Every finding on record at Vanceburg Hills

Based on interview, record review, and review of the facility's documents and policy, the facility failed to ensure the resident's representative received in writing notification of a transfer or discharge that included a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman for 5 out of 5 residents investigated for transfer and/or discharge, Resident (R) 3, R22, R46, R62, and R92.The findings include:Review of the facility's policy titled, Transfer and Discharge, revised 03/20/2025, revealed the facility's transfer/discharge notice would be provided to the resident and the resident's representative and would include the specific reason, effective date, and location of transfer; and explanation of the right to appeal the transfer or discharge; the name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman and state entity that received appeal requests; information on how to obtain an appeal form; and information on obtaining assistance in completing and submitting an appeal hearing request.1. Review of Resident (R) 3's admission Record revealed the facility admitted the resident on 06/03/2024 with diagnoses including chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF).Review of R3's Census revealed the resident was sent to the hospital on [DATE].Review of R3's document Bed Reservation Approval, dated 07/09/2026, revealed the required statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman were not included in the document.2. Review of R22's admission Record revealed the facility admitted the resident on 02/23/2022 with diagnoses including epileptic seizures, chronic obstructive pulmonary disease (COPD), and dementia.Review of R22's Census revealed the resident was sent to the hospital on [DATE].Review of R22's document Bed Reservation Approval, dated 05/14/2026, revealed the required statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman were not included in the document.3. Review of R46's admission Record revealed the facility admitted the resident on 04/14/2026 with diagnoses including cancer of the spinal cord, urine retention, and type 2 diabetes.Review of R46's Census revealed the resident was sent to the hospital on [DATE].Review of R46's document Bed Reservation Approval, dated 07/06/2026, revealed the required statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman were not included in the document.4. Review of R62's admission Record revealed the facility admitted the resident on 05/29/2026 with diagnoses including type 2 diabetes and lumbar fracture.Review of R62's Census revealed the resident was sent to the hospital on [DATE].Review of R62's document Bed Reservation Approval, dated 07/13/2026, revealed the required statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman were not included in the document.5. Review of R92's admission Record revealed the facility admitted the resident on 06/17/2026 with diagnoses including chronic obstructive pulmonary disease (COPD), type 2 diabetes, and orthopedic aftercare.Review of R92's Census revealed the resident was sent to the hospital on [DATE].Review of R92's document Bed Reservation Approval, dated 06/25/2026, revealed the required statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman were not included in the document.During an interview with the Business Office Manager (BOM) on 07/15/2026 at 9:52 AM, she stated she contacted the resident's representative via telephone and determined if the bed needed to be held whenever a resident was transferred or discharged . The BOM stated the notification was documented in the resident's chart, and a copy of the Bed Reservation Approval was sent to the representative. The BOM stated the Bed Reservation Approval notice was the only document she used for transfer/discharge/bed holds, and she was not aware that all the required information was not included in the document.During an interview with the Director of Nursing (DON) on 07/15/2026 at 1:27 PM, she stated the only form sent to the representative was the Bed Reservation Approval form, and she was not aware until today that the form was incomplete. The DON stated the facility had started revisions on the document, so it met the regulations for transfer/discharge/bed hold notification.During an interview with the interim Administrator on 07/15/2026 at 3:16 PM, he stated it was his expectation they were doing things correctly when transfer/discharge and bed hold forms were sent to the residents' representatives. He stated the forms were in the process of being changed so they included a statement of the residents' appeal rights and the contact information for the state Long-Term Care Ombudsman.

Based on interview, record review, and review of the facility's policy, the facility failed to notify the resident's physician to alter treatment when the resident's narcotic pain medication had a delay in delivery from the pharmacy for 1 of 28 sampled residents (Resident (R) 76). R76 received his last dose of his pain medication on 08/17/2024. Even though the resident was expressing verbal and nonverbal signs and symptoms of severe pain, the facility did not notify the resident's physician nor did the facility communicate with hospices services. The resident did not receive his pain medication until 08/19/2024. The facility was out of the resident's medication for 40 hours, and the medication was ordered to be administered every three hours as needed. This failure resulted in the resident sustaining actual harm due to experiencing severe pain that could have been avoided if the physician had been notified. (Cross reference F656 and F697 ) The findings include: Review of the facility's policy titled, Facility Responsibilities, revised 03/26/2024, revealed .It is the policy of this facility to uphold and comply with the facility responsibilities .13. Notification of Change. a. A facility will immediately inform the resident; consult with the resident's physician .when there is: .ii. A significant change in the residents' physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). iii. A need to alter treatment significantly . Review of R76's undated Admission Record revealed the the facility admitted the resident on 04/10/2024 with diagnoses which included alcoholic cirrhosis of liver, congestive heart failure, pain, and unilateral inguinal hernia. Review of R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/18/2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have received scheduled and PRN (as needed) pain medications. During an interview on 08/19/2024 at 11:50 AM, R76 stated the facility ran out of his narcotic pain medication of Dilaudid this past weekend. The resident stated he was in severe pain over the weekend and rated his highest pain level at a 10 on a scale of zero to 10 with 10 being the most severe pain. Review of R76's physician's Orders, revealed an order, Dilaudid Oral Tablet 4 MG [milligram] .Give 1 tablet every 3 hours as needed for pain, dated 08/05/2024. Review of R76's Medication Administration Record (MAR) for August 2024 revealed on 08/17/2024 at 4:00 PM, R76 was administered his last dose of Dilaudid medication until 08/19/2024 at 8:00 AM. The MAR also revealed R76's pain level was assessed and documented as 8 upon administration of the Dilaudid medication on 08/17/2024 at 4:00 PM. Review of R76's nursing Progress Note, dated 08/18/2024 at 5:24 PM, noted, Resident has not had pain medications all day today, as we continue to wait for the refill of his Dilaudid to come in. It has been reordered a few different times over the past week, but never came in. There was no documented evidence that the resident's physician and/or another provider was notified. During an interview on 08/21/2024 at 10:58 PM, Licensed Practical Nurse (LPN) 1 stated the facility utilized an emergency pharmacy kit (E-kit). When asked what the facility's practice was if a resident ran out of pain medication, and the pharmacy had not delivered it prior to the next scheduled dose, LPN1 stated she would first notify the physician and see if they wanted to order a medication from the E-kit and/or follow the physician's instructions. During an interview on 08/21/2024 at 11:09 AM, Nurse Practitioner (NP) 1 stated R76 was receiving hospice services; however, after collaboration with hospice, the facility was responsible for ensuring a hospice resident's medication was available at the facility to be administered as ordered. The NP stated it was her expectation nursing would have notified herself, the on-call physician service, or the Medical Director when the resident ran out of the medication, and the pharmacy had not delivered the refill of the medication. NP1 stated had she or another provider been notified, something could have been ordered from the facility's E-kit, and the provider could have inquired with the pharmacy what was causing the delay. During an interview on 08/21/2024 at 11:36 AM, the Unit Manager (UM) stated the nurses should have immediately notified the resident's physician and the hospice provider. The UM stated the physician could have ordered a pain medication stocked in the facility's E-kit for pain such as oxycodone or hydrocodone (both were narcotic pain medication used to treat pain). The UM also stated it was important the physician would have been notified to ensure R76's pain management needs were met. During an interview on 08/22/2024 at 5:15 PM, LPN2 stated she administered R76's last dose of Dilaudid on 08/17/2024 at approximately 3:00 PM. When asked if she notified the physician or another provider once she administered R76's last dose of Dilaudid, LPN2 stated she did not notify the physician or hospice services, but she should have as this was the facility's practice. When asked if there was a reason that she did not notify the physician, the LPN stated she thought R76's Fentanyl patch would cover his pain. During an interview on 08/22/2024 at 5:46 PM, the Regional Nurse Consultant (RNC) stated it was her expectation the nurses would have contacted the physician when R76's Dilaudid was not available to be administered to him. The RNC also stated had the physician been notified, the physician could have ordered a pain medication from the E-kit. She stated the hospice physician should have been notified as well. The RNC stated it was the facility's responsibility to ensure the resident's medication was ordered and available to be administered to R76. The RNC further stated the facility's Medical Director collaborated with the hospice physician, and then the Medical Director wrote the prescriptions for the hospice pain medications. During an interview on 08/22/2024 at 6:38 PM, the Medical Director stated it was her expectation the facility's nursing staff would have notified her that R76 was out of his Dilaudid pain medication. The Medical Director stated with the resident's diagnoses, the dose of Dilaudid the resident was ordered and frequently administered, and the significant amount he missed, he would have experienced pain and had she been notified or another provider notified, along with hospice being notified, a one-time order for a pain medication could have been given and administered to the resident. During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation the physician would have been notified if there was an issue with getting R76's pain medication to the facility.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement person centered comprehensive care plans for pain, activities, and a significant weight loss for 3 of 28 sampled residents, Resident (R) 76, R34, and R31. This placed the residents at risk for decreased quality of life, quality of care, and further exacerbation of an illness. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 12/23/2023, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. 1. Review of R76's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 04/10/2024 with diagnoses which included alcoholic cirrhosis of liver, congestive heart failure (CHF), pain, and unilateral inguinal hernia. Review of R76's nursing Admission progress note, dated 04/10/2024 and located in the resident's EMR under the Progress Notes tab, revealed, Resident admitted .on Hospice . Review of R76's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/18/2024 in the EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. During an interview on 08/19/2024 at 11:50 AM, R76 stated the facility ran out of his Dilaudid narcotic pain medication this past weekend. The resident stated he was in severe pain over the weekend and rated his highest pain level at a 10 on a scale of zero to 10 with 10 being the most severe pain. Review of R76's Comprehensive Care Plan (CCP), located in the resident's EMR under the Care Plan tab, revealed a focus initiated on 04/10/2024 and revised on 05/27/2024 that indicated, The resident needs pain management and monitoring related to generalized pain, enlarged scrotum, cirrhosis of liver, [and] mouth pain. R76's goal indicated, Will maintain adequate level of comfort as evidenced by minimal s/sx [signs/symptoms] of unrelieved pain or distress, or verbalizing satisfaction with level of comfort . The CCP interventions for the resident to obtain his goal included, .Provide pain medication as ordered .Utilize pain monitoring scale as ordered . Continued review of R76's CCP revealed a focus of Resident requires Hospice services elated to cirrhosis of liver, chronic hepatic failure, [and] CHF. R76's goal indicated, Resident's end of life wishes will be honored. The CCP interventions for the resident to obtain this goal included, .Administer medications as ordered .Notify hospice of any changes in resident's condition .Observe for pain and discomfort . Review of R76's nursing Progress Note, dated 08/18/2024 at 5:24 PM and located in the resident's EMR under the Progress Note tab, revealed, Resident has not had pain medications all day today, as we continue to wait for the refill of his Dilaudid to come in . During an interview on 08/21/2024 at 12:20 PM, R76 stated he received his last dose of Dilaudid Saturday afternoon. The resident stated Saturday night and all of Sunday he experienced so much pain he could not eat much of his meals and a couple of times he did not eat any of the meals. R76 stated he was nauseated and had anxiety, and the nurse had to administer Ativan (antianxiety medication) and Phenergan (antiemetic medication). During an interview on 08/21/2024 at 11:50 AM, Certified Nurse Aide (CNA) 5 stated he worked this past weekend and was assigned to R76. CNA5 stated on Saturday evening (08/17/2024) R76 asked him three or four times to let the nurse know he was in pain and was requesting his pain medication. CNA5 stated he could tell R76 was experiencing pain because he was not himself Saturday or Sunday. CNA5 stated the resident would grunt at the end of his sentences, moan, and had facial grimacing. During an interview on 08/22/2024 at 5:15 PM, Licensed Practical Nurse (LPN) 2 stated R76 was care planned for pain management, and if his pain was not controlled, then his care plan would not have been implemented fully. During an interview on 08/22/2024 at 5:46 PM, the Regional Nurse Consultant (RNC) reviewed R76's CCP and stated the resident's care plan was not implemented due to the resident experiencing pain because the facility did not have his pain medication on hand. During an interview on 08/22/2024 at 6:38 PM, the Medical Director, who was also R76's Attending Physician, stated considering the dose he was on, the amount of the Dilaudid pain mediation R76 missed was significant. The Medical Director also stated with the resident's cirrhosis of the liver and his large hernia, the resident would have been in pain. 2. Review of R34's annual MDS with an ARD date of 05/30/2024, located in the MDS tab of the EMR revealed the facility admitted the resident on 08/17/2022. R34 had a BIMS score of 14 out of 15 indicating R34's cognition was intact. R34 had diagnoses of diabetes mellitus, schizophrenia, and unspecified hallucinations, and marked as having no weight loss. Review of R34's diet order, dated 04/09/2023, located in the EMR under the Order tab, revealed, Controlled Carb [carbohydrate] diet, Regular texture, Regular/Thin consistency, Large protein portions only @ [at] all meals. May have small serving from dessert cart. May have special occasion meals. Review of R34's CCP revised 05/29/2024, located in the EMR under the Care Plan tab, revealed, Nutritional Risk r/t [related to]: -dx [diagnoses] DM II [type two diabetes mellitus], schizophrenia, HTN [hypertension], HLD [hyperlipidemia] -need for therapeutic diet -potential side effects of antipsychotic medications: increased wt [weight] and obesity -obesity status with no interest in weight reduction at this time. The goal included, R34 will maintain current level of PO [oral] intake at 76-100% [percent]/meal. An intervention for complications of R34's diabetes mellitus included, Monitor/document/report PRN [as needed] any s/sx [sign/symptom] of hyperglycemia .weight loss . Review of R34's weight history, located in the EMR under the Weight/Vitals tab, revealed R34 had lost nine percent of his body weight in five months (151 days). This included: 08/05/2024 at 237.8 Lbs. [pounds] standing; 07/05/2024 at 243.0 Lbs. standing; 06/06/2024 at 246.2 Lbs. standing; 06/05/2024 at 247.6 Lbs. standing; 05/03/2024 at 259.2 Lbs. standing; 04/03/2024 at 259.4 Lbs. standing; and 03/07/2024 at 261.6 Lbs. standing. Review of R34's Nutrition/Dietary Note, dated 06/12/2024, located in the EMR under the Progress Notes, revealed, Reweight was obtained 06/06/2024 of 246.2# [pounds], indicating a true significant weight loss of 13# (5.0%) has occurred x 30 days. Resident remains within obese BMI [body mass index] class (BMI=33.4). Has orders for CCD [controlled carbohydrate diet] diet, regular textures, thin consistencies, and large portion protein q [every] meal. Intake records show he has been eating 51-75%/meal on average over the last [seven] 7 days. Informed resident of weight change. Resident states he has not been intentionally trying to lose weight, but also is not concerned with weight loss. He voices no weight related goals at this time. Weight loss is considered beneficial due to obesity status but should be achieved at a safe/controlled rate of < [less than] 5%/month. Will continue with current plan at this time. RD [Registered Dietitian] will monitor and follow up with resident routinely and remains available PRN via consult. Review of R34's Nutrition/Dietary Note, dated 08/07/2024, located in the EMR under the Progress Notes, revealed, R34 triggers for a significant weight loss of 21.4# (8.3%) x 90 days. CBW= 237.8#. He remains within obese BMI class (BMI= 32.2). Resident has orders for CCD diet, regular textures, thin consistencies, and large portion protein q meal. Intake records show he has been eating 76-100%/meal on average over the last [seven] 7 days. Due to obesity status and resident continuing to have excellent PO intake, weight reduction is considered beneficial. No new recs [recommendations] at present time. RD will continue to monitor and follow up routinely and remains available PRN via consult. Review of R34's meal intake documentation, dated 08/03/2024 to 08/21/2024, located in the EMR under the Task tab, revealed R34 consumed 76-100% of most meals. During a telephone interview on 08/21/2024 at 5:50 PM, the RD was asked if she was aware of R34's weight loss. The RD stated she was aware of significant weight loss but it's beneficial due to his obese status. The RD acknowledged although weight loss could be beneficial for his obese status, the reason he was losing might not be beneficial should it continue. The RD was asked if the weight loss for beneficial reasons was care planned with goals, and when was R34's weight loss enough, the RD stated, I missed care planning it, I forgot. During an interview on 08/22/2024 at 8:25 AM, the Dietary Manager (DM) stated a planned weight loss needed to be care planned. 3. Review of R31's Face Sheet located in the Admission tab of the EMR, revealed R31 was admitted to the facility on [DATE] with diagnoses of Huntington's Disease, cognitive communication disorder, anxiety, and contracture of the left hand. Review of the MDS located under the MDS tab of the EMR, with an ARD of 06/25/2024, revealed R31 had a BIMS score of one out of 15 which indicated his cognition was severely impaired. Review of the MDS revealed R31 liked trivia, discussions, reading, puzzles, television, movies, bingo, cards, video games, tablet, church, nature, and musicals. The preferences further revealed R31 enjoyed church services, gospel music, and he face-timed with his wife multiple times a day. Review of R31's preferences revealed it was very important to him to go to religious services and gospel music. Review of R31's CCP, dated 03/22/2024 and 07/16/2024 located under the Care Plan tab in the EMR, revealed a problem for activities which indicated R31 preferred independent activities or spending time with his family on the Facebook portal. Review of the interventions included: resident was to be invited to activities, spend time with his family on the Facebook portal, television, country music, reading, cards, and he was to receive in-room activities three times a week. Review of the CCP further revealed R31 liked to talk to his wife daily on the Facebook portal. Review of R31's activity calendar documentation for August and July 2024 revealed R31 had used the Facebook portal one time to talk to his wife. During an interview on 08/22/2024 at 10:38 AM, R31 stated he would like to go to musicals and church if the facility had those activities. R31 stated he was not able to get up himself and depended on staff to get him up for activities. During an interview with R31's wife on 08/19/2024 at 2:42 PM, she stated they had gone to a July 4th singing activity in the dining room, and that was the only one she knew R31 had been to. She stated that she was not sure what activities the facility did with the resident. During an interview on 08/21/2024 at 3:50 PM, the Activity Director (AD) stated R31 liked to use Facebook portal to talk to his wife. The AD further revealed staff had to set the computer up for the resident to use the Facebook portal because he was unable to set it up himself. During an interview on 08/21/2024 at 4:11 PM, the Activity Assistant (AA1) stated staff did one-on-one reading, hand massages, leg massages, and talked to R31. The AA1 stated R31's arms were contracted, and he could not do puzzles, but he liked being read to and massaging his legs, but for the most part she made sure the television or radio was on. The AA1 stated that R31 had a Facebook portal, but it had to be set up for him because he was unable to set it up himself. The AA1 further stated staff did not document that she asked him if he wanted to set up the Facebook portal. During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation that residents' care plans were followed. 36190 36898

Based on interview, record review, and review of the facility's policies, the facility failed to ensure a resident, who was on end of life hospice services, pain was effectively managed per the physician orders for 1 of 2 residents reviewed for pain out of 28 sampled residents, Resident (R) 76. R76 was ordered Dilaudid (a narcotic pain medication used to treat severe pain) every three hours as needed. R76 was administered his last dose of Dilaudid on 08/17/2024 at 4:00 PM. The facility did not procure the resident's Dilaudid until 08/19/2024, and the medication was administered to the resident at 8:00 AM which indicated the resident went without the pain medication for 40 hours. This failure resulted in harm to R76 due to him experiencing severe pain. The findings include: Review of the facility's policy titled, Pain Management Program, dated 08/01/2024, revealed, Purpose: Promote recognition and intervention to manage pain at the individual's goal or tolerance level to promote the highest quality of life practicable .a. Pain can affect the person's ability to function and perform activities of daily living such as bathing, toileting, dressing, and walking. b. Pain has also been shown to increase stress, delay healing, decrease mobility and interfere with sleep and appetite. c. Chronic pain can cause psychological and emotional distress, leading to depression, low self-esteem, social isolation, and feelings of hopelessness . The goal of this program is to manage the resident's pain to optimize their quality of life. By effectively managing pain, the team continues to provide the highest quality of care while helping residents maintain their maximum level of independence.a. The physician's role .is to consider various medications and interventions that may provide pain relief that are not associated with negative impact on the resident's function or level of orientation or wakefulness . Review of the facility's policy titled, Hospice Services Facility Agreement, revised February 2023, revealed, It is the policy of this facility to provide and/or arrange for hospice services in order to protect a resident's right to a dignified existence, self-determination .e the facility will immediately notify the hospice about the following: i. A significant change in the resident's physical, mental, social, or emotional status .h. A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient .and drugs necessary for palliation of pain and symptoms associated with the terminal illness . Review of R76's undated Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 04/10/2024 with diagnoses which included alcoholic cirrhosis of liver, congestive heart failure, pain, and unilateral inguinal hernia. Review of R76's nursing Admission progress note, dated 04/10/2024 and located in the resident's EMR under the Progress Notes tab, revealed, Resident admitted .on Hospice of Hope Maysville. Review of R76's physician Orders, located in the EMR under the Orders tab, revealed an order dated 04/11/2024 for hospice. Review of R76's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/18/2024, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have received scheduled and PRN (as needed) pain medications. During an interview on 08/19/2024 at 11:50 AM, R76 stated the facility ran out of his Dilaudid narcotic pain medication this past weekend. The resident stated he was in severe pain over the weekend and rated his highest pain level at a 10 on a scale of zero to 10 with 10 being the most severe pain. Review of R76's physician Orders, located in the resident's EMR under the Orders tab, revealed an order dated 08/05/2024 for Dilaudid Oral Tablet 4 MG [milligram] .Give 1 tablet every 3 hours as needed for pain. Continued review of the Orders revealed a physician order dated 07/12/2024 for Fentanyl Transdermal Patch [medication to treat severe chronic pain] 72 Hour 72 MCG/HR [microgram/hour] .Apply 1 patch trans dermally one time a day every 3 day(s) for pain . Review of R76's Controlled Drug Receipt/Record/Disposition Form, dated 08/12/2024, revealed the facility received 30 tablets of Dilaudid 4 MG tablets for R76. Review of R76's Medication Administration Record (MAR), dated August 2024 and located in the EMR under the Orders tab, revealed from 08/12/2024 through 08/15/2024 the resident was administered the Dilaudid PRN pain medication at a minimum of five doses each day. Continued review of the MAR revealed on 08/17/2024 at 4:00 PM, R76 was administered his last dose of Dilaudid medication until 08/19/2024 at 8:00 AM. The MAR also revealed R76's pain level was assessed and documented as 8 upon administration of the Dilaudid medication on 08/17/2024 at 4:00 PM. Review of R76's nursing Progress Note, dated 08/17/2024 at 4:55 PM and located in the resident's EMR under the Progress Notes tab, revealed the nurse documented R76's follow-up post administration of the Dilaudid as effective with a post administration pain level of 2. Review of the Controlled Drug Receipt/Record/Disposition Form, dated 08/19/2024, revealed the facility received 30 tablets of Dilaudid. Further review revealed, on 08/19/2024 at 8:00 AM, R76's pain level was nine, and he was administered Dilaudid pain medication. Review of R76's nursing Progress Note, dated 08/18/2024 at 4:16 AM and located in the resident's EMR under the Progress Notes tab, revealed, Resident is out of Hydromorphone [Dilaudid] 4mg at this time. This nurse called .Pharmacy when residents [sic] refills didn't get shipped to facility .Pharmacy to STAT [rush/without delay] residents Hydromorphone (Dilaudid) 4mg to facility. Review of R76's nursing Progress Note, dated 08/18/2024 at 5:24 PM and located in the resident's EMR under the Progress Note tab, revealed, Resident has not had pain medications all day today, as we continue to wait for the refill of his Dilaudid to come in. It has been reordered a few different times over the past week, but never came in. Review of R76's nursing Progress Note, dated 08/18/2024 at 5:27 PM and located in the resident's EMR under the Progress Notes tab, revealed, Pharmacy stated this morning they would Stat it in today. During an interview on 08/21/2024 at 12:20 PM, R76 stated he received his last dose of Dilaudid Saturday afternoon. The resident stated Saturday night and all of Sunday he experienced so much pain he could not eat much of his meals and a couple times he did not eat any of the meal. R76 stated he had anxiety and was nauseated. The nurse had to administer him Ativan (antianxiety pain medication) and Phenergan (antiemetic medication). During an interview on 08/21/2024 at 11:50 AM, Certified Nurse Aide (CNA) 5 stated he worked this past weekend and was assigned to R76. CNA5 stated on Saturday evening (08/17/2024) R76 asked him three or four times to let the nurse know he was in pain and was requesting his pain medication. CNA5 stated he could tell R76 was experiencing pain because he was not himself Saturday or Sunday. CNA5 stated the resident would grunt at the end of his sentences, moan, and had facial grimacing. CNA5 stated on Sunday (08/18/2024) R76 pushed his call light numerous times and every time the resident requested his pain medication, he would be holding his stomach when asking. CNA5 stated he reported the resident's complaints of pain and requests for pain medications to Licensed Practical Nurse (LPN) 2 each time. CNA5 stated the second time CNA5 reported the resident's complaint of pain to LPN2, she stated that she was still waiting for the pharmacy to deliver the medication. CNA5 stated he asked LPN2 to go and explain this to R76. During an interview on 08/21/2024 at 6:04 PM, CNA4 stated on Saturday evening/night (08/17/2024), he went into the resident's room to bring his dinner to him, and the resident stated he was in too much pain to eat. CNA4 stated he could tell R76 was in pain because he never missed a meal, even if it was eating a peanut butter sandwich. CNA4 stated he reported the resident's complaint of pain to the nurse. During an interview on 08/21/2024 at 6:48 PM, Kentucky Medication Aide (KMA) 1 stated she was assigned to administer medications to R76 on Sunday (08/18/2024). KMA1 stated she received shift report from LPN2 and was told R76 was out of his Dilaudid, but it had been ordered from the pharmacy. KMA1 stated she could tell R76 was not feeling the best, and the resident requested his PRN Ativan because of his anxiety and Phenergan because he reported his stomach was upset. During an interview on 08/22/2024 at 5:15 PM, LPN2 stated she administered R76 his last available dose of Dilaudid on Saturday (08/17/2024) around 3:00 PM. LPN2 stated she had ordered it a couple of times herself. LPN2 stated she changed R76's Fentanyl patch Saturday morning, and to her knowledge, the resident was not in any pain prior to leaving after her shift at approximately 7:00 PM. LPN2 stated she called the pharmacy on Sunday evening to check the status of the delivery of the medication, and the pharmacy told her it was on its way. The LPN stated R76 asked her if she had heard anything about his medication, and she told the resident the pharmacy was sending the medication STAT. When asked what the resident's pain level on Saturday and Sunday was when he did not have the Dilaudid pain medication, LPN2 stated she did not assess the resident's pain. When asked if she notified the resident's physician or another provider regarding the resident being out of the Dilaudid and the pharmacy not delivering the medication, LPN2 stated she thought the resident's Fentanyl patch would provide pain coverage. LPN2 also stated it was the facility's practice to notify the resident's physician and hospice and follow their orders; however, she did not do this and stated, it's my fault. She stated it was important for hospice residents to have their end-of-life medications. During an interview on 08/21/2024 at 11:36 AM, the Unit Manager (UM) stated on 08/19/2024 she was reviewing the nursing reports from the weekend when she identified R76 was without his Dilaudid pain medication. The UM stated nursing should have notified a provider for an order for a medication out of the facility's E-kit for R76 to be administered something for pain. The UM stated it would have been important for nursing staff to notify a provider to meet the resident's needs of effective pain management. During an interview on 08/21/2024 at 11:09 AM, Nurse Practitioner (NP) 1 stated R76 was receiving hospice services, and the facility was responsible for ordering residents' pain medications from the pharmacy. NP1 stated the facility collaborated with the hospice care team including the resident's hospice physician. NP1 also stated on 08/05/2024, the resident's attending physician changed the resident's oxycodone he was receiving for breakthrough pain to Dilaudid for better control of the resident's pain. Further interview with NP1 revealed if the facility ran out of R76's Dilaudid and was having trouble receiving it from the pharmacy, the nurse should have notified the on-call physician service, herself, or attending/Medical Director for an order for R76 to be administered a pain medication from the facility's emergency pharmacy (E-kit) until the issue with the pharmacy was resolved. NP1 stated this would have been what she would have expected from the nurses. NP1 further stated R76 had a terminal prognosis with cirrhosis of the liver and an inoperable hernia. The NP stated with the resident's terminal illnesses and with the resident going all day without any Dilaudid for breakthrough pain, the resident could have experienced excruciating pain. During an interview on 08/22/2024 at 6:34 PM, the Consultant Pharmacist (CP) stated if R76 was requesting the Dilaudid pain medication, then he was probably in pain as the Dilaudid was used to cover his breakthrough pain the Fentanyl patch did not cover. The CP stated hospice residents should never go without pain medications during their end-of-life care. During an interview on 08/22/2024 at 5:46 PM, the Regional Nurse Consultant (RNC) stated it was her expectation that the nurses would have contacted the physician when R76's Dilaudid medication was not available. The RNC stated the physician could have ordered something form the facility's E-kit in the interim while waiting for the medication to arrive from the pharmacy During an interview on 08/22/2024 at 6:38 PM, the Medical Director, who was also R76's Attending Physician, stated the amount of the Dilaudid pain mediation R76 missed considering the dose he was on was significant, and with the resident's cirrhosis and his large hernia, the resident would have been in pain. The Medical Director stated the significant amount of pain could have caused the resident to experience nausea. The Medical Director also stated it was important hospice residents' pain was controlled for end-of-life comfort care. During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation R76's pain would have been managed, and his medications administered as ordered.

Based on observation, interview, record review and review of the facility's policy, the facility failed to maintain acceptable nutritional parameters by not assessing the reason for significant weight loss for 1 of 6 sampled residents, Resident (R) 34, reviewed for nutrition in the sample of 28 residents. This had the potential to cause further weight loss without a root cause analysis and/or additional interventions put in place. The findings include: Review of the facility's policy titled Nutrition Management, dated 02/01/2024, revealed, 2. Identification/assessment . c. A comprehensive nutritional assessment will be completed by a dietitian within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Components of the assessment may include but are not limited to vi. Presence of persistent hunger, poor intake, or continued weight loss. Review of R34's annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/30/2024, located in the MDS tab of the electronic medical record (EMR), revealed an admitted [DATE]. R34 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating R34's cognition was intact. R34 had diagnoses of diabetes mellitus, schizophrenia, and unspecified hallucinations, and the MDS was marked as having no weight loss. Review of R34's diet order, dated 04/09/2023, located in the EMR under the Order tab revealed a Controlled Carb [carbohydrate] diet, Regular texture, Regular/Thin consistency, Large protein portions only @ [at] all meals. May have small serving from dessert cart. May have special occasion meals. Review of R34's Care Plan, revised 05/29/2024, located in the EMR under the Care Plan tab revealed Nutritional Risk r/t [related to]: -dx [diagnoses] DM II [type two diabetes mellitus], schizophrenia, HTN [hypertension], HLD [hyperlipidemia] -need for therapeutic diet -potential side effects of antipsychotic medications: increased wt [weight] and obesity -obesity status with no interest in weight reduction at this time. The goal included R34 will maintain current level of PO [oral] intake at 76-100%/meal. An intervention for complications of R34's diabetes mellitus included, Monitor/document/report PRN [as needed] any s/sx [sign/symptom] of hyperglycemia .weight loss . Review of R34's weight history, located in the EMR under the Weight/Vitals tab, revealed R34 had lost nine percent of his body weight in five months (151 days). This included: 08/05/2024 at 237.8 Lbs. [pounds] standing; 07/05/2024 at 243.0 Lbs. standing; 06/06/2024 at 246.2 Lbs. standing; 06/05/2024 at 247.6 Lbs. standing; 05/03/2024 at 259.2 Lbs. standing; 04/03/2024 at 259.4 Lbs. standing; 03/07/2024 at 261.6 Lbs. standing. Review of the Registered Dietician (RD)'s Comprehensive Nutritional Evaluation in the EMR under the Evaluation tab, dated 05/29/2024, revealed R34 had an elevated A1C (blood test that reflected the average blood sugar level for the past two to three months). Further review, in the RD's Dietary Quarterly Evaluation, dated 02/22/2024, revealed the RD noted R34 had an elevated albumin level (blood test that checked your liver and kidney function), Fasting Blood Sugar (FBS), A1C, Blood Urea Nitrogen (BUN), BUN/Creatinine ratio, and Potassium (K+) blood level. Review of R34's Nutrition/Dietary Note, dated 06/12/2024, located in the EMR under the Progress Notes revealed, Reweight was obtained 06/06/2024 of 246.2# [pounds], indicating a true significant weight loss of 13# (5.0%) has occurred x 30 days. Resident remains within obese BMI [body mass index] class (BMI=33.4). Has orders for CCD [controlled carbohydrate diet] diet, regular textures, thin consistencies, and large portion protein q [every] meal. Intake records show he has been eating 51-75%/meal on average over the last [seven] 7 days. Informed resident of weight change. Resident states he has not been intentionally trying to lose weight, but also is not concerned with weight loss. He voices no weight related goals at this time. Weight loss is considered beneficial due to obesity status but should be achieved at a safe/controlled rate of < [less than] 5% [percent]/month. Will continue with current plan at this time. RD will monitor and follow up with resident routinely and remains available PRN [as needed] via consult. Review of R34's Nutrition/Dietary Note, dated 08/07/2024, located in the EMR under the Progress Notes revealed, R34 triggers for a significant weight loss of 21.4# (8.3%) x 90 days. CBW= 237.8#. He remains within obese BMI class (BMI= 32.2). Resident has orders for CCD diet, regular textures, thin consistencies, and large portion protein q meal. Intake records show he has been eating 76-100%/meal on average over the last [seven] 7 days. Due to obesity status and resident continuing to have excellent PO intake, weight reduction is considered beneficial. No new recs [recommendations] at present time. RD will continue to monitor and follow up routinely and remains available PRN [as needed] via consult. Review of R34's meal intake documentation, dated 08/03/2024 to 08/21/2024, located in the EMR under the Task tab revealed R34 consumed 76-100% of the meals. Observation on 08/20/2024 at 12:50 PM revealed R34 was served his lunch in his room. R34 ate 100% of his meal that consisted of a large serving of baked fish, rice, vegetables, bread, and a dessert. Observation on 08/21/2024 at 9:09 AM revealed R34 was served his breakfast in his room. R34 ate 100% of his meal that consisted of cereal, a large serving of scrambled eggs, sausage, toast, milk, and juice. R34 was asked if he got enough to eat at meals. R34 did not answer the question. During a telephone interview on 08/21/2024 at 5:50 PM, the RD was asked if she was aware of R34's weight loss. The RD stated she was aware of significant weight loss but it's beneficial due to his obese status. The RD was asked why R34 was losing weight, and the RD stated she was not sure because R34 ate well, and he was not active. The RD was asked if it was acceptable for R34 to continue to have unplanned weight loss, and if no, what was in place to address it. The RD stated, Although weight loss could be beneficial for his obese status, the reason he's losing weight may not be beneficial should it continue. Observation on 08/22/2024 at 7:58 AM revealed R34 was served his breakfast in his room. R34 ate 100% of his meal that consisted of a large portion of scrambled eggs mixed with sausage, toast, cereal, orange juice, and milk. During an interview on 08/22/2024 at 8:25 AM, the Dietary Manager (DM) was asked why R34 was losing weight. The DM stated she did ask R34 if he wanted more food this morning and he said yes. The DM stated she was not sure why R34 was losing weight but would talk to the RD about it and see if R34 needed large portions for all food items. During an interview on 08/22/2024 at 10:53 AM, the Nurse Practitioner (NP)1 was asked about R34's weight loss. NP1 stated she was not aware of any significant weight loss. NP1 reviewed the EMR and stated, R34's BMI is high but I see what you mean about R34's weight is trending down. NP1 stated the RD oversaw R34's nutrition. During an interview on 08/22/2024 at 6:07 PM, the Unit Manager (UM) was asked if the facility had a weight committee. The UM stated they had a NAR [nutrition at risk] committee. The UM was asked if she was aware of any significant weight loss for R34. The UM stated, No, R34 gets large protein at meals but that's all. The UM stated R34 was not discussed during their NAR for significant weight loss in the 08/22/2024 meeting, 08/15/2024 meeting, or 07/31/2024 meeting. The UM was asked how a resident got on the list on the NAR meetings. The UM stated the RD sent a list of residents with significant weight loss. The UM stated R34 would take more food at times when offered and would also ask for more food. The UM stated the RD documented weight loss as beneficial but no cause for the weight loss was determined. The UM asked if a root cause analysis was completed, and the UM stated she did not think so. The UM stated if there was no reason for R34 to lose weight, it could not be labeled as planned and could be a symptom of something wrong. During an interview on 08/22/2024 at 8:26 PM, the Administrator was asked about R34's weight loss and his expectations. The Administrator stated to ensure R34 was provided the correct nutrition, a root cause analysis should be done to determine why R34 was losing weight.

Based on observation, interview, record review, and review of the facility's policy, the facility's nursing staff failed to use appropriate Personal Protective Equipment (PPE) for 1 out of 28 sampled residents who were on Enhanced Barrier Precautions (EBP), Resident (R) 237. Specifically, nurses did not wear a gown when performing R237's wound treatment. This failure had the potential to cause an infection of the resident's wound. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 02/01/2024, indicated, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi drug resistant organisms [MDRO]. Enhanced Barrier precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices) all staff are expected to comply with all designated precautions . high contact resident care activities that require the use of gown and gloves .include wound care, any skin opening requiring a dressing . Review of R237 Face Sheet located in the Admission Record tab of the electronic medical record (EMR) revealed the facility admitted R237 on 08/12/2024 with diagnoses of Parkinson's, neurofibromatosis, malignant neoplasm skin, and disorder of skin and subcutaneous tissue. Review of R237 admission Minimum Data Set (MDS) located under the MDS tab of the EMR, with an assessment reference date (ARD) of 08/19/2024, revealed R237 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the assessment was unable to be completed. Review of R237 Physician Orders, dated 08/12/2024, located under the Orders tab of the EMR revealed an order for wound care to be done to the left neck. Observation on 08/21/2024 at 3:04 PM of Registered Nurse (RN) 3 and Licensed Practical Nurse (LPN) 1 revealed neither RN3 or LPN1 put on a gown prior to entering R237's room to perform the wound treatment and dressing change. Observation further revealed signage on the door stated Enhanced Barrier Precautions (EBP) was to be utilized. Observation of the signage revealed a gown, mask, and gloves were to be worn if wound care was being done. During an interview on 08/22/2024 at 3:23 PM, RN3 stated PPE should have been used with R237 because the resident had an open wound. RN3 stated that anyone with an open wound, catheter, or any opened areas should be on EBP. RN3 stated she should have put on a gown prior to performing R237's wound treatment. RN3 stated not wearing a gown during the wound treatment put other residents at risk for spreading an infection. During an interview on 08/22/2024 at 3:23 PM, LPN1 confirmed there was an isolation cart on the outside of R237's room and signage that indicated the resident was on EBP. During an interview on 08/22/2024 at 5:34 PM, the Regional Nurse Consultant (RNC) stated when EBP signage was on the door and a wound treatment was to be done, nurses should have worn a gown, mask, and gloves when doing care. The RNC stated if fluids were present then goggles should be worn. The RNC stated there was a risk for contamination with MDROs and carrying them to other residents. During an interview on 08/22/2024 at 5:00 PM, the Administrator stated that if a resident was on EBP then a gown, gloves, and mask should be worn from an infection control standpoint. The Administrator further stated failure to wear PPE would pose a risk of bringing an infection into the facility or spreading the infection to others.

Based on interview, record review, and review of the facility's policy, the facility failed to provide written notification of a facility-initiated transfer to the resident and responsible party (RP) for 2 (Resident (R) 27 and R46) of 4 residents reviewed for hospitalization in the sample of 28. The failure had the potential to affect the residents and/or their representatives concerning the reason for the transfer and the resident's appeal rights. The findings include: Review of the facility's policy titled, Transfer and Discharge, revised 03/09/2024 revealed, .4. The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. b. The effective date of transfer or discharge. c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . d. An explanation of the right to appeal the transfer or discharge to the State. e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. f. Information on how to obtain an appeal form. g. Information on obtaining assistance in completing and submitting the appeal hearing request. h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman. i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations. 1. Review of R27's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 10/13/2017. Review of R27's annual Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/14/2024 and in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of R27's nursing Progress Note, dated 07/23/2024 and located in the resident's EMR under the Progress Notes tab revealed, Per resident request, resident asked to be sent to [Name of Hospital] to be checked out R/T [related to] vomiting and pain under her left breast and through to her back. 911 called . Review of R27's nursing Progress Note, dated 07/23/2024 and located in the resident's EMR under the Progress Notes tab revealed EMS [emergency medical service] arrived to pick up resident . Review of R27's EMR revealed no documented evidence the resident and the resident's representative received a writing notice for the 07/23/2024 hospital transfer. During an interview on 08/19/2024 at 3:13 PM, R27 stated she did not remember getting anything in writing about her hospital transfer on 07/23/2024. Review of R27's EMR under the Miscellaneous tab revealed no transfer notice for 07/23/2024 was included. Review of R27's Transfer to Hospital summary, located in the EMR under the Evaluation tab, dated 07/23/2024, revealed the reason for the transfer, location to which the resident was transferred, and effective date. The summary did not include the resident's appeal rights, ombudsman information, and if the resident/representative was provided with a written Notice of Transfer. 2. Review of R46's annual MDS with an ARD of 06/13/2024 located in the EMR under the MDS tab revealed an admitted [DATE] and a BIMS score of 11 out of 15, which indicated his cognition was moderately impaired. a. Review of R46's Health Status Note, dated 02/17/2024, located in the EMR under the Progress Note tab revealed [name of transport] .call given to [name] at [hospital] e.r. [emergency room ] .was sent with res [resident]. Review of R46's Health Status Note, dated 02/20/2024, located in the EMR under the Progress Note tab revealed, Resident arrived to facility . from [hospital] . Review of R46's EMR under the Miscellaneous tab revealed no transfer notice for 02/20/2024 was included. Review of R46's Transfer to Hospital summary, located in the EMR under the Evaluation tab, dated 02/17/2024, revealed the reason for the transfer, location to which the resident was transferred, and effective date. The summary did not include the resident's appeal rights, ombudsman information, and if the resident/representative was provided with a written Notice of Transfer. b. Review of R46's Health Status Note, dated 03/08/2024, located in the EMR under the Progress Note tab revealed, Resident admitted to [hospital] for further testing. Review of R46's EMR under the Miscellaneous tab revealed a hospital transfer on 03/08/2024, but no transfer notice was included. Review of R46's Transfer to Hospital summary, located in the EMR under the Evaluation tab, dated 03/08/2024 revealed the reason for the transfer, location to which the resident was transferred, and effective date. The summary did not include the resident's appeal rights, ombudsman information, and if the resident/representative was provided with a written Notice of Transfer. c. Review of R46's Health Status Note, dated 06/16/2024, located in the EMR under the Progress Note tab revealed, Resident admitted to [hospital] with pneumonia and sepsis. Review of R46's EMR under the Miscellaneous tab revealed a hospital transfer on 06/16/2024 but no transfer notice was included. Review of R46's EMR revealed no transfer notice was found for R46's 06/16/2024 hospitalization . During an interview on 08/22/2024 at 9:18 AM, the Regional Nurse Consultant (RNC) was asked about transfer notices when R27 and R46 were sent to the hospital and for any resident transferred out of the facility that included the reason for the transfer, location to which the resident was transferred, effective date, resident's appeal rights, and ombudsman information. The RNC stated they did not do the transfer notices for any residents. The RNC stated they were unaware of the requirement. During an interview on 08/22/2024 at 8:28 PM, the Administrator stated he was unaware of the requirement. 36898

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident who had a negative Preadmission Screening and Resident Review (PASARR) Level I and then later had a significant change in status and a new serious mental illness diagnosis was accurately and timely referred for a PASARR Level II referral for 1 of 6 residents (Resident (R) 32) reviewed for PASARRs out of 28 sampled residents. This failure placed the resident at risk of qualifying for specialized services but not receiving the services due to the inaccuracy of the PASARR Level II referral. The findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/24/2023 revealed, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities .in accordance with the State's Medicaid rules for screening .b. PASARR Level II-a comprehensive evaluation by the appropriate state-designated authority that determines whether individual has MD [Mental Disorder] .and recommends any specialized services .the individual needs .8. Any resident who experiences a significant change in status will be referred promptly to the state mental health or intellectual disability authority for additional review .9. Any resident who exhibits a new evident or possible serious mental disorder .will be referred promptly to the state mental health or intellectual disability authority for a Level II resident review . Review of R32's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/08/2022 with diagnoses which included anxiety disorder. The Admission Record also revealed on 08/22/2022 the resident received a new serious mental disorder diagnosis of Psychotic Disorder With Delusions . Review of R32's Preadmission Screening and Resident Review program summary, provided by the facility revealed on 07/06/2023 the facility initiated a significant change in status PASARR Level II referral due to a new added diagnosis (psychotic disorder). The summary documented the resident received the diagnosis on 08/22/2022, 11 months prior to the Level II referral. During an interview on 08/22/2024 at 10:09 AM, the PASARR Specialist (PS) and the PASARR Nurse Coordinator (PNC) with the State's PASARR Agency both stated R32's significant change in status Level II referral was not completed timely. The PS stated the referral for a Level II should have been completed within 14 days of receiving the new mental illness diagnosis. The PNC stated when reviewing the Level II referral, the facility did not describe the diagnosis, who gave the diagnosis, or how it impaired the resident's functioning. The PS agreed and stated the facility did not correctly complete the Level II for a referral to be completed. During an interview on 08/22/2024 at 5:55 PM, the Regional Nurse Consultant (RNC) verified R32's PASARR significant change in status referral for a new diagnosis was not completed timely or fully. The RNC stated it was her expectation PASARRs be completed accurately and timely. During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation residents' PASARRs would have been completed correctly and timely.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents' Preadmission Screening and Resident Review (PASARR) Level I accurately reflected their current mental illness diagnoses for 3 of 6 residents (Resident (R) 32, R36, and R50) out of 28 sampled residents. This failure inaccurately produced negative PASARRs Level I and placed the residents at risk for unmet psychosocial needs and services had the PASARR triggered for a Level II referral. The findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, revised 12/24/2023, revealed Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities . i. Negative Level I Screen-permits admission to proceed and ends the PASARR process unless a possible serious mental disorder .arises later . 1. Review of R32's undated Admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed the facility admitted the resident on 04/08/2022 with a diagnosis of anxiety disorder. Review of R32's Preadmission Screening and Resident Review Level I, dated 04/11/2022 and provided by the facility, revealed for question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness . The diagnoses listed were Anxiety Disorder and Dementia without Behavioral Disturbance [neurocognitive disorder]. 2. Review of R36's undated Admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 06/28/2021 with diagnoses which included paranoid personality disorder and anxiety disorder. Review of R36's Preadmission Screening and Resident Review Level I, dated 06/30/2021 and provided by the facility, revealed for question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness ., the question was left blank which indicated the resident had no mental illnesses. 3. Review of R50's undated Admission Record, located in the resident's EMR under the Profile tab revealed the facility admitted the resident on 03/09/2021. The Admission Record did not list any mental health diagnoses upon admission. Review of R50's hospital Discharge Summary, dated 03/09/2021 and located in the resident's EMR under the Misc [Miscellaneous] tab, revealed the resident was discharged to the facility with diagnoses which included schizoaffective disorder, bipolar type . Review of R50's Preadmission Screening and Resident Review Level I, dated 03/11/2021 and provided by the facility, revealed for the PASARR Level I question, 2a. Diagnosis, Identify whether the individual has a current or suspected mental illness ., the question was left blank which indicated the resident had no mental illnesses. During an interview on 08/22/2024 at 10:09 AM, PASARR Specialist (PS) and PASARR Nurse Coordinator (PNC) with the State's PASARR Agency both stated R32, R36, and R50's Level I PASARRs were not completed accurately. The PS stated R32's diagnoses section was completed inaccurately as dementia was a neurocognitive disorder, and this section was specifically for mental illness diagnoses only. Continued interview revealed R36's and R50's PASARRs were incorrect as the diagnoses sections were left blank and should have included both R36 and R50's mental illness diagnoses. During an interview on 08/22/2024 at 5:55 PM, the Regional Nurse Consultant (RNC) verified the above PASARRs were inaccurate. The RNC stated it was her expectation PASARRs be completed accurately. During an interview on 08/22/2024 at 7:42 PM, the Administrator stated it was his expectation the residents' PASARRs would have been completed correctly.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure 2 out of the 3 residents with a gastrostomy tube (G-tube) had the tube placement verified and the residual determined prior to any fluids or medications being administered, Resident (R) 46 and R80. This failure had the potential for these residents to be at risk for aspiration pneumonia. The findings include: Review of the facility's policy titled, Medication Administration via Enteral Tube, dated 02/14/2024, revealed, It is the policy of the facility to ensure the safe and effective administration of medication via enteral feeding tube by utilizing best practice guidelines .enteral tube placement must be verified prior to administration of fluids or medication . 1. Review of R46's Face Sheet located in the Admission Record of the electronic medical record (EMR) revealed the facility admitted R46 on 04/01/2023 with diagnoses of malignant neoplasm of larynx, dementia, and dysphagia that required enteral feedings. Review of R46's annual Minimum Data Set (MDS) located in the MDS tab of the EMR, with an assessment reference date (ARD) of 06/13/2024, revealed R46 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated the resident's cognition was moderately impaired. Review of R46's comprehensive Care Plan located in the Care Plan tab of the EMR revealed a problem was listed for enteral feeding, and staff was to check for tube placement and gastric contents/residual volume according to the facility's protocol. Observation on 08/20/2024 at 4:45 PM of Licensed Practical Nurse (LPN) 4 revealed R46 was in the bed in his room. R46 was to receive a bolus of water through the G-tube. LPN4 did not check for placement of the G-tube prior to flushing it. LPN4 attempted to flush the G-tube, but the water would not go down the tube, so she used the plunger to get the water to flush. During this observation, LPN4 started R46's tube feeding of Two Cal formula at 50 milliliters per hour. 2. Review of R80's Face Sheet located in the Admission Record of the EMR revealed the facility admitted R80 on 03/18/2024 with diagnoses of dysphagia, gastrostomy status, dementia with psychotic features, diabetes, and malnutrition. Review of R80's significant change MDS, with an ARD of 07/25/2024, revealed a BIMS score of zero which indicated the resident was not able to complete the assessment. Review of R80's Physician Orders, dated 08/22/2024 at 7:03 AM in the EMR revealed a stat (immediate)abdominal x-ray was ordered to check for G-tube placement. Observation on 08/22/2024 at 4:55 PM of LPN4 revealed R80 was in the bed in his room. LPN4 did not check for placement or residual before flushing the tube. LPN4 flushed R80's G-tube with water, then a Glucerna bolus, flushed with water again, gave a Glucerna bolus, and ended the administration with a bolus of water. During an interview on 08/21/2024 at 11:24 AM, LPN4 revealed the G-tube placement should have been checked before she administered any fluids or feeding, but she forgot to check placement. LPN4 further revealed if the G-tube was not in the right place there was a possibility the feeding or fluids could go into the lungs which could cause aspiration pneumonia or an infection. During an interview with LPN3 on 08/21/2024 at 9:45 AM, LPN3 stated staff should check for placement of the G-tube before administering anything down the tube. LPN3 stated staff should instill about 30 ml of air, listen with your stethoscope for the air, and then check for residual before administering any fluids or medications. LPN3 stated if the G-tube was not in the right place, the fluid or medication instilled could go into the resident's lungs. During an interview on 08/21/2024 at 11:49 AM, the Director of Nursing (DON) stated that placement and residual of the G-tube should be verified before instilling anything down the tube. The DON stated the nurse should instill air into the tube and listen with the stethoscope for the air and then pull back on the syringe to check for residual. The DON revealed if the nurse did not check for placement it put the resident at risk of aspiration pneumonia. During an interview on 08/22/2024 at 5:07 PM, the Administrator stated that placement of the G-tube should be verified before any fluids or medication were administered. The Administrator further stated that fluids could go into the wrong place if the tube was misplaced.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure 1 of 28 sampled resident, Resident (R) 31, was provided with activities of his interest. The failure to provide these activities placed R31 at risk for isolation. The findings include: Review of the facility's policy titled, Activities, dated 02/01/2024 revealed, It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interest of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independent and interactive within the community .activities refers to any endeavor other than routine . Activities of Daily Living (ADL) in which a resident participates that is intended to enhance his/her sense of wellbeing and promote or enhance physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self esteem, pleasure, comfort, education, creativity, success, and independence. Activities will be designed with the intent to enhance the resident's sense of wellbeing, belonging, and usefulness, reflect residents' interest and reflect cultural and religious interests of the resident and reflect choices of the resident. Space and equipment necessary are provided to ensure the residents care plan is followed. Activities will include individual, small, and large group activities as well as indoor and outdoor activities, religious programs. The facility will consider accommodation in schedules, supplies, and timing in order to optimize a resident's ability to participate in activities of choice. Review of R31's Face Sheet located in the Admission tab of the electronic medical record (EMR) revealed the facility admitted R31 on 09/26/2017 with diagnoses of Huntington's Disease, cognitive communication disorder, and contracture of the left hand Review of R31's Minimum Data Set (MDS) located under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 06/25/2024, revealed R31 had a Brief Interview for Mental Status (BIMS) score of one out of 15 which indicated his cognition was severely impaired. Review of the MDS revealed R31 liked trivia, discussions, reading, puzzles, television, movies, bingo, cards, video games, tablet, church, nature, and musicals. The preferences further revealed R31 enjoyed church services, gospel music, and he face-timed with his wife multiple times a day. Review of R31's preferences revealed it was very important to him to go to religious services and to listen to gospel music. Review of the MDS indicated that R31 was usually understood. Review of R31's comprehensive Care Plan, dated 03/22/2024 with a target date of 07/16/2024 located in the EMR under the Care Plan tab revealed a problem for activities. Review of the care plan further revealed R31 preferred independent activities or spending time with his family on the Facebook portal. Review of the interventions included: resident was to be invited to activities, spend time with his family on the Facebook portal, television, country music, reading, cards, and he was to receive in-room activities three times a week. Review of R31's July 2024 Activity Calendar revealed on 07/02/2024 he was people watching in the hallway; on 07/03/2024 he was people watching; on 07/05/2024 he had aroma therapy and was read to; on 07/08/2024 he had aroma therapy, and his leg was massaged; on 07/10/2024 he had aroma therapy, and his arm was massaged; on 07/11/2024 he had aroma therapy, and his leg was massaged; on 07/15/2024 his television was turned on, and the Activity Assistant (AA) 1 talked to him; on 07/17/2024 AA1 set up Facebook; on 07/19/2024 AA1 turned the television on and talked to him; on 07/24/2024 AA1 read to him and massaged his legs; on 07/25/2024 and 07/26/2024 AA1 talked with R31 and did aroma therapy; on 07/29/2024 AA1 talked and read to him; on 07/30/2024 he had aroma therapy, and his legs were massaged. Review of the July 2024 Activity Calendar for all residents revealed on 07/07/2024, 07/14/2024, 07/21/2024, and 07/28/2024 gospel music and church services were offered. However, review of the documentation from these activities revealed R31 did not attend any of them. Review of R31's August 2024 Activity Calendar, through 08/21/2024, revealed on 08/02/2024 R31 was up in the hallway; on 08/07/2024 he was talked to; on 08/08/2024 he was talked to, and the television was turned on; on 08/09/2024 he was talked to, and the television was turned on; on 08/14/2024 he was up in a chair in the common area; on 08/15/2024 his wife visited, and he was read to; on 08/16/2024 he was up in a chair in the common area; on 08/19/2024 his wife visited; and on 08/21/2024 the television was turned on. Review of the August 2024 Activity Calendar, through 08/21/2024, for all residents revealed on 08/04/2024, 08/11/2024, and 08/18/2024 all day gospel music and church services were offered. Further review revealed on 08/06/2024, outdoor time and snacks were done. Also, on 08/03/2024, 08/10/2024, and 08/17/2024 the review revealed Saturday morning news was offered. Further review revealed Bible study was offered on 08/21/2024. Review of the documentation from these activities revealed R31 did not attend any of them. During an interview on 08/22/2024 at 10:38 AM, R31 stated he would like to go to musicals and church if the facility had those activities. R31 stated he was not able to get up himself and depended on staff to get him up for activities. During an interview with R31's wife on 08/19/2024 at 2:42 PM, she stated she and R31 had gone to a July 4th singing activity in the dining room. She stated she was not sure what activities the facility did with the resident. During an interview on 08/21/2024 at 4:11 PM with AA1, she stated staff did one-on-one reading, hand massages, leg massages, and talking with R31. AA1 stated she gave him things he might need for independent activities like turning on the television or radio. AA1 stated R31 was contracted and could not do puzzles, but he liked being read to and massaging his legs. She stated she tried to make sure the television or radio was on, and R31 had a Facebook portal, but it had to be set up for him because he was unable to set it up himself. AA1 stated she had not set the Facebook portal up for him in a couple of months because he had not asked her to set it up. AA1 stated she did not document that she asked him if he wanted to set up the Facebook portal. During an interview on 08/21/2024 at 3:50 PM, the Activity Director (AD) stated staff usually got R31 up daily, and he went to activities three times a week. The AD stated R31 used the Facebook portal to talk to his wife. The AD further stated staff had to set the computer up for the resident to use the Facebook portal because he was unable to set it up himself. During an interview on 08/22/2024 at 8:24 PM, the Administrator stated residents should have activities while in the facility.

Based on observation, 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 ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who had knowledge of the resident and his/her needs for one (1) of fourteen (14) sampled residents (Resident #1). On 09/26/2020, Resident #1 was exhibiting exit-seeking behaviors. Licensed Practical Nurse (LPN) #1 twice redirected Resident #1 from the door when he/she set off the door alarm. The facility failed to review and revise the resident's care plan to include interventions to closely supervise the resident because of his/her exit-seeking behaviors. Resident #1 exited the facility, on 09/26/2020 at approximately 4:46 PM, without staff knowledge. Resident #1 was found in a ditch, on 09/26/2020 around 5:43 PM, an hour later. The facility's failure to have an effective system in place to ensure CCP's were reviewed and revised for each resident, following multiple exit-seeking behaviors which led to 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) was identified on 10/15/2020 and determined to exist on 09/26/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/21/2020, alleging removal of the Immediate Jeopardy on 10/16/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 10/16/2020, 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, Comprehensive Care Plans, dated 01/13/2018, revealed the Comprehensive Care Plan (CCP) included providing services to enable the resident to live with dignity and supported the resident's goals, choices, and preferences. Further, the interdisciplinary team (IDT) was responsible for review and updating the CCP when there had been a significant change in the resident's condition; when the desired outcome was not met; when the resident had been readmitted to the facility; and at least quarterly. Core members of the IDT were the Administrator, the Director of Nursing, the Assistant Director of Nursing, the Unit Manager, the Social Services Director, and the Minimum Data Set (MDS) Coordinator. Review of the CMS Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the CCP 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 CCP 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 re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI, and then, the individualized CCP was modified as appropriate and necessary. Review of Resident #1's electronic medical record (EMR) revealed the facility admitted the resident, on 03/04/2019, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 03/11/2019, revealed for the Brief Interview for Mental Status (BIMS) Assessment, the resident had a score of six (6) out of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #1's CCP, initiated on 03/08/19, revealed the resident was at risk for elopement related to: wandering and making statements about leaving. The goal stated the resident would have no incidence of elopement. The interventions included check secure care bracelet placement every shift and function daily, involve the resident in preferred activities, involve the resident in decision making regarding daily choices, redirect the resident from doors, and take a picture of the resident upon admission for identification and for updating the elopement binder. Review of Resident #1's physician's orders [REDACTED]. Review of the facility's Long Term Care Facility-Self Reported Incident Form-Five (5) day Follow Up/Final Report, and attached facility's investigation, dated 10/02/2020 at 8:15 PM, and signed by the Administrator, revealed, on 09/26/2020 at approximately 3:30 PM, the Unit 300 Hall Door alarm sounded; the nurse responded, saw Resident #1 walking down the hallway on Unit 300, and redirected Resident #1 to Unit 100. Per report, the nurse was unable to reset the alarm and left the door to call Maintenance to fix the alarming door. The report stated, at approximately 4:50 PM, an SRNA did not see Resident #1 in the hallway, in his/her room, or in the building. The SRNA notified other staff and a search for Resident #1 was begun. The resident was found at approximately 5:43 PM. Further review of the report, revealed Resident #1 was immediately placed on one-to-one (1:1) supervision. Review of the video footage, dated 09/26/2020 from approximately 3:30 PM until 5:43 PM, and observation of the elopement route with the Administrator, on 10/12/2020 at 5:45 PM, revealed Resident #1 ambulated from the Unit 300 Hallway out the back exit door, the door that was alarming. Per observation, after the resident exited the back door, he/she ambulated down the facility sidewalk, down a hill, and into an apartment complex parking lot where Resident #1 fell into the ditch. The place where Resident #1 was found was approximately three hundred (300) feet from the facility building and one hundred thirty (130) feet from the highway. However, there was no evidence the CCP was revised, related to exiting-seeking behaviors, setting off the door alarm, and eloping, on 09/26/2020, to include increased supervision, until 09/27/2020, by the Director of Nursing. Telephone interview with Registered Nurse (RN) #1, on 10/13/2020 at 12:04 PM, revealed she should have revised Resident #1's CCP to reflect increased supervision, with placing the resident on one-to-one (1:1) supervision when the resident was exhibiting exit-seeking behaviors and setting off the door alarm, on 09/26/2020. She stated if she had placed a staff member on one-to-one (1:1) supervision with Resident #1 and placed a staff member at the door that was alarming, this elopement could have been prevented. Further, she stated it was important to have a current, accurately revised CCP to ensure direct care staff would know how to provide care to residents to meet their needs and keep residents safe and secure. Telephone interview with State Registered Nurse Aide (SRNA) #2, on 10/13/2020 at 3:52 PM, revealed she was assigned to Resident #1, on 09/26/2020. She stated she reviewed each resident's plan of care on the kiosk; however, she was not informed by RN #1 to increase supervision nor was she aware of the CCP being updated. SRNA #2 stated she did not document any changes in behaviors for Resident #1, on 09/26/2020. Interview with Unit Manager (UM) #1, on 10/14/2020 at 10:22 AM, revealed she was on-call, on 09/26/2020. Per interview, staff should have increased supervision of Resident #1 when he/she began exhibiting exit-seeking behaviors. She stated the CCP should have been updated to reflect increased supervision related to Resident #1 exit-seeking, on 09/26/2020. UM #1 stated she expected the CCP's to be revised accurately, as per the facility's policies and RAI guidelines. Telephone interview with Licensed Practical Nurse (LPN) #2, on 10/14/2020 at 11:18 AM, revealed she had worked at the facility for three (3) years. She stated she was assigned to Unit 100, on 09/26/2020, but she was not assigned to Resident #1. Per interview, any staff nurse could make revisions to the CCP. She stated the CCP's should be accurate so that staff was aware of how to care for residents. LPN #2 stated she had not revised a CCP, and she stated the MDS Coordinator or DON usually handled updating care plans. She stated, on weekends, staff would scan new orders to the DON so she could update the CCP. Further interview revealed Resident #1's CCP should have been updated, on 09/26/2020, when the resident exhibited exit-seeking behaviors and set off the door alarm. Attempts made, on 10/13/2020 at 4:04 PM , on 10/14/2020 at 9:05 AM, and on 10/21/2020 at 5:15 PM, to contact SRNA #1, RN #2, and LPN #1 by telephone were unsuccessful. Messages were left with no return phone calls received. Interview with the MDS Coordinator, on 10/14/2020 at 3:04 PM, revealed the facility utilized the CMS Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for CCP's. She stated she was responsible for revisions to the CCP related to behaviors. Additionally, it was her practice to verify physician orders [REDACTED].#1, after the resident eloped on 09/26/2020. Therefore, she stated she did not revise the CCP. However, she stated any staff nurse had access to revise the care plan. Further, she stated it was important to have a current, accurately revised CCP to ensure direct care staff would know how to provide care to residents to meet their needs. Interview with the Assistant Director of Nursing (ADON), on 10/14/2020 at 11:35 AM, revealed she expected nursing staff to update a resident's CCP when needed. She stated all licensed nurses had access to update the CCP. Further interview revealed, on 09/26/2020, staff should have increased supervision for Resident #1 and placed a staff member with the resident until the exit-seeking behaviors were resolved. Further interview revealed the CCP's should be revised as necessary to ensure residents received proper services and individualized care. Interview with the Director of Nursing (DON), on 10/14/2020 at 5:38 PM, revealed she expected the CCP's to be revised accurately, as per the facility's policies and RAI guidelines. Per interview, the MDS Coordinator was responsible for revision of the CCP, including any changes related to elopement; but, any licensed nurse could update the CCP. Additionally, she stated the current process in place was, during the facility's Morning Clinical Meeting, held on Monday through Friday, to review CCP's to ensure revisions were made as necessary and for the IDT to review re-admissions and new orders. Per interview, the MDS Coordinator was to check to ensure CCP's had been revised as necessary with the morning reviews. Continued interview revealed Resident #1's CCP should have been revised to include the change in exit-seeking behaviors, on 09/26/2020. She stated the resident should have been placed on one-to-one (1:1) supervision with staff until the exit-seeking behaviors were resolved. Further interview revealed the CCP's should be revised as necessary to ensure residents received appropriate services and individualized care. Interview with the Administrator, on 10/14/2020 at 5:50 PM, revealed the facility was to utilize the RAI Manual and facility policies as resources to ensure the CCP was revised as necessary. Per interview, it was important for the CCP to be revised accurately to reflect a resident's current status and ensure the CCP addressed each resident's individual needs. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/21/2020, which alleged removal of the Immediate Jeopardy (IJ) on 10/16/2020. Review of the AoC revealed the facility implemented the following: 1. On 09/26/2020, Resident #1 was placed on one-to-one (1:1) supervision and monitoring at the time the resident was assisted back to the building. An employee was assigned to the door where the alarm was sounding until the alarm was reset and reactivated. 2. On 09/26/2020, a skin assessment and vital signs were completed on Resident #1 upon return to the building and documented, at 6:38 PM, by the Charge RN. 3. On 09/26/2020, Resident #1's care plan was reviewed by the Director of Nursing, and on 09/27/2020, the care plan was revised to include one-to-one (1:1) safety. On 10/02/2020, the charge nurse revised the care plan to include the resident to be placed on one-to-one supervision until exit-seeking behaviors de-escalated. On 10/05/2020, the Regional Nurse revised the care plan to include checking placement and function of the secure device every shift. 4. On 09/26/2020, the Administrator reported the event to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman. The Charge Nurse notified the Physician and family on 09/26/2020. 5. On 09/26/2020, the Maintenance Assistant reset the sounding alarm on the Unit 300 exit door and ensured the door was operational. All other exit doors were secured, alarms were engaged, and doors were key-coded. 6. On 09/26/2020, the Administrator called the door vendor to check all resident accessible exit doors. The technician arrived, on 09/26/2020 at 11:00 PM, and performed the following: the exit door on Unit 300 Hall was removed, with the dyne lock rebuilt to ensure proper placement to the strike plate; the door on Unit 200 Hall had the maglock taken apart to repair contact; the door on Unit 100 Hall had the programming reset on Advantage 500de, and the reed switch was adjusted; the front door had fasteners installed to the plate to tighten the magnet; the door by the laundry had the smart lock adjusted and screws added; and the door by the beauty shop was checked, and no adjustments/repairs were needed. 7. On 09/26/2020, each unit nurse completed a head count of the residents, and all other residents were accounted for in the facility. 8. On 09/26/2020, licensed nurses assessed current residents for elopement/wandering potential and this was completed by 09/29/2020. Fourteen (14) residents were at risk for elopement at that time. No additional residents were added to the Elopement/Wandering Risk List. Six (6) residents were removed from the elopement risk list due to no longer meeting the criteria for elopement; one (1) resident was in the hospital and was removed from the list, for a total of seven (7) residents removed from the list. On 10/05/2020, the Regional Nurse reviewed elopement assessments for accuracy. Fourteen (14) were reassessed for wandering elopement, on 10/05/2020, and completed by 10/06/2020, by the DON, ADON and Unit Manager. 9. Starting, on 09/26/2020, and completed, by 10/06/2020, the DON and ADON reviewed care plans on current residents and updated them to include interventions for wandering exit-seeking behaviors and appropriate supervision. 10. On 09/26/2020, the Regional Nurse Consultant educated the Administrator and DON related to the Elopement Policy, Care Plan policy/procedure, training, and processes. The Administrator and DON then educated department leaders, including: Unit Managers, ADON, SSD, Dietary Manager, Maintenance Director, Activity Director, Central Supply, and the Business Office Manager. Administrative staff were not permitted to return to work until a one hundred (100) percent score was attained on the post-test. 11. Beginning 09/26/2020, Department Leaders re-educated current staff on the Elopement Policy, Care Plan policy/procedure, training, processes, and door alarm procedures. By 10/06/2020, ninety-five (95) of ninety-eight (98) staff, including twelve (12) agency staff, had received the education. 12. Beginning 09/26/2020, a Regional Nurse Consultant or member of the Corporate team, the Administrator, the DON or the ADON had been available on weekends to ensure continued compliance with education and monitoring established by the QAPI committee. The QAPI Committee members were the Administrator, the DON, the ADON, the UM, the Social Services Director, the MDS Coordinator, the Maintenance Director, the Dietary Manager, and the Medical Director. 13. Beginning 09/27/2020, and ongoing, facility doors will be checked for proper functioning to ensure that the doors would alarm as designed, with all egress functions working properly, verifying the system codes and keypad operations, and checking the Secure Tech Pads to make sure the doors stayed locked and alarms sounded. The Administrator, Department Managers, or the Maintenance Director/Maintenance Assistant would complete this daily function. Any concerns would be immediately reported to the Administrator and Maintenance Director. 14. On 09/27/2020, the Administrator completed environmental rounds to identify any safety issues and no concerns were identified at that time. 15. On 09/27/2020, the Administrator contacted the door vendor and obtained a quote on upgrading the door alarm system to Wander Guard Blue to be installed on all remaining resident accessible exit doors. The quote was approved, and the facility was working with the vendor for an installation date. 16. On 09/28/2020, Elopement Binders were reviewed and updated for accuracy by the Social Services Director (SSD), the DON, the ADON, the Unit Manager, and the MDS Coordinator to reflect current elopement/wandering risk evaluations. Seven (7) residents were removed from the list, which included one (1) resident in the hospital. 17. On 09/28/2020, the SSD and Activity Director conducted interviews on residents with a BIMS' score of greater than eight (8) to determine if anyone had any knowledge of any prior elopements or safety concerns. No concerns were validated. The Admissions Coordinator and Scheduler also conducted interviews, on 09/28/2020, with current staff to determine if anyone had any knowledge of prior elopements, and no concerns were validated. 18. On 09/28/2020, an elopement drill was completed by the Maintenance Director. Then, the Administrator, the DON, the Maintenance Director, or Department Heads started conducting drills on alternating shifts and weekends until 10/15/2020. 19. On 09/29/2020, the Maintenance Director and the Administrator reviewed the Technology Enhanced Learning System (TELS), an online maintenance system that tracked door checks to ensure all doors had been checked for locking alarms, maglock, and delayed egress for the past thirty (30) days. Furthermore, all doors were inspected per policy and the door vendor corrected verified issues identified. On 08/24/2020, the door vendor replaced the maglock on an exit door and wired/tested all systems that were verified to be normal. 20. On 09/30/2020, the ADON and Unit Manager began monitoring orders to evaluate wandering behaviors every shift on the residents at risk for elopement, and these orders were placed on the Treatment Administration Record (TAR). 21. On 10/05/2020, the DON conducted a thirty (30) day look back in the electronic medical record (EMR) for all events that had occurred in the facility and in the progress notes for exit-seeking behavior. No exit-seeking behaviors were noted. 22. On 10/05/2020, the ADON reviewed and updated monitoring orders to check placement and function of secure care devices every shift on the TARS. The Unit Manager verified, on 10/06/2020, all residents currently residing in the facility identified as at Risk for Elopement had the Wander Alert Devices on and functioning properly. 23. On 10/05/2020, the DON reviewed current residents at risk for elopement/wandering to ensure current residents had orders to verify secure device placement and function and behavior monitoring on TAR related to exit-seeking behaviors. 24. Starting 10/05/2020, Department Leaders completed staff questionnaires to review and validate verbal understanding of elopement procedures. Ten (10) employees per day, on alternating shifts, were interviewed until 10/15/2020. 25. On 10/07/2020, the Nurse Managers, the DON, the Administrator, and the SSD started reviewing Nurse's Notes and Social Services Notes to ensure appropriate steps were being taken to ensure residents were placed on the elopement/wandering risk list daily Monday-Friday in the Clinical Meeting. 26. A QAPI meeting was conducted on 09/26/2020, 09/29/2020 and weekly through 10/15/2020, by the Administrator with the following attendees: the Medical Director, the Administrator, the DON, the Nurse Consultant, the ADON, the UM, and the SSD. An immediate action was to discuss monitoring and supervision so there would be no elopements and processes to ensure compliance with this. Any concerns noted would have recommendations. 27. On 10/15/2020, a QAPI meeting was conducted with the following attendees, the Administrator, the DON, the ADON, the UM, the SSD, the Activity Director, the Medical Director and the Nurse Consultant. Action was taken to place Resident #1 on one-to-one (1:1) supervision until appropriate interventions could be implemented to ensure the resident's safety. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Interview with Registered Nurse (RN) #1, on 10/13/2020 at 12:04 PM; the Director of Nursing (DON), on 10/13/2020 at 11:34 AM; the Administrator, on 10/13/2020 at 12:27 PM; State Registered Nurse Aide (SRNA) #2, on 10/13/2020 at 3:52 AM; SRNA #5, on 10/13/2020 at 4:50 PM; SRNA #4, at 10/13/2020 at 4:56 PM; the Maintenance Assistant, on 10/14/2020 at 9:53 AM; and Unit Manager (UM) #1, on 10/14/2020 at 10:22 AM, revealed Resident #1 was placed on one-to-one supervision immediately after the incident, and this was ongoing. Further interview and review of the Door Alarm Check Sheets revealed a staff member was assigned to the door on Unit 300, on 09/26/2020, until after the door vendor arrived later that evening to ensure all doors were functioning properly. 2. Review of the Skin Monitoring Comprehensive Shower Review sheet, completed on 09/26/2020, and signed off by RN #1 revealed a skin assessment and vital signs were completed on Resident #1 upon return to the building and documented, at 6:38 PM, by the Charge RN. Interview with RN #1, on 10/13/2020 at 12:04 PM, revealed, as soon as they got the resident into the building, the SRNA's took Resident #1 to give him/her a shower, and RN #1 performed a skin assessment with no injuries noted. 3. Review of Resident #1's Comprehensive Care Plan (CCP), revealed it was reviewed by the DON, on 09/26/2020, and revised by the DON, on 09/27/2020, to include the one-to-one monitoring safety measure. Further review of the CCP revealed it was revised again, on 10/02/2020, by the Unit Manager and again, on 10/05/2020, by the Regional Nurse. Interview with the UM, on 10/22/2020 at 10:37 AM, the Regional Nurse, on 10/22/2020 at 11:16 AM, and the DON, on 10/22/2020 at 11:30 AM, revealed the DON reviewed the CCP, on 09/26/2020, and made revisions, on 09/27/2020, to include one-to-one supervision. In addition, the Unit Manager made revisions, on 10/02/2020, to include one-to-one supervision until exit-seeking behaviors de-escalated; and the Regional Nurse confirmed revising the CCP for Resident #1, on 10/05/2020, to include checking placement and function of the secure care device every shift. 4. Review of the initial report sent to the OIG, APS, and the Ombudsman was received, on 09/26/2020. Review of Resident #1's Progress Notes revealed the Physician and the POA were notified, on 09/26/2020 at 6:30 PM. Interview with the POA on 10/13/2020 at 10:29 AM and phone interview with the MD on 10/22/2020 at 10:34 AM, revealed they were notified on 09/26/2020 of the elopement related to Resident #1. 5. Interview with the Maintenance Assistant, on 10/14/2020 at 9:53 AM, revealed he received a call, at approximately 4:00 PM on 09/26/200, from the Maintenance Director that the Unit 300 exit door was alarming and staff was unable to get it to reset. Per interview, he went into the building and fixed the door to reset the alarm, and while he was there, he ensured the doors were engaged and functioning properly prior to leaving. 6. Review of the door vendor invoice, dated 09/26/2020, revealed when the technician arrived to fix the door, he had to remove and rebuild the dyno lock on the Unit 300 door, and the lock was over an inch away from the strike plate. On Unit 200, he took the maglock apart to repair contact, it was not closing fully; on Unit 100, he reset the programming on Advantage 500de and adjusted the reed switch; on the front door, he took down the dyno lock to install fasteners to the plate due to the maglock wobbling; on the therapy door, he inspected and adjusted the maglock and adjusted the door closer; on the laundry door, he adjusted the smart lock and added screws; and on the beauty shop door, he checked its operation with no repairs needed. Interview with the Administrator, on 10/13/2020 at 12:27 PM, revealed she called the door vendor when she arrived at the facility, the evening of 09/26/2020. Per interview, she stayed until the technician arrived, at approximately 11:00 PM, to ensure all doors were inspected and functioning properly. Interview with the door vendor Technician, on 10/22/2020 at 11:45 PM, revealed he did arrive at approximately 11:00 PM and performed the repairs as stated on the invoice dated 09/26/2020. 7. Review of census sheets, from 09/26/2020, used to perform head counts within the facility, revealed complete head counts were done on all three (3) units by the nurses and all residents were accounted for in the facility. Interview with RN #1, on 10/13/2020 at 12:04 PM; LPN #2, on 10/14/2020 at 11:18 AM; UM #1, on 10/13/2020 at 10:22 AM; and the Administrator, on 10/14/2020 at 11:00 AM, revealed head counts were conducted, on 09/26/2020, after the incident occurred, and all residents were accounted for within the facility. 8. Review of Wandering Risk Assessments revealed assessments were completed on fourteen (14) residents, on 09/26/2020, by licensed nurses. Six (6) residents were removed from the elopement risk list due to no longer meeting the criteria for elopement. Further review revealed the Regional Nurse reviewed the elopement assessments for accuracy, on 10/05/2020; and starting 10/05/2020 and ending 10/06/2020, the DON, the ADON and UM #1 reassessed the fourteen (14) residents for wandering/elopement. Interview with RN #1, on 10/13/2020 at 12:04 PM, and LPN #2, on 10/14/2020 at 11:18 AM, revealed licensed nurses reassessed fourteen (14) residents, on 09/26/2020, that were at risk for elopement. Further interview revealed six (6) of those fourteen (14) were removed from the list due to no longer meeting criteria. Interview with the Regional Nurse Consultant, on 10/22/2020 at 11:16 AM, revealed, on 10/05/2020, she reviewed the elopement risk assessments for accuracy and validated six (6) residents were removed due to no longer meeting criteria. Interview with UM #1, on 10/22/2020 at 10:37 AM, the ADON, on 10/22/2020 at 11:03 AM, and the DON, on 10/22/2020 at 11:30 AM, revealed, beginning on 10/05/2020 and ending on 10/06/2020, they reassessed all fourteen (14) residents at risk for elopement and agreed that six (6) could be removed due to no longer meeting criteria. 9. Review of the care plans on current residents, with a beginning date of 09/26/2020 and end date of 10/06/2020, revealed one hundred (100) percent of residents' care plans were reviewed and updated to include interventions for wandering exit-seeking behaviors and appropriate supervision by the DON and the ADON. Interview with the ADON, on 10/22/2020 at 11:03 AM, and with the DON, on 10/22/2020 at 11:30 AM, revealed they reviewed care plans for current residents, updated them to include interventions for wandering/exit-seeking behaviors, and added any appropriate interventions. 10. Review of the Education Sign in Sheets, dated 09/26/2020, revealed the Regional Nurse educated the Administrator and the DON on the Elopement Policy, Care Plan Policy, procedures, training, and processes. The Administrator and the DON then educated department leaders, including: Unit Managers, the ADON, the SSD, the Dietary Manager, the Maintenance Director, the Activity Director, Central Supply, and the Business Office Manager, on 09/26/2020 via telephone. The Administrative staff were not permitted to return to work until a one hundred (100) percent score was attained on the post-test. Review of the POS [REDACTED]. Interview with the Regional Nurse, on 10/22/2020 at 11:16 AM, revealed she did educate the Administrator and the DON, on 09/26/2020, on the Elopement Policy, Care Plan Policy, procedures, training, and processes. Interview with the DON, on 10/22/2020 at 11:30 AM, and the Administrator, on 10/22/2020 at 11:44 AM, revealed they were re-educated on the policies, procedures, and processes related to Elopement, Care Plans, door alarms. Interview with the Maintenance Director, on 10/22/2020 at 9:08 AM; the Medical Records Director, on 10/22/2020 at 10:00 AM; UM #1, on 10/22/2020 at 10:37 AM; the MDS Coordinator, on 10/22/2020 at 10:45 AM; the Admissions Director, on 10/22/2020 at 10:50 AM; the SSD, on 10/22/2020 at 10:53 AM; the Activity Director, on 10/22/2020 at 11:00 AM; the ADON on 10/22/2020 at 11:03 AM; and the Dietary Manager, on 10/22/2020 at 11:11 AM, confirmed they received the education, performed a post-test, and were instructed they could not work until a one hundred (100) percent score was achieved. 11. Review of the in-service sign in sheets, beginning 09/26/2020 through 10/06/2020, revealed ninety-five (95) out of ninety-eight (98) received a second in-service on the Elopement Policy, Care Plan Policy, and door alarm procedures. Three (3) staff members were absent, using the Family and Medical Leave Act (FMLA) provisions. Interview with RN #1, on 10/13/2020 at 12:04 PM; LPN #2, on 10/14/2020 at 11:18 AM; SRNA #2, on 10/13/2020 at 3:52 PM, SRNA #5, on 10/13/2020 at 4:50 PM; SRNA #4, on 10/13/2020 at 4:56 PM; SRNA #6, on 10/22/2020 at 9:24 AM; SRNA #7, on 10/22/2020 at 9:18 AM; Activity Assistant, on 10/22/2020 at 9:21 AM; Housekeeper #1, on 10/22/2020 at 9:35 AM; SRNA #8, on 10/22/2020 at 9:40 AM; the SRNA/Scheduler, on 10/22/2020 at 9:42 AM; SRNA #11, on 10/22/2020 at 9:45 AM; Agency SRNA #12, on 10/22/2020 at 9:56 AM; SRNA #13, on 10/22/2020 at 10:00 AM; LPN #6, on 10/22/2020 at 10:06 AM; LPN #5, on 10/22/2020 at 10:13 AM; and LPN #7, on 10/22/2020 at 10:19 AM, revealed they were re-educated on the Elopement Policy and procedures, Care Plan Policy; door alarms, and the procedure if a resident eloped. 12. Review of sign in sheets, dated 09/26/2020, revealed the Regional Nurse, the Administrator, the DON or the ADON had been available on weekends to ensure continued compliance with education and monitoring related to the elopement. Interview with the Regional Nurse, on 10/22/2020 at 11:16 AM; the ADON, on 10/22/2020 at 11:03 AM; the DON, on 10/22/2020 at 11:30 AM; and the Administrator, on 10/22/2020 at 11:44 AM, validated they had been working weekends and had made themselves available to all shifts to ensure continued compliance with actions of monitoring and supervision. 13. Review of Facility Door Log Sheets, beginning 09/27/2020 and ongoing, revealed the facility's doors were being checked for proper function, that all egresses were working properly, verifying the system code and keypad o (TRUNCATED)

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 to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of fourteen (14) sampled residents (Resident #1). The facility admitted Resident #1, on 03/04/2019, with [DIAGNOSES REDACTED]. Interviews revealed the resident had poor decision-making ability and wandered aimlessly throughout the facility. Interviews and record review revealed the facility assessed Resident #1, on 08/18/2020, to be an elopement risk, exhibited exit-seeking behaviors, and had a Secure Care bracelet in place. Per interview, on 09/26/2020 at approximately 3:30 PM, staff observed Resident #1 near the exit door on Unit 300 and redirected the resident away from the door, but staff was unable to silence the alarm and unable to secure the door lock at that time. Interview revealed the resident was redirected down the hallway by Licensed Practical Nurse (LPN) #1 two (2) additional times before maintenance arrived, at approximately 4:30 PM on 09/26/2020, to secure the door. Staff failed to implement increased supervision or monitoring of Resident #1. At approximately 4:50 PM, staff assigned to care for Resident #1 could not locate the resident. Resident #1 was found, at approximately 5:43 PM, lying in a ditch, over three hundred (300) feet from the facility and one-hundred thirty (130) feet from a highway, crying out for help. The initial skin assessment, completed on 09/26/2020, noted no injury; however, the follow-up skin assessment, completed on 10/01/2020, noted a two (2) centimeter (cm) discolored area to the right inside area of the buttock, a one (1) cm discolored area to the left inside area of the upper arm, a pale discolored area to the left shoulder, a one (1) cm discolored area to the left outer buttocks, and scratches noted above the right knee. 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 10/15/2020 and determined to exist on 09/26/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/21/2020, alleging removal of the Immediate Jeopardy on 10/16/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 10/16/2020, prior to exit on 10/22/2020, 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, Elopement Management Program, dated 12/26/2016, revealed, for those residents determined to have a potential for, or were at risk for elopement, the program relied on a systematic approach by the Interdisciplinary Team. Further review of the policy revealed a resident's environment would remain as free from accident hazards as was possible, and each resident received adequate supervision and assistance devices to prevent accidents. Per policy, the resident's care plan would indicate the resident was at risk for elopement or other safety issues, and interventions to try to maintain safety, such as a detailed monitoring plan, would be included. Review of Resident #1's medical record revealed the facility admitted the resident, on 03/04/2019, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing Assessment, dated 03/04/2019 at 6:39 PM, signed by LPN #8, revealed the resident was admitted from home, and the reason for admission was due to Resident #1's cognitive status and safety awareness, Resident #1 needed long term care. Further review of the Nursing Assessment, revealed the resident was alert and oriented to person; had memory loss; and was independent with ambulation, transfers, toileting and eating. Per the Nursing Assessment, the resident was at low risk for elopement. Observations, on 10/12/2020 at 4:30 PM, 10/12/2020 at 5:15 PM, and 10/14/2020 at 2:30 PM, revealed Resident #1 wandering aimlessly in the hallways. The resident was walking alone without staff assistance. Review of Resident #1's Baseline Care Plan, revealed a focus problem, initiated on 03/08/2019, of the resident was at risk for elopement related to wandering and making statements about leaving. The goal, initiated on 03/08/2019, revealed the resident would have no incidence of elopement. The interventions included: involve the resident in preferred activities; involve the resident in decision making regarding daily choices; redirect the resident from doors; and take a picture of the resident upon admission for identification for updating the elopement book. However, the Baseline Care Plan did not specify the supervision level required to keep the resident safe, or specific interventions to implement if the resident exhibited wandering and exit-seeking behaviors. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 03/11/2019, revealed for the Brief Interview for Mental Status (BIMS) Assessment, the resident had a score of six (6) out of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #1's Elopement Risk Assessment, dated 03/04/2019, completed by LPN #8, revealed she assessed Resident #1 as being at low risk for elopement. Review of Resident #1's physician's orders [REDACTED]. Review of the facility's Long Term Care Facility-Self Reported Incident Form -Five (5) day Follow Up/Final Report, and the facility's investigation, dated 10/02/2020 at 8:15 PM, and signed by the Administrator, revealed, on 09/26/2020 at approximately 3:30 PM, the Unit 300 hall door alarm was sounding. Per the report, the nurse responded and saw Resident #1 walking down the hallway on Unit 300; then, she redirected Resident #1 to Unit 100 and proceeded back to the Unit 300 hall door to reset the alarm. Further review revealed the nurse was unable to reset the alarm and left the door to call Maintenance to fix the alarming door. The report stated, at approximately 4:50 PM, a State Registered Nurse Aide (SRNA) noticed, during rounds, that she did not see Resident #1 in the hallway or in his/her room. The SRNA looked around the building and notified other staff that she could not locate Resident #1. Per the report, it was initially reported by staff that Resident #1 was found by the dumpster on facility grounds. However, after further investigation and review of the facility's video footage, the resident was located one hundred thirty (130) feet from the dumpster and was found at approximately 5:43 PM. Further review of the report, revealed Resident #1 was immediately placed on one-to-one (1:1) supervision, and the nurse completed a head-to-toe skin assessment. Continued review revealed Resident #1's wander guard was in place and functioning properly. In addition, the report stated the Physician was notified of the incident, and of the resident's return to the facility; Resident #1 remained on one-to-one (1:1) supervision until 09/28/2020. Review of the local weather history, revealed the temperature was seventy-five (75) degrees Fahrenheit and sunny on 09/26/2020. Per the Director of Nursing (DON), the Police Department was called; however, they did not take a report related to the Resident #1's elopement. Review of the video footage dated 09/26/2020 from approximately 3:30 PM until 5:43 PM and observation of the elopement route with the Administrator, on 10/12/2020 at 5:45 PM, revealed Resident #1 ambulated from the Unit 300 Hallway out the back exit door, the door that was alarming. Per observation, after the resident exited the back door, he/she ambulated down the facility sidewalk, down a hill, and into an apartment complex parking lot where Resident #1 fell into the ditch. The place where Resident #1 was found was approximately three hundred (300) feet from the facility building and one hundred thirty (130) feet from the highway. Interview with the Director of Maintenance (DOM), on 10/14/2020 at 9:35 AM, revealed he received a call from LPN #1, on 09/26/2020 at 3:44 PM, stating a door on Unit 300 Hallway was alarming and could not be reset. He stated he was unavailable to return to the facility, so he contacted his assistant. The DOM stated it took his assistant approximately forty (40) minutes to arrive at the facility. Further interview revealed the Unit 300 door was unsecured until his assistant could get the door shut and reactivate the alarm. Per interview, the facility had been having trouble with that door for quite some time, and the previous Administrator was aware. He further stated the door vendor did the most recent repair on the door in August 2020. Telephone interview with SRNA #2, on 10/13/2020 at 3:52 PM, revealed she was assigned to Resident #1, on 09/26/2020. Per interview, LPN #1 came to another resident's room where she and SRNA #1 were providing care. She stated LPN #1 informed them they could not locate Resident #1, and they all began to look for Resident #1. SRNA #2 stated they looked inside first, because Resident #1 wandered aimlessly all the time and would be found in other residents' beds. Per interview, they were unable to locate Resident #1 inside the building, so she and SRNA #1 went outside while Registered Nurse (RN) #2 got in her car and started driving down the road searching for the resident. Further interview revealed the alarm on Unit 300 had been alarming for a long time and staff had been waiting on maintenance to fix the alarm. SRNA #2 stated staff did try to keep a closer eye on Resident #1 related to exit-seeking behaviors; however, there was no instruction from the nurses to initiate one-to-one (1:1) supervision or to complete checks on the resident at specific intervals, on 09/26/2020. She stated she was so busy she just did not have time to monitor the resident closely, on 09/26/2020. Further, SRNA #2 stated, at approximately 5:43 PM, as she and SRNA #1 were by the dumpster searching for Resident #1, they heard someone crying; when they looked down the hill by the road, they found Resident #1 lying in a ditch. Per interview, she stated the resident did not appear to have any injuries; however, the resident was wet with muddy clothes. SRNA #2 stated she ran into the building to alert RN #1 they had found the resident and to bring a wheelchair. Continued interview with SRNA #2 revealed, on 09/26/2020, before the elopement, she had last seen Resident #1 at approximately 3:00 PM, and she remembered hearing an alarm sound after 3:30 PM and prior to the resident being found. Additional interview revealed when the door alarm sounded, staff was to go to the door that was alarming and look outside to make sure a resident did not go outside. Per interview, if no resident was seen outside, staff was to reset the alarm and inform the nurse, in order for a head count to be completed to make sure all residents were accounted for and were safe. Telephone interview with Registered Nurse (RN) #1, on 10/13/2020 at 12:04 PM, revealed she was working Unit 100, on 09/26/2020, and was assigned to Resident #1. She stated the resident wandered the halls most of the day. She further stated she was in another resident's room performing a dressing change when she was informed that Resident #1 was missing. She stated the alarm on Unit 300 had been sounding a long time, and she was aware that maintenance had been notified to fix the door and reactivate the alarm. RN #1 stated Resident #1 would be redirected back to his/her room multiple times a day. Per interview, RN #1 stated she did not increase supervision of Resident #1 when the resident was exit-seeking, on 09/26/2020, nor did she place someone at the door that was alarming to secure the door. She stated she should have implemented one-to-one (1:1) supervision and placed someone at the door; and, if she had done so, this incident could have been prevented. The RN further stated she was unsure of how long Resident #1 was gone. RN #1 stated she did not call Administration until after the resident was found. She stated the resident was brought back to the facility and was given a shower by SRNA #1 and SRNA #2. She stated a head-to-toe assessment was completed and no injuries were noted to Resident #1. Per interview, after Administration was notified, staff was instructed to place the resident on one-to-one (1:1) supervision. She further stated she was initially told by staff the resident was found by the dumpster; however, the Administrator told her later the resident was found in a ditch and had been gone for over an hour. Continued interview with RN #1, on 10/13/2020 at 12:04 PM, revealed Resident #1 was alert to name only and needed constant direction back to his/her room. RN #1 stated, although Resident #1's care was assigned to her, on 09/26/2020, and she was aware the resident was exhibiting exit-seeking behaviors, she did not recall initiating any increased supervision of the resident, nor did she document the resident's exit-seeking behaviors prior to the elopement. Furthermore, review of Resident #1's Progress Notes, revealed no evidence the resident was exhibiting exit-seeking behaviors and no evidence staff implemented increased supervision and monitoring of the resident related to exit-seeking behaviors on 09/26/2020. Attempts were made, on 10/13/2020 at 4:04 PM, 10/14/2020 at 9:05 AM, and 10/21/2020 at 5:15 PM, to contact by phone SRNA #1, RN #2 and LPN #1, but all were unsuccessful. In addition, messages were left with no return phone calls received from any of these individuals, whom no longer worked at the facility. Telephone interview with SRNA #5, on 10/13/2020 at 4:50 PM, revealed she was assigned to work Unit 200, on 09/26/2020; however, she was not assigned to Resident #1. SRNA #5 stated she saw Resident #1 wandering the halls most of the day, and everyone was aware of the need to watch Resident #1. However, she stated staff did not increase the supervision level for the resident when the alarm sounded on Unit 300. She stated Resident #1 was at the door on Unit 300 a couple of times and was redirected back to his/her unit. SRNA #5 stated when she was made aware Resident #1 was missing, she stayed in the building and helped RN #1 search for the resident. She stated she was told the resident had been found by the dumpster. Telephone interview with SRNA #4, on 10/13/2020 at 4:56 PM, revealed, on 09/26/2020, she was assigned to work Unit 200. She stated she was outside on break when the staff realized Resident #1 was missing. SRNA #4 stated by the time she was aware of the elopement, staff was pulling the resident out of the ditch. She further stated the resident always wandered aimlessly up and down the halls and, at times, would be found in another resident's room. Per interview, on 09/26/2020, the alarm on Unit 300 had been sounding for a while, and staff told her that maintenance had been notified. SRNA #4 stated staff did not increase supervision on Resident #1 after the resident was redirected multiple times from the Unit 300 door, before the resident eloped. She further stated she had never received training related to the Elopement policy or procedures until after Resident #1 eloped, on 09/26/2020. Interview with the Maintenance Assistant, on 10/14/2020 at 9:53 AM, revealed he received a call, at approximately 4:00 PM on 09/26/2020, from the Maintenance Director that the Unit 300 door was alarming and staff was unable to reset the alarm. Per interview, he stated when he arrived, at approximately 4:30 PM, the door was alarming and no staff was monitoring the door. He further stated he had been working on Unit 300 earlier in the day, on 09/26/2020, and Resident #1 had wandered over to Unit 300; he stated he redirected the resident back to Unit 100 where he/she resided. Further interview revealed he was at the facility when staff found the resident outside in the ditch near the apartment building. He further stated if an alarm was sounding, staff should stay at the door until the alarm could be reset. Per interview, when the alarm sounded, staff should have checked outside the door for any resident and immediately perform a head count. The Maintenance Assistant stated the facility had experienced problems with the doors for quite some time. Interview with Unit Manager (UM) #1, on 10/14/2020 at 10:22 AM, revealed she was on-call, on 09/26/2020. She stated she received a call from RN #1, at approximately 6:00 PM. She stated RN #1 alerted her Resident #1 had eloped and sustained no injuries. Per interview, the nurse informed her the Unit 300 door had been alarming since around 3:30 PM, and maintenance had been called to reset it. UM #1 stated she instructed RN #1 to place Resident #1 on one-to-one (1:1) supervision and to place a staff member at the door to keep watch. She further stated when she arrived at the facility, shortly thereafter, she obtained statements from the staff that was present. Unit Manager #1 stated she just could not understand why staff did not place the resident on one-to-one (1:1) supervision because the resident was exit-seeking and why they did not place a staff member at the door that was alarming. She stated if staff had implemented one-to-one (1:1) supervision for Resident #1 and placed staff at the door that was alarming, this elopement would have been avoided. She further stated she was thankful the resident was found with no injuries. Continued interview with UM #1 revealed the initial skin assessment, completed on 09/26/2020, revealed no injuries. However, on 10/02/2020, she performed a follow-up skin assessment on Resident #1 and noted a two (2) centimeter (cm) discolored area to the right inside area of the buttock, a one (1) cm discolored area to the left inside area of the upper arm, a pale discolored area to the left shoulder, a one (1) cm discolored area to the left outer buttocks, and scratches noted above the right knee. Telephone interview with Resident #1's Power of Attorney (POA), on 10/13/2020 at 10:29 AM, revealed the resident lived at home with his/her daughter prior to admission to the facility. She stated the resident's daughter was hospitalized , and the resident was unable to stay alone at home related to safety concerns. The POA stated she had received a phone call from the nurse that Resident #1 had left the building; however, staff brought the resident back into the building. Per interview, a few days later, she received a call from the Ombudsman informing her the resident had fallen. She further stated Resident #1 had a history of [REDACTED]. Telephone interview with LPN #2, on 10/14/2020 at 11:18 AM, revealed she had worked at the facility for three (3) years. She stated, on 09/26/2020, she was assigned to Unit 100, but she was not assigned to Resident #1. She stated, on the day of 09/26/2020, the Maintenance Assistant had been painting on Unit 300, and when the door alarm sounded, she did not think much about it because she assumed it had something to do with the Maintenance Assistant. LPN #2 stated RN #2 had informed her the Unit 300 door was alarming; she was unable to get it reset, and she had called maintenance. She stated she was providing care to another resident when SRNA #2 informed her Resident #1 was missing. LPN #2 stated staff looked everywhere and was unable to locate the resident. Further interview revealed she had received a call from SRNA #1 that the resident had been found in a ditch just past the dumpster. Per interview, they got the resident out of the ditch, placed him/her in a wheelchair, and returned him/her to the building. She stated after the resident was found, all staff started freaking out because the alarm had been sounding for over an hour, and no one had secured the door. She further stated all staff should have checked all doors and outside the doors when the alarm was sounding. Further interview revealed when the resident was exit-seeking and was redirected by RN #2 twice from the door, they should have increased supervision and placed the resident on one-to-one (1:1) supervision. LPN #2 stated if staff had done these things, the elopement might have been avoided. She further stated she had never participated in an elopement drill and was not quite sure what to do when this incident happened. LPN #2 stated she could not recall or say how long the resident was gone. Interview with the Assistant Director of Nursing (ADON), on 10/14/2020 at 11:35 AM, revealed she had worked at the facility for twenty-eight (28) years. She stated staff should have put someone at the door when it was alarming, increased supervision for Resident #1 when he/she was exit-seeking, and notified Administration. She further stated she expected staff to follow the policies and procedure of the facility. Interview with the Medical Director, on 10/22/2020 at 10:34 AM, revealed that Resident #1, from admission, was at risk for elopement related to wandering aimlessly in the hallways and the resident's Dementia. Per interview, the wander guard was placed on the resident as an assistive device in an attempt to keep the resident safe; however, the resident was able to get out of the facility without staff's knowledge. The Medical Director stated Resident #1 had wandered aimlessly since she knew him/her. Continued interview revealed that since Covid-19, Resident #1's exit-seeking and other behaviors had exacerbated. Interview with the Director of Nursing (DON), on 10/13/2020 at 11:32 AM, revealed on 09/26/2020, she received a call from UM #1 informing her of the elopement. Per interview, she then called the Administrator. The DON stated since the UM was in route to the facility, she worked from home getting background information from the aides as to where they found Resident #1. Additional interview revealed it was standard practice for residents to be checked by staff every two (2) hours, and, on 09/26/2020, staff should have increased supervision and monitoring to one-to-one (1:1) supervision for Resident #1 due to the resident exhibiting exit-seeking behaviors. Continued interview with the DON, on 10/13/2020 at 11:32 AM revealed it was standard practice for staff to monitor any door that was alarming until the door could be reset and reactivated, and staff knew this. Further interview revealed, when the door alarm sounded, staff was to go to the door, look out, and then go on a perimeter search of the building to ensure a resident had not gone outside unaccompanied by staff. Per interview, if staff could not locate the resident who sounded the alarm, staff was to return inside the building and start a head count. She further stated, on 09/26/2020, these procedures should have been followed, and if they had, this elopement might have been prevented. The DON further stated there was the chance for harm or even death to a resident who eloped. Interview with the Administrator, on 10/13/2020 at 12:27 PM, revealed she had worked at the facility since September 2020. She stated when she arrived at the facility, she made sure the doors were secured and placed staff at the doors until the vendor could arrive to check the functioning of all doors. She further stated Administration was not notified of this incident until it was all over. Further interview revealed staff initially reported the resident was found at the dumpster; however, after she was able to view the video footage, she learned the resident had been gone for over an hour and was found one hundred thirty (130) feet from the dumpster and not on facility property. She stated per the facility's video footage, Resident #1 exited the Unit 300 door, on 09/26/2020, at approximately 4:50 PM. Resident #1 walked the perimeter of the building, down the sidewalk, and turned right past the dumpster. The resident walked down the hill towards the apartment complex and just past a building with bushes, then Resident #1 was no longer present on the video camera. Per interview, she expected staff to follow the facility's elopement policy and procedures. She stated staff should have notified her sooner, and she could have put measures into place to increase supervision of Resident #1 and place staff at the door that was alarming. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/21/2020, which alleged removal of the Immediate Jeopardy (IJ) on 10/16/2020. Review of the AoC revealed the facility implemented the following: 1. On 09/26/2020, Resident #1 was placed on one-to-one (1:1) supervision and monitoring at the time the resident was assisted back to the building. An employee was assigned to the door where the alarm was sounding until the alarm was reset and reactivated. 2. On 09/26/2020, a skin assessment and vital signs were completed on Resident #1 upon return to the building and documented, at 6:38 PM, by the Charge RN. 3. On 09/26/2020, Resident #1's care plan was reviewed by the Director of Nursing, and on 09/27/2020, the care plan was revised to include one-to-one (1:1) safety. On 10/02/2020, the charge nurse revised the care plan to include the resident to be placed on one-to-one supervision until exit-seeking behaviors de-escalated. On 10/05/2020, the Regional Nurse revised the care plan to include checking placement and function of the secure device every shift. 4. On 09/26/2020, the Administrator reported the event to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman. The Charge Nurse notified the Physician and family on 09/26/2020. 5. On 09/26/2020, the Maintenance Assistant reset the sounding alarm on the Unit 300 exit door and ensured the door was operational. All other exit doors were secured, alarms were engaged, and doors were key-coded. 6. On 09/26/2020, the Administrator called the door vendor to check all resident accessible exit doors. The technician arrived, on 09/26/2020 at 11:00 PM, and performed the following: the exit door on Unit 300 Hall was removed, with the dyne lock rebuilt to ensure proper placement to the strike plate; the door on Unit 200 Hall had the maglock taken apart to repair contact; the door on Unit 100 Hall had the programming reset on Advantage 500de, and the reed switch was adjusted; the front door had fasteners installed to the plate to tighten the magnet; the door by the laundry had the smart lock adjusted and screws added; and the door by the beauty shop was checked, and no adjustments/repairs were needed. 7. On 09/26/2020, each unit nurse completed a head count of the residents, and all other residents were accounted for in the facility. 8. On 09/26/2020, licensed nurses assessed current residents for elopement/wandering potential and this was completed by 09/29/2020. Fourteen (14) residents were at risk for elopement at that time. No additional residents were added to the Elopement/Wandering Risk List. Six (6) residents were removed from the elopement risk list due to no longer meeting the criteria for elopement; one (1) resident was in the hospital and was removed from the list, for a total of seven (7) residents removed from the list. On 10/05/2020, the Regional Nurse reviewed elopement assessments for accuracy. Fourteen (14) were reassessed for wandering elopement, on 10/05/2020, and completed by 10/06/2020, by the DON, ADON and Unit Manager. 9. Starting, on 09/26/2020, and completed, by 10/06/2020, the DON and ADON reviewed care plans on current residents and updated them to include interventions for wandering exit-seeking behaviors and appropriate supervision. 10. On 09/26/2020, the Regional Nurse Consultant educated the Administrator and DON related to the Elopement Policy, Care Plan policy/procedure, training, and processes. The Administrator and DON then educated department leaders, including: Unit Managers, ADON, SSD, Dietary Manager, Maintenance Director, Activity Director, Central Supply, and the Business Office Manager. Administrative staff were not permitted to return to work until a one hundred (100) percent score was attained on the post-test. 11. Beginning 09/26/2020, Department Leaders re-educated current staff on the Elopement Policy, Care Plan policy/procedure, training, processes, and door alarm procedures. By 10/06/2020, ninety-five (95) of ninety-eight (98) staff, including twelve (12) agency staff, had received the education. 12. Beginning 09/26/2020, a Regional Nurse Consultant or member of the Corporate team, the Administrator, the DON or the ADON had been available on weekends to ensure continued compliance with education and monitoring established by the QAPI committee. The QAPI Committee members were the Administrator, the DON, the ADON, the UM, the Social Services Director, the MDS Coordinator, the Maintenance Director, the Dietary Manager, and the Medical Director. 13. Beginning 09/27/2020, and ongoing, facility doors will be checked for proper functioning to ensure that the doors would alarm as designed, with all egress functions working properly, verifying the system codes and keypad operations, and checking the Secure Tech Pads to make sure the doors stayed locked and alarms sounded. The Administrator, Department Managers, or the Maintenance Director/Maintenance Assistant would complete this daily function. Any concerns would be immediately reported to the Administrator and Maintenance Director. 14. On 09/27/2020, the Administrator completed environmental rounds to identify any safety issues and no concerns were identified at that time. 15. On 09/27/2020, the Administrator contacted the door vendor and obtained a quote on upgrading the door alarm system to Wander Guard Blue to be installed on all remaining resident accessible exit doors. The quote was approved, and the facility was working with the vendor for an installation date. 16. On 09/28/2020, Elopement Binders were reviewed and updated for accuracy by the Social Services Director (SSD), the DON, the ADON, the Unit Manager, and the MDS Coordinator to reflect current elopement/wandering risk evaluations. Seven (7) residents were removed from the list, which included one (1) resident in the hospital. 17. On 09/28/2020, the SSD and Activity Director conducted interviews on residents with a BIMS' score of greater than eight (8) to determine if anyone had any knowledge of any prior elopements or safety concerns. No concerns were validated. The Admissions Coordinator and Scheduler also conducted interviews, on 09/28/2020, with current staff to determine if anyone had any knowledge of prior elopements, and no concerns were validated. 18. On 09/28/2020, an elopement drill was completed by the Maintenance Director. Then, the Administrator, the DON, the Maintenance Director, or Department Heads started conducting drills on alternating shifts and weekends until 10/15/2020. 19. On 09/29/2020, the Maintenance Director and the Administrator reviewed the Technology Enhanced Learning System (TELS), an online maintenance system that tracked door checks to ensure all doors had been checked for locking alarms, maglock, and delayed egress for the past thirty (30) days. Furthermore, all doors were inspected per policy and the door vendor corrected verified issues identified. On 08/24/2020, the door vendor replaced the maglock on an exit door and wired/tested all systems that were verified to be normal. 20. On 09/30/2020, the ADON and Unit Manager began monitoring orders to evaluate wandering behaviors every shift on the residents at risk for elopement, and these orders were placed on the Treatment Administration Record (TAR). 21. On 10/05/2020, the DON conducted a thirty (30) day lo (TRUNCATED)

Based on observation, interview, review of medical records, review of facility documents, review of the Centers for Disease Control and Infection Prevention (CDC) guidelines, and review of the facility's policy, 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 the development and transmission of communicable disease and infections. Observation, on 10/14/2020 at 1:50 PM, revealed the Activity Assistant entering a resident's room on the 100 Unit without donning (putting on) gloves. She touched the resident's face just below the left eye with her bare hand to assess the resident's eye. She then exited the room without proper hand washing and entered another resident's room further down the hall on the 100 Unit without donning gloves prior to touching the resident's face performing assessment of his/her eye. She then exited the room without proper hand washing. The findings include: Review of the facility's Infection Control Policy, revealed the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections and these policies apply to all personnel. Further review revealed all personnel would be trained on the infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Review of the facility's Hand Washing/Hand Hygiene policy, dated August 2019, revealed the facility considered hand hygiene the primary means to prevent the spread of infections. Further review revealed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Review of the facility's Education and Training records revealed facility staff received ongoing training and education regarding Donning and Doffing (putting on and taking off) PPE, COVID-19 Infection Control, Handwashing and Sanitizing, Respiratory Hygiene, and Strategies for Minimizing the Spread of COVID-19. Observation, on 10/14/2020 at 1:50 PM, revealed the Activity Assistant entering a resident's room on the 100 Unit without donning gloves. She touched the resident's face just below the left eye with her bare hand to assess the resident's eye, then exited the room without washing her hands. She then entered another resident's room further down the hall on the 100 Unit without donning gloves prior to entering the room and touching the resident's face performing an assessment of the resident's eye. The Activity Assistant then exited the room without washing her hands. Interview with the Activity Assistant on 10/14/2020 at 1:50 PM, revealed she should have washed her hands prior to entering the resident's room. She stated she should have donned her gloves prior to touching the resident and then performed hand hygiene again prior to entering another resident's room. Per interview, she stated she had been educated on hand washing and donning of gloves. She stated she just forgot but she should have followed the facility's policy and procedures. Further interview revealed by not washing her hands and donning of gloves she could have spread infection to others. Interview with the Assistant Director of Nursing (ADON), on 10/14/2020 at 5:17 PM, revealed all staff was required to don and doff PPE per facility and CDC guidelines before entering and exiting a resident's room and staff should perform hand hygiene before entering and exiting residents' rooms. Further, she expected the facility's policy (s) on infection control and CDC guidelines to be maintained at all times to prevent the spread of infection. Additionally, she expected staff to wash their hands and appropriate PPE to be worn. Interview with the Unit Manager, on 10/14/2020 at 5:45 PM, revealed it was her expectation for staff to perform proper hand hygiene prior to entering a resident's room and prior to exiting a resident's room. The Unit Manager stated hand washing was the main thing to perform to stop the spread of infections. She further stated the staff member should have donned gloves prior to touching any resident and doffed the gloves when she finished providing care to a resident. Interview with the Director of Nursing (DON), on 10/22/2020 at 11:30 AM, revealed she expected all staff to be trained and educated on the facility's policy and the CDC's guidelines related to infection control. Per interview, she expected all staff to don and doff PPE per the facility's policy and CDC's guidelines when indicated for a resident. Additional interview revealed she expected staff to practice proper hand hygiene prior to entering a resident's room and prior to exiting a resident's room. Further, it was important to maintain infection control per the facility's policies and CDC guidelines to prevent transmission of disease. Interview with the Administrator, on 10/22/2020 at 11:45 AM, revealed she expected staff to maintain the facility's policies, CDC guidelines, and regulations related to infection control practices specific to donning and doffing PPE, and proper hand hygiene to stop the spread of contagious diseases.

Based on interview and record review, it was determined the facility failed to ensure the resident's representative was notified whenever there was a change in condition for a resident. Resident #2 tested positive for COVID-19; however, his/her responsible party was not contacted and did not discover Resident #2 had acquired COVID-19 until days later. The findings include: Review of the facility's policy, Documentation in the Clinical Record, dated 12/26/16, revealed entries should be recorded in the clinical record by licensed personnel in accordance with state law and facility policy. Further review revealed changes in a resident's condition would be documented in the record as well as family notification of the change(s) in the resident's condition. Review of Resident #2's medical record revealed Resident #2 was admitted to the facility, on 05/01/2013, with [DIAGNOSES REDACTED]. Continued review of Resident #2's medical record revealed he/she was tested for COVID-19 in a facility-wide test, on 08/11/2020. Resident #2 tested positive for the COVID-19 virus, with the facility receiving his/her test results on 08/13/2020. Further review revealed there was no record in the progress notes or elsewhere in the record of Resident #2's responsible party, a State Guardian, being notified of the positive test results. Interview with the State Guardian, on 08/27/2020 at 9:10 AM, revealed the facility did not contact him when Resident #2 tested positive for COVID-19. He went on to reveal he contacted the facility around 2:00 PM or 2:30 PM on 08/17/2020, after another of his residents, Resident #3, had been sent to the hospital, and he believed he would not have found out about Resident #2's positive COVID-19 test if he had not called the facility at that time. He stated he checked the on-call log and checked with the secretary, but there was no record the facility had called him to report Resident #2's positive COVID-19 test result on 08/13/2020. Further, the guardian stated the Director of Nursing (DON) did apologize for not contacting him. Interview with the DON, on 08/27/2020 at 12:56 PM, revealed she expected nurses on the floor to be responsible for making notification of any type of change of condition with a resident. In addition, she stated she expected nurses to inform management staff if there was a problem with notification so they could offer assistance. Per interview, she stated when Resident #2 tested positive for COVID-19, things were hectic at the facility (multiple positive cases with room changes), and there might have been miscommunication on who was making notifications. The DON stated she believed Resident #2 's guardian notification, unfortunately, got missed. She stated notifications were normally reviewed in morning meetings, and unit managers would usually notice if notifications had not been made; but, morning meetings had also been hectic lately. The Executive Director was not available for interview at the time of exit.

Based on interview, medical record review, review of the facility's documents, and review of the Centers for Medicare and Medicaid Services (CMS) memos, it was determined the facility failed to ensure provisions in the written agreement between the facility and a Medicare-certified hospice provider were followed. The facility contract with hospice specified free access to the facility by hospice employees and unrestricted visiting privileges, which the facility failed to honor. One (1) of three (3) sampled residents, Resident #4, was admitted to hospice services but had only been allowed to receive telehealth visits with the hospice provider. The findings include: Review of the facility's contract with Hospice of Hope, Inc., effective 12/01/2016, revealed the facility would permit free access to hospice employees and unrestricted visiting privileges on a twenty-four (24) hour basis. The contract further established Hospice of Hope was responsible for providing the same level of services as if the resident were in his or her own home. Review of Quality, Safety, and Oversight (QSO) Memo, dated 03/20/2020, number QSO-20-20-All, revealed CMS, the regulating body for the facility, determined healthcare staff providing services, such as hospice care, should be allowed to enter the facility provided they were wearing appropriate personal protective equipment (PPE) and did not meet the criteria for restricted access. Review of a QSO Memo, dated 04/24/2020, number QSO-20-28-NH, revealed health care workers, such as hospice workers, should be permitted to come into the facility as long as they met the Centers for Disease Control and Infection Prevention (CDC) guidelines for healthcare workers. QSO-20-28-NH went on to reveal health care workers should be screened following CDC guidance. Review of Resident #4's medical record revealed Resident #4 was admitted to the facility, on 04/17/2019, with [DIAGNOSES REDACTED]. More recently, as of 07/30/2020, Resident #4 had been diagnosed with [REDACTED]. Review of a Discharge Summary from the hospital, dated 08/14/2020, revealed Resident #4 had been admitted , on 08/11/2020, with a [DIAGNOSES REDACTED]. Further review of the discharge summary revealed Resident #4 had been admitted to Hospice of Hope for continued care and symptom management. Interview with the Power of Attorney (POA) for Resident #4, on 08/26/2020 at 9:22 AM, revealed the Physician at the hospital had contacted her about hospice services. She stated her understanding was Resident #4 would be receiving hospice services at the facility through telehealth on Wednesdays. Interview with the Hospice Director of Clinical Services (DCS), on 08/27/2020 at 11:28 AM, revealed even prior to COVID, there had been problems between hospice and the facility. She shared there had been residents (unsampled) in the past referred for hospice services while hospitalized , but when the admissions nurse from hospice arrived at the facility, he/she had been asked to leave the premises by the facility's social worker and admissions staff. She revealed, more recently, there was another appointment set up with a family for referral to hospice services for another unsampled (former) resident. The DCS stated the hospice nurse was told by the social worker he/she was not allowed in the facility, and it was a corporate decision. She revealed, from all conversations she had recently with facility staff, from the Activities Director (AD), to the Director of Nursing (DON), to the Executive Director (ED), she had been informed the corporate office currently was not allowing vendors; this included hospice services. The DCS stated she informed the facility's management she would like for her staff to be allowed in at least weekly but was informed telehealth visits was her only option. Further, she stated she accepted the telehealth option. Per interview, she revealed some facilities in other states were also restricting them to telehealth, although this facility was the only Kentucky facility that was restricting their access to residents. She stated her concerns centered around being able to honor resident choices in providing hospice services. She stated she had offered to hold her own employees to the same standards the facility's staff were held to, which included COVID-19 tests for hospice employees with test results back within twelve (12) hours and providing PPE to their employees to help conserve facility supplies. Interview with the DON, on 08/27/2020 at 12:56 PM, revealed hospice services routinely were not allowed in due to COVID-19. She stated this was not a written policy but had been conveyed to her in a meeting with corporate. The DON stated she, the Executive Director, and corporate representatives had a conference call with hospice, on 08/26/2020, and it was her understanding they were now permitted in during end-of-life care. She revealed the facility currently had one (1) hospice patient who was stable. Another interview with the DON, on 08/27/2020 at 3:01 PM, revealed the facility had shared with newly admitted residents, when the pandemic hit, they could receive services at home if they desired hospice services. She stated, prior to COVID-19, the facility never had a problem with hospice coming to the facility. The DON stated corporate had informed her and other management staff hospice was not considered an essential service until end-of-life care was needed. The Executive Director was not available for interview at the time of exit.

Based on observation, 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 ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who had knowledge of the resident and his/her needs for one (1) of three (3) sampled residents (Resident #3). Review of Resident #3's Physician Orders, revealed, on the [DATE] re-admission, the resident's Code Status was changed to Do Not Resuscitate (DNR); however, the Comprehensive Care Plan (CCP) was not revised to reflect this change. The findings include: Review of the facility's policy, Comprehensive Care Plans, dated [DATE], revealed the Comprehensive Care Plan (CCP) included providing services to enable the resident to live with dignity and supported the resident's goals, choices, and preferences. Further, the interdisciplinary team (IDT) was responsible for the review and updating the CCP when there had been a significant change in the resident's condition; when the desired outcome was not met; when the resident had been readmitted to the facility; and at least quarterly. Review of the 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 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 CCP 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 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 #3's CCP, initiated [DATE], revealed the resident had an Advance Directive designating his/her code status as Full Code from his/her re-admission on [DATE]. The goal stated the resident's wishes would be honored. The intervention included Cardiopulmonary Resuscitation (CPR) would be performed because Resident #3 was a Full Code. Continued record review revealed a KY EMS DNR Order form, dated [DATE]. The resident's Power of Attorney (POA) signed the DNR order which indicated the resident's authentic wish was not to be resuscitated. Additional review of Resident #3's electronic health record (EHR) revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #3's physician's orders [REDACTED].>However, there was no documented evidence the CCP related to Advance Directives was revised upon Resident #3's re-admission to the facility on [DATE], with the new physician's orders [REDACTED]. Interview with the Minimum Data Set (MDS Nurse), on [DATE] at 12:45 PM, revealed the facility utilized the CMS Resident Assessment Instrument (RAI) Manual 3.0, as a guideline for CCP's. She stated she was responsible for revisions to the CCP related to Advance Directives. Additionally, it was her practice to verify Code Status paper work prior to revising the CCP, and she was unable to find any documents for Resident #3 after re-admission on [DATE]. Therefore, she stated she did not revise the CCP to include DNR status. Further, she stated it was important to have a current, accurately revised CCP, to ensure direct care staff would know how to provide care to residents to meet their needs and honor their wishes. Interview with the Director of Nursing (DON), on [DATE] at 1:25 PM, revealed she expected the CCP's to be revised accurately, as per the facility's policies and RAI guidelines. Per interview, the MDS Nurse was responsible for the revision of the CCP to include Advance Directives/Code Status. Additionally, she stated the current process in place was to review CCP's to ensure revisions were made as necessary and for the IDT to review re-admissions and new orders each morning. Per interview, the MDS Nurse was to check to ensure the CCPs had been revised as necessary with the morning reviews. Continued interview revealed Resident #3's CCP should have been revised to include the change in Code Status on [DATE] to DNR. Further interview revealed the CCP's should be revised as necessary to ensure residents received appropriate services and individualized care Interview with the Administrator, on [DATE] at 2:00 PM, revealed the facility was to utilize the RAI Manual and facility policies as resources to ensure the CCP was revised as necessary. Per interview, it was important for the CCP to be revised accurately to reflect a resident's current status and ensure the CCP addressed each resident's individual needs.

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 to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of fourteen (14) sampled residents (Resident #1). The facility admitted Resident #1, on 03/04/2019, with [DIAGNOSES REDACTED]. Interviews revealed the resident had poor decision-making ability and wandered aimlessly throughout the facility. Interviews and record review revealed the facility assessed Resident #1, on 08/18/2020, to be an elopement risk, exhibited exit-seeking behaviors, and had a Secure Care bracelet in place. Per interview, on 09/26/2020 at approximately 3:30 PM, staff observed Resident #1 near the exit door on Unit 300 and redirected the resident away from the door, but staff was unable to silence the alarm and unable to secure the door lock at that time. Interview revealed the resident was redirected down the hallway by Licensed Practical Nurse (LPN) #1 two (2) additional times before maintenance arrived, at approximately 4:30 PM on 09/26/2020, to secure the door. Staff failed to implement increased supervision or monitoring of Resident #1. At approximately 4:50 PM, staff assigned to care for Resident #1 could not locate the resident. Resident #1 was found, at approximately 5:43 PM, lying in a ditch, over three hundred (300) feet from the facility and one-hundred thirty (130) feet from a highway, crying out for help. The initial skin assessment, completed on 09/26/2020, noted no injury; however, the follow-up skin assessment, completed on 10/01/2020, noted a two (2) centimeter (cm) discolored area to the right inside area of the buttock, a one (1) cm discolored area to the left inside area of the upper arm, a pale discolored area to the left shoulder, a one (1) cm discolored area to the left outer buttocks, and scratches noted above the right knee. 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 10/15/2020 and determined to exist on 09/26/2020. The facility provided an acceptable credible Allegation of Compliance (AoC) on 10/21/2020, alleging removal of the Immediate Jeopardy on 10/16/2020. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 10/16/2020, prior to exit on 10/22/2020, 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, Elopement Management Program, dated 12/26/2016, revealed, for those residents determined to have a potential for, or were at risk for elopement, the program relied on a systematic approach by the Interdisciplinary Team. Further review of the policy revealed a resident's environment would remain as free from accident hazards as was possible, and each resident received adequate supervision and assistance devices to prevent accidents. Per policy, the resident's care plan would indicate the resident was at risk for elopement or other safety issues, and interventions to try to maintain safety, such as a detailed monitoring plan, would be included. Review of Resident #1's medical record revealed the facility admitted the resident, on 03/04/2019, with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing Assessment, dated 03/04/2019 at 6:39 PM, signed by LPN #8, revealed the resident was admitted from home, and the reason for admission was due to Resident #1's cognitive status and safety awareness, Resident #1 needed long term care. Further review of the Nursing Assessment, revealed the resident was alert and oriented to person; had memory loss; and was independent with ambulation, transfers, toileting and eating. Per the Nursing Assessment, the resident was at low risk for elopement. Observations, on 10/12/2020 at 4:30 PM, 10/12/2020 at 5:15 PM, and 10/14/2020 at 2:30 PM, revealed Resident #1 wandering aimlessly in the hallways. The resident was walking alone without staff assistance. Review of Resident #1's Baseline Care Plan, revealed a focus problem, initiated on 03/08/2019, of the resident was at risk for elopement related to wandering and making statements about leaving. The goal, initiated on 03/08/2019, revealed the resident would have no incidence of elopement. The interventions included: involve the resident in preferred activities; involve the resident in decision making regarding daily choices; redirect the resident from doors; and take a picture of the resident upon admission for identification for updating the elopement book. However, the Baseline Care Plan did not specify the supervision level required to keep the resident safe, or specific interventions to implement if the resident exhibited wandering and exit-seeking behaviors. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 03/11/2019, revealed for the Brief Interview for Mental Status (BIMS) Assessment, the resident had a score of six (6) out of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #1's Elopement Risk Assessment, dated 03/04/2019, completed by LPN #8, revealed she assessed Resident #1 as being at low risk for elopement. Review of Resident #1's physician's orders [REDACTED]. Review of the facility's Long Term Care Facility-Self Reported Incident Form -Five (5) day Follow Up/Final Report, and the facility's investigation, dated 10/02/2020 at 8:15 PM, and signed by the Administrator, revealed, on 09/26/2020 at approximately 3:30 PM, the Unit 300 hall door alarm was sounding. Per the report, the nurse responded and saw Resident #1 walking down the hallway on Unit 300; then, she redirected Resident #1 to Unit 100 and proceeded back to the Unit 300 hall door to reset the alarm. Further review revealed the nurse was unable to reset the alarm and left the door to call Maintenance to fix the alarming door. The report stated, at approximately 4:50 PM, a State Registered Nurse Aide (SRNA) noticed, during rounds, that she did not see Resident #1 in the hallway or in his/her room. The SRNA looked around the building and notified other staff that she could not locate Resident #1. Per the report, it was initially reported by staff that Resident #1 was found by the dumpster on facility grounds. However, after further investigation and review of the facility's video footage, the resident was located one hundred thirty (130) feet from the dumpster and was found at approximately 5:43 PM. Further review of the report, revealed Resident #1 was immediately placed on one-to-one (1:1) supervision, and the nurse completed a head-to-toe skin assessment. Continued review revealed Resident #1's wander guard was in place and functioning properly. In addition, the report stated the Physician was notified of the incident, and of the resident's return to the facility; Resident #1 remained on one-to-one (1:1) supervision until 09/28/2020. Review of the local weather history, revealed the temperature was seventy-five (75) degrees Fahrenheit and sunny on 09/26/2020. Per the Director of Nursing (DON), the Police Department was called; however, they did not take a report related to the Resident #1's elopement. Review of the video footage dated 09/26/2020 from approximately 3:30 PM until 5:43 PM and observation of the elopement route with the Administrator, on 10/12/2020 at 5:45 PM, revealed Resident #1 ambulated from the Unit 300 Hallway out the back exit door, the door that was alarming. Per observation, after the resident exited the back door, he/she ambulated down the facility sidewalk, down a hill, and into an apartment complex parking lot where Resident #1 fell into the ditch. The place where Resident #1 was found was approximately three hundred (300) feet from the facility building and one hundred thirty (130) feet from the highway. Interview with the Director of Maintenance (DOM), on 10/14/2020 at 9:35 AM, revealed he received a call from LPN #1, on 09/26/2020 at 3:44 PM, stating a door on Unit 300 Hallway was alarming and could not be reset. He stated he was unavailable to return to the facility, so he contacted his assistant. The DOM stated it took his assistant approximately forty (40) minutes to arrive at the facility. Further interview revealed the Unit 300 door was unsecured until his assistant could get the door shut and reactivate the alarm. Per interview, the facility had been having trouble with that door for quite some time, and the previous Administrator was aware. He further stated the door vendor did the most recent repair on the door in August 2020. Telephone interview with SRNA #2, on 10/13/2020 at 3:52 PM, revealed she was assigned to Resident #1, on 09/26/2020. Per interview, LPN #1 came to another resident's room where she and SRNA #1 were providing care. She stated LPN #1 informed them they could not locate Resident #1, and they all began to look for Resident #1. SRNA #2 stated they looked inside first, because Resident #1 wandered aimlessly all the time and would be found in other residents' beds. Per interview, they were unable to locate Resident #1 inside the building, so she and SRNA #1 went outside while Registered Nurse (RN) #2 got in her car and started driving down the road searching for the resident. Further interview revealed the alarm on Unit 300 had been alarming for a long time and staff had been waiting on maintenance to fix the alarm. SRNA #2 stated staff did try to keep a closer eye on Resident #1 related to exit-seeking behaviors; however, there was no instruction from the nurses to initiate one-to-one (1:1) supervision or to complete checks on the resident at specific intervals, on 09/26/2020. She stated she was so busy she just did not have time to monitor the resident closely, on 09/26/2020. Further, SRNA #2 stated, at approximately 5:43 PM, as she and SRNA #1 were by the dumpster searching for Resident #1, they heard someone crying; when they looked down the hill by the road, they found Resident #1 lying in a ditch. Per interview, she stated the resident did not appear to have any injuries; however, the resident was wet with muddy clothes. SRNA #2 stated she ran into the building to alert RN #1 they had found the resident and to bring a wheelchair. Continued interview with SRNA #2 revealed, on 09/26/2020, before the elopement, she had last seen Resident #1 at approximately 3:00 PM, and she remembered hearing an alarm sound after 3:30 PM and prior to the resident being found. Additional interview revealed when the door alarm sounded, staff was to go to the door that was alarming and look outside to make sure a resident did not go outside. Per interview, if no resident was seen outside, staff was to reset the alarm and inform the nurse, in order for a head count to be completed to make sure all residents were accounted for and were safe. Telephone interview with Registered Nurse (RN) #1, on 10/13/2020 at 12:04 PM, revealed she was working Unit 100, on 09/26/2020, and was assigned to Resident #1. She stated the resident wandered the halls most of the day. She further stated she was in another resident's room performing a dressing change when she was informed that Resident #1 was missing. She stated the alarm on Unit 300 had been sounding a long time, and she was aware that maintenance had been notified to fix the door and reactivate the alarm. RN #1 stated Resident #1 would be redirected back to his/her room multiple times a day. Per interview, RN #1 stated she did not increase supervision of Resident #1 when the resident was exit-seeking, on 09/26/2020, nor did she place someone at the door that was alarming to secure the door. She stated she should have implemented one-to-one (1:1) supervision and placed someone at the door; and, if she had done so, this incident could have been prevented. The RN further stated she was unsure of how long Resident #1 was gone. RN #1 stated she did not call Administration until after the resident was found. She stated the resident was brought back to the facility and was given a shower by SRNA #1 and SRNA #2. She stated a head-to-toe assessment was completed and no injuries were noted to Resident #1. Per interview, after Administration was notified, staff was instructed to place the resident on one-to-one (1:1) supervision. She further stated she was initially told by staff the resident was found by the dumpster; however, the Administrator told her later the resident was found in a ditch and had been gone for over an hour. Continued interview with RN #1, on 10/13/2020 at 12:04 PM, revealed Resident #1 was alert to name only and needed constant direction back to his/her room. RN #1 stated, although Resident #1's care was assigned to her, on 09/26/2020, and she was aware the resident was exhibiting exit-seeking behaviors, she did not recall initiating any increased supervision of the resident, nor did she document the resident's exit-seeking behaviors prior to the elopement. Furthermore, review of Resident #1's Progress Notes, revealed no evidence the resident was exhibiting exit-seeking behaviors and no evidence staff implemented increased supervision and monitoring of the resident related to exit-seeking behaviors on 09/26/2020. Attempts were made, on 10/13/2020 at 4:04 PM, 10/14/2020 at 9:05 AM, and 10/21/2020 at 5:15 PM, to contact by phone SRNA #1, RN #2 and LPN #1, but all were unsuccessful. In addition, messages were left with no return phone calls received from any of these individuals, whom no longer worked at the facility. Telephone interview with SRNA #5, on 10/13/2020 at 4:50 PM, revealed she was assigned to work Unit 200, on 09/26/2020; however, she was not assigned to Resident #1. SRNA #5 stated she saw Resident #1 wandering the halls most of the day, and everyone was aware of the need to watch Resident #1. However, she stated staff did not increase the supervision level for the resident when the alarm sounded on Unit 300. She stated Resident #1 was at the door on Unit 300 a couple of times and was redirected back to his/her unit. SRNA #5 stated when she was made aware Resident #1 was missing, she stayed in the building and helped RN #1 search for the resident. She stated she was told the resident had been found by the dumpster. Telephone interview with SRNA #4, on 10/13/2020 at 4:56 PM, revealed, on 09/26/2020, she was assigned to work Unit 200. She stated she was outside on break when the staff realized Resident #1 was missing. SRNA #4 stated by the time she was aware of the elopement, staff was pulling the resident out of the ditch. She further stated the resident always wandered aimlessly up and down the halls and, at times, would be found in another resident's room. Per interview, on 09/26/2020, the alarm on Unit 300 had been sounding for a while, and staff told her that maintenance had been notified. SRNA #4 stated staff did not increase supervision on Resident #1 after the resident was redirected multiple times from the Unit 300 door, before the resident eloped. She further stated she had never received training related to the Elopement policy or procedures until after Resident #1 eloped, on 09/26/2020. Interview with the Maintenance Assistant, on 10/14/2020 at 9:53 AM, revealed he received a call, at approximately 4:00 PM on 09/26/2020, from the Maintenance Director that the Unit 300 door was alarming and staff was unable to reset the alarm. Per interview, he stated when he arrived, at approximately 4:30 PM, the door was alarming and no staff was monitoring the door. He further stated he had been working on Unit 300 earlier in the day, on 09/26/2020, and Resident #1 had wandered over to Unit 300; he stated he redirected the resident back to Unit 100 where he/she resided. Further interview revealed he was at the facility when staff found the resident outside in the ditch near the apartment building. He further stated if an alarm was sounding, staff should stay at the door until the alarm could be reset. Per interview, when the alarm sounded, staff should have checked outside the door for any resident and immediately perform a head count. The Maintenance Assistant stated the facility had experienced problems with the doors for quite some time. Interview with Unit Manager (UM) #1, on 10/14/2020 at 10:22 AM, revealed she was on-call, on 09/26/2020. She stated she received a call from RN #1, at approximately 6:00 PM. She stated RN #1 alerted her Resident #1 had eloped and sustained no injuries. Per interview, the nurse informed her the Unit 300 door had been alarming since around 3:30 PM, and maintenance had been called to reset it. UM #1 stated she instructed RN #1 to place Resident #1 on one-to-one (1:1) supervision and to place a staff member at the door to keep watch. She further stated when she arrived at the facility, shortly thereafter, she obtained statements from the staff that was present. Unit Manager #1 stated she just could not understand why staff did not place the resident on one-to-one (1:1) supervision because the resident was exit-seeking and why they did not place a staff member at the door that was alarming. She stated if staff had implemented one-to-one (1:1) supervision for Resident #1 and placed staff at the door that was alarming, this elopement would have been avoided. She further stated she was thankful the resident was found with no injuries. Continued interview with UM #1 revealed the initial skin assessment, completed on 09/26/2020, revealed no injuries. However, on 10/02/2020, she performed a follow-up skin assessment on Resident #1 and noted a two (2) centimeter (cm) discolored area to the right inside area of the buttock, a one (1) cm discolored area to the left inside area of the upper arm, a pale discolored area to the left shoulder, a one (1) cm discolored area to the left outer buttocks, and scratches noted above the right knee. Telephone interview with Resident #1's Power of Attorney (POA), on 10/13/2020 at 10:29 AM, revealed the resident lived at home with his/her daughter prior to admission to the facility. She stated the resident's daughter was hospitalized , and the resident was unable to stay alone at home related to safety concerns. The POA stated she had received a phone call from the nurse that Resident #1 had left the building; however, staff brought the resident back into the building. Per interview, a few days later, she received a call from the Ombudsman informing her the resident had fallen. She further stated Resident #1 had a history of [REDACTED]. Telephone interview with LPN #2, on 10/14/2020 at 11:18 AM, revealed she had worked at the facility for three (3) years. She stated, on 09/26/2020, she was assigned to Unit 100, but she was not assigned to Resident #1. She stated, on the day of 09/26/2020, the Maintenance Assistant had been painting on Unit 300, and when the door alarm sounded, she did not think much about it because she assumed it had something to do with the Maintenance Assistant. LPN #2 stated RN #2 had informed her the Unit 300 door was alarming; she was unable to get it reset, and she had called maintenance. She stated she was providing care to another resident when SRNA #2 informed her Resident #1 was missing. LPN #2 stated staff looked everywhere and was unable to locate the resident. Further interview revealed she had received a call from SRNA #1 that the resident had been found in a ditch just past the dumpster. Per interview, they got the resident out of the ditch, placed him/her in a wheelchair, and returned him/her to the building. She stated after the resident was found, all staff started freaking out because the alarm had been sounding for over an hour, and no one had secured the door. She further stated all staff should have checked all doors and outside the doors when the alarm was sounding. Further interview revealed when the resident was exit-seeking and was redirected by RN #2 twice from the door, they should have increased supervision and placed the resident on one-to-one (1:1) supervision. LPN #2 stated if staff had done these things, the elopement might have been avoided. She further stated she had never participated in an elopement drill and was not quite sure what to do when this incident happened. LPN #2 stated she could not recall or say how long the resident was gone. Interview with the Assistant Director of Nursing (ADON), on 10/14/2020 at 11:35 AM, revealed she had worked at the facility for twenty-eight (28) years. She stated staff should have put someone at the door when it was alarming, increased supervision for Resident #1 when he/she was exit-seeking, and notified Administration. She further stated she expected staff to follow the policies and procedure of the facility. Interview with the Medical Director, on 10/22/2020 at 10:34 AM, revealed that Resident #1, from admission, was at risk for elopement related to wandering aimlessly in the hallways and the resident's Dementia. Per interview, the wander guard was placed on the resident as an assistive device in an attempt to keep the resident safe; however, the resident was able to get out of the facility without staff's knowledge. The Medical Director stated Resident #1 had wandered aimlessly since she knew him/her. Continued interview revealed that since Covid-19, Resident #1's exit-seeking and other behaviors had exacerbated. Interview with the Director of Nursing (DON), on 10/13/2020 at 11:32 AM, revealed on 09/26/2020, she received a call from UM #1 informing her of the elopement. Per interview, she then called the Administrator. The DON stated since the UM was in route to the facility, she worked from home getting background information from the aides as to where they found Resident #1. Additional interview revealed it was standard practice for residents to be checked by staff every two (2) hours, and, on 09/26/2020, staff should have increased supervision and monitoring to one-to-one (1:1) supervision for Resident #1 due to the resident exhibiting exit-seeking behaviors. Continued interview with the DON, on 10/13/2020 at 11:32 AM revealed it was standard practice for staff to monitor any door that was alarming until the door could be reset and reactivated, and staff knew this. Further interview revealed, when the door alarm sounded, staff was to go to the door, look out, and then go on a perimeter search of the building to ensure a resident had not gone outside unaccompanied by staff. Per interview, if staff could not locate the resident who sounded the alarm, staff was to return inside the building and start a head count. She further stated, on 09/26/2020, these procedures should have been followed, and if they had, this elopement might have been prevented. The DON further stated there was the chance for harm or even death to a resident who eloped. Interview with the Administrator, on 10/13/2020 at 12:27 PM, revealed she had worked at the facility since September 2020. She stated when she arrived at the facility, she made sure the doors were secured and placed staff at the doors until the vendor could arrive to check the functioning of all doors. She further stated Administration was not notified of this incident until it was all over. Further interview revealed staff initially reported the resident was found at the dumpster; however, after she was able to view the video footage, she learned the resident had been gone for over an hour and was found one hundred thirty (130) feet from the dumpster and not on facility property. She stated per the facility's video footage, Resident #1 exited the Unit 300 door, on 09/26/2020, at approximately 4:50 PM. Resident #1 walked the perimeter of the building, down the sidewalk, and turned right past the dumpster. The resident walked down the hill towards the apartment complex and just past a building with bushes, then Resident #1 was no longer present on the video camera. Per interview, she expected staff to follow the facility's elopement policy and procedures. She stated staff should have notified her sooner, and she could have put measures into place to increase supervision of Resident #1 and place staff at the door that was alarming. The facility provided an acceptable credible Allegation of Compliance (AoC), on 10/21/2020, which alleged removal of the Immediate Jeopardy (IJ) on 10/16/2020. Review of the AoC revealed the facility implemented the following: 1. On 09/26/2020, Resident #1 was placed on one-to-one (1:1) supervision and monitoring at the time the resident was assisted back to the building. An employee was assigned to the door where the alarm was sounding until the alarm was reset and reactivated. 2. On 09/26/2020, a skin assessment and vital signs were completed on Resident #1 upon return to the building and documented, at 6:38 PM, by the Charge RN. 3. On 09/26/2020, Resident #1's care plan was reviewed by the Director of Nursing, and on 09/27/2020, the care plan was revised to include one-to-one (1:1) safety. On 10/02/2020, the charge nurse revised the care plan to include the resident to be placed on one-to-one supervision until exit-seeking behaviors de-escalated. On 10/05/2020, the Regional Nurse revised the care plan to include checking placement and function of the secure device every shift. 4. On 09/26/2020, the Administrator reported the event to the Office of Inspector General (OIG), Adult Protective Services (APS), and the Ombudsman. The Charge Nurse notified the Physician and family on 09/26/2020. 5. On 09/26/2020, the Maintenance Assistant reset the sounding alarm on the Unit 300 exit door and ensured the door was operational. All other exit doors were secured, alarms were engaged, and doors were key-coded. 6. On 09/26/2020, the Administrator called the door vendor to check all resident accessible exit doors. The technician arrived, on 09/26/2020 at 11:00 PM, and performed the following: the exit door on Unit 300 Hall was removed, with the dyne lock rebuilt to ensure proper placement to the strike plate; the door on Unit 200 Hall had the maglock taken apart to repair contact; the door on Unit 100 Hall had the programming reset on Advantage 500de, and the reed switch was adjusted; the front door had fasteners installed to the plate to tighten the magnet; the door by the laundry had the smart lock adjusted and screws added; and the door by the beauty shop was checked, and no adjustments/repairs were needed. 7. On 09/26/2020, each unit nurse completed a head count of the residents, and all other residents were accounted for in the facility. 8. On 09/26/2020, licensed nurses assessed current residents for elopement/wandering potential and this was completed by 09/29/2020. Fourteen (14) residents were at risk for elopement at that time. No additional residents were added to the Elopement/Wandering Risk List. Six (6) residents were removed from the elopement risk list due to no longer meeting the criteria for elopement; one (1) resident was in the hospital and was removed from the list, for a total of seven (7) residents removed from the list. On 10/05/2020, the Regional Nurse reviewed elopement assessments for accuracy. Fourteen (14) were reassessed for wandering elopement, on 10/05/2020, and completed by 10/06/2020, by the DON, ADON and Unit Manager. 9. Starting, on 09/26/2020, and completed, by 10/06/2020, the DON and ADON reviewed care plans on current residents and updated them to include interventions for wandering exit-seeking behaviors and appropriate supervision. 10. On 09/26/2020, the Regional Nurse Consultant educated the Administrator and DON related to the Elopement Policy, Care Plan policy/procedure, training, and processes. The Administrator and DON then educated department leaders, including: Unit Managers, ADON, SSD, Dietary Manager, Maintenance Director, Activity Director, Central Supply, and the Business Office Manager. Administrative staff were not permitted to return to work until a one hundred (100) percent score was attained on the post-test. 11. Beginning 09/26/2020, Department Leaders re-educated current staff on the Elopement Policy, Care Plan policy/procedure, training, processes, and door alarm procedures. By 10/06/2020, ninety-five (95) of ninety-eight (98) staff, including twelve (12) agency staff, had received the education. 12. Beginning 09/26/2020, a Regional Nurse Consultant or member of the Corporate team, the Administrator, the DON or the ADON had been available on weekends to ensure continued compliance with education and monitoring established by the QAPI committee. The QAPI Committee members were the Administrator, the DON, the ADON, the UM, the Social Services Director, the MDS Coordinator, the Maintenance Director, the Dietary Manager, and the Medical Director. 13. Beginning 09/27/2020, and ongoing, facility doors will be checked for proper functioning to ensure that the doors would alarm as designed, with all egress functions working properly, verifying the system codes and keypad operations, and checking the Secure Tech Pads to make sure the doors stayed locked and alarms sounded. The Administrator, Department Managers, or the Maintenance Director/Maintenance Assistant would complete this daily function. Any concerns would be immediately reported to the Administrator and Maintenance Director. 14. On 09/27/2020, the Administrator completed environmental rounds to identify any safety issues and no concerns were identified at that time. 15. On 09/27/2020, the Administrator contacted the door vendor and obtained a quote on upgrading the door alarm system to Wander Guard Blue to be installed on all remaining resident accessible exit doors. The quote was approved, and the facility was working with the vendor for an installation date. 16. On 09/28/2020, Elopement Binders were reviewed and updated for accuracy by the Social Services Director (SSD), the DON, the ADON, the Unit Manager, and the MDS Coordinator to reflect current elopement/wandering risk evaluations. Seven (7) residents were removed from the list, which included one (1) resident in the hospital. 17. On 09/28/2020, the SSD and Activity Director conducted interviews on residents with a BIMS' score of greater than eight (8) to determine if anyone had any knowledge of any prior elopements or safety concerns. No concerns were validated. The Admissions Coordinator and Scheduler also conducted interviews, on 09/28/2020, with current staff to determine if anyone had any knowledge of prior elopements, and no concerns were validated. 18. On 09/28/2020, an elopement drill was completed by the Maintenance Director. Then, the Administrator, the DON, the Maintenance Director, or Department Heads started conducting drills on alternating shifts and weekends until 10/15/2020. 19. On 09/29/2020, the Maintenance Director and the Administrator reviewed the Technology Enhanced Learning System (TELS), an online maintenance system that tracked door checks to ensure all doors had been checked for locking alarms, maglock, and delayed egress for the past thirty (30) days. Furthermore, all doors were inspected per policy and the door vendor corrected verified issues identified. On 08/24/2020, the door vendor replaced the maglock on an exit door and wired/tested all systems that were verified to be normal. 20. On 09/30/2020, the ADON and Unit Manager began monitoring orders to evaluate wandering behaviors every shift on the residents at risk for elopement, and these orders were placed on the Treatment Administration Record (TAR). 21. On 10/05/2020, the DON conducted a thirty (30) day lo (TRUNCATED)

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure a resident's choices regarding Code Status was readily available in the Electronic Health Record (EHR), for one (1) of three (3) residents (Resident #3). Review of Resident #3's physician's orders [REDACTED].#3's EHR revealed no documented evidence of the facility's CPR/DNR Documentation Form or the Kentucky (KY) Emergency Medical Service (EMS) DNR Order form scanned into the EHR. Further review of Resident #3's Progress Notes, dated [DATE], revealed the resident was sent to the hospital, but DNR paperwork was not available, and the resident was treated as a Full Code. The findings include: Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), Do Not Initiate Cardiopulmonary Resuscitation (DNR) Informed Consent, dated [DATE], revealed the facility would support and provide the right of each resident to formulate a resuscitation advance directive. Additionally, the decision for Full Code (CPR) or DNR would be documented on the CPR/DNR Documentation Form. Per policy, a physician's orders [REDACTED]. Further review of the policy revealed the facility would follow state regulations. Review of Resident #3's EHR revealed the resident was admitted to the facility on [DATE]. Additional review revealed a scanned copy of a CPR/DNR form, dated [DATE], and signed by the resident; the resident chose not to formulate or issue any Advance Directives at that time. However, there was no further documented evidence of a more current CPR/DNR form scanned into the EHR. Continued review for Resident #3 revealed a KY EMS DNR Order form (provided when requested, not scanned into the EHR), dated [DATE]. The resident's Power of Attorney (POA) signed the DNR order indicating the resident's authentic wish not to be resuscitated. Review of Resident #3's EHR revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's physician's orders [REDACTED].>Review of Resident #3's Progress Notes, dated [DATE], revealed a new order to send the resident to the hospital for evaluation due to decrease in awareness. Additional review of the Progress Notes, dated [DATE], revealed EMS was at the facility to transport the resident to the hospital; however, DNR paperwork was not available, so the resident would be treated as a Full Code, but the resident did not require CPR during the hospitalization prior to returning to the facility. Further review of Resident #3's EHR revealed no documented evidence of the KY EMS DNR Order form or the facility's CPR/DNR Documentation Form scanned into the EHR. Interview with the Registered Nurse (RN) Unit Manager, on [DATE] at 1:00 PM, revealed she was responsible for sending Resident #3 to the hospital on [DATE]. Per interview, Resident #3's DNR paper work was not scanned into the EHR at the time of transfer on [DATE]. Continued interview revealed the staff member responsible for scanning DNR paper work into the EHR had been out of the facility for several days related to testing positive for COVID-19, and in her absence, the facility had not developed or implemented a system to ensure DNR paper work was scanned into the EHR. Additionally, when she called the DON, Administrator, and Social Service Director, on [DATE] at the time of transfer, no one could locate Resident #3's DNR paper work. Further interview revealed since the resident's DNR paper work was not scanned into the EHR on [DATE] (re-admission) and the original paper work could not be located, the resident was transferred with EMS to the hospital as a Full Code even though he/she had a physician's orders [REDACTED]. Per interview, it was important to have a system to ensure a resident's choices regarding Code Status was readily available in the Electronic Health Record (EHR) to maintain communication on what care needs were necessary in an emergency situation and to provide accurate care. Interview with the Director of Nursing (DON), on [DATE] at 1:25 PM, revealed the Medical Records Clerk was responsible for scanning DNR paper work (CPR/DNR facility form and KY EMS DNR Order form) into the EHR; however, she had been out of the facility because she had been diagnosed with [REDACTED]. Per interview, in the absence of the Medical Record Clerk, the facility did not develop or implement a system to ensure documents were scanned into the EHR. Further interview revealed the facility identified missing information (KY EMS DNR Order form) in the EHR when Resident #3's DNR paper work was not available for transfer, on [DATE]. Further interview revealed a system should be in place at all times to ensure Code Status and DNR paper work were readily available in the EHR for floor staff in emergency situations. Per interview, knowing a resident's Code Status was important to ensure staff know the resident's choice and were able to provide accurate care. Interview with the Administrator, on [DATE] at 2:00 PM, revealed Code Status documents should be scanned into the EHR to ensure the resident's code status was easily accessible to staff in an emergency situation. Further interview revealed it was important to have a system in place to ensure DNR paper work was readily available to staff to ensure there was no hesitation in case of a medical emergency and staff knew how to provide care to residents.

Based on interview, review of medical records, review of facility documents, review of the Centers for Disease Control and Infection Prevention (CDC) guidelines, and review of the facility's policy, 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 the development and transmission of communicable disease and infections to properly prevent and/or contain COVID-19. Observation, on 08/11/2020 at 4:40 PM, revealed the Assistant Director of Nursing (ADON) and the Infection Control (IFC) Nurse exited the COVID-19 unit and entered the facility lobby without cleaning or disinfecting their extended use eye protection (face shield), per facility policy and CDC guidelines. Further, interviews and review of the facility's Education and Training records, revealed no documented evidence the facility provided training and education related to strategies for optimizing the supply of eye protection or instructions for cleaning and disinfecting extended use eye protection. The findings include: Review of the facility's policy, Isolation-Categories of Transmission-Based Precautions, dated October 2018, revealed Transmission-Based Precautions (TBP) were initiated when a resident developed signs and symptoms of a transmissible infection; arrived for admission with symptoms of an infection; or had laboratory confirmed infection and was at risk for transmitting the infection to other residents. Additionally, standard precautions were used when caring for residents at all times regardless of their suspected or confirmed infection status. Per policy, TBP were additional measures that protected staff, visitors, and other residents from becoming infected, and were determined by how specific pathogens spread from person-to-person. Further, when TBP were in effect, if resident-care equipment items required re-use and could not be dedicated to a single resident, the item would be cleaned and disinfected according to current guidelines before use with another resident. Continued review of this policy revealed Droplet Precautions would be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplets that could be generated by the individual coughing, sneezing, talking, or by the performance of procedures. Additionally, mask, gloves, gown, and goggles should be worn when entering a resident's room with Droplet Precautions. Review of the facility's General Infection Control Practices, undated, revealed the outside of goggles or face shields were contaminated and should be removed by handling the clean headband of earpieces. Further, the eye protection should be placed in a designated receptacle for reprocessing or in a waste container. Review of the facility's COVID-19 Protocols, undated, revealed if there was a shortage of Personal Protective Equipment (PPE), goggles (eye protection) could be reused. Review of the CDC document, Coronavirus Disease 2019: Strategies for Optimizing the Supply of Eye Protection, dated 07/15/2020, revealed strategies or options to optimize supplies of eye protection in healthcare settings with a limited supply. Additional review revealed extended use of eye protection was the practice of wearing the same eye protection for repeated close contact encounters with several different patients, without removing eye protection between patient encounters. Extended eye protection should be removed and reprocessed if it becomes visibly soiled or difficult to see through, and when leaving the isolation area, prior to putting it back on. Further, cleaning and disinfection instructions, for single use disposable face shields were: 1. While wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe; 2. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution; 3. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue; 4. Fully dry (air dry or use clean absorbent towels) the face shield or goggles; and 5. Remove gloves and perform hand hygiene. Review of the facility's Education and Training records revealed nursing staff received ongoing training and education regarding Donning and Doffing (putting on and taking off) PPE, COVID-19 Infection Control, Handwashing and Sanitizing, Respiratory Hygiene, and Strategies for Minimizing the Spread of COVID-19. However, there was no documented evidence the training included strategies for optimizing the supply of eye protection or instructions for cleaning and disinfecting extended use eye protection. Review of the facility's CMS 802, Matrix for Providers, dated 08/11/2020, revealed seventeen (17) residents were in Transmission Based Precautions for an active infection (COVID-19). Observations, on 08/11/2020 at 3:45 PM, revealed the hallway leading to the COVID-19 unit was covered with a thick contract plastic taped to the walls, ceiling, and floor creating a barrier. Access to the COVID-19 unit (yellow hallway) was accessible only from an exterior door. Additional observations, on 08/11/2020 at 4:00 PM, revealed the ADON and IFC Nurse doffed their gowns, shoe coverings, and gloves in a receptacle on the COVID-19 unit. Further observations revealed both nurses exited the COVID-19 unit onto the sidewalk and walked around the facility back to the lobby where they entered the facility still wearing their face shields. Continued observations revealed no supplies, cleaning/disinfecting products, or new supplies of eye protection were readily available outside the COVID-19 unit. The ADON and the IFC Nurse failed to clean or disinfect their extended use eye protection before entering the lobby. Interview with the IFC, on 08/12/2020 at 3:00 PM, revealed all residents on the COVID-19 Unit (red hall) were on Droplet Precautions. Therefore, all staff were required to don and doff PPE per facility and CDC guidelines before entering the unit (including mask, gloves, eye protection, shoes, coverings, and gown) and perform hand hygiene before entering and exiting. Additionally, the IFC revealed staff were expected to change their dedicated face shields weekly, and to clean them after exiting each resident's room and when exiting the COVID-19 unit (red hall). She stated disinfecting the face shields should be done to minimize spread of infection and cross-contamination. Continued interview revealed her surveillance and audit process did not identify problems/concerns with staff disinfecting extended use face shields. Further, she stated on 08/11/2020 at 4:00 PM, she should not have entered the lobby wearing the extended use face mask and face shield worn into the COVID-19 unit (red hall); she should have disinfected/cleaned the face shield before she entered the lobby and donned a new mask. Interview with the Assistant Director of Nursing (ADON), on 08/12/2020 at 3:45 PM, revealed the COVID-19 Unit (red hall) residents were in Droplet isolation related to positive COVID test results. Per the ADON, she expected the facility's policy (s) on infection control and CDC guidelines to be maintained at all times to prevent the spread of infection. Additionally, she expected staff to clean dedicated face shields when exiting resident rooms and before leaving the COVID-19 unit. Per interview, PPE worn in the COVID-19 unit should remain on the unit and never be worn into the clean side of the building (lobby). Further, she stated on 08/11/2020 at 4:00 PM, she should not have entered into the lobby wearing the extended use face mask and face shield worn in the COVID-19 unit (red hall); she should have disinfected/cleaned the face shield before she entered the lobby and donned a new mask. Interview with the Director of Nursing (DON), on 08/13/2020 at 1:25 PM, revealed she expected all staff to be trained and educated on facility policy and CDC guidelines related to infection control. Per interview, she expected all staff to don and doff PPE per facility policy and CDC guidelines each time they entered an isolation room. Additional interview revealed she expected staff to practice proper cleaning and disinfecting of extended use face shields each time they entered and exited a resident's room and the COVID-19 Unit. Further, it was important to maintain infection control per the facility's policies and CDC guidelines to prevent transmission of disease. Interview with the Administrator, on 08/13/2020 at 2:00 PM, revealed he expected staff to maintain the facility's policies, CDC guidelines, and regulations related to infection control practices specific to donning and doffing PPE, and disinfecting extended use face shields. Further, he stated it was important to train and educate all staff on infection control practices to reduce the chance of spreading contagious diseases.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective Infection Control program designed to provide a safe, sanitary environment to help prevent the development and transmission of disease and infection as evidenced by failure to have a system in place to monitor the disinfection of the facility's whirlpool (w/p) tub and failure to develop and implement effective policies and procedures for the disinfection of the w/p tub. Observation, on 05/23/13, revealed one (1) whirlpool tub was present in the facility. Record review revealed Resident #2 and Resident #4 both had infections and utilized the whirlpool tub. Resident #2 had a Decubitus Ulcer that was cultured and revealed the ulcer contained two (2) organisms, Pseudomonas Aeruginosa and Acinetobacter Species (these bacteria can cause infection in persons with weakened immune systems according to the Centers for Disease Control). Resident #4 had a history of [REDACTED]. Resident #4 was admitted to the hospital on [DATE] and diagnosed with [REDACTED]. Cultures performed on the Decubitus Ulcers were positive for Acinetobacter Species. Resident #4 received a w/p tub bath on 03/30/13; however, there was no documented evidence the facility ensured the resident was no longer infectious prior to receiving the w/p tub bath. Observation of the facility's whirlpool tub disinfecting system, on 05/23/13, revealed no presence of a disinfecting solution in the system. Interview with facility staff revealed the Maintenance Director was responsible for maintaining the disinfection system. However, interview with the Maintenance Director revealed he had never refilled the disinfectant in the system in the three (3) years he had been employed by the facility. Interview with Certified Nursing Assistants (CNAs) revealed some used Citrus II disinfectant, diluted with water, to clean the whirlpool tub. However, review of the manufacturer's recommendations revealed this solution was not effective when diluted with water. Further interview with the CNAs revealed some used the whirlpool tub disinfecting system; however, the system contained no disinfectant. Additionally, the facility failed to ensure staff followed the facility's policy and was knowledgeable in the transportation of soiled linens from rooms to the soiled linen cart, to prevent cross-contamination. Further the facility failed to ensure staff sanitized hands between residents while assisting with meals, as per the facility's policy. Based on the above findings, it was determined the facility's failure to maintain an infection control program designed to provide a safe, sanitary and comfortable environment in order to prevent the development and transmission of disease and infection has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 05/24/13 and determined to exist on 03/30/13. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/25/13 with the facility alleging removal of the Immediate Jeopardy on 05/25/13. Immediate Jeopardy was verified removed on 05/26/13, as alleged on 05/25/13, prior to exiting with the facility, with remaining non-compliance at a scope and severity of an "E", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance continues to monitor to ensure a safe, sanitary and comfortable environment and to prevent the development and transmission of disease. The findings include: 1. Review of the facility policies revealed no documented evidence of a policy for the use of the disinfecting system for the facility's whirlpool (w/p) tub. Further review of the facility's policies revealed an undated policy, which stated if the w/p tub disinfecting system was out of order, staff was to fill the w/p tub with water; add an unspecified amount of disinfectant (Citrus II); and, allow the w/p jets to run for twenty (20) to thirty (30) minutes. Observation, on 05/23/13 at 3:45 PM, revealed one (1) whirlpool (w/p) tub present in the facility. Review, of the facility's Group Bathing Report, dated May 2012 through May 26, 2013, revealed the facility provided a total of four hundred and eighty (480) baths in the w/p tub to include a total of thirty-three (33) current residents. Review of the Bathing Report revealed Resident #2 and Resident #4 received whirlpool tub baths. Record review revealed the facility admitted Resident #2 on 06/14/11, and readmitted the resident on 10/12/12, with Decubitus Ulcers to his/her sacrum, right and left buttocks, and right Trochanter (one of the bony prominences toward the near end of the thigh bone). Review of the laboratory reports revealed a culture was performed of the right Trochanter ulcer on 01/22/13. Review of the culture results revealed the ulcer contained two (2) organisms, Pseudomonas Aeruginosa and Acinetobacter Species (these bacteria can cause infection in persons with weakened immune systems according to the Centers for Disease Control). Review of the facility's Bathing Report revealed Resident #2 had received twenty-four (24) w/p tub baths since his/her admission, both prior to the culture of the Decubitus Ulcer and on 01/24/13 after the culture was completed. Record review revealed Resident #4 had an original admission date of [DATE], and was readmitted to the facility on [DATE], with chronic Decubitus Ulcers on his/her buttocks and bowel incontinence. Review revealed the resident was noted to have a history of Methicillin Resistant Staphylococcus Aureus (MRSA) and [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE). Continued review revealed Resident #4 had been admitted to the hospital on [DATE] where he/she was diagnosed with [REDACTED]. Additionally, cultures were performed on the Decubitus Ulcers on the resident's buttocks during the hospitalization . Review of the hospital culture results, revealed the Decubiti to be positive for Acinetobacter Species. Record review revealed Resident #4 was discharged back to the facility on [DATE], and was still being treated for [REDACTED].#4 was noted to have received a total of fourteen (14) w/p tub baths to include a w/p tub bath on 03/30/13; however, record review revealed there was no documented evidence the facility ensured the resident was no longer infectious prior to receiving the w/p tub bath 03/30/13. Staff interviews revealed inconsistencies on disinfecting the w/p tub and lack of knowledge related to procedures for the w/p tub disinfecting system. Interview, on 05/23/13 at 5:45 PM, with Certified Nursing Assistants (CNAs) #15 and #24 revealed they used the disinfecting system on the w/p tub; however, they did not know how to tell if there was disinfectant in the system. They stated they were not sure who was responsible for refilling the disinfectant in the w/p tub disinfecting system. The CNAs stated they did not know who to ask to have the disinfectant refilled and did not know how to tell if it needed refilling. Interview, on 05/24/13 at 10:15 PM, with CNA #5 revealed she used the w/p tub disinfecting system for disinfecting the tub after resident baths; however, she was unable to tell if there was disinfectant in the system. She stated she was not sure how to disinfect the w/p tub if the disinfecting system was broken. Interview, on 05/25/13 at 10:50 AM, with CNA #1 revealed she had never used the w/p tub disinfecting system to disinfect the tub. She stated she "wiped it out". However, was unable to say what she "wiped it out" with. She stated she had never been shown how to disinfect the w/p tub and was unable to tell if there was disinfectant in the disinfecting system. Interview, on 05/23/13 at 7:10 PM, CNA #6 revealed she disinfected the w/p tub with spray that was located in the linen closet. She stated she thought it was a bleach spray, however she was not sure. Interview, on 05/25/13 at 9:40 AM, with CNA #12 revealed she had used the "cleaning stuff" in the supply room to disinfect the w/p tub; however, was unable to recall what the "cleaning stuff" was. She stated no one had ever shown her how to disinfect the w/p tub. Interview, on 05/25/13 at 9:55 AM, with CNA #13 revealed she used the w/p tub disinfecting system for disinfecting the tub. She stated she could tell the disinfectant was coming out of the system by observing for a "mist". She stated she thought the Maintenance Director was responsible for refilling the disinfecting system. Per interview, CNA #13 stated she used the Citrus II disinfectant when the disinfecting system was out of disinfectant; however, was unable to tell how she knew when the disinfectant in the w/p tub disinfecting system was out. Interview, on 05/23/13 at 3:45 PM, with CNA #3 revealed she used the w/p disinfecting system after resident baths. She stated she would turn the w/p disinfecting system on, the water would bubble, and that's how she could tell the disinfectant was in the tub. She stated if there was no disinfectant in the disinfecting system it wouldn't bubble and she would tell a nurse, who would tell the Maintenance Director and he would refill the disinfectant. She indicated if the Maintenance Director was not present in the facility she would "guess" the nurse would refill the disinfectant in the w/p tub disinfecting system. Interview, on 05/24/13 at 4:00 PM, with Licensed Practical Nurse (LPN) #4 revealed nurses were not aware of the disinfecting process for the w/p tub. She stated the CNAs were responsible for this, as they gave the baths. The LPN stated nurses did not monitor the w/p tub disinfection. According to the LPN, she thought the Maintenance Director was who the CNAs would tell if they needed anything related to the w/p tub. Observation, on 05/23/13 at 6:15 PM, of the facility's locked w/p tub disinfecting system revealed no visual evidence of the presence of a disinfecting solution in the system. Interview, during the observation with the Maintenance Director, who staff indicated was responsible for refilling the disinfectant, revealed he occasionally sanitized the w/p tub himself with the disinfectant in the w/p tub disinfecting system. Interview, on 05/23/13 at 4:50 PM, with the Assistant Director of Nursing (ADON), who was also the facility's Infection Control Nurse, revealed there was no system in place to monitor the w/p tub disinfectant. Additional interview, on 05/23/13 at 6:10 PM, with the ADON revealed she did not know how staff could tell if there was disinfectant in the w/p tub disinfecting system. The ADON revealed she was unaware of what the disinfecting solution for the w/p tub disinfecting system looked like. She indicated it was the Maintenance Director's responsibility to refill the w/p tub disinfecting system with disinfectant. However, further interview with the Maintenance Director on 05/23/13 at 6:30 PM, revealed he had never refilled the disinfectant in the w/p tub disinfecting system in the three (3) years he had been employed. He stated he did not know what the disinfectant container looked like and didn't know who would know. Interview, on 05/23/13 at 6:10 PM, with the ADON revealed the disinfectant for the w/p tub disinfecting system was stored in the "cage" (facility's main supply area). However, observation during the interview of the facility's supply area, revealed no evidence of the disinfecting solution for the whirlpool disinfecting system. Interview, on 05/23/13 at 6:45 PM, with the Central Supply Clerk, who was responsible for ordering products, revealed she was unaware the w/p tub had a disinfecting system. She stated she had never been asked to order the disinfectant solution for the disinfecting system on the w/p tub. Further interview, on 05/25/13 at 4:37 PM, with the ADON revealed on 05/14/13 she was made aware that a piece on the w/p tub disinfecting system was broken. She developed a policy for disinfecting the w/p tub with a disinfectant used for disinfecting shower chairs and wheelchairs (Citrus II disinfectant). Per interview, an inservice was held and staff were instructed to fill the w/p tub with water; add an unspecified amount of disinfectant (Citrus II); and, allow the w/p jets to run for twenty (20) to thirty (30) minutes. However, review of the Citrus II disinfectant label revealed the disinfectant was "ready to use". Review, of a facility e-mail dated 05/24/13, timed 9:12 AM, from the Customer Service Manager of the supplier of the Citrus II, revealed the Citrus II disinfectant would not be "an effective cleaner for a whirlpool system". The e-mail stated this product was designed to be used full strength, once it was diluted with water the "kill times" and claims could no longer be supported. Further interview, on 05/25/13 at 4:37 PM, with the ADON revealed she was unaware the Citrus II disinfectant should not be diluted with water when she developed the policy on 05/14/13. However, the disinfectant label stated "ready to use". Interview, on 05/23/13 at 6:35 PM, with the Director of Nursing (DON) revealed the Citrus II should be diluted with water. However, there were no instructions on the label to dilute the product. Further interview, on 05/26/13 at 3:54 PM, with the DON revealed she was not aware the Citrus II disinfectant should not be diluted until 05/24/13 when the facility received the email from the supplier of the Citrus II. Interview, on 05/24/13 at 9:53 AM, with the DON revealed the facility did not have a process in place to culture the w/p tub jets. Further interview, on 05/26/13 at 3:54 PM, revealed the facility should have had policies and procedures in place for the disinfection of the w/p tub to promote resident safety and prevent cross-contamination. She stated there should have been a process in place for the monitoring of the disinfection of the w/p tub. Interview, on 05/26/13 at 3:37 PM, with the Administrator revealed she came to the facility in September 2012. She stated she knew the w/p tub was purchased in 2008. Per interview, she was not aware the w/p had not been disinfected until 05/14/13 when staff indicated to her that they had never used the w/p tub disinfecting system since the purchase of the tub. Per interview, she was not aware the Citrus II disinfectant shouldn't be diluted with water when she had instructed the ADON to develop a policy for disinfecting the w/p tub with the Citrus II. Interview, on 05/24/13 at 3:25 PM, with the Medical Director revealed she was not aware of there being no disinfectant in the w/p tub disinfecting system. She stated she would assume the w/p tub was being disinfected between residents. The Medical Director stated if there was no disinfectant used there would be potential for cross-contamination/transmission of organisms to other residents. Interview, on 05/25/13 at 3:23 PM, with the representative of the company who supplied the w/p tub, revealed the w/p tub disinfecting system should always be used for disinfecting the w/p tub. He stated if the disinfecting system was broken then the w/p tub should not be used until the disinfecting system was fixed. 2. A review of the facility's policy titled, "Handling Linens to Prevent and Control Infection Transmission" undated, revealed it was important that all potentially contaminated linen be handled with appropriate measures to prevent cross-transmission. The facility handled all used linen as potentially contaminated. Further review of the facility procedure for Direct Caregiver Infection Control, dated 01/13/12, revealed dirty linen carts were to be placed by the doorway when entering a room for resident care. Review revealed if linens were soiled they should be placed in a bag in the room, then into the dirty linen cart. Otherwise dirty bed linen could be placed in the dirty linen cart directly outside of resident doorways. Observation on the initial tour, on 05/23/13 at 9:30 AM, revealed CNA #4 carried soiled linen against her clothing from room [ROOM NUMBER] to the soiled linen cart across the hall in front of room [ROOM NUMBER]. Interview with CNA #4, on 05/23/13 at 9:30 AM, revealed she always carried the soiled linens out of the resident's room to the soiled cart. She stated she should not have carried soiled linens against her clothes because of the risk for cross contamination. Observation at the time of the interview revealed no evidence of bags in the room to place soiled linen in as per facility's policy. Interview, on 05/25/13 at 4:37 PM, with the ADON, who also was the facility's Infection Control Nurse, revealed staff should not carry dirty linen against their clothing because that could contaminate their clothing and carry organisms to other residents. She stated staff should have a dirty linen cart outside the room and carry the linen to it. The ADON indicated staff should not carry dirty linen in the hallway. According to the ADON, the only time the facility had staff put dirty linen in a bag in the room, was when it was heavily soiled with bowel movement. 3. Review of the facility's policy titled, "Handwashing / Hand Hygiene", revised August 2012, revealed all personnel was to follow the established Handwashing/Hand Hygiene procedure to prevent the spread of infections and disease to other personnel, residents, and visitors. Further review revealed personnel was to wash hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water before and after assisting a resident with meals and after handling soiled equipment or utensils. Observation of the meal service in the community's dining room, on 05/23/13 at 12:20 PM, revealed CNA #15 assisted Unsampled Resident A with cuing during meals. After Unsampled Resident A stopped feeding himself/herself, CNA #15 picked up Unsampled Resident A's eating utensil, and helped the resident continue eating. CNA #15 then proceeded to assist Unsampled Resident B by grasping his/her eating utensil and encouraged him/her to continue eating. CNA #15 was observed not sanitizing or washing hands between residents. Interview, on 05/23/13 at 12:30 PM, with CNA #15, revealed she should have sanitized her hands in between residents. CNA #15 further revealed that by not doing so, she could spread germs. CNA #15 stated,"it is unsanitary". Interview, on 05/24/13 at 2:10 PM, DON revealed that personnel should sanitize their hands between providing assistance with each resident. The DON further revealed that staff should sanitize hands in-between resident care. The DON stated proper handwashing was important due to infection control. Review of the facility's acceptable AoC, dated 05/25/13, revealed the following: 1. The whirlpool (w/p) tub was placed out of service on 05/23/13, by placing signs on the w/p tub and on the w/p disinfecting system. 2. The water to the w/p tub was turned off on 05/24/13 and "banding" was placed across the w/p tub to prevent further use. 3. On 05/24/13, the Central Supply Clerk notified the w/p tub representative to obtain a manual for the w/p, the disinfectant and the parts needed for the w/p tub disinfecting system were ordered. The manual was faxed that day to the facility and copies were given to the DON, ADON, Administrator, Maintenance Director, and Central Supply Clerk. 4. The w/p tub representative scheduled a date (05/29/13) to bring the parts for the disinfectant, if he could not come that day the w/p tub was to remain out of service until the representative arrived. 5. All nursing staff, all housekeeping staff, the Central Supply Clerk and Maintenance Director were to be inserviced on how to properly disinfect the w/p tub by the DON, ADON, or Minimum Data Set (MDS) Nurse. They were then to perform a competency checkoff that was developed from the w/p tub manual on the disinfection process. This inservice with return demonstration was started on 05/24/13. Staff would not be allowed to work until they had completed the inservice and performed the checkoff. 6. A Master Staff List was being kept to ensure all nursing staff, all housekeeping staff, the Central Supply Clerk and Maintenance Director received the inservice education and performed the competency. 7. The inservice education and competency check list were added to the orientation packet for all new nursing staff and housekeeping staff. 8. Whirlpool tub cleaning instructions were posted by the w/p tub on 05/25/13. 9. A w/p check list was developed on 05/24/13. The Central Supply Clerk was to check the w/p disinfecting system for appropriate levels of disinfectant daily when on duty. The 200 wing Housekeeper was responsible for checking the w/p when the Central Supply Clerk was not on duty. If the disinfectant was low an order was to be placed into the facility's computer system for maintenance. 10. Observance of the proper use of w/p disinfecting process was to be audited three (3) times a week for four (4) weeks, then one (1) time weekly for four (4) weeks, then once a month ongoing. The audits were to be performed by the Administrator or her designee. Any issues were to be presented to the Quality Assurance/Process Improvement Committee. The surveyors validated the corrective action taken by the facility, prior to exit on 05/26/13, as follows: *Observation, on 05/26/13 at 2:40 PM, of the whirlpool tub room revealed a sign on the wall by the w/p tub with the disinfecting instructions. Observation revealed the w/p tub to have "banding" on the w/p tub to prevent use, out of order signs on the w/p tub, and the water to the w/p tub to be turned off. Further observation revealed two (2) staff persons receiving the inservice education with return demonstration. *Review of an orientation packet revealed the inservice education and competency check list were present in the packet. *Review of the materials submitted for review related to the abatement revealed a Master Staff List of all nursing staff, all housekeeping staff, the Central Supply Clerk and Maintenance Director who had received the inservice education and performed the competency; and of those who still required the education and competency check off. *Interview, on 05/26/12 at 1:30 PM, with the Central Supply Clerk revealed she had obtained the manual and received a copy of it. She indicated the DON, ADON, and Maintenance Director had all received copies of the manual also. The Central Supply Clerk stated she had ordered the parts and disinfecting solution for the w/p tub. She stated she had received inservice education on the disinfection of the w/p tub with a return demonstration for competency. Further interview revealed it was now her responsibility to check the w/p tub disinfectant in the disinfecting system once per day when she's on duty. She stated there was now a clipboard with a checklist on it that she must fill out when observing the disinfectant. Continued interview revealed she works Monday through Friday and would be checking it on those days. The Central Supply Clerk stated she would refill the disinfectant if it was low and order a new supply to replace it. *Interview, on 05/26/13 at 3:00 PM, with the DON revealed the facility had contacted the w/p tub representative for a copy of the w/p tub manual. She stated she had received a copy of the manual, as well as, the ADON, Maintenance Director, and Central Supply Clerk. She stated she had developed her inservice and competency check list material from the disinfection process in the manual. The DON stated she had trained the ADON, MDS Coordinator, Central Supply Clerk, and Maintenance Director. In addition, she stated staff was being trained by herself, the ADON, and the MDS Coordinator. She stated staff would not be allowed to work until they had received the inservice training and performed a return demonstration for competency. The DON indicated the w/p tub representative had scheduled a date (05/29/13) to bring the parts, the disinfectant, and to provide education to her, the ADON, Maintenance Director, and Central Supply Clerk on any updates related to the w/p tub and disinfection process. According to the DON, if the w/p tub representative could not come that day, the w/p tub was to remain out of service until the representative arrived. *Interview, on 05/26/13 at 2:00 PM, with the 200 Hall Housekeeping Supervisor revealed she had been inserviced on the w/p tub disinfecting system on 05/25/13. She stated if the Central Supply Clerk was not present to conduct the daily checking of the w/p tub disinfectant the 200 Hall Housekeeper would be responsible for checking. *Interview, on 05/26/13 at 12:10 PM, with Housekeeper #3 who worked on the 200 Hall; at 11:25 AM with Housekeeper #2, who was working on the 100 Hall; and, at 11:30 AM with Housekeeper #1, who was working on the 100 Hall, revealed they had all been inserviced on 05/24/13 and 05/25/13 related to the w/p tub disinfecting system and had performed a return demonstration for competency. They stated the w/p disinfecting system was to be checked daily by the Central Supply Clerk if she was on duty and if she wasn't, the Housekeeper on the 200 Hall would be responsible for performing the check to ensure there was disinfectant in the system. *Interview, on 05/26/13 at 1:30 PM, with the Maintenance Director revealed he had turned the water off to the w/p tub and it would remain turned off until the w/p tub part was fixed and the disinfectant for the w/p disinfecting system was received. He stated he had been given a copy of the w/p tub manual. The Maintenance Director stated he had been inserviced on the w/p tub disinfecting system and had completed a return demonstration for competency. *Interview, on 05/26/13 at 3:40 PM, with the MDS Coordinator revealed she had received an inservice given by the DON on the w/p tub disinfecting system and had performed a return demonstration for competency. She stated she had provided inservices to staff and observed return demonstrations for competency since being trained. She stated staff would not be allowed to work until they had received the inservice training and performed a return demonstration for competency. *Interviews were conducted on 05/26/13 to verify that staff had received education, performed a return demonstration for competency, and verify staffs' knowledge of the disinfection of the w/p tub as follows: Licensed Practical Nurse (LPN) #2 at 2:00 PM, LPN #1 at 2:10 PM, LPN #3 at 2:45 PM, LPN #5 at 3:20 PM, CNA #5 at 11:40 AM, CNA #21 at 1:40 PM, CNA #1 at 1:42 PM, CNA #6 at 2:00 PM, CNA #22 at 2:15 PM, CNA #13 at 2:30 PM, CNA #20 at 2:40 PM, CNA #16 at 2:15 PM, CNA #19 at 2:20 PM, CNA #18 at 2:25 PM, CNA #17 at 2:30 PM, CNA #25 at 2:37 PM, CNA #23 at 4:45 PM, and Registered Nurse (RN) #1 at 2:50 PM. All staff verbalized having received the inservice training on 05/24/13 or 05/25/13 related to the w/p tub disinfection process, and performance of return demonstration for competency, and were aware the w/p tub would remain out of use until the tub was repaired and the disinfecting solution for the disinfecting system was obtained. Record review validated the training was provided on 05/24/13 and 05/25/13. *Interview, on 05/26/13 at 3:47 PM, with the Administrator revealed the w/p tub was placed out of order on 05/23/13 in the evening. She stated the w/p representative was contacted, a copy of the w/p tub manual was requested and the part for the w/p tub was ordered. She also stated the disinfectant for the w/p tub disinfecting system was ordered, and the representative made an appointment to come on 05/29/13 to bring the part and disinfectant solution and provide training on any updates to the w/p tub and disinfecting system. The Administrator stated a copy of the w/p tub manual was received and copies were given to her, the DON, the ADON, the Maintenance Director, and the Central Supply Clerk. She stated inservice training had been developed with a competency check list. According to the Administrator, staff was being trained and required to do a return demonstration for competency prior to being allowed to work. The Administrator stated the w/p tub would remain out of service until the part and disinfecting solution came in. Further interview revealed observation of disinfecting process would be audited three (3) times a week for four (4) weeks, one (1) time a week for four (4) weeks, then once monthly and ongoing.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility's Administration failed to ensure the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, or psychosocial well-being of each resident. The facility failed to have a system in place to ensure disinfection of the facility's whirlpool (w/p) tub and failed to ensure effective policies and procedures were developed and implemented for the disinfection of the w/p tub. Observation, on 05/23/13, revealed one (1) whirlpool tub was present in the facility. Resident #2 and Resident #4 both had infections and utilized the whirlpool tub. Resident #2, who utilized the w/p tub, had a Decubitus Ulcer that was cultured and revealed the ulcer contained two (2) organisms, Pseudomonas Aeruginosa and Acinetobacter Species (these bacteria can cause infection in persons with weakened immune systems according to the Centers for Disease Control). Resident #4 was noted to have a history of [MEDICAL CONDITION] (MRSA) and [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE). Resident #4 was admitted to the hospital on [DATE] and diagnosed with [REDACTED]. Cultures were performed on the Decubitus Ulcers on Resident #4's buttocks and were positive for Acinetobacter Species. Resident #4 was noted to have received a w/p tub bath on 03/30/13, however there was no documented evidence the facility ensured the resident was no longer infectious prior to receiving the w/p tub bath. Observation of the facility's whirlpool tub disinfecting system, on 05/23/13, revealed no presence of a disinfecting solution in the system. Interview with facility staff revealed the Maintenance Director was responsible for maintaining the disinfection system. However, interview with the Maintenance Director revealed he had never refilled the disinfectant in the system in the three (3) years he had been employed by the facility. Interview with Certified Nursing Assistants (CNAs) revealed some used Citrus II disinfectant, diluted with water, to clean the whirlpool tub. However, review of the manufacturer's recommendations revealed this solution was not effective when diluted with water. Further interview with the CNAs revealed some used the whirlpool tub disinfecting system; however, the system contained no disinfectant. Based on the findings, it was determined the facility's Administration failed to ensure policies and procedures were developed and staff was educated related to the disinfection of the w/p tub to ensure the prevention, development and transmission of diseases and infection is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on 05/24/13 and determined to exist on 03/30/13. The facility provided an acceptable credible Allegation of Compliance (AoC) on 05/25/13 with the facility alleging removal of the IJ on 05/25/13. On 05/26/13 the State Agency verified removal of the IJ as the facility alleged on 05/25/13 prior to exiting with the facility, with remaining non-compliance at a scope and severity of an "E", while the facility develops and implements a Plan of Correction and the facility's Quality Assurance along with Administration continues to monitor to ensure a safe, sanitary and comfortable environment and to prevent the development and transmission of disease and infection. (Refer to F-441) The findings include: Review of the facility's policies and procedures revealed no documented evidence of policies and procedures for the disinfecting system for the facility's w/p tub. Observation, on 05/23/13 at 3:45 PM, revealed one (1) whirlpool (w/p) tub present in the facility. Review of the facility's Group Bathing Report and record review revealed two of the residents utilizing the w/p tub had infections, Resident #2 and Resident #4. However, observation of the facility's locked w/p tub disinfecting system revealed no visual evidence of the presence of a disinfecting solution in the system and staff interviews revealed lack of knowledge on how to disinfect the w/p tub. Observation revealed the disinfecting solution for the w/p tub disinfecting system was not located in the facility and interview with the Central Supply Clerk revealed Administration had never instructed her to order the disinfectant solution for the w/p tub disinfecting system. Interview, on 05/26/13 at 3:37 PM, with the Administrator revealed she was hired in September 2012 and was not aware there was no system in place to monitor the disinfection of the w/p tub. She stated there should be a policy and procedure for everything and staff should have been educated on the procedure for the disinfecting system for the w/p tub. Per interview, on 05/14/13, she was told the disinfecting system for the w/p tub was broken and a piece was missing on the w/p tub. The Administrator stated she talked to staff to see how they were disinfecting the w/p tub since the piece was missing. She stated staff told her they were using the "Citrus cleaner" and she then asked the Director of Nursing (DON) and Assistant Director of Nursing (ADON) to "write up" the procedure the CNAs were using for disinfection of the w/p tub. However, interviews on 05/23/13 with CNAs #7, #15, and #24 revealed they did not use the Citrus II disinfectant for disinfecting the w/p tub. According to the CNAs, the Citrus II disinfectant was to be used for disinfecting wheelchairs and shower chairs. Review of this undated policy, describing how to disinfect the w/p tub if the disinfecting system was out of order, revealed staff was to use the disinfectant used to sanitize showers and wheelchairs (Citrus II disinfectant). The policy instructed staff to fill the w/p tub with water; add an unspecified amount of disinfectant (Citrus II); and, run the w/p jets for twenty (20) to thirty (30) minutes. However, review of the Citrus II disinfectant label revealed the disinfectant was "ready to use" and an e-mail dated 05/24/13, timed 9:12 AM, from the Customer Service Manager stated the product was designed to be used full strength. The e-mail stated once the product was diluted with water the "kill times" and claims could no longer be supported. Interview, on 05/23/13 at 6:35 PM, with the DON revealed she thought the Citrus II should be diluted with water. Interview, on 05/25/13 at 4:37 PM, with the ADON who developed the undated policy, revealed she was not aware the Citrus II disinfectant should not be diluted with water until 05/24/13, when they received the e-mail from the product's Customer Service Manager. Additional interview with the Administrator, on 05/26/13 at 3:37 PM, revealed she reviewed the undated policy; however, she was not aware the Citrus II disinfectant, indicated for use in the undated policy, should not be diluted with water until 05/24/13. Review of the facility's acceptable AoC, dated 05/25/13, revealed the following: 1. The whirlpool (w/p) tub was placed out of service on 05/23/13, by placing signs on the w/p tub and on the w/p disinfecting system. 2. The water to the w/p tub was turned off on 05/24/13 and "banding" was placed across the w/p tub to prevent further use. 3. On 05/24/13, the Central Supply Clerk notified the w/p tub representative to obtain a manual for the w/p, the disinfectant and the parts needed for the w/p tub disinfecting system were ordered. The manual was faxed that day to the facility and copies were given to the DON, ADON, Administrator, Maintenance Director, and Central Supply Clerk. 4. The w/p tub representative scheduled a date (05/29/13) to bring the parts for the disinfectant, if he could not come that day the w/p tub was to remain out of service until the representative arrived. 5. All nursing staff, all housekeeping staff, the Central Supply Clerk and Maintenance Director were to be inserviced on how to properly disinfect the w/p tub by the DON, ADON, or Minimum Data Set (MDS) Nurse. They were then to perform a competency checkoff that was developed from the w/p tub manual on the disinfection process. This inservice with return demonstration was started on 05/24/13. Staff would not be allowed to work until they had completed the inservice and performed the checkoff. 6. A Master Staff List was being kept to ensure all nursing staff, all housekeeping staff, the Central Supply Clerk and Maintenance Director received the inservice education and performed the competency. 7. The inservice education and competency check list were added to the orientation packet for all new nursing staff and housekeeping staff. 8. Whirlpool tub cleaning instructions were posted by the w/p tub on 05/25/13. 9. A w/p check list was developed on 05/24/13. The Central Supply Clerk was to check the w/p disinfecting system for appropriate levels of disinfectant daily when on duty. The 200 wing Housekeeper was responsible for checking the w/p when the Central Supply Clerk was not on duty. If the disinfectant was low an order was to be placed into the facility's computer system for maintenance. 10. Observance of the proper use of w/p disinfecting process was to be audited three (3) times a week for four (4) weeks, then one (1) time weekly for four (4) weeks, then once a month ongoing. The audits were to be performed by the Administrator or her designee. Any issues were to be presented to the Quality Assurance/Process Improvement Committee. The surveyors validated the corrective action taken by the facility, prior to exit on 05/26/13, as follows: *Observation, on 05/26/13 at 2:40 PM, of the whirlpool tub room revealed a sign on the wall by the w/p tub with the disinfecting instructions. Observation revealed the w/p tub to have "banding" on the w/p tub to prevent use, out of order signs on the w/p tub, and the water to the w/p tub to be turned off. Further observation revealed two (2) staff persons receiving the inservice education with return demonstration. *Review of an orientation packet revealed the inservice education and competency check list were present in the packet. *Review of the materials submitted for review related to the abatement revealed a Master Staff List of all nursing staff, all housekeeping staff, the Central Supply Clerk and Maintenance Director who had received the inservice education and performed the competency; and of those who still required the education and competency check off. *Interview, on 05/26/12 at 1:30 PM, with the Central Supply Clerk revealed she had obtained the manual and received a copy of it. She indicated the DON, ADON, and Maintenance Director had all received copies of the manual also. The Central Supply Clerk stated she had ordered the parts and disinfecting solution for the w/p tub. She stated she had received inservice education on the disinfection of the w/p tub with a return demonstration for competency. Further interview revealed it was now her responsibility to check the w/p tub disinfectant in the disinfecting system once per day when she's on duty. She stated there was now a clipboard with a checklist on it that she must fill out when observing the disinfectant. Continued interview revealed she works Monday through Friday and would be checking it on those days. The Central Supply Clerk stated she would refill the disinfectant if it was low and order a new supply to replace it. *Interview, on 05/26/13 at 3:00 PM, with the DON revealed the facility had contacted the w/p tub representative for a copy of the w/p tub manual. She stated she had received a copy of the manual, as well as, the ADON, Maintenance Director, and Central Supply Clerk. She stated she had developed her inservice and competency check list material from the disinfection process in the manual. The DON stated she had trained the ADON, MDS Coordinator, Central Supply Clerk, and Maintenance Director. In addition, she stated staff was being trained by herself, the ADON, and the MDS Coordinator. She stated staff would not be allowed to work until they had received the inservice training and performed a return demonstration for competency. The DON indicated the w/p tub representative had scheduled a date (05/29/13) to bring the parts, the disinfectant, and to provide education to her, the ADON, Maintenance Director, and Central Supply Clerk on any updates related to the w/p tub and disinfection process. According to the DON, if the w/p tub representative could not come that day, the w/p tub was to remain out of service until the representative arrived. *Interview, on 05/26/13 at 2:00 PM, with the 200 Hall Housekeeping Supervisor revealed she had been inserviced on the w/p tub disinfecting system on 05/25/13. She stated if the Central Supply Clerk was not present to conduct the daily checking of the w/p tub disinfectant the 200 Hall Housekeeper would be responsible for checking. *Interview, on 05/26/13 at 12:10 PM, with Housekeeper #3 who worked on the 200 Hall; at 11:25 AM with Housekeeper #2, who was working on the 100 Hall; and, at 11:30 AM with Housekeeper #1, who was working on the 100 Hall, revealed they had all been inserviced on 05/24/13 and 05/25/13 related to the w/p tub disinfecting system and had performed a return demonstration for competency. They stated the w/p disinfecting system was to be checked daily by the Central Supply Clerk if she was on duty and if she wasn't, the Housekeeper on the 200 Hall would be responsible for performing the check to ensure there was disinfectant in the system. *Interview, on 05/26/13 at 1:30 PM, with the Maintenance Director revealed he had turned the water off to the w/p tub and it would remain turned off until the w/p tub part was fixed and the disinfectant for the w/p disinfecting system was received. He stated he had been given a copy of the w/p tub manual. The Maintenance Director stated he had been inserviced on the w/p tub disinfecting system and had completed a return demonstration for competency. *Interview, on 05/26/13 at 3:40 PM, with the MDS Coordinator revealed she had received an inservice given by the DON on the w/p tub disinfecting system and had performed a return demonstration for competency. She stated she had provided inservices to staff and observed return demonstrations for competency since being trained. She stated staff would not be allowed to work until they had received the inservice training and performed a return demonstration for competency. *Interviews were conducted on 05/26/13 to verify that staff had received education, performed a return demonstration for competency, and verify staffs' knowledge of the disinfection of the w/p tub as follows: Licensed Practical Nurse (LPN) #2 at 2:00 PM, LPN #1 at 2:10 PM, LPN #3 at 2:45 PM, LPN #5 at 3:20 PM, CNA #5 at 11:40 AM, CNA #21 at 1:40 PM, CNA #1 at 1:42 PM, CNA #6 at 2:00 PM, CNA #22 at 2:15 PM, CNA #13 at 2:30 PM, CNA #20 at 2:40 PM, CNA #16 at 2:15 PM, CNA #19 at 2:20 PM, CNA #18 at 2:25 PM, CNA #17 at 2:30 PM, CNA #25 at 2:37 PM, CNA #23 at 4:45 PM, and Registered Nurse (RN) #1 at 2:50 PM. All staff verbalized having received the inservice training on 05/24/13 or 05/25/13 related to the w/p tub disinfection process, and performance of return demonstration for competency, and were aware the w/p tub would remain out of use until the tub was repaired and the disinfecting solution for the disinfecting system was obtained. Record review validated the training was provided on 05/24/13 and 05/25/13. *Interview, on 05/26/13 at 3:47 PM, with the Administrator revealed the w/p tub was placed out of order on 05/23/13 in the evening. She stated the w/p representative was contacted, a copy of the w/p tub manual was requested and the part for the w/p tub was ordered. She also stated the disinfectant for the w/p tub disinfecting system was ordered, and the representative made an appointment to come on 05/29/13 to bring the part and disinfectant solution and provide training on any updates to the w/p tub and disinfecting system. The Administrator stated a copy of the w/p tub manual was received and copies were given to her, the DON, the ADON, the Maintenance Director, and the Central Supply Clerk. She stated inservice training had been developed with a competency check list. According to the Administrator, staff was being trained and required to do a return demonstration for competency prior to being allowed to work. The Administrator stated the w/p tub would remain out of service until the part and disinfecting solution came in. Further interview revealed observation of disinfecting process would be audited three (3) times a week for four (4) weeks, one (1) time a week for four (4) weeks, then once monthly and ongoing.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had been assessed by the facility as being at risk for wandering and/or exit seeking behaviors received adequate supervision for one (1) of six (6) sampled residents (Resident #1), of the twelve (12) residents the facility had assessed as being at risk. Resident #1 exited the facility, without staff knowledge, on 11/19/10, and was found beyond the back parking lot in a grassy area near a highway. The temperature was forty-eight (48) degrees when the resident exited the facility. The failure of the facility to provide adequate supervision for residents at risk for elopement placed residents in the facility at risk for serious harm, injury, impairment or death. The findings include: Based on record review, it was revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 09/24/10 quarterly Minimum Data Set (MDS) assessment revealed the facility assessed Resident #1 as having both short and long-term memory problems and moderately impaired cognitive skills for daily decision making. The facility assessed Resident #1 as being at risk for elopement, and an elopement safety bracelet was implemented on 01/06/08. A review of Resident #1's care plan, dated 11/13/10 revealed interventions including an elopement safety bracelet, redirection of Resident #1 from exit doors, and involving the resident in preferred activities. The care plan was updated on 11/19/10, following the elopement, to include every fifteen (15) minutes checks, and snacks throughout the day and evening. Review of the "Verification of Investigation Report" dated 11/19/10, and an investigation summary dated 11/24/10, revealed Resident #1 exited the facility on 11/19/10, between 5:20 PM and 5:30 PM, and was found outside the facility at 5:30 PM. Interview with Certified Nursing Assistant (CNA) #3, on 12/01/10 at 3:17 PM, revealed Resident #1's behavior was "normal" on 11/19/10, and the resident had mentioned wanting to go home. The CNA stated she would redirect Resident #1 by encouraging him/her to take a break from work and have a snack. According to CNA #3 the facility had the fire doors closed on 11/19/10, and she was unable to closely monitor residents on the unit. The CNA stated she last observed Resident #1 on the 300 Unit hallway at 5:20 PM on 11/19/10. The CNA did not hear any alarms prior to the resident being returned to the facility, but did hear the front door alarm when the resident was returned to the facility. The CNA thought any sounding alarm could have been muffled by the closed fire doors and other noise on the unit. Interview with CNA #7, on 12/02/10 at 11:45 AM, revealed she was assigned to provide care for Resident #1 on 11/19/10. The CNA stated she observed Resident #1 on the 300 Unit, near the nurse's station at 5:20 PM. The CNA stated she spoke with the resident at that time, and had looked at her watch when she spoke with the resident. CNA #7 stated the resident was wearing a hat, sweater, shoes, pants and a grey sweater coat. CNA #7 explained that Resident #1 was behaving as usual, thought he/she was an employee of the facility, and had work to do. Interview with Licensed Practical Nurse (LPN) #1, on 12/01/10 at 2:30 PM, revealed she, or other staff, would usually check on Resident #1 every few minutes. She described Resident #1 as "pretty hard to miss" in his/her Merri-Walker. The LPN stated she was not certain when she last observed Resident #1 on 11/19/10. The LPN assessed Resident #1 upon his/her return to the facility, and found no physical problems. She stated Resident #1 was unable to state where he/she had been going or what he/she had been doing. The LPN did not hear an alarm sound prior to Resident #1 being returned to the facility. Interview with one of the Paramedics who found Resident #1 outside of the facility, on 12/01/10 at 9:35 AM, revealed the Paramedic returned the resident to the facility on [DATE], after observing him/her outside the facility, toward the back of the parking lot in a Merri-Walker. The Paramedic stated Resident #1 did not appear to be in any distress. The Paramedic continued that no alarms were sounding as they approached the door to the facility, but the alarm sounded when Resident #1 entered the facility through the front door. According to the Paramedic, the resident was returned to the facility at 5:30 PM. Interview with the Director of Nursing (DON), on 12/01/10 at 9:00 AM, revealed no explanation as to how Resident #1 was able to exit the facility, or why the alarm did not sound on the door. The DON stated the resident had exited the facility at dusk, and the temperature outside was forty-eight (48) degrees when the resident exited. According to the DON, Resident #1 was placed on every fifteen (15) minute checks when he/she returned to the facility. She stated she checked Resident #1's elopement bracelet, as well as, the front door, and determined both to be functioning. When asked about the every fifteen (15) minutes checks, the DON stated she thought the checks were an appropriate intervention, and the resident's family had agreed to the intervention. Interview with the Maintenance Supervisor (MS), on 12/02/10 at 11:35 AM, revealed he placed a call requesting inspection of the front door alarm system on 11/22/10, the first business day following the elopement. He continued that he placed a second call on 11/24/10, a third call on 11/29/10, and a fourth call on 12/01/10. He stated no additional interventions were implemented to ensure wandering residents did not exit the front door. Observation on 12/01/10 revealed six (6) exit doors would have been accessible to Resident #1, including three (3) fire doors at the back of the facility, one (1) fire door on each side of the facility, and the front door. All six (6) doors had keypads for exiting without triggering an alarm. Additionally, the front door had an elopement safety system in place that would both temporarily lock and alarm whenever an elopement safety device reached the door. The three (3) back fire doors all led to a long flight of stairs that exited at the back parking lot. One (1) side door led to a steep grassy area that merged into someone's back yard. The other side door led to the front parking lot. The front door led to the front parking lot. All doors were checked in the morning and afternoon of 12/01/10 and were found to alarm as appropriate. The front door was checked against an elopement safety bracelet and alarmed when approached. Additionally, on 12/01/10, staff demonstrated the checks that were made each nursing shift to ensure the functioning of all elopement safety devices. Observation on 12/02/10 from 12:15 PM to 12:30 PM revealed Resident #1 was ambulating using a Merri-Walker from the 200 Unit around an adjoining hall to the 300 Unit where he/she stopped at a fire door and looked out. Resident #1 was initially standing and propelling the Merri-Walker, then sat down upon reaching the fire door. Resident #1 was observed as having a second elopement safety bracelet on the leg of his/her Merri-Walker. Resident #1 ambulated at a steady pace. Observations over the course of the investigation, from 8 AM to 6 PM, revealed Resident #1 to be active wandering throughout the facility. After reviewing the "Verification of Investigation Report" dated 11/19/10, and an investigation summary dated 11/24/10, an observation revealed that, following the route outlined in the report, Resident #1 would have traveled through part of the front parking lot, down a side street with a roughly thirty (30) degree slope, turning left into the facility's back parking lot, traveling through the back parking lot to end in the grassy area beyond, near a highway. ********** An acceptable Allegation of Compliance (AOC) was received on 12/07/10. Review of inservice records revealed on 11/20/10 the DON conducted an Elopement Risk Inservice, providing handouts to all staff outlining the facility's Clinical Guide: Elopement; as well as a handout of a power point presentation. On 11/24/10, a second Elopement inservice was held with a stronger focus on prevention and awareness. A third Elopement inservice conducted on 12/02/10 stressed the importance of security in terms of not sharing the door codes. Observation on 12/06/10 at 4:00 PM revealed signs posted on all exits indicating visitors should see staff for assistance with the doors, and also that visitors should not assist any resident seeking exit without staff notification or assistance. The MS stated, in an interview on 12/07/10 at 1:45 PM, that door codes had been changed on 12/02/10. He stated the door codes would be changed quarterly. An interview with the Executive Director (ED) on 12/06/10 at 4:30 PM revealed he had assigned staff to continuously monitor the front door on 12/02/10, after Immediate Jeopardy had been identified. The ED stated staff monitoring of the front door to ensure no further elopement would continue until additional corrective action was taken. Review of the facility's Front Door Checks revealed staff were recording monitoring of the front door from 12/02/10 forward. Interviews with staff members on 12/07/10 from 3:00 PM to 5:30 PM (RN #1, RN #2, Dietary manager (DM), CNA #13, CNA #14) revealed staff were knowledgeable about facility elopement policy, including the need to not give out door codes, which had been changed, and to respond quickly to alarms. Staff were aware the front door was being continuously monitored, beginning 12/02/10. Staff were knowledgeable about which residents on their units were at risk for elopement, and were knowledgeable of the location of the Missing Resident Profile book on the 200 Unit. The Immediate Jeopardy was determined to be removed on 12/03/10. Noncompliance continued with the scope and severity lowered to a "D" based on the facility's need to evaluate the effectiveness of quality assurance activities related to elopement.