders [REDACTED].>14. In-Service Education was provided on [DATE] through [DATE] by the DON and Clinical Coordinators to sixty-five (65) of one-hundred three (103) nursing staff, with no staff member permitted to work without first receiving education including licensed and certified staff on Accidents and Supervision per the Care Plan. 15. All education will be added to orientation for new hires and distributed to contract staffing organizations for agency staffing to be educated prior to working at the facility. The facility Scheduler will track and monitor for any staff member who has not received all appropriate training. The facility Scheduler will notify the DON and/or Clinical Coordinators, who will be responsible for ensuring that training is provided to all appropriate staff members prior to working their next regularly scheduled shift. 16. On [DATE], the daily Walking Shift Report was assigned to the facility's ancillary department managers who are certified or license including MDS Coordinators, Activities Director, Scheduler, Central Supply Manager, Medical Records, and Environmental Services Manager providing managerial supervision for all seven (7) neighborhoods. The reports document room number, resident name, meal percentage, bath/shower, perineal-care needs, if the resident is in or out of bed at shift change, if the resident was turned every two (2) hours, vital signs, oral care, behaviors and any other comments as needed. The Walking Shift Report is signed by the neighborhood Charge Nurse prior to the SRNA's completing shift change and placed in the Manager's bin on each neighborhood for collection and review the following morning during clinical meeting as a quality assurance system with all areas for improvement noted on the daily follow up sheets and distributed back out to each neighborhood Charge Nurse. The weekend Nursing Clinical Coordinator will ensure that all Walking Shift Reports are monitored over the weekend. The DON, Clinical Coordinators and MDS Coordinators will utilize this system as a monitoring instrument for assuring care plans are updated and interventions are being implemented appropriately. 17. The Corporate Compliance Officer/Human Resources Director provided education on [DATE] covering the below topics with the Administrator and DON. A) Job Descriptions: which identify management as having responsibility to ensure overall safety within the facility. B) Policies and Procedures: for mitigating risk of accidents/incidents and follow-up should one occur. C) Forms: for the purpose of detailing necessary steps and provide overall documentation of actions taken following an accident/incident. 18. On [DATE], an Ad Hoc QAPI meeting was held with an additional meeting held on [DATE] and the next meeting scheduled for [DATE], then weekly on Thursday, and continued monitoring until recommendation for alternate meeting schedule will be determined. 19. On [DATE], the Interdisciplinary Team (IDT) reviewed the past 90 days Risk Management events ensuring a root-cause analysis was performed and proper supervision was provided at the time based on the resident's care plan with no adverse outcomes due to supervision. Risk Management events included falls, bruising, skin tear, resident to resident events, elopement and other traumatic injury. The IDT team consists of the DON, Clinical Coordinators, MDS Coordinators and Social Service. 20. On [DATE], the DON provided one-on-one education to all staff that cared for Resident #1 on [DATE] between 2:00 PM to 5:00 PM covering Code Status, Emergency Response, Care Plan and Supervision. 21. Social Services will audit all Emergency Binders weekly starting [DATE], ensuring resident code status is accurate and available on each neighborhood. Results of the audits will be documented on a log presented at the next QAPI committee meeting. The Admissions Director and Social Services Directors completed chart audits on every resident comparing the Advance Directives to the physician's orders [REDACTED]. 22. A Quality Assurance Performance Improvement Project was implemented. The DON was monitoring for code status compliance by interviewing staff about the facility's CPR policy and procedure, as well as requesting return demonstration of the CPR process. Compliance checks will be conducted two (2) times weekly for three (3) months. The findings will be reported at monthly QAPI Committee meeting. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the Facility's Policies Log Sheets revealed the Administrator reviewed and updated facility policies and procedures between [DATE] and [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he conducted a review/update of all of the facility's policy and procedures between [DATE] and [DATE]. He further stated the updates were documented on a log for review at the ad hoc QAPI meeting held on [DATE]. 2. Review of the new facility's operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response revealed they were reviewed and revised on [DATE] through [DATE]. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed they developed and executed the following operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response on [DATE] through [DATE]. 3. Review of the Disaster Preparedness Manual revealed the announcement of code blue to Nurse Stat on [DATE] by the Administrator and DON. Nurse Stat is now the facility's universal nurse emergency announcement including but not limited cardiopulmonary events requiring appropriate nursing staff to respond to the emergency with the code book and crash carts for all facility emergencies. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, and SRNA #17 on [DATE] at 11:53 AM, revealed, Nurse Stat is now what is announced overhead. Further interview revealed it replaced Code Blue. Per interview appropriate nursing staff would respond and they were to get the binder from the nurse's station each time it was announced, along with the crash carts. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed Nurse Stat was now the universal nurse emergency response announcement. 4. Review of In-Service Sheets dated [DATE], revealed the DON, Clinical Coordinator, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator were educated on Walking Shift Report and Room Rounds by the Administrator. Interview with DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, MDS Coordinator on [DATE] at 12:53 PM, Activities Director on [DATE] at 12:44 PM, revealed they were educated on Walking Shift Report and Room Rounds by the Administrator on [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he educated all of the Leadership Team on Walking Shift Report and Room Rounds. Per interview they have been implemented and the forms were discussed in QAPI. 5. Review of In-Service Sign in Sheets dated [DATE], revealed the Admiss (TRUNCATED)

Based on interview, record review, review of facility's policies, and review of the Kentucky Board of Nursing's (KBN), Advisory Opinion Statements (AOS), review of the American Nurse's Association, Nursing Scope and Standards of Practice 3rd Edition, and review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding Cardiopulmonary Resuscitation (CPR) at the Start versus Withdrawing CPR at the End, it was determined the facility failed to have an effective system to ensure services provided met professional standards of quality for one (1) of eight (8) sampled residents (Resident #1). The facility failed to ensure nursing staff honored the resident's Advanced Directives; and, failed to ensure a resident's code status before initiating cardiopulmonary resuscitation (CPR). On [DATE], Resident #1's designated Guardian signed the Baptist Convalescent Center Resuscitation Status form, stating resuscitation will not be attempted and a Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order Form. The facility also obtained a physician's orders [REDACTED]. On [DATE], per staff interviews and record review, at approximately 5:00 PM, staff observed Resident #1 to be non-responsive, with no visible signs of life; and, staff failed to honor Resident #1's Advance Directives as Cardiopulmonary Resuscitation (CPR) was initiated immediately. Licensed Practical Nurse (LPN) #1 did not attempt to determine the resident's code status and staff began CPR at approximately 5:00 PM. After approximately five (5) minutes, staff stopped CPR when Licensed Practical Nurse (LPN) #4 verified Resident #1's code status to be a DNR, on the Electronic Medical Record (EMR). Resident #1's pronouncement of death was on [DATE] at 5:10 PM. The facility's failure to ensure services provided met professional standards of quality related to Advance Directives regarding residents' requested code status; related to verifying a resident's code status before initiating cardiopulmonary resuscitation (CPR); and ensuring CPR was not initiated, if there was a physician's orders [REDACTED]. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable credible Allegation of Compliance (AOC) was received on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Resuscitation Decision Documentation Policy, dated [DATE], revealed every resident or their legal representative had the right to make their own healthcare decisions including the initiation or withholding of CPR in the event of cardiac or respiratory arrest. Additionally a Resuscitation Form, a physician's orders [REDACTED]. Further, a green dot will be placed on the resident's identification band to reflect a DNR status and the resident's DNR status will be included on his/her care plan. Review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding CPR at the Start versus Withdrawing CPR at the End, dated [DATE], revealed Basic Life Support (BLS) Training urges the average citizen responding first to a [MEDICAL CONDITION] to perform CPR. Continued review revealed healthcare professionals are expected to provide BLS and Advanced Cardiac Life Support (ACLS) as part of their professional duty to respond. The exceptions included: when a person lies dead, with no obvious clinical signs of irreversible death; when attempts to perform CPR would place the rescuer at risk of physical injury; and when the patient or surrogate has indicated that resuscitation is not desired. Review of the American Nurse's Association, Nursing Scope and Standards of Practice 3rd Edition, revealed the Registered Nurse develops a plan that prescribes strategies to attain expected, measurable outcomes; develops an individualized evidenced based plan in partnership with the healthcare consumer and inter-professional team; and advocates for responsible and appropriate use of interventions to minimize unwanted or unwarranted treatment and/or healthcare consumer suffering. Review of the KBN's Advisory Opinion Statement (AOS) #36, Resuscitation, approved February 2008, revealed nurses were required to honor the Advanced Directives of patients who had the Advanced Directive documented in the medical record, unless a Physician or healthcare facility refused to comply and the patient and surrogate were informed of the refusal. Review of Resident #1's clinical record revealed the facility admitted the resident on [DATE]. Review of Resident #1's Order of Appointment of Guardianship, dated [DATE], revealed the resident was wholly disabled in managing his/her decisions and had a Legal Guardian. Review of the facility's Baptist Convalescent Center Resuscitation Status form, dated [DATE] for Resident #1, revealed the Form was checked resuscitation will not be attempted. Further review revealed the resident's Legal Guardian signed the form. Review of the Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order Form, revealed the undersigned person or surrogate who has been designated to make health care decisions in accordance with Kentucky Revised Statutes, hereby direct that in the event of cardiac or respiratory arrest that this Do Not Resuscitate (DNR) Order be honored. The form was dated [DATE], had been signed by Resident #1's Legal Guardian. Review of Resident #1's physician's orders [REDACTED]. Continued review revealed an order for [REDACTED]. Review of Resident #1's Comprehensive Care Plan, revealed no documented evidence of the resident's DNR status. Review of Progress Notes, dated [DATE] at 5:00 PM, completed by LPN #4, revealed Resident #1 was found to be non-responsive with no audile or visible signs of life, unable to obtain blood pressure; unable to auscultate an apical pulse or palpate any peripheral pulses; respirations were nonexistent; pupils non-reactive to light and were fixed and dilated. Further review of Progress Notes, dated [DATE] at 5:14 PM, revealed the on call doctor was notified of the above findings. Pronouncement of death was made via telephone with an order received to release the remains to the funeral home of choice. Interview with LPN #1, on [DATE] at 1:10 PM, revealed upon entering the resident's room, Resident #1 was seated on the floor in front of his/her wheelchair, his/her left arm was out of the sleeve of the t-shirt and the right arm was in the sleeve; however, the right sleeve of the shirt was caught on the back of the right arm rest of the wheelchair. The neck of the shirt was pulled tight around Resident #1's neck and the resident was not breathing or responsive. LPN #1 stated she panicked and cut the shirt off the resident, laid him/her flat on the floor and began chest compressions without verifying the resident's code status. Further, LPN #1 stated it was facility practice to not initiate CPR until verifying a resident's code status on the Electronic Medical Record (EMR); however, she did not want to leave the room to log into a computer to verify the code status and delay life saving measures. Continued interview with LPN #1 revealed she directed a State Registered Nursing Assistant (SRNA) to make an overhead announcement for Stat Nurse while she performed CPR on the resident. Per interview, LPN #4 responded to the Stat Nurse announcement and when she entered Resident #1's room, LPN #1 asked her to verify the resident's code status. She further stated she was not familiar with a green dot on an identification bracelet to indicate if a resident's code status was DNR, per the facility policy. Further interview with LPN #1, revealed after approximately five (5) minutes of CPR, LPN #4 came to the room and told her to stop CPR, because the resident had a DNR code status and CPR was stopped, at approximately 5:05 PM. Telephone interview with LPN #4, on [DATE] at 3:00 PM, revealed she arrived to assist with Resident #1 at approximately 5:00 PM and LPN #1 was performing chest compressions. Per interview, she checked for vital signs and the resident had no pulse or respirations. Continued interview revealed LPN #1 asked her to verify the resident's code status. Per interview, she left the resident's room and went to the nurse's desk; directed another nurse to get the crash cart; she then logged into the EMR, searched for Resident #1, and located the code status. Continued interview revealed she returned to the resident's room at approximately 5:05 PM and told LPN #1 to stop CPR, because the resident was a DNR code status. Further interview revealed she called the Director of Nursing (DON), reported the above, and was directed to follow the facility's death protocol; LPN #4 notified the physician and pronouncement of death was made via telephone. Interview with the DON, on [DATE] at 1:33 PM, revealed the facility's Resuscitation Decision Documentation policy was inaccurate. Per the DON, a green dot indicating the DNR status on the identification bracelets was not the current practice for identifying code status in an emergency. Additionally, it was not the facility's current practice for a Care Plan to be developed to identify a resident's code status. She stated the Advance Directives including the Code Status documents were scanned into the EMR on admission and/or with any changes as necessary. Continued interview revealed a physician's orders [REDACTED]. Further interview revealed the DON expected nurses to verify a resident's code status in the EMR based on the resident's Advance Directives, and the resident's physician's orders [REDACTED]. Interview with the Administrator, on [DATE] at 2:45 PM, revealed Resident #1's Advance Directive was not honored by the facility. Additionally he revealed the LPN should have verified the resident's code status in the EMR before initiating CPR during the emergency when Resident #1 was found unresponsive with no visible signs of life. Further, he stated it was his expectation that staff verify a resident's code status in the EMR before initiating CPR. He stated, he expected a resident's code status be honored and accurate care be provided. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. Review of the AoC revealed the facility implemented the following: 1. The Administrator conducted a review/update of all facility policies and procedures between [DATE] and [DATE]. All updates were documented on a log for review at the ad hoc QAPI meeting on [DATE]. 2. The Administrator and DON developed and executed new facility operational guidelines including: Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response on [DATE]-[DATE]. 3. The Administrator and DON updated the facility Emergency Code Announcement in the Disaster Preparedness Manual from the announcement of code blue to the announcement of Nurse Stat on [DATE]. Nurse Stat announcement is now the facility's universal nurse emergency announcement including but not limited to cardiopulmonary events requiring appropriate nursing staff response with emergency code book and crash carts for all facility emergencies. 4. On [DATE] the Administrator educated the leadership team those included were the DON, Clinical Coordinators, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator on Walking Shift Report and Room Rounds. 5. The Admissions Director, both Social Services Managers, DON, Clinical Coordinator, and MDS Coordinator were educated in Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat announcement on [DATE] by the Administrator. 6. An Emergency Code Binder was created on [DATE] as the primary source for obtaining resident code status in the event of need. Policies including Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response have all been updated to include responsibilities associated with updating and maintaining the Emergency Code Binders on each neighborhood. The binders are stored at each neighborhood nursing station with the code status of each resident residing on that neighborhood. Mock emergency response drills are being conducted two (2) times per day to ensure compliance with the facilities new process. Each binder is brought to every emergency announcement of Nurse Stat. 7. On [DATE] the Facility Clinical Coordinator developed a care plan focus category titled Advance Directives for utilization in the point click care resident electronic medical record. The Advanced Directives Care Plan will be utilized in all resident comprehensive care plans and SRNA care plans. 8. On [DATE] and [DATE] the MDS Coordinator and Clinical Coordinators reviewed and updated all residents' care plans. The finding of the care plan audit was documented on an audit log noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Charge Nurse, Clinical Coordinators and Social Services Managers are responsible for on-going resident care plan updates. 9. The Admissions Director and Social Service Managers provided in-service education to nursing staff on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat code announcement with posttest given between [DATE] through [DATE] with eighty-three (83) out of one-hundred three (103) nursing staff including licensed, State Registered Nurse Aides (SRNA) and KMA educated. No nursing staff member was permitted to work beyond [DATE] without first receiving in-service education covering Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat code announcement with posttest given. 10. The DON, Clinical Coordinators and MDS Coordinators will perform a mock code Nurse Stat daily starting [DATE] on first and second shifts (facility deploys 12 hour nurse rotations) until substantial compliance is achieved. Once substantial compliance is achieved, daily mock code Nurse Stat per shift will continue for one month and then weekly thereafter on a continual basis or until advised by the QAPI committee. The Mock Code Evaluation Checklist will be used as a quality assurance instrument with all areas of improvement noted and corrected immediately on the spot and reported at the following QAPI committee meeting. 11. The Clinical Coordinator conducted a new Facility Assessment in abaQIS (the facility's Electronic Record System) on [DATE]. Results of facility assessment will be presented during ad hoc QAPI meeting on [DATE]. Recommendations made by QAPI committee will be implemented immediately. 12. The Human Resources Manager audited all nursing personnel files between [DATE] and [DATE] to include: verification of credentials and evidence of verification prior to hire for CPR certification (as appropriate), licensure, TB testing and background checks. 13. In-Service Education was conducted on [DATE] by the DON, Clinical Coordinators, and MDS Coordinators provided to twenty-nine (29) of thirty-four (34) licensed nursing staff with no staff member permitted to work without first receiving education. The education was on Baseline Care Plans, Care Plan Policy and Behavior Documentation with emphasis training for the Charge Nurses related to implementing care plan interventions and discretion to implement one on one care as needed and per the physician's orders [REDACTED].>14. In-Service Education was provided on [DATE] through [DATE] by the DON and Clinical Coordinators to sixty-five (65) of one-hundred three (103) nursing staff, with no staff member permitted to work without first receiving education including licensed and certified staff on Accidents and Supervision per the Care Plan. 15. All education will be added to orientation for new hires and distributed to contract staffing organizations for agency staffing to be educated prior to working at the facility. The facility Scheduler will track and monitor for any staff member who has not received all appropriate training. The facility Scheduler will notify the DON and/or Clinical Coordinators who will be responsible for ensuring that training is provided to all appropriate staff members prior to working their next regularly scheduled shift. 16. On [DATE] the daily Walking Shift Report was assigned to the facilities ancillary department managers who are certified or license including MDS Coordinators, Activities Director, Scheduler, Central Supply Manager, Medical Records, and Environmental Services Manager providing managerial supervision for all seven (7) neighborhoods. The reports document room number, resident name, meal percentage, bath/shower, perineal-care needs, if the resident is in or out of bed at shift change, if the resident was turned every two (2) hours, vital signs, oral care, behaviors and any other comments as needed. The Walking Shift Report is signed by the neighborhood Charge Nurse prior to the SRNA's completing shift change and placed in the Managers bin on each neighborhood for collection and review the following morning during clinical meeting as a quality assurance system with all areas for improvement noted on the daily follow up sheets and distributed back out to each neighborhood Charge Nurse. The weekend nursing Clinical Coordinator will ensure that all Walking Shift Reports are monitored over the weekend. The DON, Clinical Coordinators and MDS Coordinators will utilize this system as a monitoring instrument for assuring care plans are updated and interventions are being implemented appropriately. 17. The Corporate Compliance Officer/Human Resources Director provided education on [DATE] covering the below topics with the Administrator and DON. A) Job Descriptions: which identify management as having responsibility to ensure overall safety within the facility B) Policies and Procedures: for mitigating risk of accidents/incidents and follow-up should one occur. C) Forms: for the purpose of detailing necessary steps and provide overall documentation of actions taken following an accident/incident. 18. On [DATE] an Ad Hoc QAPI meeting was held with an additional meeting held on [DATE] and the next scheduled for [DATE] then weekly on Thursday as continued monitoring until recommendation for alternate meeting schedule will be determined. 19. On [DATE] the Interdisciplinary Team (IDT) reviewed the past 90 days risk management events ensuring a root-cause analysis was performed and proper supervision was provided at the time based on the residents care plan with no adverse outcomes due to supervision. Risk Management events included falls, bruising, skin tear, resident to resident events, elopement and other traumatic injury. The IDT team consists of DON, Clinical Coordinators, MDS Coordinators and Social Service. 20. On [DATE] the DON provided one-on-one education to all staff that cared for Resident #1 on [DATE] between 2:00 PM to 5:00 PM covering Code Status, Emergency Response, Care Plan and Supervision. 21. Social Services will audit all Emergency Binders weekly starting [DATE], ensuring resident code status is accurate and available on each neighborhood. Results of the audits will be documented on a log presented at the next QAPI committee meeting. The Admissions Director and Social Services Directors completed chart audits on every resident comparing the Advance Directives to the physician's orders [REDACTED]. 22. A Quality Assurance Performance Improvement Project was implemented. The DON was monitoring for code status compliance by interviewing staff about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted two (2) times weekly for three (3) months. Findings will be reported at monthly QAPI Committee meeting. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the Facilities Policies Log Sheets revealed the Administrator reviewed and updated facility policies and procedures between [DATE] and [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he conducted a review/update of all facilities policy and procedures between [DATE] and [DATE]. He further stated the updates were documented on a log for review at the ad hoc QAPI meeting held on [DATE]. 2. Review of the new facility operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response revealed they were reviewed and revised on [DATE] through [DATE]. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed they developed and executed the following operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response on [DATE] through [DATE]. 3. Review of the Disaster Preparedness Manual revealed the announcement of code blue to Nurse Stat on [DATE] by the Administrator and DON. Nurse Stat is now the facility's universal nurse emergency announcement including but not limited cardiopulmonary events requiring appropriate nursing staff to respond to emergency code book and crash carts for all facility emergencies. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed, Nurse Stat is now what is announced overhead. Further interview revealed it replaced Code Blue. Per interview appropriate nursing staff respond and they are to get the Binder from the nurse's station each time it's announced along with crash carts. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed Nurse Stat is now the universal nurse emergency response announcement. 4. Review of In-Service Sheets dated [DATE], revealed the DON, Clinical Coordinator, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator were educated on Walking Shift Report and Room Rounds by the Administrator. Interview with DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, MDS Coordinator on [DATE] at 12:53 PM, Activities Director on [DATE] at 12:44 PM, revealed they were educated on Walking Shift Report and Room Rounds by the Administrator on [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he educated all of the Leadership Team on Walking Shift Report and Room Rounds. Per interview they have been implemented and the forms are discussed in QAPI. 5. Review of In-Service Sign in Sheets dated [DATE], revealed the Admissions Director, Social Services Directors, DON, Clinical Coordinator and MDS coordinator were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with DON on [DATE] at 1:34 PM, Social Services Director on [DATE] at 2:34 PM, Clinical Coordinator on [DATE] 1:03 PM and MDS Coordinator on [DATE] at 12:53 PM, revealed they were in-serviced by the administrator on [DATE] on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with the Administrator on [DATE] at 2:00 PM revealed, he in-serviced the Admissions Director, Social Services Directors, DON, Clinical Coordinator and MDS coordinator were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement on [DATE]. 6. Review of Emergency Code Binders on each neighborhood revealed a Face Sheet for each resident to include code status. The binders also included the following policies, Resident Rights, Advance Directives, Communication of Code Status, and Medical Emergency Response. The Binders are stored in the cabinet above the nurse's station and each Binder is brought to each announcement of Nurse Stat. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed the Emergency Response Binders were located on each neighborhood in the cabinet above the nurses station. Further interview revealed the Binders had face sheets of each resident that included code status. Per interviews Mock Emergency Response Drills are being conducted two times per day from the Management Team and each Binder is brought to every announcement of Nurse Stat. 7. Review of care plan focus category titled Advanced Directives was initiated in Point Click Care (PCC) resident electronic medical record. This category was developed on [DATE] by the Facility Clinical Coordinator. Record review of Resident #1, #2, #3, #4, #5, #6, #7 and #8 electronic records revealed this care plan focus category was on each residents' care plan. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, and MDS Coordinator on [DATE] at 12:53 PM, revealed the new care plan focus category was added to PCC for each resident in their medical record. 8. Review of the Care Plan Audit Log dated [DATE] and [DATE] revealed all residents care plans were updated by the MDS and Clinical Coordinators. The audit log consisted of: noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Interview with LPN #10 on [DATE] at 10:49 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, LPN #13 on [DATE] at 11:40 AM, MDS Coordinator on [DATE] at 12:53 PM, Clinical Coordinator on [DATE] at 1:03 PM, Social Services on [DATE] at 1:13 PM and the DON on [DATE] at 1:34 PM, revealed all care plans were reviewed and updated. Further interview revealed the Charge Nurses, Social Services and Clinical Coordinators were responsible for on-going updates to the care plans. 9. Review of In-Service Sign-In Sheets and Posttest dated [DATE] through [DATE] revealed eighty-three (83) out of one-hundred three (103) nursing staff were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed, the Admissions Director and Social Service Managers provided in-service education on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Further interview revealed they had to do a posttest. Interview with Social Services Director on [DATE] at 10:54 AM, revealed she and the Admissions Director provided an in-service to nursing staff on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Further interview revealed they had to do a posttest after the in-service. 10. Review of Mock Code Evaluation Checklist dated [DATE] continuing on two (2) times daily on each neighborhood are being conducted by the DON, Clinical Coordinators and MDS Coordinators. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, and MDS Coordinator on [DATE] at 12:53 PM, revealed Mock Codes are being conducted two (2) times a day on each shift, for each neighborhood. Further interview revealed on the spot education is being provided. 11. Review of the Facility Assessment revealed it was created by the Clinical Coordinator in abaQIS on [DATE]. The assessment was presented to QAPI committee on [DATE]. Review of the Ad-Hoc QAPI Agenda/Meeting Template revealed the facility assessment that was created by the Facility Clinical Coordinator was discussed and reviewed on [DATE]. Interview with the Clinical Coordinator on [DATE] at 1:03 PM, revealed she created the Facility Assessment and presented it to the QAPI meeting held on [DATE]. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed they discussed (TRUNCATED)

Based on interview, record review, review of facility's policies, review of the Kentucky Board of Nursing's (KBN), Advisory Opinion Statements (AOS) and review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding Cardiopulmonary Resuscitation (CPR) at the Start versus Withdrawing CPR at the End, it was determined the facility failed to have an effective system to ensure staff could immediately identify a resident's code status in an emergency (identify if the resident was a Do Not Resuscitate {DNR} or a full code which would require Cardiopulmonary Resuscitation {CPR}); for one (1) of eight (8) residents (Resident #1). The facility failed to ensure nursing staff honored the resident's Advanced Directives; and, failed to ensure a resident's code status before initiating cardiopulmonary resuscitation (CPR). On [DATE], Resident #1's Legal Guardian signed the Baptist Convalescent Center Resuscitation Status form, requesting resuscitation will not be attempted and a Kentucky (KY) Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form. The facility also obtained a physician's orders [REDACTED].#1 to have a DNR code status. On [DATE], per staff interviews and record review, at approximately 5:00 PM, staff observed Resident #1 to be unresponsive with the absence of respirations and heartbeat. Staff failed to honor Resident #1's Advance Directives as Cardiopulmonary Resuscitation (CPR) was initiated immediately. Licensed Practical Nurse (LPN) #1 failed to determine the resident's code status and staff began CPR at approximately 5:00 PM. After approximately five (5) minutes, staff stopped CPR when LPN #4 verified Resident #1's code status was a DNR on the Electronic Medical Record (EMR). Resident #1's pronouncement of death was on [DATE] at 5:10 PM. Due to the facility's failure to have an effective system in place to immediately validate a resident's code status in an emergency, staff failed to honor the resident's Advance Directive for no life prolonging treatment and initiated cardiopulmonary resuscitation (CPR); which caused or is likely to cause serious injury, harm, impairment, or death to the resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined it existed on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable credible Allegation of Compliance (AOC) was received on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was remove as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Resuscitation Decision Documentation Policy, dated [DATE], revealed every resident or their legal representative had the right to make their own healthcare decisions including the initiation or withholding of CPR in the event of cardiac or respiratory arrest. Additionally a Resuscitation Form, a physician's orders [REDACTED]. Further review revealed a green dot will be placed on the resident's identification band to reflect a DNR status and the resident's DNR status will be included on his/her care plan. Review of the Kentucky Board of Nursing's (KBN) Advisory Opinion Statement (AOS) #36, Resuscitation, approved February 2008, revealed nurses were required to honor the Advanced Directives of the patients who had the Advanced Directive documented in the medical record, unless a Physician or healthcare facility refused to comply and the patient and surrogate were informed of the refusal. Review of the American Heart Association Journal, Ethical Issues Around Out of Hospital Resuscitation, Withholding CPR at the Start versus Withdrawing CPR at the End, dated [DATE], revealed healthcare professionals were expected to provide Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) as part of their professional duty to respond. Continued review revealed the exceptions to provide BLS and ACLS included when the patient or surrogate had indicated that resuscitation was not desired. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with diagnoses, which included but was not limited to Moderate Intellectual Disabilities, [MEDICAL CONDITION] Disorder, Major [MEDICAL CONDITION], Mood Disorder, Transient Alteration of Awareness, [MEDICAL CONDITION], Restlessness and Agitation, and Adjustment Disorder with Anxiety. Review of the facility's Baptist Convalescent Center Resuscitation Status form, dated [DATE] for Resident #1, revealed the form was checked resuscitation will not be attempted. Further review revealed Resident #1's Legal Guardian signed the form. Review of the Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form, revealed the undersigned person or surrogate who has been designated to make health care decisions in accordance with Kentucky Revised Statutes, hereby direct that in the event of cardiac or respiratory arrest that this Do Not Resuscitate (DNR) Order be honored. Continued review revealed the form was signed by Resident #1's Legal Guardian and dated [DATE]. Review of Resident #1's physician's orders [REDACTED]. Continued review revealed a physician's orders [REDACTED].#1 to have a DNR code status. Review of a Progress Note, dated [DATE] at 5:00 PM, completed by Licensed Practical Nurse (LPN) #4, revealed Resident #1 was found to be non-responsive with no audible or visible signs of life, unable to obtain blood pressure; unable to auscultate an apical pulse or palpate any peripheral pulses; respirations were nonexistent; pupils were not reactive to light and were fixed and dilated. Further review of the Progress Notes, dated [DATE] at 5:14 PM, revealed the on call doctor was notified of the above findings. Per the note, Resident #1's pronouncement of death was made via telephone with an order received to release the remains to the funeral home of choice. Telephone interview with LPN #4, on [DATE] at 3:00 PM, revealed she arrived to assist with Resident #1 at approximately 5:00 PM and found LPN #1 performing chest compressions. Per interview, she checked Resident #1 for vital signs and the resident had no pulse or respirations. Continued interview revealed LPN #1 asked her to verify the resident's code status. She stated, she left the resident's room and went to the nurse's desk; directed another nurse to get the crash cart; she then logged into the Electronic Medical Record (EMR), searched for Resident #1, located the code status and determined Resident #1 had a DNR status. Continued interview revealed she returned to the resident's room at approximately 5:05 PM and told LPN #1 to stop CPR, because the resident had a DNR code status. Further interview revealed she called the Director of Nursing (DON), reported the above, and was directed to follow the facility's death protocol; LPN #4 notified the physician and pronouncement of death was made via telephone. Interview with LPN #1, on [DATE] at 1:10 PM, revealed she did not attempt to verify the resident's code status on the Electronic Medical Record (EMR) when Resident #1 was found non responsive with no visible signs on life. Per interview she stated, she panicked and failed to verify Resident #1's code status before initiating Cardiopulmonary Resuscitation (CPR) on the resident. LPN #1 stated CPR was performed for approximately five (5) minutes until another nurse was available to verify Resident #1's Code Status. She stated she should have left the resident's room, logged on to the computer and into the EMR and verified Resident #1's Code status prior to initiating CPR to ensure she was providing accurate care. However, LPN #1 stated she did not want to leave the room to log into a computer to verify the code status and delay life saving measures. Interview with the Director of Nursing (DON), on [DATE] at 1:33 PM, revealed the facility's Resuscitation Decision Documentation policy was inaccurate. Per the DON, a green dot indicating a DNR status on the resident's identification bracelet was not the current practice for identifying code status in an emergency. Continued interview revealed it was not the current practice for a Care Plan to be developed to identify a resident's code status. Per interview, Advance Directives including Code Status documents were scanned in the EMR on admission and/or with changes as necessary. Per interview, a physician's orders [REDACTED]. Further interview revealed LPN #1 failed to verify the resident's code status when Resident #1 was found unresponsive with no visible signs of life. Further interview revealed the nurse was responsible to verify a resident's code status before initiating CPR. The DON further revealed, by not verifying the resident's code status in the EMR, based on the resident's Advanced Directives, Kentucky Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order form, the Baptist Convalescent Center Resuscitation Status form, and physician's orders [REDACTED]. Additional interview, revealed the DON expected nurses to verify a resident's code status in the EMR based on the resident's scanned Advance Directives, and the resident's physician's orders [REDACTED]. Interview with the Administrator, on [DATE] at 2:45 PM, revealed Resident #1's Advance Directive was not honored by the facility. Additionally he stated the LPN should have verified the resident's code status in the EMR before initiating CPR during the emergency when Resident #1 was found unresponsive with no visible signs of life. Further, he stated it was his expectation that a resident's code status be honored and accurate care provided. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. Review of the AoC revealed the facility implemented the following: 1. The Administrator conducted a review/update of all facility policies and procedures between [DATE] and [DATE]. All updates were documented on a log for review at the ad hoc QAPI meeting on [DATE]. 2. The Administrator and DON developed and executed new facility operational guidelines including: Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response on [DATE]-[DATE]. 3. The Administrator and DON updated the facility Emergency Code Announcement in the Disaster Preparedness Manual from the announcement of code blue to the announcement of Nurse Stat on [DATE]. Nurse Stat announcement is now the facility's universal nurse emergency announcement including but not limited to cardiopulmonary events requiring appropriate nursing staff response with emergency code book and crash carts for all facility emergencies. 4. On [DATE] the Administrator educated the leadership team those included were the DON, Clinical Coordinators, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator on Walking Shift Report and Room Rounds. 5. The Admissions Director, both Social Services Managers, DON, Clinical Coordinator, and MDS Coordinator were educated in Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat announcement on [DATE] by the Administrator. 6. An Emergency Code Binder was created on [DATE] as the primary source for obtaining resident code status in the event of need. Policies including Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response have all been updated to include responsibilities associated with updating and maintaining the Emergency Code Binders on each neighborhood. The binders are stored at each neighborhood nursing station with the code status of each resident residing on that neighborhood. Mock emergency response drills are being conducted two (2) times per day to ensure compliance with the facilities new process. Each binder is brought to every emergency announcement of Nurse Stat. 7. On [DATE] the Facility Clinical Coordinator developed a care plan focus category titled Advance Directives for utilization in the point click care resident electronic medical record. The Advanced Directives Care Plan will be utilized in all resident comprehensive care plans and SRNA care plans. 8. On [DATE] and [DATE] the MDS Coordinator and Clinical Coordinators reviewed and updated all residents' care plans. The finding of the care plan audit was documented on an audit log noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Charge Nurse, Clinical Coordinators and Social Services Managers are responsible for on-going resident care plan updates. 9. The Admissions Director and Social Service Managers provided in-service education to nursing staff on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat code announcement with posttest given between [DATE] through [DATE] with eighty-three (83) out of one-hundred three (103) nursing staff including licensed, State Registered Nurse Aides (SRNA) and KMA educated. No nursing staff member was permitted to work beyond [DATE] without first receiving in-service education covering Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat code announcement with posttest given. 10. The DON, Clinical Coordinators and MDS Coordinators will perform a mock code Nurse Stat daily starting [DATE] on first and second shifts (facility deploys 12 hour nurse rotations) until substantial compliance is achieved. Once substantial compliance is achieved, daily mock code Nurse Stat per shift will continue for one month and then weekly thereafter on a continual basis or until advised by the QAPI committee. The Mock Code Evaluation Checklist will be used as a quality assurance instrument with all areas of improvement noted and corrected immediately on the spot and reported at the following QAPI committee meeting. 11. The Clinical Coordinator conducted a new Facility Assessment in abaQIS (the facility's Electronic Record System) on [DATE]. Results of facility assessment will be presented during ad hoc QAPI meeting on [DATE]. Recommendations made by QAPI committee will be implemented immediately. 12. The Human Resources Manager audited all nursing personnel files between [DATE] and [DATE] to include: verification of credentials and evidence of verification prior to hire for CPR certification (as appropriate), licensure, TB testing and background checks. 13. In-Service Education was conducted on [DATE] by the DON, Clinical Coordinators, and MDS Coordinators provided to twenty-nine (29) of thirty-four (34) licensed nursing staff with no staff member permitted to work without first receiving education. The education was on Baseline Care Plans, Care Plan Policy and Behavior Documentation with emphasis training for the Charge Nurses related to implementing care plan interventions and discretion to implement one on one care as needed and per the physician's orders [REDACTED].>14. In-Service Education was provided on [DATE] through [DATE] by the DON and Clinical Coordinators to sixty-five (65) of one-hundred three (103) nursing staff, with no staff member permitted to work without first receiving education including licensed and certified staff on Accidents and Supervision per the Care Plan. 15. All education will be added to orientation for new hires and distributed to contract staffing organizations for agency staffing to be educated prior to working at the facility. The facility Scheduler will track and monitor for any staff member who has not received all appropriate training. The facility Scheduler will notify the DON and/or Clinical Coordinators who will be responsible for ensuring that training is provided to all appropriate staff members prior to working their next regularly scheduled shift. 16. On [DATE] the daily Walking Shift Report was assigned to the facilities ancillary department managers who are certified or license including MDS Coordinators, Activities Director, Scheduler, Central Supply Manager, Medical Records, and Environmental Services Manager providing managerial supervision for all seven (7) neighborhoods. The reports document room number, resident name, meal percentage, bath/shower, perineal-care needs, if the resident is in or out of bed at shift change, if the resident was turned every two (2) hours, vital signs, oral care, behaviors and any other comments as needed. The Walking Shift Report is signed by the neighborhood Charge Nurse prior to the SRNA's completing shift change and placed in the Managers bin on each neighborhood for collection and review the following morning during clinical meeting as a quality assurance system with all areas for improvement noted on the daily follow up sheets and distributed back out to each neighborhood Charge Nurse. The weekend nursing Clinical Coordinator will ensure that all Walking Shift Reports are monitored over the weekend. The DON, Clinical Coordinators and MDS Coordinators will utilize this system as a monitoring instrument for assuring care plans are updated and interventions are being implemented appropriately. 17. The Corporate Compliance Officer/Human Resources Director provided education on [DATE] covering the below topics with the Administrator and DON. A) Job Descriptions: which identify management as having responsibility to ensure overall safety within the facility B) Policies and Procedures: for mitigating risk of accidents/incidents and follow-up should one occur. C) Forms: for the purpose of detailing necessary steps and provide overall documentation of actions taken following an accident/incident. 18. On [DATE] an Ad Hoc QAPI meeting was held with an additional meeting held on [DATE] and the next scheduled for [DATE] then weekly on Thursday as continued monitoring until recommendation for alternate meeting schedule will be determined. 19. On [DATE] the Interdisciplinary Team (IDT) reviewed the past 90 days risk management events ensuring a root-cause analysis was performed and proper supervision was provided at the time based on the residents care plan with no adverse outcomes due to supervision. Risk Management events included falls, bruising, skin tear, resident to resident events, elopement and other traumatic injury. The IDT team consists of DON, Clinical Coordinators, MDS Coordinators and Social Service. 20. On [DATE] the DON provided one-on-one education to all staff that cared for Resident #1 on [DATE] between 2:00 PM to 5:00 PM covering Code Status, Emergency Response, Care Plan and Supervision. 21. Social Services will audit all Emergency Binders weekly starting [DATE], ensuring resident code status is accurate and available on each neighborhood. Results of the audits will be documented on a log presented at the next QAPI committee meeting. The Admissions Director and Social Services Directors completed chart audits on every resident comparing the Advance Directives to the physician's orders [REDACTED]. 22. A Quality Assurance Performance Improvement Project was implemented. The DON was monitoring for code status compliance by interviewing staff about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted two (2) times weekly for three (3) months. Findings will be reported at monthly QAPI Committee meeting. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the Facilities Policies Log Sheets revealed the Administrator reviewed and updated facility policies and procedures between [DATE] and [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he conducted a review/update of all facilities policy and procedures between [DATE] and [DATE]. He further stated the updates were documented on a log for review at the ad hoc QAPI meeting held on [DATE]. 2. Review of the new facility operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response revealed they were reviewed and revised on [DATE] through [DATE]. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed they developed and executed the following operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response on [DATE] through [DATE]. 3. Review of the Disaster Preparedness Manual revealed the announcement of code blue to Nurse Stat on [DATE] by the Administrator and DON. Nurse Stat is now the facility's universal nurse emergency announcement including but not limited cardiopulmonary events requiring appropriate nursing staff to respond to emergency code book and crash carts for all facility emergencies. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed, Nurse Stat is now what is announced overhead. Further interview revealed it replaced Code Blue. Per interview appropriate nursing staff respond and they are to get the Binder from the nurse's station each time it's announced along with crash carts. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed Nurse Stat is now the universal nurse emergency response announcement. 4. Review of In-Service Sheets dated [DATE], revealed the DON, Clinical Coordinator, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator were educated on Walking Shift Report and Room Rounds by the Administrator. Interview with DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, MDS Coordinator on [DATE] at 12:53 PM, Activities Director on [DATE] at 12:44 PM, revealed they were educated on Walking Shift Report and Room Rounds by the Administrator on [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he educated all of the Leadership Team on Walking Shift Report and Room Rounds. Per interview they have been implemented and the forms are discussed in QAPI. 5. Review of In-Service Sign in Sheets dated [DATE], revealed the Admissions Director, Social Services Directors, DON, Clinical Coordinator and MDS coordinator were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with DON on [DATE] at 1:34 PM, Social Services Director on [DATE] at 2:34 PM, Clinical Coordinator on [DATE] 1:03 PM and MDS Coordinator on [DATE] at 12:53 PM, revealed they were in-serviced by the administrator on [DATE] on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with the Administrator on [DATE] at 2:00 PM revealed, he in-serviced the Admissions Director, Social Services Directors, DON, Clinical Coordinator and MDS coordinator were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement on [DATE]. 6. Review of Emergency Code Binders on each neighborhood revealed a Face Sheet for each resident to include code status. The binders also included the following policies, Resident Rights, Advance Directives, Communication of Code Status, and Medical Emergency Response. The Binders are stored in the cabinet above the nurse's station and each Binder is brought to each announcement of Nurse Stat. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed the Emergency Response Binders were located on each neighborhood in the cabinet above the nurses station. Further interview revealed the Binders had face sheets of each resident that included code status. Per interviews Mock Emergency Response Drills are being conducted two times per day from the Management Team and each Binder is brought to every announcement of Nurse Stat. 7. Review of care plan focus category titled Advanced Directives was initiated in Point Click Care (PCC) resident electronic medical record. This category was developed on [DATE] by the Facility Clinical Coordinator. Record review of Resident #1, #2, #3, #4, #5, #6, #7 and #8 electronic records revealed this care plan focus category was on each residents' care plan. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, and MDS Coordinator on [DATE] at 12:53 PM, revealed the new care plan focus category was added to PCC for each resident in their medical record. 8. Review of the Care Plan Audit Log dated [DATE] and [DATE] revealed all residents care plans were updated by the MDS and Clinical Coordinators. The audit log consisted of: noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Interview with LPN #10 on [DATE] at 10:49 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, LPN #13 on [DATE] at 11:40 AM, MDS Coordinator on [DATE] at 12:53 PM, Clinical Coordinator on [DATE] at 1:03 PM, Social Services on [DATE] at 1:13 PM and the DON on [DATE] at 1:34 PM, revealed all care plans were reviewed and updated. Further interview revealed the Charge Nurses, Social Services and Clinical Coordinators were responsible for on-going updates to the care plans. 9. Review of In-Service Sign-In Sheets and Posttest dated [DATE] through [DATE] revealed eighty-three (83) out of one-hundred three (103) nursing staff were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed, the Admissions Director and Social Service Managers provided in-service education on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Further interview revealed they had to do a posttest. Interview with Social Services Director on [DATE] at 10:54 AM, revealed she and the Admissions Director provided an in-service to nursing staff on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Further interview revealed they had to do a posttest after the in-service. 10. Review of Mock Code Evaluation Checklist dated [DATE] continuing on two (2) times daily on each neighborhood are being conducted by the DON, Clinical Coordinators and MDS Coordinators. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, and MDS Coordinator on [DATE] at 12:53 PM, revealed Mock Codes are being conducted two (2) times a day on each shift, for each neighborhood. Further interview revealed on the spot education is being provided. 11. Review of the Facility Assessment revealed it was created by the Clinical Coordinator in abaQIS on [DATE]. The assessment was presented to QAPI committee on [DATE]. Review of the Ad-Hoc QAPI Agenda/Meeting Template revealed the facility assessment that was created by the Facility Clinical Coordinator was discussed and reviewed on [DATE]. Interview with the Clinical Coordinator on [DATE] at 1:03 PM, revealed she created the Facility Assessment and presented it to the QAPI meeting held on [DATE]. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed they discussed and reviewed the Facility Assessment on [DATE] 12. Review of the audit sheet titled Personnel File Review revealed all nursing personnel files were audited between [DATE] through [DATE] which included: hire date, application, reference check, criminal background check, drug screens, abuse registry/exclusions list check, License/Certification verified, Forms I-9 and W4, Signed Job Description, Completed Orientation Checklist, License/certification Renewal, CPR Certification Current, Required Trainings and Nurse Aide Required Training Based on Hire Date. Interview with the Human Resources manager on [DATE] at 12:34 PM, revealed she performed the audits on the personnel files between [DATE] and [DATE]. She stated they had a CPR class on (TRUNCATED)

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one (1) of eight (8) sampled residents (Resident #1). The facility assessed Resident #1 to have behavioral symptoms directed toward others and behavioral symptoms not directed toward others, per the Quarterly Minimum Data Set ((MDS) dated [DATE]. Interviews revealed, on [DATE] at 2:00 PM, Resident #1 exhibited yelling out behaviors, which progressed to behaviors including sliding down in his/her chair and bumping his/her wheelchair into other residents. According to the Comprehensive Care Plans (CCP) dated [DATE], [DATE], and [DATE], Resident #1 was to be provided one-to-one (1:1) care as needed or directed by the supervisor or management to decrease the potential for the resident to harm self or others. However, interviews revealed, on [DATE], Resident #1 was not provided one-to-one (1:1) care as per the CCP. On [DATE] at 4:00 PM, Resident #1 exhibited behaviors of yelling out and bumping into other residents. Additionally, at 4:00 PM, SRNA #8 assisted Resident #1 to his/her room, pulled the door together leaving the resident alone in his/her room, and left the unit for a thirty (30) minute break. LPN #1 visualized Resident #1, at 4:15 PM, in his/her room with continued yelling out behaviors. However, LPN #1 assisted SRNA #8 with providing care to another resident in his/her room with the door closed, leaving no staff to supervise Resident #1's behaviors. At 5:00 PM, staff found Resident #1 with the lower half of his/her body on the floor, with his/her shirt wrapped tightly around his/her neck and around the arm of the wheelchair, non-responsive, and with no visible signs of life; the resident was pronounced deceased . Due to the facility's failure to have an effective system in place to ensure supervision of residents to prevent accidents caused or is likely to cause serious injury, harm, impairment, or death to the resident. Immediate Jeopardy (IJ) was identified, on [DATE], and was determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable credible Allegation of Compliance (AoC) was received on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy, Accidents and Supervision, dated [DATE], revealed the residents' environment would remain as free of accident hazards as possible, and each resident would receive adequate supervision to prevent accidents. Additional review revealed the systematic approach to minimize accident hazards included implementing interventions to reduce hazards and risks, monitoring for consistency and effectiveness, and modifying interventions when necessary. Further, implementation of specific interventions to reduce a resident's risks from hazards in the environment included ensuring direct approach interventions were put into action. Review of Resident #1's medical record revealed the facility admitted the resident, on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's CCP, revised [DATE], revealed the resident was developmentally challenged and childlike as evidenced by temper tantrums, crying, hitting/kicking staff and residents, wrapping the call light around his/her neck, sliding out of the chair, yelling/screaming, throwing self on the floor, abusive language, and threatening staff. The goal stated there would be no exacerbation of symptoms and the resident would not harm self or others. The interventions included (one to one) 1:1 supervision as needed; assess and address factors that could be contributing to agitation; offer pleasant diversions, structured activities, food, conversation, and television; give boxes to pull apart when agitated; give Lego blocks; give stuffed animals and blankets; give reassurance and praise; take to room when throwing things; modify environment (adjust air, temperature, noise level, dim lights); notify nurse and physician immediately of harmful behaviors; and re-approach later when agitated. Additional review of Resident #1's CCP, revised [DATE], revealed Resident #1 had potential to have poor impulse control and physical behaviors directed toward others. Specifically, he/she would hit other residents, hit staff, and kick. The goal stated the resident would have no physical behaviors. The interventions included, assess and address needs; provide one-to-one (1:1) care as needed or directed by the charge nurse to decrease the potential for the resident to harm self or others; modify the environment (comfortable temperature, quiet surroundings, dim light) to help deescalate behaviors; give positive feedback; analyze triggers surrounding behaviors, and document findings. Further review of Resident #1's CCP, revised on [DATE], revealed Psychoactive/[MEDICAL CONDITION] Drug Use related to [DIAGNOSES REDACTED]. The goal stated the resident would remain free from any adverse drug reaction from use of these medications, improve mood stability and decrease hostility to others, and decrease throwing things. The interventions included, ensure safety when he/she wished to throw self on floor; provide boxes to break down; provide Lego blocks, stuffed animals, and blanket; provide one-to-one care (1:1) as directed by supervisor/management for behaviors; and give medications as directed. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 as rarely/never making himself/herself understood or understanding others. Additional review revealed the resident had severely impaired cognitive skills for daily decision making. Further review revealed the facility assessed the resident as having behavioral symptoms that were verbally directed toward others and other behaviors not directed toward others four (4) to six (6) days per week, but less than daily. Review of the Progress Notes, dated [DATE] at 4:30 PM, completed by Licensed Practical Nurse (LPN) #1, revealed Resident #1 was yelling in the dinning room and bumping into other residents with his/her wheelchair. Additionally, the action taken was the resident was taken to his/her room. Further, the resident's response was he/she was not able to be redirected. Additional review of the Progress Notes, dated [DATE] at 5:00 PM, completed by LPN #4, revealed Resident #1 was found to be non-responsive with no audible or visible signs of life. Continued review revealed staff was unable to obtain his/her blood pressure, auscultate an apical pulse, or palpate any peripheral pulses. Per review, respirations were nonexistent, pupils were non-reactive to light, and pupils were fixed and dilated. Further review of the Progress Notes, dated [DATE] at 5:14 PM, completed by LPN #4, revealed the on-call doctor was notified of the above findings. Pronouncement of death was made via telephone with an order received to release his/her remains to the funeral home of choice. Interview with LPN #1, on [DATE] at 1:10 PM, revealed she worked on the 6:00 AM to 6:00 PM shift on [DATE], and Resident #1 was his/her normal self, stating the resident had a good morning. Per interview, the resident spent the morning in the common area and began to have a behavior outburst with yelling around shift change, at 2:00 PM. LPN #1 stated she had moved the residents around in the common area while she provided care to other residents. Per LPN #1, Resident #1 stayed with nursing staff the majority of the time. LPN #1 stated it was common for Resident #1 to have increased behaviors at shift change (2:00 PM) because he would get bored while nursing staff were giving report to the oncoming nurses. Additional interview revealed nursing staff used the CCP and Physician orders [REDACTED]. Per interview, non-pharmaceutical interventions (re-direction and diversion) were always attempted first before administering medications. LPN #1 stated it was important to provide adequate supervision and necessary care to ensure a resident's safety. Continued interview with LPN #1 revealed, on [DATE] at 4:00 PM, Resident #1 remained in the common area and was bumping his/her wheelchair into another resident. She stated she moved the resident away from the other resident and repositioned Resident #1 in his/her wheelchair because he/she was sliding down. She also assisted the resident in moving his/her legs off the wheelchair foot pedals so he/she could rest his/her feet on the floor. Per interview, she then left the unit for fifteen (15) minutes, leaving Agency SRNA #8 and SRNA #9 on the hallway without a licensed nurse. LPN #1 stated when she returned to the unit, at approximately 4:15 PM, she asked Agency SRNA # 8 and SRNA #9 why Resident #1 was in his/her room and both responded because he/she continued to yell. Per interview, LPN #1 saw the resident sitting in his/her wheelchair in his/her room with the door open, and the resident continued to yell. However, at that time, LPN #1 stated she did not identify the need to implement a care planned intervention to decrease the potential for the resident to harm himself/herself, including one-to-one (1:1) care. LPN #1 stated it was normal behavior for Resident #1 to continue to yell when left in his/her room alone. Continued interview with LPN #1, revealed, on [DATE] at approximately 4:30 PM, SRNA #9 left the unit to go on break, and LPN #1 and Agency SRNA #8 entered into another resident's room, closed the door, and provided care to that resident. LPN #1 stated when she came out of the room, she no longer heard Resident #1 yelling. LPN #1 stated it was common practice to have one (1) SRNA and one (1) nurse on the unit during breaks to provide care and supervision to all residents. Per interview, she and SRNA #8 provided care to the other resident for twenty (20) minutes, and during that time, there was no staff on the unit providing supervision to residents not being cared for by LPN #1 and SRNA #8. Continued interview with LPN #1 revealed, on [DATE] at approximately 5:00 PM, SRNA #9 reported there was an emergency in Resident #1's room. Per interview, LPN #1 immediately responded and went to the resident's room. She stated Resident #1 was seated on the floor in front of his/her wheelchair, his/her left arm was out of the sleeve of the t-shirt, and the right arm was in the sleeve; however, the right sleeve of the shirt was caught on the back of the right arm rest of the wheelchair. LPN #1 stated the neck of the shirt was pulled tight around Resident #1's neck, and he/she was not breathing or responsive. LPN #1 stated she panicked, cut the shirt off the resident, laid him/her flat on the floor, and began chest compressions. Telephone interview with Agency SRNA #8, on [DATE] at 3:10 PM, revealed she had worked at the facility for four (4) months, and on [DATE], she worked on the 2:00 PM to 6:00 PM shift. Per interview, she used the CCP to know how to provide care for residents with behaviors and relied on regular facility staff to direct her as necessary on how to provide care for residents with behaviors. SRNA #8 stated it was important to follow the care plan to ensure residents' needs were met, and they were supervised and safe. Additionally SRNA #8 stated it was normal behavior for Resident #1 to scream and cry for extended periods of time. Continued interview with Agency SRNA #8 revealed, on [DATE] at approximately 4:00 PM, she asked SRNA #9 about Resident #1's continued yelling and what intervention should be attempted, since LPN #1 was not on the unit. Per interview, she asked SRNA #9 if she could assist Resident #1 to his/her room because the resident had been yelling and screaming in the common area since 2:00 PM; SRNA #9 agreed that it was appropriate to put the resident in his/her room to watch cartoons. SRNA #8 assisted the resident to his/her room, sat him/her (in the wheelchair) in front of the television, and pulled the door together. Further, SRNA #8 revealed she heard Resident #1 continue to yell and scream in his/her room until she left the unit for break, at approximately 4:05 PM. Continued interview with Agency SRNA #8, revealed, on [DATE] at approximately 4:35 PM, she returned to the unit, and SRNA #9 reported to her all the residents had just been checked on and were okay; SRNA #9 then went on break off the hallway. Per interview, at approximately 4:40 PM, she and LPN #1 entered another resident's room and closed the door to provide care. SRNA #8 stated she heard Resident #1 yelling and screaming while they were providing care for the other resident. Per interview, at approximately 5:00 PM, SRNA #9 rushed into the other resident's room and told LPN #1 there was an emergency with Resident #1. Continued interview with Agency SRNA #8, revealed, when she entered Resident #1's room his/her lower body was in front of the wheelchair, and the resident was almost seated on the floor. She stated it appeared the resident had slid out of the chair onto the floor, but the shirt had caught on the right arm of the wheelchair before he/she made it all the way. SRNA #8 stated the resident had his/her right arm in the shirt and the other arm was out of the shirt; the shirt was tight around his/her neck. Per interview, the resident's eyes were open, and he/she was obviously dead. In addition, SRNA #8 stated LPN #1 cut the shirt away from the resident's neck and laid the resident on the floor. Telephone interview with SRNA #9, on [DATE] at 4:40 PM, revealed on [DATE], she worked on the 2:00 PM to 10:00 PM shift. Per interview, she used the CCP to know how to provide care for residents with behaviors, and it was important to check on those residents frequently to meet their needs and ensure their safety. SRNA #9 stated Resident #1 stayed in the common areas of the unit many times because staff frequently interacted with him/her due to the resident's behaviors. She stated Resident #1 was yelling and bumping into other residents with the wheelchair, in the common area, on [DATE] between 2:00 PM and 4:30 PM. Continued interview with SRNA #9 revealed, on [DATE] at approximately 4:30 PM, she left the unit for a thirty (30) minute break. She stated when she returned to the unit, Resident #1 was no longer in the common area of the unit, and she did not hear the resident yelling. Per interview, she immediately went to Resident #1's room where she saw the resident sitting on the floor in front of the wheelchair with his/her legs stretched out in front of him/her. In addition, the resident's hands were open and laying by each side. She stated, Resident #1's head was laying over to the right side and his/her tongue was out of his/her mouth and blue. SRNA #9 revealed the resident's shirt was caught on the back of the wheelchair arm and the neck of the shirt was tight around the resident's neck. Continued interview with SRNA #9 revealed she immediately went to LPN #1 and informed her Resident #1 was non-responsive. Per interview, LPN #1 cut the shirt away from Resident #1's neck, laid the resident on the floor, and began Cardiopulmonary Recitation (CPR). Telephone interview with LPN #4, on [DATE] at 3:00 PM, revealed she was the facility Supervisor Nurse, on [DATE] for the 2:00 PM to 10:00 PM shift. She stated, on [DATE] at approximately 5:00 PM, she responded to stat nurse call on the overhead paging system and entered Resident #1's room. She stated LPN #1 told her the resident was found non-responsive on the floor in front of his/her wheelchair, and (CPR) was initiated. Per interview, LPN #4 stated she was not made aware of Resident #1's ongoing behaviors since 2:00 PM and staff placing the resident in his/her room until approximately 5:10 PM, after the emergency situation. Continued interview with LPN #4 revealed she contacted the Director of Nursing (DON) about the emergency situation and the information LPN #1 had reported to her. Per LPN #4, the DON instructed her to treat Resident #1's death as a normal death in the facility. Per interview, it was important for residents to receive adequate supervision, to meet their specific needs as outlined in the CCP, and to ensure their safety. Interview with the DON, on [DATE] at 1:33 PM, revealed she expected residents to be provided adequate supervision and all nursing staff to implement behavior interventions per the CCP to ensure quality and safe care. Additionally, she stated nursing staff were instructed during orientation and throughout the year on how to provide supervision and safe care per the CCP. The DON stated she received a call from LPN #4, the Nurse Supervisor, on [DATE], regarding Resident #1. She stated LPN #4 informed her Resident #1 had been agitated and had behaviors of yelling and bumping into other residents earlier in the shift. She stated she was also informed staff had assisted the resident to his/her room, where the resident continued to have behaviors. Per interview, she was informed staff did not visualize the resident for thirty (30) minutes while providing care to another resident; and then, the resident was found non-responsive, and LPN #1 initiated CPR. Further, the DON stated the facility did not begin an investigation related to Resident #1's death because it was a natural death. Interview with the Administrator, on [DATE] at 2:45 PM, revealed all personnel were to provide supervision and care to meet the residents' care needs. He stated the SRNA's and nurses were expected to be knowledgeable regarding care of the residents, which included their behavioral health status and where to reference if they required information regarding the care of a resident. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. Review of the AoC revealed the facility implemented the following: 1. The Administrator conducted a review/update of all facility policies and procedures between [DATE] and [DATE]. All updates were documented on a log for review at the ad hoc QAPI meeting on [DATE]. 2. The Administrator and DON developed and executed new facility operational guidelines including: Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response on [DATE]-[DATE]. 3. The Administrator and DON updated the facility Emergency Code Announcement in the Disaster Preparedness Manual from the announcement of code blue to the announcement of Nurse Stat on [DATE]. Nurse Stat announcement is now the facility's universal nurse emergency announcement including but not limited to cardiopulmonary events requiring appropriate nursing staff response with emergency code book and crash carts for all facility emergencies. 4. On [DATE] the Administrator educated the leadership team those included were the DON, Clinical Coordinators, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator on Walking Shift Report and Room Rounds. 5. The Admissions Director, both Social Services Managers, DON, Clinical Coordinator, and MDS Coordinator were educated in Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat announcement on [DATE] by the Administrator. 6. An Emergency Code Binder was created on [DATE] as the primary source for obtaining resident code status in the event of need. Policies including Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response have all been updated to include responsibilities associated with updating and maintaining the Emergency Code Binders on each neighborhood. The binders are stored at each neighborhood nursing station with the code status of each resident residing on that neighborhood. Mock emergency response drills are being conducted two (2) times per day to ensure compliance with the facilities new process. Each binder is brought to every emergency announcement of Nurse Stat. 7. On [DATE] the Facility Clinical Coordinator developed a care plan focus category titled Advance Directives for utilization in the point click care resident electronic medical record. The Advanced Directives Care Plan will be utilized in all resident comprehensive care plans and SRNA care plans. 8. On [DATE] and [DATE] the MDS Coordinator and Clinical Coordinators reviewed and updated all residents' care plans. The finding of the care plan audit was documented on an audit log noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Charge Nurse, Clinical Coordinators and Social Services Managers are responsible for on-going resident care plan updates. 9. The Admissions Director and Social Service Managers provided in-service education to nursing staff on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat code announcement with posttest given between [DATE] through [DATE] with eighty-three (83) out of one-hundred three (103) nursing staff including licensed, State Registered Nurse Aides (SRNA) and KMA educated. No nursing staff member was permitted to work beyond [DATE] without first receiving in-service education covering Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat code announcement with posttest given. 10. The DON, Clinical Coordinators and MDS Coordinators will perform a mock code Nurse Stat daily starting [DATE] on first and second shifts (facility deploys 12 hour nurse rotations) until substantial compliance is achieved. Once substantial compliance is achieved, daily mock code Nurse Stat per shift will continue for one month and then weekly thereafter on a continual basis or until advised by the QAPI committee. The Mock Code Evaluation Checklist will be used as a quality assurance instrument with all areas of improvement noted and corrected immediately on the spot and reported at the following QAPI committee meeting. 11. The Clinical Coordinator conducted a new Facility Assessment in abaQIS (the facility's Electronic Record System) on [DATE]. Results of facility assessment will be presented during ad hoc QAPI meeting on [DATE]. Recommendations made by QAPI committee will be implemented immediately. 12. The Human Resources Manager audited all nursing personnel files between [DATE] and [DATE] to include: verification of credentials and evidence of verification prior to hire for CPR certification (as appropriate), licensure, TB testing and background checks. 13. In-Service Education was conducted on [DATE] by the DON, Clinical Coordinators, and MDS Coordinators provided to twenty-nine (29) of thirty-four (34) licensed nursing staff with no staff member permitted to work without first receiving education. The education was on Baseline Care Plans, Care Plan Policy and Behavior Documentation with emphasis training for the Charge Nurses related to implementing care plan interventions and discretion to implement one on one care as needed and per the physician's orders [REDACTED].>14. In-Service Education was provided on [DATE] through [DATE] by the DON and Clinical Coordinators to sixty-five (65) of one-hundred three (103) nursing staff, with no staff member permitted to work without first receiving education including licensed and certified staff on Accidents and Supervision per the Care Plan. 15. All education will be added to orientation for new hires and distributed to contract staffing organizations for agency staffing to be educated prior to working at the facility. The facility Scheduler will track and monitor for any staff member who has not received all appropriate training. The facility Scheduler will notify the DON and/or Clinical Coordinators who will be responsible for ensuring that training is provided to all appropriate staff members prior to working their next regularly scheduled shift. 16. On [DATE] the daily Walking Shift Report was assigned to the facilities ancillary department managers who are certified or license including MDS Coordinators, Activities Director, Scheduler, Central Supply Manager, Medical Records, and Environmental Services Manager providing managerial supervision for all seven (7) neighborhoods. The reports document room number, resident name, meal percentage, bath/shower, perineal-care needs, if the resident is in or out of bed at shift change, if the resident was turned every two (2) hours, vital signs, oral care, behaviors and any other comments as needed. The Walking Shift Report is signed by the neighborhood Charge Nurse prior to the SRNA's completing shift change and placed in the Managers bin on each neighborhood for collection and review the following morning during clinical meeting as a quality assurance system with all areas for improvement noted on the daily follow up sheets and distributed back out to each neighborhood Charge Nurse. The weekend nursing Clinical Coordinator will ensure that all Walking Shift Reports are monitored over the weekend. The DON, Clinical Coordinators and MDS Coordinators will utilize this system as a monitoring instrument for assuring care plans are updated and interventions are being implemented appropriately. 17. The Corporate Compliance Officer/Human Resources Director provided education on [DATE] covering the below topics with the Administrator and DON. A) Job Descriptions: which identify management as having responsibility to ensure overall safety within the facility B) Policies and Procedures: for mitigating risk of accidents/incidents and follow-up should one occur. C) Forms: for the purpose of detailing necessary steps and provide overall documentation of actions taken following an accident/incident. 18. On [DATE] an Ad Hoc QAPI meeting was held with an additional meeting held on [DATE] and the next scheduled for [DATE] then weekly on Thursday as continued monitoring until recommendation for alternate meeting schedule will be determined. 19. On [DATE] the Interdisciplinary Team (IDT) reviewed the past 90 days risk management events ensuring a root-cause analysis was performed and proper supervision was provided at the time based on the residents care plan with no adverse outcomes due to supervision. Risk Management events included falls, bruising, skin tear, resident to resident events, elopement and other traumatic injury. The IDT team consists of DON, Clinical Coordinators, MDS Coordinators and Social Service. 20. On [DATE] the DON provided one-on-one education to all staff that cared for Resident #1 on [DATE] between 2:00 PM to 5:00 PM covering Code Status, Emergency Response, Care Plan and Supervision. 21. Social Services will audit all Emergency Binders weekly starting [DATE], ensuring resident code status is accurate and available on each neighborhood. Results of the audits will be documented on a log presented at the next QAPI committee meeting. The Admissions Director and Social Services Directors completed chart audits on every resident comparing the Advance Directives to the physician's orders [REDACTED]. 22. A Quality Assurance Performance Improvement Project was implemented. The DON was monitoring for code status compliance by interviewing staff about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted two (2) times weekly for three (3) months. Findings will be reported at monthly QAPI Committee meeting. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the Facilities Policies Log Sheets revealed the Administrator reviewed and updated facility policies and procedures between [DATE] and [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he conducted a review/update of all facilities policy and procedures between [DATE] and [DATE]. He further stated the updates were documented on a log for review at the ad hoc QAPI meeting held on [DATE]. 2. Review of the new facility operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response revealed they were reviewed and revised on [DATE] through [DATE]. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed they developed and executed the following operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response on [DATE] through [DATE]. 3. Review of the Disaster Preparedness Manual revealed the announcement of code blue to Nurse Stat on [DATE] by the Administrator and DON. Nurse Stat is now the facility's universal nurse emergency announcement including but not limited cardiopulmonary events requiring appropriate nursing staff to respond to emergency code book and crash carts for all facility emergencies. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed, Nurse Stat is now what is announced overhead. Further interview revealed it replaced Code Blue. Per interview appropriate nursing staff respond and they are to get the Binder from the nurse's station each time it's announced along with crash carts. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed Nurse Stat is now the universal nurse emergency response announcement. 4. Review of In-Service Sheets dated [DATE], revealed the DON, Clinical Coordinator, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator were educated on Walking Shift Report and Room Rounds by the Administrator. Interview with DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, MDS Coordinator on [DATE] at 12:53 PM, Activities Director on [DATE] at 12:44 PM, revealed they were educated on Walking Shift Report and Room Rounds by the Administrator on [DATE] (TRUNCATED)

Based on interview, record review, review of the facility's policies, and review of the Director of Nursing and Administrator's Job Descriptions, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The Administrator failed to ensure the facility had a system in place to ensure implementation of a resident's person centered care plan related to mood, behavior, supervision, and safety for one (1) of eight (8) sampled residents (Resident #1). Further, the Administrator failed to ensure a system was in place to ensure a resident's Advanced Directives related to code status was honored and could be quickly identified in an emergency. On [DATE], Resident #1's Legal Guardian signed the Baptist Convalescent Center Resuscitation Status form, stating resuscitation would not be attempted and a Kentucky (KY) Emergency Medical Services (EMS) Do Not Resuscitate (DNR) Order Form. The facility also obtained a physician's orders [REDACTED]. In addition, the Comprehensive Care Plans (CCP) dated [DATE], [DATE], and [DATE], stated Resident #1 was to be provided one-to-one (1:1) care as needed or directed by the supervisor or management to decrease the potential for the resident to harm self or others. On [DATE] from 2:00 PM to 4:00 PM, per staff interviews and record review, Resident #1 was exhibiting yelling out behaviors which progressed to behaviors including sliding down in his/her chair and bumping his/her wheelchair into other residents. Staff did not implement assessed care plan interventions to address the displayed behaviors. At 4:00 PM, staff assisted Resident #1 to his/her room leaving the resident alone in his/her room. On [DATE], per staff interviews and record review, at approximately 5:00 PM, staff observed Resident #1 to be unresponsive with the absence of respirations and heartbeat; staff failed to honor Resident #1's Advance Directives as Cardiopulmonary Resuscitation (CPR) was initiated immediately. Licensed Practical Nurse (LPN) #1 did not attempt to determine the resident's code status, and staff began CPR at approximately 5:00 PM. After approximately five (5) minutes, staff stopped CPR when LPN #4 verified Resident #1's code status to be a DNR on the Electronic Medical Record (EMR). Resident #1's pronouncement of death was on [DATE] at 5:10 PM. (Refer to and F-656 and F-678) The facility's failure to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to not having an effective system in place to ensure assessed care plan interventions were implemented related to Mood and Behavior and to verify a resident's code status before initiating CPR for a resident who was DNR, caused or is likely to cause serious injury, harm, impairment, or death to the resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined it existed on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable credible Allegation of Compliance (AoC) was received on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Job Description for Administrator, dated [DATE], revealed the Administrator provided leadership in operations of the campus and all of its parts, providing executive direction, regulatory, financial and business development. Additionally, the Administrator provided leadership in the supervision of resident care in the facility. Further review revealed the Administrator's responsibilities included: ensuring the rights of residents were respected; participating in the development and implementation of facility policies and procedures; evaluating the quality of resident care being provided and providing leadership in the enhancement of quality; identifying and problem solving issues; maintaining disciplinary oversight of staff; providing oversight of various resident and staff meetings; participating in interdisciplinary team members in daily review of resident issues; addressing issues and concerns with the resident and the resident's legal representative; providing a high level of oversight to nursing; demonstrating knowledge of and the ability to apply principles of administration, management and leadership; and demonstrating knowledge of basic nursing care and standards of nursing practice. Review of the facility's Job Description for Director of Nursing (DON), dated [DATE], revealed the DON managed the overall operations of the nursing department in accordance with company policies, standards of nursing practice and governmental regulations to maintain excellent care of all the residents' needs. The Essential Duties and Responsibilities included: to demonstrate knowledge of State and Federal nursing home regulations; to manage duties such as training, developing, coaching, and counseling; to plan, develop, organize, implement, evaluate and direct the nursing services department in accordance with current rules, regulations and guidelines that govern a long-term care facility; to assume administrative authority, responsibility, and accountability for all functions, activities and training of the nursing department; to participate in Department Supervisor meetings, Resident Care Plan meetings, Safety Committee meetings, Quality Assessment and Assurance Committee meetings; to ensure in-service education was given, as directed by the Administrator; to make daily rounds of the nursing department to verify nursing services was performing their work assignments in accordance with acceptable nursing standards; to provide appropriate departmental in-service education programs in compliance with State and Federal Guidelines; to work closely with the Administrator in resolving grievances with nursing staff, family, and residents; to inform the state of any reportable incidents within appropriate time frames; to complete investigative analysis as required; to regularly inspect the facility and nursing practice for compliance with federal, state and local standards and regulation; to inform the Administrator daily of nursing department functions; and to monitor nursing service personnel to verify they were following established safety regulations. Further review revealed the DON was responsible to verify nursing care was administered in accordance with the resident's wishes; to ensure nursing service personnel followed established departmental policies and procedures; to be on-call for emergencies; to assure proper handling and emergency care of residents; to assure residents had a comfortable, safe environment; and to comply and enforce safety policy. Review of the facility's policy, Resuscitation Decision Documentation, dated [DATE], revealed every resident or their legal representative had the right to make their own healthcare decisions including the initiation or withholding of CPR in the event of cardiac or respiratory arrest. Additionally, the policy stated a Resuscitation Form, a physician's orders [REDACTED]. Further, a green dot would be placed on the resident's identification band to reflect DNR status, and the resident's DNR status would be included on his/her care plan. Review of the facility's policy, Care Plan, dated [DATE], revealed the Comprehensive Care Plan (CCP) was a resident specific plan of care based on information gathered through the Resident Assessment Instrument (RAI) process as well as ancillary assessments and evaluations. Additionally, the CCP was prepared by an interdisciplinary team of health care professionals and would be developed to identify which discipline(s) would be responsible to carry out the approaches and interventions. Per policy, the CCP was designed to maintain the resident's current status or assist the resident to attain his/her highest potential while respecting the resident's rights and choices. Further, personnel on all shifts had access to the care plan via the Electronic Medical Record (EMR), and it was their responsibility to report changes in the resident's status that could affect the accuracy of the care plan. Further review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review revealed the CCP was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and CCP would re-evaluate the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs), using the RAI and then modifying the individualized care plan as appropriate and necessary. Interview with the DON, on [DATE] at 1:33 PM, revealed she was notified on [DATE] at approximately 5:00 PM, Resident #1 was found non-responsive, and she directed staff to follow the facility's routine death protocol. However, she stated she was not initially informed and did not inquire about specifics of the events before or around the time the resident was found non-responsive. Additional interview revealed hours after the resident's death, on [DATE], she was informed by LPN #1 and LPN #4 the resident had been agitated and had behaviors of yelling and bumping into other residents earlier in the shift; the resident had been assisted to his/her room, where the resident continued to have behaviors; staff did not visualize the resident for thirty (30) minutes while providing care to another resident; the resident was found in his/her room seated on the floor in front of the wheelchair, with a shirt up by his/her neck; and LPN #1 had to cut off the shift before performing CPR. However, she stated she did not initiate an investigation of the events surrounding Resident #1's death, on [DATE], after being informed by LPN #1 and LPN #4 about the circumstances. Continued interview with the DON revealed, during the days following Resident #1's death, there were allegations made by staff that the resident hanged himself/herself on the wheelchair with a shirt. Per interview, the DON stated she interviewed direct care staff involved in the care of Resident #1, on [DATE], and staff who were making the allegations. Per the DON, the interviews were documented on notebook paper and turned into the Administrator. She stated she reviewed the interviews with the Administrator, and it was determined the allegations were rumors. The DON stated the facility did not identify the need to complete a more thorough investigative analysis related to the events around Resident #1's death. Further, the DON stated she had not initiated any training or re-education to nursing staff related to implementing assessed CCP interventions related to Mood and Behavior and providing adequate supervision and safety. Per interview, she also had not initiated training or re-education related to honoring Advance Directives regarding residents' requested code status; verifying a resident's code status before initiating CPR; or ensuring CPR was not initiated, if there was a physician's orders [REDACTED]. Additional interview with the DON, on [DATE] at 7:20 PM, revealed it was her responsibility to verify nursing care was administered in accordance with the residents' wishes. Per interview, it was her role to assure proper handling and emergency care of residents and that residents were provided a comfortable, safe environment. Further, she stated the facility should have effective systems in place to ensure implementation of a resident's CCP. She stated the facility should have an effective system in place to ensure a resident's Advanced Directives related to code status was honored and to ensure CPR was not initiated for a resident whose code status was DNR. Interview with the Administrator, on [DATE] at 2:45 PM, revealed his role was to provide leadership and high-level oversight to nursing by demonstrating knowledge of and the ability to apply principles of administration, management and leadership, and by demonstrating knowledge of basic nursing care and standards of nursing practice. Per interview, he was notified of Resident #1's death on [DATE]. However, he stated there was no documented evidence the facility completed an investigative analysis related to the resident's death, because it was a natural death and God's will. Additional interview revealed the facility did not identify deficiencies related to implementation of Resident #1's CCP for Mood and Behavior or adequate supervision secondary to the resident's behaviors on [DATE]. Further interview revealed he was aware LPN #1 initiated CPR on the resident. Per the Administrator, the facility had an effective system in place for nurses to verify a resident's code status in the EMR, before initiating CPR. However, he stated the facility did not identify the necessity to provide re-education or training to LPN #1 or other licensed nurses in the facility, after the events on [DATE] with Resident #1. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] that alleged removal of the Immediate Jeopardy (IJ) on [DATE]. Review of the AoC revealed the facility implemented the following: 1. The Administrator conducted a review/update of all facility policies and procedures between [DATE] and [DATE]. All updates were documented on a log for review at the ad hoc QAPI meeting on [DATE]. 2. The Administrator and DON developed and executed new facility operational guidelines including: Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response on [DATE]-[DATE]. 3. The Administrator and DON updated the facility Emergency Code Announcement in the Disaster Preparedness Manual from the announcement of code blue to the announcement of Nurse Stat on [DATE]. Nurse Stat announcement is now the facility's universal nurse emergency announcement including but not limited to cardiopulmonary events requiring appropriate nursing staff response with emergency code book and crash carts for all facility emergencies. 4. On [DATE] the Administrator educated the leadership team those included were the DON, Clinical Coordinators, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator on Walking Shift Report and Room Rounds. 5. The Admissions Director, both Social Services Managers, DON, Clinical Coordinator, and MDS Coordinator were educated in Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat announcement on [DATE] by the Administrator. 6. An Emergency Code Binder was created on [DATE] as the primary source for obtaining resident code status in the event of need. Policies including Resident Rights and Advance Directives, Communication of Code Status, and Medical Emergency Response have all been updated to include responsibilities associated with updating and maintaining the Emergency Code Binders on each neighborhood. The binders are stored at each neighborhood nursing station with the code status of each resident residing on that neighborhood. Mock emergency response drills are being conducted two (2) times per day to ensure compliance with the facilities new process. Each binder is brought to every emergency announcement of Nurse Stat. 7. On [DATE] the Facility Clinical Coordinator developed a care plan focus category titled Advance Directives for utilization in the point click care resident electronic medical record. The Advanced Directives Care Plan will be utilized in all resident comprehensive care plans and SRNA care plans. 8. On [DATE] and [DATE] the MDS Coordinator and Clinical Coordinators reviewed and updated all residents' care plans. The finding of the care plan audit was documented on an audit log noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Charge Nurse, Clinical Coordinators and Social Services Managers are responsible for on-going resident care plan updates. 9. The Admissions Director and Social Service Managers provided in-service education to nursing staff on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response, and Nurse Stat code announcement with posttest given between [DATE] through [DATE] with eighty-three (83) out of one-hundred three (103) nursing staff including licensed, State Registered Nurse Aides (SRNA) and KMA educated. No nursing staff member was permitted to work beyond [DATE] without first receiving in-service education covering Provision of Quality of Care, Resident Rights and Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat code announcement with posttest given. 10. The DON, Clinical Coordinators and MDS Coordinators will perform a mock code Nurse Stat daily starting [DATE] on first and second shifts (facility deploys 12 hour nurse rotations) until substantial compliance is achieved. Once substantial compliance is achieved, daily mock code Nurse Stat per shift will continue for one month and then weekly thereafter on a continual basis or until advised by the QAPI committee. The Mock Code Evaluation Checklist will be used as a quality assurance instrument with all areas of improvement noted and corrected immediately on the spot and reported at the following QAPI committee meeting. 11. The Clinical Coordinator conducted a new Facility Assessment in abaQIS (the facility's Electronic Record System) on [DATE]. Results of facility assessment will be presented during ad hoc QAPI meeting on [DATE]. Recommendations made by QAPI committee will be implemented immediately. 12. The Human Resources Manager audited all nursing personnel files between [DATE] and [DATE] to include: verification of credentials and evidence of verification prior to hire for CPR certification (as appropriate), licensure, TB testing and background checks. 13. In-Service Education was conducted on [DATE] by the DON, Clinical Coordinators, and MDS Coordinators provided to twenty-nine (29) of thirty-four (34) licensed nursing staff with no staff member permitted to work without first receiving education. The education was on Baseline Care Plans, Care Plan Policy and Behavior Documentation with emphasis training for the Charge Nurses related to implementing care plan interventions and discretion to implement one on one care as needed and per the physician's orders [REDACTED].>14. In-Service Education was provided on [DATE] through [DATE] by the DON and Clinical Coordinators to sixty-five (65) of one-hundred three (103) nursing staff, with no staff member permitted to work without first receiving education including licensed and certified staff on Accidents and Supervision per the Care Plan. 15. All education will be added to orientation for new hires and distributed to contract staffing organizations for agency staffing to be educated prior to working at the facility. The facility Scheduler will track and monitor for any staff member who has not received all appropriate training. The facility Scheduler will notify the DON and/or Clinical Coordinators who will be responsible for ensuring that training is provided to all appropriate staff members prior to working their next regularly scheduled shift. 16. On [DATE] the daily Walking Shift Report was assigned to the facilities ancillary department managers who are certified or license including MDS Coordinators, Activities Director, Scheduler, Central Supply Manager, Medical Records, and Environmental Services Manager providing managerial supervision for all seven (7) neighborhoods. The reports document room number, resident name, meal percentage, bath/shower, perineal-care needs, if the resident is in or out of bed at shift change, if the resident was turned every two (2) hours, vital signs, oral care, behaviors and any other comments as needed. The Walking Shift Report is signed by the neighborhood Charge Nurse prior to the SRNA's completing shift change and placed in the Managers bin on each neighborhood for collection and review the following morning during clinical meeting as a quality assurance system with all areas for improvement noted on the daily follow up sheets and distributed back out to each neighborhood Charge Nurse. The weekend nursing Clinical Coordinator will ensure that all Walking Shift Reports are monitored over the weekend. The DON, Clinical Coordinators and MDS Coordinators will utilize this system as a monitoring instrument for assuring care plans are updated and interventions are being implemented appropriately. 17. The Corporate Compliance Officer/Human Resources Director provided education on [DATE] covering the below topics with the Administrator and DON. A) Job Descriptions: which identify management as having responsibility to ensure overall safety within the facility B) Policies and Procedures: for mitigating risk of accidents/incidents and follow-up should one occur. C) Forms: for the purpose of detailing necessary steps and provide overall documentation of actions taken following an accident/incident. 18. On [DATE] an Ad Hoc QAPI meeting was held with an additional meeting held on [DATE] and the next scheduled for [DATE] then weekly on Thursday as continued monitoring until recommendation for alternate meeting schedule will be determined. 19. On [DATE] the Interdisciplinary Team (IDT) reviewed the past 90 days risk management events ensuring a root-cause analysis was performed and proper supervision was provided at the time based on the residents care plan with no adverse outcomes due to supervision. Risk Management events included falls, bruising, skin tear, resident to resident events, elopement and other traumatic injury. The IDT team consists of DON, Clinical Coordinators, MDS Coordinators and Social Service. 20. On [DATE] the DON provided one-on-one education to all staff that cared for Resident #1 on [DATE] between 2:00 PM to 5:00 PM covering Code Status, Emergency Response, Care Plan and Supervision. 21. Social Services will audit all Emergency Binders weekly starting [DATE], ensuring resident code status is accurate and available on each neighborhood. Results of the audits will be documented on a log presented at the next QAPI committee meeting. The Admissions Director and Social Services Directors completed chart audits on every resident comparing the Advance Directives to the physician's orders [REDACTED]. 22. A Quality Assurance Performance Improvement Project was implemented. The DON was monitoring for code status compliance by interviewing staff about facility CPR policy and procedure, as well as requesting return demonstration of CPR process. Compliance checks will be conducted two (2) times weekly for three (3) months. Findings will be reported at monthly QAPI Committee meeting. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the Facilities Policies Log Sheets revealed the Administrator reviewed and updated facility policies and procedures between [DATE] and [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he conducted a review/update of all facilities policy and procedures between [DATE] and [DATE]. He further stated the updates were documented on a log for review at the ad hoc QAPI meeting held on [DATE]. 2. Review of the new facility operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response revealed they were reviewed and revised on [DATE] through [DATE]. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed they developed and executed the following operational guidelines to include: Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status and Medical Emergency Response on [DATE] through [DATE]. 3. Review of the Disaster Preparedness Manual revealed the announcement of code blue to Nurse Stat on [DATE] by the Administrator and DON. Nurse Stat is now the facility's universal nurse emergency announcement including but not limited cardiopulmonary events requiring appropriate nursing staff to respond to emergency code book and crash carts for all facility emergencies. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed, Nurse Stat is now what is announced overhead. Further interview revealed it replaced Code Blue. Per interview appropriate nursing staff respond and they are to get the Binder from the nurse's station each time it's announced along with crash carts. Interview with the DON on [DATE] at 1:34 PM and the Administrator on [DATE] at 2:00 PM revealed Nurse Stat is now the universal nurse emergency response announcement. 4. Review of In-Service Sheets dated [DATE], revealed the DON, Clinical Coordinator, MDS Coordinators, Activities Director, Scheduler, Central Supply, Medical Records, Environmental Services, Senior Clinical Coordinator were educated on Walking Shift Report and Room Rounds by the Administrator. Interview with DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, MDS Coordinator on [DATE] at 12:53 PM, Activities Director on [DATE] at 12:44 PM, revealed they were educated on Walking Shift Report and Room Rounds by the Administrator on [DATE]. Interview with the Administrator on [DATE] at 2:00 PM, revealed he educated all of the Leadership Team on Walking Shift Report and Room Rounds. Per interview they have been implemented and the forms are discussed in QAPI. 5. Review of In-Service Sign in Sheets dated [DATE], revealed the Admissions Director, Social Services Directors, DON, Clinical Coordinator and MDS coordinator were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with DON on [DATE] at 1:34 PM, Social Services Director on [DATE] at 2:34 PM, Clinical Coordinator on [DATE] 1:03 PM and MDS Coordinator on [DATE] at 12:53 PM, revealed they were in-serviced by the administrator on [DATE] on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement. Interview with the Administrator on [DATE] at 2:00 PM revealed, he in-serviced the Admissions Director, Social Services Directors, DON, Clinical Coordinator and MDS coordinator were educated on Provision of Quality of Care, Resident Rights, Advance Directives, Communication of Code Status, Medical Emergency Response and Nurse Stat announcement on [DATE]. 6. Review of Emergency Code Binders on each neighborhood revealed a Face Sheet for each resident to include code status. The binders also included the following policies, Resident Rights, Advance Directives, Communication of Code Status, and Medical Emergency Response. The Binders are stored in the cabinet above the nurse's station and each Binder is brought to each announcement of Nurse Stat. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, revealed the Emergency Response Binders were located on each neighborhood in the cabinet above the nurses station. Further interview revealed the Binders had face sheets of each resident that included code status. Per interviews Mock Emergency Response Drills are being conducted two times per day from the Management Team and each Binder is brought to every announcement of Nurse Stat. 7. Review of care plan focus category titled Advanced Directives was initiated in Point Click Care (PCC) resident electronic medical record. This category was developed on [DATE] by the Facility Clinical Coordinator. Record review of Resident #1, #2, #3, #4, #5, #6, #7 and #8 electronic records revealed this care plan focus category was on each residents' care plan. Interview with Kentucky Medication Aide (KMA) #1 on [DATE] at 10:35 AM, SRNA #13 on [DATE] at 10:41 AM, LPN #10 on [DATE] at 10:49 AM, SRNA #14 on [DATE] at 11:20 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, SRNA #15 on [DATE] at 11:35 AM, LPN #13 on [DATE] at 11:40 AM, SRNA #10 on [DATE] at 11:44 AM, SRNA #16 on [DATE] at 11:47 AM, SRNA #17 on [DATE] at 11:53 AM, DON on [DATE] at 1:34 PM, Clinical Coordinator on [DATE] at 1:03 PM, and MDS Coordinator on [DATE] at 12:53 PM, revealed the new care plan focus category was added to PCC for each resident in their medical record. 8. Review of the Care Plan Audit Log dated [DATE] and [DATE] revealed all residents care plans were updated by the MDS and Clinical Coordinators. The audit log consisted of: noting compliance in the areas of duplicate care plans, care plan intent, obtainable care plan, proper intervention and focus, resident centeredness, code status, and any care plans requiring resolution with a special focus with resident behaviors and supervision. Social Services updated all behavior care plans as necessary. Interview with LPN #10 on [DATE] at 10:49 AM, LPN #7 on [DATE] at 11:26 AM, LPN #18 on [DATE] at 11:31 AM, LPN #13 on [DATE] at 11:40 AM, MDS Coordinator on [DATE] at 12:53 PM, Clinical Coordinator on [DATE] at 1:03 PM, Social Services on [DATE] at 1:13 PM and the DON on [DATE] at 1:34 PM, revealed all care plans were reviewed and updated. Further interview revealed the Charge Nurses, Social Services and Clinical Coordinators were responsible for on-going updates to the care plans. 9. Review of In-Service Sign- (TRUNCATED)

Based on interview, record review, review of facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to have an effective system to review and revise the Comprehensive Care Plan for one (1) of nine (9) sampled residents (Resident #1), when the resident exhibited changes in behavior. Resident #1 was admitted to the facility on [DATE], and a Wander Guard/Roam Alert bracelet (a tracking device designed to prevent persons at risk for wandering from leaving the facility, unaccompanied) was provided on 09/11/18. The resident's Wanderguard was discontinued on 09/17/18, as the resident was not observed wandering beyond the Maple Unit during the first week of admission, per staff interview. The Comprehensive Care Plan initiated 09/10/18, and revised 09/24/18, revealed the resident had the potential for adjustment problems related to new placement and wandering, with the goal initiated 09/18/18 and revised 10/05/18, stating the resident would not leave the neighborhood unassisted. However, there was no documented evidence of interventions to be implemented in order to attain this goal. On 10/06/18 at approximately 10:50 AM, Resident #1 wandered sixty-three (63) feet from the Maple Unit to the vicinity of two (2) elevators without staff's knowledge, and was assisted back to the Maple Unit by staff assigned to another unit. Although the Maple Unit Nurse/Registered Nurse (RN) #1 informed the Unit Manager of the resident's wandering behavior, there was no documented evidence of a revision to the Comprehensive Care Plan related to the new behavior of wandering off the unit, with interventions to be implemented to prevent further occurrences. On 10/06/18 at 2:57 PM, Resident #1 walked by the facility's lobby Receptionist, exited the building without staff's knowledge, walked across a busy two (2) lane road, and was located by a staff member four-tenths (0.4) of a mile from the facility. Resident #1 was returned to the facility at 3:20 PM and assessed with [REDACTED]. The facility's failure to have an effective system in place to ensure the Comprehensive Care Plan was reviewed and revised has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 10/11/18, and determined to exist on 10/06/18. The facility provided an acceptable Allegation of Compliance (AoC) on 10/18/18, with the facility alleging removal of the Immediate Jeopardy on 10/16/18. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 10/16/18, prior to exit on 10/23/18, with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Policy titled, Care Plans, revised 10/30/17, revealed the comprehensive care plan would be prepared by an interdisciplinary team of health care professionals and would identify which discipline(s) were responsible for carrying out the approaches and interventions. The care plan would be updated based on the target dates used for each goal by the interdisciplinary team, as well as anytime the plan of treatments or resident needs dictate. The comprehensive care plan would incorporate risk factors as applicable, identify strengths and weaknesses and reflect treatment or refusals of treatment. Further review revealed the care plan was designed to maintain the residents' current status or assist the resident to attain his/her highest potential while respecting the resident rights and choices. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised on an ongoing basis to reflect changes in the resident and the care the resident received. Review of Resident #1's Medical Record revealed the facility admitted the resident on 09/10/18 with [DIAGNOSES REDACTED]. Review of the Admission Nursing Assessment, dated 09/10/18 at 7:20 PM, unsigned, revealed Resident #1 was admitted from the hospital, was ambulatory, and had an admitting [DIAGNOSES REDACTED]. The Elopement Risk Assessment Section of this Assessment, revealed Resident #1 was assessed to not be at risk for elopement. Review of Resident #1's Baseline Care Plan, dated 09/10/18, under the Social Service Section, revealed the resident had Dementia and behavior concerns of wandering behavior, and a wanderguard (Roam Alert bracelet) was in place. The Social Worker signed this section on 09/12/18. Review of the (MONTH) (YEAR) Monthly Physician's Orders, revealed an order for [REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 09/17/18, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) Score of five (5) out of fifteen (15), indicating the resident was severely cognitively impaired. Per the MDS Assessment, wandering behavior occurred one (1) to three (3) days during the look back period. Review of the Care Area Assessment (CAA) Worksheet, dated 09/18/18, triggered by the MDS assessment dated [DATE], revealed wandering was identified as an Actual Problem/Need, as Resident #1 had been noted to exhibit wandering behavior on the unit, but had made no attempts to exit. Additional review revealed cognition was identified as an Actual Problem/Need, as Resident #1 fluctuated greatly with cognitive abilities and would appear lucid one minute and express severe cognitive impairments the next. Review of the OBRA Ancillary Assessment, dated 09/18/18, under the Elopement Risk Section, revealed the subsection titled Actual Elopement Risk Factors had a check mark next to none assessed, and the subsection titled Potential Elopement Risk Behaviors had a check mark next to wanders aimlessly. There was also a note documented in this section stating the resident was noted to wander, but on 09/17/18 per Nursing Notes, the wanderguard was discontinued due to no wandering/elopement behavior noted. Review of Resident #1's Comprehensive Care Plan revealed a focus problem initiated 09/10/18, revised 09/24/18, which stated the resident had the Potential for adjustment problems related to new placement and wandering. The goal which was initiated 09/18/18, revised 10/05/18, revealed the resident would not leave the neighborhood (Maple Unit) unassisted. The interventions included the following: allow resident to participate in daily care and decisions; allow to express feelings; encourage socialization; and orient to surrounding. However, there was no documented evidence of interventions related to the goal, in an attempt to keep the resident from leaving the neighborhood unassisted. Additionally, there was no documented evidence of specific interventions to address Resident #1's wandering and/or exit seeking behaviors. Review of the Comprehensive Care Plan, revealed a focus problem initiated 09/11/18, revised 09/18/18, which stated the resident was an Elopement Risk related to either history of elopement, purposeful wandering, exit seeking behavior, observed packing belongings, or potential to learn the door code. The goal initiated 09/18/18, revealed the resident would make no attempt to exit seek. However, the only intervention listed was initiated 09/11/18, revised 09/18/18, and stated I need staff to determine cause for wandering, what is my unmet need? This Care Plan focus problem and intervention was resolved (discontinued), on 09/18/18; however, the goal remained with no specific interventions to be implemented related to the goal. Review of Resident #1's Progress Note dated 09/17/18 at 11:33 AM, completed by RN #1, revealed the resident was notified the wanderguard was discontinued, no wandering and elopement behavior noted. Review of the Physician's Order, dated 09/17/18, revealed new orders for the Wander Guard to be discontinued. Review of the Plan of Care Note, dated 09/18/18, at 3:56 PM, completed by Unit Manager (UM) #1, revealed Resident #1 made no attempt to leave unit unassisted, will discontinue wanderguard. Review of the Progress Note, dated 10/06/18 at 1:19 PM, completed by RN #1, revealed the resident was re-directed away from the elevator by staff, had mild confusion, and stated he/she was going to call his/her nephew. Per the Note, the resident was placed on every thirty (30) minute checks. Interview with SRNA #1, on 10/09/18 at 2:41 PM, revealed she was returning to the Magnolia Unit from her break on 10/06/18, when she found Resident #1 out of his/her neighborhood (Maple Unit) and standing in the hallway near the staff time clock and service elevators. SRNA #1 stated she asked Resident #1 if he/she needed help and the resident revealed he/she was looking for a phone book. Per interview, SRNA #1 assisted Resident #1 back to the Maple Unit neighborhood and told SRNA #7 and SRNA #14 who were working the Maple Unit, she had found Resident #1 wandering in the hallway outside the Maple Unit near the elevators, and thought the resident was trying to leave the facility. Interview with RN #1, on 10/10/18 at 9:47 AM, revealed he worked on the Maple Unit and was very familiar with Resident #1's wandering behaviors. Further interview revealed on 10/06/18, he was assigned to Resident #1 on the Maple Unit, and at approximately 11:00 AM on that date, the resident was brought back to the Maple Unit nursing station by SRNA #1. Per interview, he was informed by SRNA #1, the resident had been found wandering unassisted near the staff time clock between the elevators in the hallway outside the Maple Unit neighborhood. He stated Resident #1 wandered on the unit, but the behavior of wandering out of the unit unassisted was a new wandering behavior for the resident. RN #1 stated he contacted UM #1, to report Resident #1's behavior and was instructed to initiate visual checks of the resident's location every thirty (30) minutes. Per interview, he began visualizing and recording Resident #1's location every fifteen (15) minutes on 10/06/18 beginning at 11:30 AM, with the last documented recording revealing the resident was on the Maple Unit in hall at 2:45 PM. However, there no documented evidence the Comprehensive Plan of Care was reviewed and revised on 10/06/18, when Resident #1 left his/her neighborhood unassisted by staff and was found by another unit's staff member, in the hallway near the service elevators. Review of the Progress Note, dated 10/06/18 at 3:20 PM, completed by RN #1, revealed staff was unable to directly locate Resident #1 on the Maple Unit and a Code Ten (10) (procedure for missing resident) was initiated. Continued review revealed the Resident was returned to the facility via the Unit Manager's truck. Per the Progress Note, the resident stated he/she was headed home. Observation of Resident #1, on 10/09/18 at 10:42 AM, revealed the resident had a sling to the left arm, and was wearing a Wander Guard/Roam Alert bracelet. Interview was attempted during the observation, and the resident stated he/she had never left the building. Further interview with RN #1, on 10/11/18 at 10:47 AM, revealed the MDS Nurse developed and revised the Comprehensive Care Plans with the MDS Assessments, and the Unit Managers revised the Comprehensive Care Plans between MDS Assessments for changes in resident's status. Per interview, when Resident #1 was found wandering outside the unit and in the hallway near the elevators on 10/06/18, this was a new behavior for the resident, and the resident's Care Plan should have been revised related to this new behavior with interventions to prevent reoccurrence. However, he stated he did not know how soon the Care Plan was to be revised when new behaviors were noted. Additional interview revealed Resident #1's Comprehensive Care Plan was not complete related to wandering behavior, as the goal for the resident to not leave the neighborhood unassisted had no specific interventions to guide staff when wandering behavior occurred. Interview, on 10/09/18 at 11:08 AM and 10/11/18 at 11:39 AM, with Unit Manager #1, revealed the facility's process was for the Comprehensive Care Plans to be developed and revised by the MDS Nurse with the MDS Assessments. Per interview, the Unit Managers were to update/ revise the care plan when there were changes in the residents status between MDS Assessments. However, per interview, when there were changes in the resident's status or behavior, the Care Plan did not have to be revised immediately, and was usually revised within a few days. Further interview revealed on 10/06/18, when RN #1 informed her Resident #1 was found outside of the neighborhood unassisted and without staff 's knowledge near the service elevators, she did not revise the resident's Care Plan. Per interview, this was because she did not think Resident #1 was exit seeking or had a new behavior. Further interview revealed the care plan focus areas should include goals and specific interventions to attain the goal. Per interview, she did not know why Resident #1's wandering behavior goal of not leaving the neighborhood unassisted, was not revised with specific interventions in order to attain the goal. Interview with the Clinical Coordinator, on 10/11/18 at 6:26 PM, revealed the MDS nurse who developed Resident #1's Comprehensive Care Plan was off on leave; however she was supervisor to the MDS nursing staff and could answer questions regarding Care Plans. Per interview, the MDS nurse was responsible to develop and revise care plans with the MDS Assessments and the Unit Managers were to revise the Care Plans with resident changes between MDS assessments. She stated Care Plans should have problem areas identified by the facility with goals and specific interventions to be implemented in order to attain that goal. Per interview, Resident #1's Comprehensive Care Plan initiated 09/10/18, revealed the facility had identified a problem of wandering with a goal stating the resident would not leave the neighborhood (unit) unassisted. She stated the goal initiated 09/18/18 stating the resident would not leave the neighborhood unassisted should have had specific interventions listed on the Care Plan in order for the staff to implement the interventions when wandering behavior was noted in order to attain that goal. Further interview revealed on 10/05/18, the MDS nurse reviewed the resident's wandering Care Plan and goal; however, again did not ensure there were interventions related to the goal. Additional interview revealed on 10/06/18, Resident #1's care plan should have been revised by the Unit Manager when Resident #1 left the resident's neighborhood unassisted and without staff's knowledge and was found near the service elevators by staff from another unit, in an attempt to prevent further occurrences of wandering off the unit, or elopement. Interview with the Director of Nursing (DON), on 10/11/18 at 6:39 PM, revealed the MDS nurse was responsible to develop and revise the comprehensive care plans with the MDS Assessment, and the Unit Managers were ultimately responsible to update/revise the care plan with any changes, behaviors or new Physician's Orders between MDS Assessments. Per interview, the Care Plan should be updated/revised on the same day a change in the resident's status was noted. Per interview, when Resident #1 left his/her neighborhood unassisted by staff and was found by another unit's staff member in the hallway near the service elevators, on 10/06/18, the Care Plan should have been revised with interventions to be implemented in an attempt to prevent this new behavior, as per the facility's policy. Further interview revealed Resident #1's care plan for wandering was not complete and should have had specific interventions to guide staff when the resident was exhibiting wandering or exit seeking behavior. Interview with the Administrator, on 10/11/18 at 7:47 PM, revealed the MDS nurse was responsible for developing and revising the Comprehensive Care Plan with the MDS Assessments and the Unit Manager was responsible for updating/revising the care plan with new Physician's orders or with changes in the resident's condition, status, or behaviors, between MDS Assessments. Per interview, these revisions needed to be completed as soon as possible. Further, Resident #1's wandering Care Plan with a goal to not leave the neighborhood unassisted should have had specific interventions as this was a reference for staff to provide necessary care for the resident. Per interview, Resident #1's goal stating, no attempt to exit seek, initiated on 09/18/18, should have had specific interventions documented. Continued interview revealed Resident #1's Comprehensive plan should have been revised on 10/06/18, when Resident #1 left his/her neighborhood unassisted by staff and was found by another unit's staff member, in the hallway near the service elevators with interventions to be utilized to prevent the resident from leaving the unit. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/18/18, with the facility alleging removal of the Immediate Jeopardy on 10/16/18. Review of the AoC revealed the facility implemented the following: 1. On 10/06/18, Resident #1 returned to the facility, and was assessed by the Nursing Supervisor with no injuries noted. The resident's physician and responsible party were notified. 2. On 10/06/18, the Administrator and Charge Nurses reviewed the facility's camera footage related to Resident #1's elopement. On 10/08/18, the Unit Managers reviewed the facility's camera footage related to the resident's elopement. 3. On 10/06/18, the Director of Nursing (DON) completed an Elopement Risk Assessment on Resident #1 and a Wander Guard/Roam Alert was ordered and applied. Every fifteen (15) minute activity awareness checks were initiated. Resident #1's Comprehensive Care Plan was updated by the Unit Manager to meet current resident care needs. 4. Starting 10/06/18 through 10/08/18, all residents were re-assessed for elopement potential utilizing the Nursing Elopement Assessment by the DON/Unit Managers. On 10/08/18, all resident care plans were reviewed/updated by the Unit Managers or MDS Nurses for any changes found on the elopement assessment. On 10/06/18 through 10/08/18, the Elopement books were updated by the Unit Managers to reflect current elopement assessments. 5. On 10/08/18, the Maintenance Director and facility Maintenance Manager checked all the doors in the facility to ensure all doors were locked and secured and that delayed egress was functioning properly. On 10/11/18, the door alarm company came onsite to assess the system for any issues. 6. On 10/08/18, the facility designated Training Unit Managers were given a training list created by the DON, Clinical Coordinator, Assistant Administrator, and Administrator as the result of the Elopement Event. The Training Unit Managers were educated on observing suspicious individuals on facility property, facility sign in/out sheet, facility visitor badges, Code 10, and Wander Guard/Roam Alert placement. A posttest was given after the training. 7. Starting 10/08/18 through 10/15/18, all staff were educated by the designated Training Unit Managers related to Code 10, observing suspicious individuals on facility property, Wander Guard/Roam Alert placement for all wandering behavior, the facility sign in/out guidelines and facility visitor name badges. A posttest was given with 100% score achieved for all staff with re-education performed for any incorrect answers and re-tested . One hundred and forty-two (142) staff members out of one hundred eighty-nine (189) received the education by 10/15/18, with no staff members permitted to work without receiving the training prior to working. In addition, on 10/13/18 through 10/15/18, one hundred and five (105) out of one hundred eighty-nine (189) staff were educated on the facility's Wandering Resident Elopement Risk Assessment Policy, including guidelines by Unit Managers, with no staff permitted to work without first receiving the education beyond 10/15/18. Verbal competency acknowledgement was obtained by the Unit Managers for all staff at the time of the training. 8. On 10/09/18, an elopement drill was conducted by the Administrator to ensure staff compliance with the Code 10 Policy. An elopement drill will be completed weekly on each shift beginning the week of 10/15/18 by maintenance staff until Jeopardy is abated, and will be conducted quarterly on each shift after. 9. On 10/10/18, Resident #1 was discharged to a secured memory care placement. 10. On 10/11/18, the Unit Manager created Care of the Wandering Resident Guidelines. 11. On 10/11/18, the facility conducted a Quality Assurance Performance Improvement (QAPI) meeting to review the AoC plan in its state at that time, with all Unit Managers in attendance. A second meeting was conducted with the DON, Clinical Coordinator, Assistance Administrator, and the Administrator on 10/12/18, to formalize and document the training plan. The lead Training Unit Manager was educated on the training plan on 10/12/18. An educational review with all Unit Managers was conducted on 10/13/18, prior to initiation of staff education. 12. Starting 10/13/18 through 10/15/18, thirty-five (35) out of forty-nine (49) State Registered Nursing Assistant (SRNA) received education by the Unit Managers on documentation of wandering in the daily SRNA mandatory Point Click Care resident documentation tasks. No staff member will be permitted to work without first receiving education with agency staff educated prior to working beyond 10/15/18. 13. Starting 10/13/18 through 10/15/18, twenty-seven (27) out of twenty-nine (29) nurses were educated by the Unit Managers related to: behavior documentation with emphasis on wandering and new behaviors; expectations of nurses for responding, managing, and charting alerts with emphasis on change in status; changes to the Twenty-four (24) Hour Report to now include communication of new behaviors and changes to the care plan. Changes to the care planning included: nurse on the floor to initiate care plans, set goals and interventions; and review of the care plan to include one (1) review note validating a review of behavior care plans, goals and interventions. Agency staff will be educated prior to working beyond 10/15/18. 14. Starting 10/13/18 through 10/15/18, the Assistant Administrator and/or Unit Manager educated the Weekend Manager and the Weekend and Evening Supervisors related to weekend/evening Quality Assurance (QA) Supervisor Report and QA call to each neighborhood requesting change in resident status, change in residents' behavior, and behavior reporting which included generating the behavior documentation reports from Point Click Care - Electronic Medical Record (EMR). A verbal competency acknowledgement was obtained by the Unit Manager for all staff at the time of training. On 10/15/18, the Social Service Director was educated by the Assistant Administrator related to the Care Conference Procedure to include Interdisciplinary Team (IDT) review and revision of the care plan with resident or responsible party involvement during the care conference. A printed copy of the Care Plan will be distributed to the resident and family/responsible party at the end of the care conference meeting. 15. On 10/15/18, twenty-two (22) out of thirty (30) MDS staff, Social Service staff, Registered Dietician (RD) and Therapy staff received education related to: review of the care plan to include one (1) review note validating review; changes to the Twenty-four (24) Hour Report regarding communication of new behaviors; and changes to care plans. A verbal competency acknowledgement was obtained by the Unit Manager for all staff at the time of training with no staff permitted to work without first receiving education by the Unit Manger. 16. Orientation for all new hires and Agency staff will include: Wandering Resident Elopement Risk Assessment Policy including guidelines; Code 10; observing suspicious individuals on facility property; new wander guard/roam alert protocol including discontinuing a Wander Guard/Roam Alert; programing a Wander Guard/Roam Alert; Wander Guard/Roam Alert placement for all wandering behavior; facility sign in/out guidelines; facility visitor badge guidelines; behavior documentation with emphasis on wandering and new behaviors; expectations of nurses for responding, managing, and charting alerts; changes to the Twenty-four (24) Hour Report; changes in care plan procedure (nurse on the floor to initiate care plans, set goals, and interventions, and review of the care plan to include one (1) review note validating review of behavioral care plans, goals, interventions); and documentation of wandering in the daily SRNA mandatory Point of Care documentation tasks. A posttest will be given with 100% score achieved for all staff with re-education performed for any incorrect answers and posttest retaken. 17. By 10/15/18, the Director of Nursing, Unit Mangers, Clinical Coordinator and Weekend Manager reviewed all Incident/Accident Reports for the previous thirty (30) days to identify any concerns of suspected lack of supervision, new, worsening, or exit seeking behaviors. 18. On 10/15/18, the Activities Director re-assessed all activity care plans and needs to ensure all the care plans were individualized and met the resident's needs. Unit Managers audited one hundred percent (100%) of the care plans for appropriate goals and interventions related to wandering residents. 19. The Unit Managers will review the care plans daily for those residents experiencing a change in status related to wandering, to ensure new or modified interventions have been addressed and documented regarding the resident's care until jeopardy is abated. The DON will validate that the Unit Manager reviews care plans daily during the morning QA Clinical Meeting by reviewing the Unit Managers' tracking tool. 20. The IDT consisting of the DON, Assistant Administrator, Clinical Coordinator, Unit Managers, RD, Social Service Director (SSD), and MDS staff will review each Incident Report daily during daily morning QA clinical meeting to ensure appropriate interventions were implemented and the plan of care was updated until Jeopardy is abated. The DON will validate daily utilizing a tracking tool during the morning QA Clinical Meeting that the review was complete. 21. The Administrator will audit the Salto door monitoring system daily until Jeopardy is abated and then weekly for four (4) weeks. 22. Daily mandatory wandering documentation tasks and alerts for all residents have been created in the SRNA Point Click Care by the Clinical Coordinator on 10/15/18. Each shift the facility's SRNAs will document specific wandering behaviors on all residents for the nurse to follow up. 23. On 10/15/18, a new protocol for updating care plans was executed. The nurse on the floor will now be expected to update the care plan to include initiation of the care plan, creation of care plan goals, and establishment of care plan interventions as individualized as possible. All care plan revisions will be documented in a care plan revision note. All care plan revision notes will be reviewed during daily morning QA (clinical) meeting Monday through Friday. 24. On 10/15/18, a new protocol was implemented for monitoring resident status. During the week (Monday - Friday) on day shift, the Unit Managers will review behavior documentation reports, then perform a QA call to each neighborhood documenting a QA report daily for each neighborhood. During the evenings (Monday - Sunday), the supervisor will utilize the reports to conduct a QA call to each neighborhood and document a daily QA report for each neighborhood. During the weekend (Saturday - Sunday), the weekend manager will run and distribute behavior documentation reports for the past seven (7) days to the supervisor. The supervisor will utilize the reports to conduct a QA call to each neighborhood and document a daily QA report for each neighborhood. All QA reports will be reviewed by the DON daily on the communication board to validate appropriate action was taken to ensure residents receive the highest practical physical, mental, and psychosocial wellbeing possible. The DON will conduct a chart review, ensure the care plan was updated with appropriate interventions and goals, validate physician orders, speak to the nurse, and observe the resident. The DON will monitor the resident Twenty-four (24) Hour Report, communication board, and behavior reports during morning QA meeting to evaluate for needed further interventions. A QA call consists of making contact with each neighborhood requesting any change in resident status and behavioral changes for all residents. 25. On 10/15/18, a new protocol for discontinuing a Wander Guard/Roam Alert was executed. Discontinuation of new Wander Guard/Roam Alert assessment in Point Click Care is performed by either the facility Care Nurse or Unit Manager. Discontinuation assessment is presented to the DON, and Clinical Coordinator, who will involve the IDT for determination. When the determination is made by the IDT to discontinue a Wander Guard/Roam Alert, the DON will contact the resident's legal representative requesting permission to discontinue the device. 26. On 10/15/18, a new addition to the Morning QA meeting was executed. The daily QA report will be reviewed during the Morning QA for validating appropriate action taken. The new Twenty-four (24) Hour Report will be reviewed during QA meeting for validating that appropriate action was taken. All care plans for those residents experiencing a change in status related to wandering will be reviewed for appropriate initiation, goals, and interventions as necessary. 27. On 10/15/18, a new protocol for individualizing a resident's care plan during the care conference was executed. The care plan for each resident during the care plan conference will be reviewed with the resident and/or representative. The care plans will be reviewed by the Social Service Director (SSD) to ensure the plan, goals, and interventions are individualized. A copy of the care plan will be distributed to the resident and/or representative. 28. By 10/15/18, every fifteen (15) minute activity awareness checks will be performed for all new admissions for seventy-two (72) hours. 29. On 10/15/18, all updated policies were posted in the locked employee announcement board for review until the QAPI Committee determines further action. 30. A Quality Assurance meeting was held on 10/08/18, with the Administrator, Assistant Administrator, DON, Clinical Coordinator, SSD, Central Supply, RD, Admissions Director, Administrative Assistant, Medical Records, MDS Staff, Nurse Scheduler, Environmental Service Director to review occurrence. The Medical Director was contacted by telephone. A second meeting was held on 10/11/18, with the Medical Director Administrator, Assistant Administrator, DON, Clinical Coordinator, Pharmacy Representative, RD, Activities Director, all Unit Mangers and the Restorative Nurse. The QAPI will meet monthly for recommendations and further follow up regarding the above stated plan. At that time, based upon evaluation of the QA Committee, it will determine at what frequency any ongoing audits will ne

Based on observation, interview, record review, review of the facility's Policies, and review of the facility's Investigation, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for one (1) of nine (9) sampled residents (Resident #1). The facility admitted Resident #1 on 09/10/18, and assessed the resident on that date, per the Elopement Risk Assessment, as not being at risk for elopement. On 09/11/18, the facility provided a Wander Guard/Roam Alert bracelet (a tracking device designed to prevent persons at risk for wandering from leaving the facility, unless they were accompanied) as a precautionary measure, per staff interviews. Staff interviews further revealed the resident was not observed wandering beyond the Maple Unit during his/her first week at the facility, and the Roam Alert bracelet was discontinued on 09/17/18, without another Elopement Assessment being completed. Review of the Comprehensive Care Plan initiated on 09/10/18, and revised on 09/24/18, revealed the resident had the potential for adjustment problems related to new placement and wandering. The goal initiated on 09/18/18 and revised on 10/05/18, revealed the resident would not leave the neighborhood unassisted. However, there was no documented evidence of interventions to be implemented related to this goal. On 10/06/18 at approximately 10:50 AM, Resident #1 wandered sixty-three (63) feet from the Maple Unit to the vicinity of two (2) elevators without staff's knowledge, and was accompanied back to the Maple Unit by staff assigned to another unit, with report given to the Maple Unit staff. Additional staff interviews revealed the Maple Unit Nurse/Registered Nurse (RN) #1 discussed the resident's wandering behavior with the Unit Manager; however, was not directed to utilize the Wandering Resident/Elopement Risk Assessment for this new exit seeking behavior in order to assess if the resident required a Wander Guard/Roam Alert bracelet, as per the facility's Policy. In addition, there was no revision to the Comprehensive Care Plan related to the new behavior of wandering off the unit, with interventions to prevent further occurrences. On 10/06/18 at 2:57 PM, Resident #1 walked by the facility's lobby receptionist, exited the building without staff's knowledge, walked across a busy two (2) lane road, and was found by a staff member four-tenths (0.4) of a mile from the facility. Resident #1 was returned to the facility at 3:20 PM and was assessed with [REDACTED]. (Refer to F-657) The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 10/11/18 and determined to exist on 10/06/18. The facility provided an acceptable Allegation of Compliance (AoC) on 10/18/18, with the facility alleging removal of the Immediate Jeopardy on 10/16/18. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 10/16/18, prior to exit on 10/23/18, with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Wandering Resident/Elopement Risk Assessment Policy, dated 03/29/18, revealed wandering was defined as movement about an area without a fixed goal, and elopement was defined as slipping away secretly, running away, or leaving without accompaniment or knowledge of staff. Further review revealed, residents should be evaluated for elopement risk at admission with each Omnibus Budget Reconciliation Act (OBRA) assessment (quarterly, annual or significant change) and any time a new wandering or exit seeking behavior was exhibited. The Elopement Assessment describes the steps to take depending on the results of the Assessment. Review of the attached Elopement Risk Assessment, under the Section titled, Potential Elopement Risk Behaviors, revealed one (1) or more potential risk behaviors, MAY require roam alert bracelet: resistant to care; hides from staff; packs belongings; on psychoactive medication due to agitation/mod disturbance; and, wanders aimlessly. Further, review of the Assessment, under the Section titled, Actual Elopement Risk Behaviors, revealed if one (1) or more of the following areas are checked, REQUIRES a roam alert bracelet: follows people out of exits; potential to learn door code; opens exit doors; observation of staff; will attempt to exit if not monitored; newly admitted with history of wandering from home or other setting; and, hovers at exits, seeks doors or exits. Review of the facility's Guidelines for Checking Roam Alerts Policy, dated 04/10/18, revealed residents were evaluated for elopement risk at admission, with each subsequent OBRA Minimum Data Set (MDS) Assessment (quarterly, annual, or significant change assessment) or at any time the resident begins to display wandering or exit-seeking behaviors. Further review revealed, use a stand-alone Elopement Assessment Form located in the Electronic Medical Record. Review of Resident #1's Medical Record revealed the facility admitted the resident on 09/10/18 with [DIAGNOSES REDACTED]. Review of the Admission Summary Note, dated 09/10/18 at 6:50 PM, completed by the Nurse Supervisor, revealed Resident #1 arrived to the facility per the family car and was alert and oriented to self, place and time. Per the Note, the resident had a sling to left elbow due to [MEDICAL CONDITION]. Continued review revealed the resident was not happy to be at the facility and his/her spouse, also a resident, didn't seem excited to see the spouse here. Per the Note, Resident #1 kept asking the nurse to send him/her back home. Further review revealed Resident #1 was refusing skin checks and seemed bothered by anyone's presence. Review of the Admission Nursing Assessment, dated 09/10/18 at 7:20 PM, unsigned, revealed the resident was admitted from the hospital, was ambulatory, and had an admitting [DIAGNOSES REDACTED]. The Elopement Risk Assessment Section of this Assessment, revealed the resident was assessed to not be at risk for elopement. Review of Resident #1's Baseline Care Plan, completed upon admission, dated 09/10/18, under the Social Service Section, revealed the resident had Dementia and behavior concerns of wandering behavior. Further, a wanderguard (Roam Alert bracelet) was in place. This section was signed by the Social Worker on 09/12/18. Review of Resident #1's (MONTH) (YEAR) Monthly physician's orders [REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 09/17/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of five (5) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed wandering behavior had occurred one (1) to three (3) days during the look back period. Review of Resident #1's Care Area Assessment (CAA) Worksheet, dated 09/18/18, and triggered by the MDS assessment dated [DATE], revealed wandering was identified as an Actual Problem/Need, as Resident #1 had been noted to exhibit wandering behavior on the unit, but had made no attempts to exit. Further review revealed cognition was identified as an Actual Problem/Need, as the resident fluctuated greatly with cognitive abilities and would appear lucid one minute and express severe cognitive impairments the next. Review of the OBRA Ancillary Assessment, dated 09/18/18, revealed Resident #1 was assessed to have difficulty with balance or poor trunk control; exhibit a loss of balance while standing; have decreased muscle coordination; and have an alteration in safety awareness due to cognitive decline. Continued review of the Assessment, under the Elopement Risk Section, revealed the subsection titled Actual Elopement Risk Factors had a check mark next to none assessed, and the subsection titled Potential Elopement Risk Behaviors had a check mark next to wanders aimlessly. There was a note documented in this section stating the resident was noted to wander; however, on 09/17/18 per Nursing Notes, the wanderguard was discontinued due to no wandering/elopement behavior noted. Review of the Comprehensive Care Plan, revealed a focus problem initiated 09/10/18, revised 09/24/18, stating the resident had the Potential for adjustment problems related to new placement and wandering. The goal initiated 09/18/18, revised 10/05/18, revealed the resident would not leave the neighborhood unassisted. The interventions included: allow resident to participate in daily care and decisions; allow to express feelings; encourage socialization; and, orient to surrounding. However, there was no documented evidence of interventions to be implemented related to the resident's wandering behavior. Review of the Comprehensive Care Plan, revealed a focus problem initiated 09/11/18, revised 09/18/18, stating the resident was an Elopement Risk related to either history of elopement, purposeful wandering, exit seeking behavior, observed packing belongings, or potential to learn the door code. The goal with initiated date of 09/18/18, revealed the resident would make no attempt to exit seek. However, the only intervention was initiated 09/11/18, revised 09/18/18, and stated I need staff to determine cause for wandering; what is my unmet need? This Care Plan focus problem and intervention was resolved (discontinued) on 09/18/18; however, the goal remained with no specific interventions to be implemented related to the goal. Review of the Progress Note dated 09/17/18 at 11:33 AM, completed by RN #1, revealed the resident was notified the wanderguard was discontinued, no wandering and elopement behavior noted. Review of the physician's orders [REDACTED]. Review of the Plan of Care Note, dated 09/18/18, at 3:56 PM, completed by Unit Manager (UM) #1, revealed the resident made no attempt to leave unit unassisted, will discontinue wanderguard. Review of Resident #1's Progress Note, dated 10/06/18 at 1:19 PM, completed by RN #1, revealed the resident was re-directed away from the elevator by staff. Per the Note, the resident had mild confusion and stated he/she was going to call his/her nephew. According to the Note, the resident was placed on every thirty (30) minute checks. However, there was no documented evidence Resident #1 was assessed for the new behavior of wandering utilizing the Wandering Resident/Elopement Risk Assessment, as per policy, when the resident was located off the Maple Unit, even though this was new wandering or exit seeking behavior for this resident. In addition, there was no documented evidence the Comprehensive Care Plan was revised related to the resident wandering off the Maple Unit, with revisions to prevent reoccurrence. Review of the Resident #1's Progress Note, dated 10/06/18 at 3:20 PM, completed by RN #1, revealed staff was unable to directly locate Resident #1 on the Maple Unit and a Code Ten (10) (procedure for missing resident) was initiated. Further review revealed the Resident was returned to the facility via the Unit Manager's truck. Per the Progress Note, the resident stated he/she was headed home. Review of the facility's Investigative Findings Report, undated, submitted for review by the Administrator, on 10/11/18, revealed the Nurse Supervisor (NS), indicated on Admission on 09/10/18, Resident #1 repeatedly asked to be sent back home; stated he/she did not want to remain in the facility; and repeatedly requested someone come to pick him/her up. Per the Report, the NS and Licensed Practical Nurse (LPN) #3 requested a physician's orders [REDACTED]. Further review of the Report, revealed the OBRA Assessment/Section A, Elopement Risk Assessment, dated 09/17/18, indicated no actual elopement risk behaviors were assessed; with wandering aimlessly listed as a potential elopement risk behavior. Per the Report, the Care Plan Progress Note, dated 09/17/18, stated Resident #1 had made no attempt to leave the unit unassisted, and a physician's orders [REDACTED]. Continued review of the Investigation Findings Report, revealed on 10/06/18 at approximately 11:20 AM, State Registered Nursing Assistant (SRNA) #1 found Resident #1 wandering near the staff time clock outside of the Maple Unit neighborhood and between two (2) elevators. Per the Report, SRNA #1 returned Resident #1 to the Maple Unit neighborhood, and reported to Maple Unit SRNA #7 and Maple Unit SRNA #14, she had found Resident #1 wandering in the hallway outside of the Maple Unit near the employee time clock. Further review revealed the resident stated he/she was looking for a phone book, and SRNA #1 thought the resident was trying to leave the facility. Per the Report, RN #1 initiated visual checks every thirty (30) minutes for Resident #1, and the resident was observed every fifteen (15) minutes from 11:30 AM to 2:30 PM, with the last documented sighting before elopement at 2:50 PM, by SRNA #7. Additional review of the Investigation Findings Report, revealed per the video footage, on 10/06/18, Resident #1 ambulated into the facility lobby, exited through the facility's main entrance at 2:57 PM, and left the facility property at 3:01 PM. Further review revealed at approximately 3:00 PM, SRNA #12 observed a person by the road at the end of the facility driveway and reported this to Unit Manager (UM) #1. Continued review revealed a Code Ten (10)/Missing Resident was announced by the Front Lobby Receptionist at 3:09 PM. Further review revealed Resident #1 was returned to the facility in UM #1's private owned vehicle and ambulated through the front lobby entrance door, with assistance by UM #1, at 3:19 PM. Per review, upon return to the Maple Unit neighborhood, Resident #1 was assessed by UM #1 with no noted health status changes, with hydration offered and accepted by the resident. Observation of the pictures from video footage on 10/06/18 at 3:20 PM, revealed the resident was wearing a long sleeve shirt, pants, and shoes, and had a sling to the left arm. Observation on 10/09/18 at 9:15 AM, of the elopement route, revealed Resident #1 would have ambulated from the Maple Unit neighborhood's main entry doors fifteen (15) feet to the elevator, and after taking the elevator from the second floor to the first floor, ambulated an additional seventy (70) feet from the elevator through the front lobby door, passing by the receptionist. The resident would have continued to ambulate through the facility parking lot to a busy two (2) lane road with no sidewalks. Further observation revealed the resident would have crossed the busy two (2) lane road and ambulated in a northwest direction and down a side country road, before being found by UM #1 four-tenths (0.4) of a mile from the facility entrance. Observation of Resident #1, on 10/09/18 at 10:42 AM, revealed the resident had a sling to the left arm, and was wearing a Wander Guard/Roam Alert bracelet. Interview was attempted during the observation. The resident stated he/she did not recall the elopement on 10/06/18, and stated he/she had never left the building. Interview with SRNA #1, on 10/09/18 at 2:41 PM, revealed she was assigned to the Magnolia Unit neighborhood on 10/06/18. Continued interview revealed she was returning to the Magnolia Unit neighborhood from her break on 10/06/18, when she found Resident #1 out of his/her neighborhood (Maple Unit) and standing in the hallway near the staff time clock and service elevators. Per interview, SRNA #1 asked Resident #1 if he/she needed help and the resident stated he/she was looking for a phone book. Further interview revealed SRNA #1 assisted Resident #1 back to the Maple Unit neighborhood and told SRNA #7 and SRNA #14 who were working the Maple Unit, she had found Resident #1 wandering in the hallway outside the Maple Unit and near the elevators, and thought the resident was trying to leave the facility. Interview with SRNA #7, on 10/10/18 at 1:04 PM, revealed she frequently provided care for Resident #1 on the Maple Unit. Per interview, she was assigned to the Maple Unit neighborhood on 10/06/18, and on that date at approximately 11:20 AM, she observed Resident #1 being escorted back to the Maple Unit by SRNA #1. She stated SRNA #1 told her Resident #1 had been found outside of the neighborhood and in the hallway near the service elevator. Continued interview revealed SRNA #1 reported the incident to RN #1 at 11:30 AM and RN #1 initiated visual checks of Resident #1's location every fifteen (15) minutes. SRNA #7 revealed although the resident normally wandered on the unit, wandering outside of the unit was a new behavior for this resident. Interview with RN #1, on 10/10/18 at 9:47 AM, revealed he had worked almost exclusively on the Maple Unit neighborhood for the last three (3) months and had provided care for Resident #1 during that time. Per interview, Resident #1 received the Wander Guard/Roam Alert bracelet as a precautionary measure because he/she was a new admission, and use of a Wander Guard during the first three-to-seven days after admission allowed staff to evaluate the resident to see if continued use of a Wander Guard was warranted due to a resident's behavior. RN #1 stated the Wander Guard was discontinued on 09/17/18 because the resident had not exhibited behavior of wandering off the unit, only wandering within the unit. Continued interview revealed on 10/06/18, he was assigned to Resident #1, and at approximately 11:00 AM on that date, the resident was brought back to the Maple Unit neighborhood nursing station by SRNA #1. RN #1 stated he was informed by SRNA #1, the resident had been found wandering unassisted near the staff time clock between the elevators in the hallway outside the Maple Unit neighborhood. Per interview, Resident #1 wandered on the unit since admission, but the behavior of being out of the neighborhood unassisted was a new wandering behavior for the resident and he was not aware the resident was off the neighborhood until the resident was accompanied back to the unit. Additional interview with RN #1, revealed he contacted UM #1, to report Resident #1's behavior and to receive instructions and guidance. Per interview, RN #1 was not instructed by UM #1 to complete an Elopement Risk Assessment, but was instructed to initiate visual checks of the resident's location every thirty (30) minutes. RN #1 stated, he began visualizing and recording Resident #1's location every fifteen (15) minutes beginning at 11:30 AM on 10/06/18, with the last documented recording prior to the elopement revealing the resident was on the Maple Unit in the hall at 2:45 PM. Further interview revealed checking the resident every thirty (30) minute checks was an appropriate intervention; however, he stated he should have assessed Resident #1 utilizing the Elopement Risk Assessment because this Assessment was to be utilized when warranted if new exit seeking behavior was observed or reported, and would indicate if a Wander Guard/Roam Alert bracelet was needed. Review of the Activity Log dated 10/06/18, revealed Resident #1's location was checked every fifteen (15) minutes from 11:30 AM to 2:45 PM. Interview with Unit Manager (UM) #1, on 10/11/18 at 11:39 AM, revealed she was the UM for the Maple Unit neighborhood and was familiar with Resident #1's wandering behaviors. She stated Resident #1's Wander Guard/Roam Alert bracelet was placed as a precautionary manner, until the resident's behavior could be observed. She further stated the resident's Wander Guard/Roam Alert bracelet was discontinued on 09/17/18 because although the resident was wandering on the Maple Unit, the resident had not exhibited exit-seeking behavior. Continued interview revealed on 10/06/18, RN #1 reported to her, Resident #1 had been found in the hallway outside the Maple Unit around the staff time clock by SRNA #1, and was accompanied back to the Maple Unit. UM #1 stated she instructed RN #1 to initiate visual checks of Resident #1's location every thirty (30) minutes; however, she did not instruct RN #1 to initiate the facility's Elopement Risk Assessment to find out if the resident was at risk for elopement, as per Policy. She stated this was because she did not think Resident #1 was exhibiting exit-seeking behaviors, and at the time she felt checking on the resident every thirty (30) minute checks was an appropriate intervention. Interview with SRNA #12, on 10/10/18 at 6:47 PM, revealed she was usually assigned to the River Birch Unit, and was not familiar with Resident #1. Further interview revealed on 10/06/18 at approximately 3:00 PM, she was on her break retrieving an article from her vehicle parked in the employee parking lot, when she noticed an older person waiting to cross the two (2) lane road in front of the facility. SRNA #12 stated as she walked toward the facility to re-enter the building, she saw UM #1 and reported the elderly person at the street. Continued interview revealed UM #1 immediately re-entered the building, and shortly after SRNA #12 arrived back on the River Birch Unit, she heard the announcement of a Code Ten (10) over the speaker system. Additional interview revealed SRNA #12 remained on River Birch Unit throughout the Code Ten (10) which was discontinued a few minutes later. Additional interview with UM #1, on 10/09/18 at 11:08 AM, revealed on 10/06/18 at approximately 3:00 PM, SRNA #12 reported to UM #1 she had seen an elderly gray haired person cross the two (2) lane road in front of the facility. Additional interview revealed UM #1 immediately went to the Maple Unit neighborhood and instructed RN #1 and the other staff to perform a head count of the residents. Per interview, it was determined from the head count, Resident #1 was missing. Further interview revealed UM #1 and RN #1 proceeded to the front lobby by taking different elevators to the first floor. Per interview, when they met in the front lobby without finding Resident #1, RN #1 directed the Receptionist to initiate a Code Ten (10) audio call over the facility speaker system. UM #1 stated she then left the facility in her private vehicle, to attempt to locate Resident #1. Continued interview revealed UM #1 visualized Resident #1 standing to the right side of the two (2) lane road, four-tenths (0.4) of a mile from the facility. Per interview, after assisting him/her into the vehicle, UM #1 called RN #1 at the facility to discontinue the Code Ten (10), and noted the time as 3:16 PM. She stated Resident #1 was then transported back to the front door of the facility, and UM #1 accompanied the resident as he/she ambulated back to the Maple Unit neighborhood. Additional interview revealed she assessed Resident #1 and noted no change in condition, and provided him/her with hydration. Additional interview with RN #1, on 10/11/18 at 10:47 AM, revealed on 10/06/18 at approximately 3:00 PM, he was informed by UM #1 that an elderly person was seen attempting to cross a two (2) lane road in front of the facility by SRNA #12 while she was in the facility parking lot on a break, and RN #1 ordered all Maple Unit staff to search the unit for Resident #1. Continued interview revealed Resident #1 could not be located on the Maple Unit, and RN #1 and UM #1 proceeded to search the second floor hallway and elevators, with each searching different routes, taking both the Passenger and Service Elevators to the first floor and lobby area. Additional interview revealed UM #1 and RN #1 arrived in the front lobby at 3:08 PM, without locating Resident #1, and at that time RN #1 instructed the Receptionist to announce by audio speaker system a Code Ten (10): Elopement Incident to all facility staff, which she did. Further interview with RN #1, revealed UM #1 stated she would use her personal vehicle to drive along the two (2) lane road to verify whether the person seen crossing the road was Resident #1, while RN #1 remained in the facility and directed a complete search of the facility and grounds according to the facility's Code Ten (10) policy. Continued interview revealed RN #1 received a phone report from UM #1 at 3:16 PM, stating she had located Resident #1 and was returning her to the facility. Per interview, UM #1 escorted Resident #1 through the front lobby door at 3:20 PM and both RN #1 and UM #1 escorted Resident #1 back to Maple Unit neighborhood. RN #1 stated he assessed Resident #1 upon return to the Maple Unit, with no injuries noted. Further interview revealed notifications were made to the Physician, the Director of Nursing, the Administrator, and Resident #1's Durable Power of Attorney (DPOA). Per interview, an order for [REDACTED]. Interview with the facility Receptionist, on 10/10/18 at 2:57 PM, revealed she was seated at the Reception Desk in the front lobby facing the main entrance doors, on 10/06/18, when Resident #1 eloped, and did not notice Resident #1 exit through the main door at 2:57 PM. Per interview, lots of people had entered and exited the facility through the main entrance that afternoon related to a party for a resident on the Personal Care Unit. Continued interview revealed, UM #1 and RN #1 arrived in the lobby shortly after 3:00 PM, and RN #1 asked if she had seen a someone wearing a green shirt and black arm sling exit the building, and when she answered, No, he instructed her to announce a Code Ten (10) over the speaker system, which she did. The Receptionist stated she then observed UM #1 leave the building. Per interview, when RN #1 received communication by walkie-talkie from UM #1 that she had found Resident #1 a few minutes later, RN #1 instructed her to discontinue the Code Ten (10), which she announced by speaker system in the facility. Additional interview revealed she remained at the Reception Desk monitoring the telephone until UM #1 assisted Resident #1 into the lobby through the main entrance. Phone interview with Resident #1's Durable Power of Attorney (DPOA), on 10/22/18 at 4:05 PM, revealed prior to Resident #1's admission, he would bring him/her to the facility to visit his/her spouse, Resident #2, on the Maple Unit. Per interview, after assisting Resident #1 to sign in with the Lobby Receptionist, he would allow the resident to navigate to the Maple Unit neighborhood by him/herself, and would leave to run errands. Continued interview revealed when he returned to the facility in two (2) to three (3) hours he would always go to the Maple Unit neighborhood to pick Resident #1 up and assist him/her in exiting the facility. Additional interview revealed once Resident #1 was admitted to the facility, he observed the resident always hung around the elevator when he visited; however, he never informed staff. Further interview revealed the DPOA was traveling out of the country when Resident #1 eloped on 10/06/18, and he was notified of the elopement by the facility per telephone after Resident #1 was returned to the facility. Phone interview with Resident #1's Physician, on 10/10/18 at 3:33 PM, revealed he initially ordered the Wander Guard/Roam Alert bracelet for Resident #1 on 09/11/18, as requested by a nurse related to Resident #1's wandering behaviors. Per interview, he discontinued the order on 09/17/18, when the nurse reported the resident was not exhibiting exit-seeking behaviors. Further interview revealed the Physician based his decision on the nurse's judgment regarding the necessity of using the Wander Guard/Roam Alert bracelet for Resident #1. Per interview, it was his expectation the facility staff would have knowledge of the resident's location and not allow the resident to leave the facility unassisted and without staff's knowledge. Phone interview with facility's Medical Director (MD), on 10/22/18 at 1:43 PM, revealed Wander Guards/Roam Alert bracelets were ordered for newly-admitted residents when nurses reported concerns that a new resident had a history of [REDACTED]. Per interview, if nurses reported no observations of these behaviors during the first week after admission, the Wander Guard/Roam Alert bracelet order would be discontinued. Further interview revealed when a resident exhibited new wandering or exit-seeking behaviors an Elopement Risk Assessment should be completed per the facility's policy. Per interview, she would order a Wander Guard/Roam Alert bracelet for a resident if she was informed the resident was exhibiting new wandering or exit-seeking behaviors. Interview with the Director of Nursing (DON), on 10/11/18 at 6:39 PM, revealed Resident #1's Elopement Risk Assessment performed on admission to the facility on [DATE], indicated he/she was not at risk for elopement. She stated there was no documentation indicating why a Wander Guard/Roam Alert bracelet was requested by nurses and ordered by the physician on 09/11/18; however, staff should have documented a note stating the reason for the Wander Guard/Roam Alert bracelet, with the physician's orders [REDACTED].#1's Wander Guard/Roam Alert bracelet was discontinued on 09/17/18, based on the judgment of nursing staff; however, per interview, there was no documented evidence an Elopement Risk Assessment was completed or documentation for criteria utilized for the removal of the Wander Guard/Roam Alert. Further interview revealed she felt it was an appropriate intervention for staff to implement the every thirty (30) minute checks on Resident #1 after he/she was found wandering unassisted near the staff time clock between the elevators in the hallway outside the Maple Unit neighborhood on 10/06/18; however, the intervention failed and the resident eloped. Additional interview revealed staff should also have assessed Resident #1 utilizing the Elopement Risk Assessment after Resident #1 was found off the Maple Unit neighborhood unassisted and without staff's knowledge, as per the facility policy. Continued interview revealed it was her expectation staff follow the facility's policy and complete an Elopement Risk Assessment any time a new wandering or exit seeking behavior was exhibited. She stated the importance of the Elopement Risk Assessment was to identify whether a resident was a safety risk because of new behaviors such as exit-seeking. Per interview, if exit seeking behaviors were identified, a Wander Guard could then be initiated, or in Resident #1's case, re-applied. Interview with the Administrator, on 10/11/18 at 7:47 PM, revealed it was his expectation nurses document rationale for requesting placement of, and discontinuance of, the Wander Guards/Roam Alert bracelets. Per interview, staff should have performed an Elopement Risk Assessment for Resident #1 on 10/06/18, when he/she was returned to the Maple Unit after being found wandering in the hall near the time clock and service elevators, away from the Maple Unit main doors, as per facility policy. He stated leaving the Maple Unit was a new behavior for the resident. Continued interview revealed the facility failed because the interventions implemented after Resident #1 was found wandering in the hall outside the unit unassisted, and without staff's knowledge