Every finding on record at West Liberty Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to post the nurse staffing data daily at the beginning of each shift.The findings include:Observation on 08/24/2025 at 11:30 AM, revealed a posted daily staffing sheet dated 08/21/2025. The facility had not updated its posted staffing sheet for three days. The facility must post the following information daily: facility name, the current date, the total number, and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:1. Registered nurses.2. Licensed practical nurses or licensed vocational nurses (as defined under State law).3. Certified nurse aides.4. Resident census.In an interview on 08/24/2025 at 11:30 AM, the Weekend Supervisor stated that she was not sure where the daily staffing sheet was located. The Weekend Supervisor continued to state that she had never been trained on how to access the staffing data or how to post it. The Weekend Supervisor asked Registered Nurse (RN)1 if she knew where the daily staffing information was located, and RN1 stated that she did not.In an interview on 08/26/2025 at 9:20 AM, the Director of Nursing (DON) stated that she was responsible for posting the daily staffing coverage Monday through Friday and that Registered Nurses were responsible for updating and posting the daily staffing coverage on the weekends. The DON continued to state that she expected the staffing to be posted daily.In an interview on 08/26/2025 at 1:41 PM, the Administrator stated that the facility did not have a policy for posting daily staffing data. Daily staffing was posted in the facility because the Centers for Medicare and Medicaid Services (CMS) requires it, according to the Administrator. The Administrator stated she expected daily staffing data to be posted so staff knew who was working and what the resident census was for the day.

Number of residents sampled: Number of residents cited: Based on observations, interviews, and policy review, the facility failed to ensure proper storage of all medications. The findings include:Review of the undated policy titled Medication Storage revealed it is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Observation on 08/24/2025 at 12:04 PM, 25 loose pills were retrieved by SSA from the bottom of the medication drawers of cart one (1), and 11 loose pills were retrieved from the medication drawers of cart two (2). It appeared the pills had fallen from the multiple blister packs located in the drawers. During an interview on 08/24/2025 at 12:12 PM with Kentucky Medication Aid (KMA)1, she stated that she was not aware that the pills had fallen to the bottom of the cart drawers. She continued to state it was the nurse/KMA's responsibility to check the cart for loose pills and to dispose of them. She stated that they should be inside the blister packs as delivered from the pharmacy. She further stated the risk of loose pills in the cart had the potential for nurse/KMA to grab the wrong pill if it was thought that one had been dropped at the time of administration and could cause harm to a resident if administered from receiving a contaminated or wrong medication. She further stated that medication should not be administered from the bottom of the drawer. During an interview on 08/26/2025 at 2:11 PM, Registered Nurse (RN) 2 stated it was the nurses' and KMA's responsibility to be aware of the condition of the medication cart. She stated the concern she had with medications being loose in the drawer was if a pill were to make its way into an open blister of a blister pack, a resident could receive the wrong pill. During an interview on 08/26/2025 at 4:32 PM, the Director of Nurses stated it was up to the nursing staff to periodically spot-check the cart for loose pills and to keep it clean. She added that if someone dropped a pill and grabbed the wrong one by mistake, a resident could be harmed because of the medication error. During an interview on 08/26/2025 at 4:38 PM, the Administrator stated that she expected the staff to keep their carts clean and follow the facility's policies.

Number of residents sampled: Number of residents cited: Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the menu was followed as written.Findings include: Review of the facility's policy titled, Food: Quality and Palatability dated 02/2023, revealed Food would be prepared by methods that conserve nutritive value, flavor and appearance. Food would be palatable, attractive and served at a safe and appetizing temperature. Continued review revealed food palatability refers to the taste and/or flavor of the food. Further review revealed Menu items were to be prepared according to the menu, production guidelines, and standardized recipes. Cooks were to use proper cooking techniques to ensure color and flavor retention. During an observation of the dinner service tray line on 08/24/2025 at 5:50PM the [NAME] notified the Dietary Manger (DM) she had run out of regular ground beef for the last six trays. DM went and retrieved 8 frozen hamburger patties and put them on the stove to cook. Regional Dietary Manager (RDM) took over cooking the meat and crumbling it up. When the meat was cooked, he sprinkled a small amount of taco seasoning on the meat and put it in the meat pan on the tray line. The tray line was interrupted for 10 minutes delaying the meal delivery.Review of the facility's recipe for dinner on 08/24/2025 titled Potato Baked Beef Taco Entree revealed there was to be fresh tomato and onions in the meat mixture as well as cumin and salt and topped with shredded cheddar cheese and salsa. The potato only had the meat mixture on top of it which did not contain cumin, salt or onion. During an observation on 08/24/2025 at 6:15PM staff passed the last tray in the dining room and at that time the test tray for taste and temperature was taken out of the food cart by the RDM. The potato tested at 125.4 degrees Fahrenheit, meat tested at 126.1 degrees Fahrenheit, milk tested at 46.2 degrees Fahrenheit, jello tested at 52.5 degrees Fahrenheit, lemonade tested at 50.9 degrees Fahrenheit. The food on the test tray was noted to be bland and lacked seasoning by 2 state surveyors. During an interview on 08/24/2025 at 11:55AM Resident (R) 15 stated the food isn't good and lacks variety.During an interview on 08/24/2025 at 11:58AM R40 stated the food was just ok and did not taste good.Observation on 08/24/2025 at 5:50 PM revealed the last daily menu posted was for 08/22/2025.During an interview on 08/24/2025 at 6:28 PM with the RDM stated it was the responsibility of the dietary staff to update menu postings. Continued interview revealed the dietary staff had to make extra ground beef to complete dinner service and the ground beef was not weighed, seasoning was just eyeballed, and the recipe was not followed. During an interview on 08/26/2025 at 9:18AM the Dietary Manager (DM) stated she tastes the food everyday she works for palatability. She further stated that she does not always follow the recipe instructions. The DM Stated she would boil chicken instead of baking it because baking it makes the chicken too hard for the residents to chew. The DM further stated by not following the recipe the food might not come out as intended and not taste as its supposed too. During an interview on 08/26/2025 at 1:40pm R4 stated the chicken was hard and difficult to chew and lacked flavor. R4 also stated he would not want it again. During an interview on 08/26/2025 at 11:30AM the RDM stated his expectation was the menu was to be followed as written.During an interview on 08/26/2025 at 3:00PM State Registered Nursing Assistant (SRNA) 5 stated there were 4 residents who routinely do not like the main entree at dinner. SRNA 5 continued to state these four residents do not like chicken, and the chicken does not look appetizing. During an interview on 08/26/2025 with the Executive Director revealed her expectation was the menu was followed as written.

Number of residents sampled: Number of residents cited: Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for one of one meal trays tested for taste and temperature.Findings include: Review of the facility's policy titled, Food: Quality and Palatability dated 02/2023, revealed Food would be prepared by methods that conserve nutritive value, flavor and appearance. Food would be palatable, attractive and served at a safe and appetizing temperature. Continued review revealed food palatability refers to the taste and/or flavor of the food. Further review revealed Menu items were to be prepared according to the menu, production guidelines, and standardized recipes. Cooks were to use proper cooking techniques to ensure color and flavor retention. During an observation of the dinner service tray line on 08/24/2025 at 5:50PM, Cook10 notified the Dietary Manger (DM) that she had run out of regular ground beef for the last six trays. The DM retrieved 8 frozen hamburger patties and put them on the stove to cook. The Regional Dietary Manager (RDM) took over cooking the meat and crumbling it up. When the meat was cooked, the RDM sprinkled a small amount of taco seasoning on the meat and put it in the meat pan on the tray line. The tray line was interrupted for 10 minutes delaying the meal delivery. During an observation on 08/24/2025 at 6:15PM staff passed the last tray in the dining room and at that time the test tray was taken out of the food cart by the RDM. The potato tested at 125.4 degrees Fahrenheit, meat tested at 126.1 degrees Fahrenheit, milk tested at 46.2 degrees Fahrenheit, Jello tested at 52.5 degrees Fahrenheit, lemonade tested at 50.9 degrees Fahrenheit. The test tray was tested by two state surveyors and the food served were found to be bland to taste and lacked seasoning. Review of the facility's recipe for dinner on 08/24/2025 titled Potato Baked Beef Taco Entree revealed there was to be fresh tomato, onions, cumin and salt in the meat mixture and topped with shredded cheddar cheese and salsa. The potato only had the meat mixture on top of it which did not contain cumin, salt or onion. During an interview on 08/24/2025 at 6:28 PM the RDM stated the dietary staff had to make extra ground beef to complete the dinner service. The RDM further stated the ground beef was not weighed, seasoning was just eyeballed, and the recipe was not followed. During an interview on 08/24/2025 at 11:55AM resident (R) 15 stated the food wasn't good and lacked variety.During an interview on 08/24/2025 at 11:58AM R40 stated the food was just ok and did not taste good. During an interview on 08/26/2025 at 1:40pm R4 stated that the chicken was hard and difficult to chew, warm, and lacked flavor. R4 also stated he would not want it again. During an interview on 08/26/2025 at 11:30AM RDM stated his expectation was that the menu was to be followed as written. During an interview on 08/26/2025 at 3:00PM State Registered Nursing Assistant (SRNA) 5 stated there were four residents who routinely do not like the main entree at dinner when chicken was served because those residents do not like chicken. The SRNA stated the chicken does not look appetizing. During an interview on 08/26/2025 at 9:20 AM, Administrator stated she expected that menus and recipes be followed as written to ensure that the palatability of the food was consistent.

Based on observation, interview, record review and facility policy, the facility failed to provide food and drink that accommodated resident preferences for 3 of 6 sampled Residents. (R 1,3,17). The findings include:Review of the facility policy titled Dining and Food Preferences revised 10/2022 revealed individual dining, food, and beverage preferences would be identified for all residents. Further review of the policy revealed the Dining Services Director, or designee would interview the resident or resident representative to complete a Food Preference Interview within seventy-two hours of admission. The Food Preference Interview would be entered into the medical record. Further review of the policy revealed the tray assembly ticket would identify all food items appropriate for the resident based on diet order, allergies/intolerances, and preferences. Observation on 08/24/2025 at 5:35 PM revealed Resident (R)3's food tray consisted of rice with a ground meat mixture, chicken noodle soup, tea and milk. The resident stated she had requested the chicken noodle soup with all meals, but she had consistently informed staff that she did not eat rice, nor drink tea. The resident was not provided with crackers for her soup. R3 stated she had asked for crackers, staff had gone to the kitchen to obtain crackers, then came back and informed R3 there were no crackers in the kitchen.Record review of R3's admission Face Sheet revealed R3 was admitted to the facility on [DATE] with diagnoses of chronic diastolic heart failure, chronic obstructive pulmonary disease (COPD) and Diabetes mellitus with polyneuropathy.Review of R3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/12/2025 revealed a Brief Interview for Mental Status (BIMS) score of 12 of 15, which indicated R3 had moderate cognitive impairments.Review of R3's Physician Order dated 08/25/2025 revealed a diet order for no added salt, regular texture, regular consistency, and house shakes with all meals.Review of R3's Food Preference Interview form dated 06/30/2025 revealed the resident disliked rice, and preferred a beverage of orange juice, pineapple juice, milk, and sprite.Observation on 08/24/2025 at the 5:38 PM dinner meal service revealed R1 was served ground beef, on a small potato as the entree. Further observation revealed R1 had a tossed salad which she was eating and R1 stated that was all she would eat off the tray and that she had attempted to get an alternative food in the past and never received it, so she had not requested anything different since then.Review of R1's admission Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), and major depression. Review of R1's admission MDS with ARD of 05/13/2025 revealed a BIMS score of 12 of 15 which indicated R1with moderate cognitive impairmentsReview of R1's Physician order dated 05/07/2025 revealed a regular texture, thin consistency, no added salt diet.Review of R1's Food Preference Interview Form dated 08/15/2025 revealed R1's dislikes included beef, cold cuts, sausage, and the resident preferred apple juice, cranberry juice, coffee and sprite. During an interview with R1 on 08/24/2025 at 5:40 PM she stated that she had requested on numerous occasions to not be served ground beef. Furthermore, she stated no one can seem to get the message that I do not want ground beef. Review of R1's tray card revealed in handwriting main entree. There were no designated likes/dislikes on the tray card.Review of R17 admission Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses of Diabetes and COPD.Review of R17's quarterly MDS with an ARD of 07/09/2025, revealed a BIMS score of 15 which indicated the resident was cognitively intact. Review of R17's Food Preference Interview Form dated 08/15/2025 revealed R17 did not like tea.During an interview on 08/26/2025 at 1:50 PM with R17, she stated she did not get a lunch tray today. R17 further stated staff made the kitchen aware, and a tray was brought up to her. R17 stated she received a peanut butter and jelly sandwich, chips, and salad. R17 further stated she received tea, which she did not like. R17 stated she preferred lemonade but did not receive it. Review of R17's Physician order dated 05/01/2025 revealed a Controlled Carbohydrate Diet (CCD) regular texture, thin consistency diet with soy milk had been ordered for the resident.During an interview on 08/25/2025 at 10:22 AM the Regional Dietary Manager (RDM) stated within seventy-two hours after admission, the Dietary Manager (DM) was to complete the food preference form for the resident. The information was then put into the operating system called Meal Suites in the kitchen, so the preferences would be printed on the meal cards. The RDM further stated if the Resident had a dislike or a special diet, such as Carbohydrate controlled Diet, the system would change the tray card to an alternative. However, observation on 08/27/2025 of the lunch tray card for R17 revealed only the verbiage substitute needed instead of a specific alternative. Further review of the tray cards revealed no listing of the likes/dislikes on the tray cards.During an interview on 08/26/2025 at 9:30 AM the DM stated she was the primary person responsible for completion of the Food Preference form for new residents on admission, quarterly, and with a significant change in resident diet. The DM stated she then entered the information into the system in the kitchen, then the information would print out on the resident tray cards, which were used when plating the food during meals. The DM stated that sometimes she was made aware of a change in Resident food request by the Certified Nurse Aides (CNA)'s and she made the change in the computer system in the kitchen. The DM stated, if residents received foods, they did not like it could cause weight loss. During an interview on 08/26/2025 at 4:39 PM the Administrator she stated her expectation was the resident's preferences were honored as much as they could be with consideration of the physician ordered diets. She stated if the preferences were not followed it could cause dissatisfaction and weight loss with the residents.

Number of residents sampled: Number of residents cited: Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection as per accepted national standards and guidelines.The findings include:The facility's policy titled Infection Prevention and Control Program, last revised on12/12/2023, stated, all staff are responsible for following all policies and procedures related to the program. The policy further stated that hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Further, it revealed that all reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with the current procedures governing the cleaning and sterilization of soiled or contaminated equipment, and finally, that all staff shall demonstrate competence in relevant infection control practices.Review of the policy titled Hand Hygiene, undated, stated, All staff will perform proper hand hygiene procedures to prevent the spread of infections to other personnel, residents, and visitors. This applies to all staff working in the locations within the facility.Center for Disease Control (CDC) guidance, provided by the facility, titled Handwashing: Clean Hands Save Lives, dated 08/10/2020, reads that germs spread when you prepare or eat food and drinks with unwashed hands. It also lists the key times to wash hands are before, during, and after preparing food.An undated copy of the New-Hire education packet included a sheet regarding handwashing, which stated, Key times to wash hands were before and after preparing food.On 08/24/2025 at 9:02 AM, the housekeeping supervisor was observed sweeping the floor in front of a meal cart, while meal services were in progress.During an interview on 08/24/2025 at 2:17 PM, the housekeeping supervisor stated that she would not take the cleaning cart on the floor during mealtime; however, she took the broom and dustpan to clean a mess on the floor in front of the food cart. She stated that occasionally, she would sweep up things during mealtime, but she understood that it was not a good idea due to the increased risk of spreading dust and germs.On 08/24/2025 at 3:50 PM, a wedge, used for resident positioning in bed, was observed on the floor, near the door of room [ROOM NUMBER] A.On 08/24/2025 at 6:45 PM, Certified Nursing Assistant (CNA) 1 was observed carrying a clear trash bag with approximately 4,000 cc's (1 Gallon) of clear yellow liquid identified by CNA 1 as urine, from a resident room to the shower room for disposal. As she exited the shower room, she continued to wear her dirty gloves into the hall.During an interview on 08/24/2025 at 6:47 PM, CNA 1 stated that the room where she removed the urine did not have a bathroom, and she was expected to take the urine to the nearby shower room for disposal. She stated that there was potential for the bag to tear and spread urine in the hall and that would cause an increased risk of spreading body fluids in the hall. She further stated that she forgot to remove her gloves before coming out into the hall.During an observation on 08/25/2025 at 12:15 PM, the resident nutrition refrigerator, located at the nurses' station, revealed the temperature log was incomplete and was missing the refrigerator and freezer temperature documentation for evenings of 08/21, 08/22, 08/23/ and 08/24/2025. Both morning and evening documentation were missing on 08/23/2025 and 08/24/2025. There were no food products in the freezer at that time. The refrigerator had a resident's [NAME] and two (2) dated Styrofoam cups with lids, containing a dessert-type food.During an interview on 08/26/2025 at 10:40 AM with the Dietary Manager (DM), she stated that she regularly checked the temperatures, documented on a paper that was located on the door of the nutrition refrigerator. She further stated that although other staff, including dietary and/or nursing staff, may enter the information, she was responsible for making sure it was done and there were no concerns. She stated that the appropriate temperature for the freezer was zero degrees Fahrenheit (0 F) or below. SSA asked the DM about the four (4) observations on 08/16/2025 - 08/20/2025, where the freezer temperature was 20 F, and the observations on 08/21 - 08/22/2025, where 10 F was listed as the freezer temperature and the DM stated it was an oversight. She added that one of the staff members who entered those numbers was a new employee and may not have read it correctly. She further stated that refrigerator and freezer temperatures outside of the appropriate temperature range could result in foods not freezing well enough and could allow those foods to continue to grow bacteria.During an observation on 08/25/2025 at 6:30 PM, CNA 4 was observed in the dining room setting up resident trays and feeding two residents without washing her hands between them.During an interview on 08/25/2025 at 6:52 PM with CNA 4, she stated the residents at this table required assistance to eat their meals. The CNA offered bites to two (2) residents without cleaning her hands between them. She verbalized the serving process that would have prevented this error, had not been followed, and as a result, she was trying to satisfy the impulsive behavior of those residents by offering them a bite. She stated that by not washing her hands, she could spread germs from resident to resident or from herself to a resident.During an interview on 08/26/2025 at 2:11 PM, with Registered Nurse (RN) 2, she stated that if the refrigerator or freezer were not kept at the proper temperature, it could cause the food to spoil, and a resident could become ill. She further stated that the process for emptying bed pans, bedside commodes, and urinals in rooms that do not have bathrooms was the containers were to be double-bagged and carried to the shower room to be disposed of. She continued to state that staff were not to wear gloves in the hall and once items were bagged, a clean bag was on the outside, so the gloves were to come off, and then reapply new gloves once it was time to empty the bag. During an interview on 08/26/2025 at 3:08 PM with the Infection Preventionist (IP), she stated that housekeeping duties should not be performed during meal service due to the risk of spreading germs and dirt onto residents' food. Assisting residents with their meals required staff to wash their hands with soap and water or use sanitizing gel, sit one (1) staff member between two (2) residents, and feed one resident with the left hand and another with the right as not to contaminate the other tray. There would be an increased risk of spreading germs if the policy were not followed. She stated that the process of emptying urinals and bedpans from the rooms that did not have access to a toilet required the staff to bag the urinal, bedpan or graduate and take it to the shower room at the end of the hall. Body fluids should not be carried in a bag without an appropriate container. It was possible for the bag to have a leak and spread bacteria all over the floor and the staff that was carrying it, causing an increased risk of illness among residents and/or staff. The IP nurse stated that nothing should be stored on the ground, especially something that is used in direct patient contact, such as a wedge that is used to support a resident's position in bed. It would introduce germs to the resident and their bedding, and this could cause a resident to get sick. She verified that the correct freezer temperature should be zero F (0 F) and stated that the potential risks for food not frozen at the correct temperature, or monitoring of the refrigerator temperature for accuracy, would be an increased risk of bacterial growth, which could make the resident(s) sick.During an interview on 08/26/2025 at 4:32 PM with the Director of Nurses (DON), she stated that she expected all staff would follow the facility's policy and procedures regarding infection control. Specifically, she stated, hand hygiene before and after assisting a resident with their meal was important to decrease the potential spread of germs. She added that resident items should not be stored on the floor but rather, on the end of the bed, in the resident closets, or on the sink. She continued to state that storing items on the floor allowed germs to go from the floor to the residents' beds or on their persons and increased their risk of becoming ill. The DON stated it was never appropriate to wear dirty gloves into the hall or sweep the floor during mealtime due to the risk of spreading germs. The DON further stated that the temperature log was completed by nursing and dietary; however, it was the responsibility of the Dietary Manager to ensure it was complete, and no problems were identified and that the appropriate temperature was zero (0) and if food had been stored in the freezer, it would have been possible that it had not frozen to the temperature required to assure adequate safety. She further stated missing documentation may mean that temperatures were not checked on those days and there could be no guarantee that they were not out of range during that time and that she expected that if there was a problem with the refrigerator or freezer, the staff would contact her or maintenance.During an interview on 08/26/2025 at 4:38 PM with the Administrator, she stated that staff had access to her number and access to maintenance 24 hours a day / 7 days a week. If there were concerns about the temperature of the refrigerator or freezer, she would expect it to be reported for repair. She added that if the food was allowed to get too warm, it may make a resident sick. SSA discussed observations regarding dirty gloves, unwashed hands, storage of resident personal items on the floor, and floor care during meal service were reviewed, and she stated that she expected that staff would follow the facility's infection control policy and procedures.

Based on observation, interview, and record review, it was determined the facility failed to provide the residents with a right to a safe, clean, comfortable, and homelike environment for three of 14 sampled residents (Resident (R)3, R7, R18). The findings include:Review of the facility policy titled, Resident Rights undated, revealed the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living. On 08/24/2025 at 11:58 AM, observation of Resident (R)3's room revealed a black substance was on the floor around the baseboard. Continued observation of R3's room revealed cracked tile in the floorOn 08/24/2025 at 12:08 PM in the north hall men's shower room revealed 8 cracked tiles in the floor and around the baseboard. Continued observation revealed a tile missing around the toilet. On 08/24/2025 at 12:14 PM in the north hall women's shower room revealed 6 cracked tiles and 4 missing tiles around the baseboard. The trim around the toilet had 2 missing tiles.On 08/25/2025 at 10:54 AM observation of R7s room revealed a black substance on the baseboards of the room. Continued observation revealed baseboards were missing underneath the air condition unit along with a hole in the wall under the bottom of the unit.On 08/25/2025 at 11:08 AM observation of R18's room revealed paint chipped around the sink. Continued observation revealed a 2-inch hole in the wall around the baseboard.On 08/25/2025 at 11:22 AM observation of the dining room revealed the baseboard peeling off the wall next to the sprinkler system doors. On 08/25/2025 at 11:31 AM observation in the hallway revealed paint missing at the entrance to room [ROOM NUMBER]. Continued observation revealed a hole in the wall next to the baseboard outside room [ROOM NUMBER]. On 08/25/2025 at 12:08 PM observation in the hallway in front of the soiled utility room revealed a cracked tile in the middle of the hall.During an interview with R3 on 08/24/2025 at 1:34 PM he/she stated that having cracked tiles in the shower room and in the hallway makes R3 feel dirty.During an interview with R28 on 08/24/2025 at 3:18 PM the resident stated that this wouldn't be the conditions their home would be like if they were able to clean. R28 stated that they were used to keeping their home very clean and they don't feel like they do that at this facility.During an interview with the Senior Maintenance Director on 08/25/2025 at 3:12 PM he stated that all work orders would be prioritized when they came in and done within a timely manner. He also stated that no resident should have to feel dirty due to a cracked tile or environmental issue. The Director of Nursing (DON) stated in an interview on 08/25/2025 at 3:28 PM that all residents should feel like they have a clean and homelike environment to live in. The DON further stated the facility should ensure this happens by making sure work orders were done in a timely manner. We have just recently terminated our last maintenance director so we may have some work orders that are stacking up right now. Our regional team is going to do what they can to help while we hire a new maintenance director.The Administrator stated in an interview on 08/25/2025 at 3:43 PM that she was aware the shower rooms have some cracked tiles, and she was trying to get someone to fix them. She further stated that the last maintenance guy couldn't do ceramic tile, so we have to contract it out and we just haven't got to it yet.In an interview with the housekeeping supervisor on 08/25/2025 at 4:12 PM she stated that anytime they find a crack or missing tile, they let maintenance know. She further stated, Sometimes when we are cleaning the floors a tile will just fall off the wall. We just lay it back up there and let maintenance know. This is a really old building, and we do the best we can.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the comprehensive person-centered care plan was developed and implemented with interventions necessary for monitoring a resident with behaviors of wandering, who was at risk for elopement for one (1) of five (5) residents (Resident #20). The facility admitted Resident #20 with a history of wandering and elopement at home. The facility assessed Resident #20 to have wandering behaviors and care planned the resident as an elopement risk due to disorientation to place and impaired safety awareness. The facility's interventions for Resident #20 included observing for unmet needs and redirecting the resident when wandering, wearing a Wander Guard bracelet, checking the placement and function of the Wander Guard. However, on [DATE], even though Resident #20 had the Wander Guard bracelet in place, the resident was allowed to exit the facility and elope approximately 1.5 miles away from the facility without staff's knowledge. The facility's failure to ensure the comprehensive person-centered care plan was developed and implemented with necessary interventions for monitoring residents at risk for elopement has caused or is likely to cause serious injury, serious harm or death to other residents in the facility. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.25 Quality of Care, F689; and 42 CFR 483.21 Comprehensive Centered Care Plans, F656 both at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy on [DATE]. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated the facility's IJ Removal Plan and found the facility removed the immediacy on [DATE], as alleged, prior to exit on [DATE]. The facility remained out of compliance in the area of 42 CFR 483.25 Quality of Care, F689, at a Scope and Severity (S/S) of D while the facility developed and implemented a Plan of Correction and monitored for the effectiveness of the systemic changes. In addition, the facility failed to ensure the use of chewing tobacco was addressed on the care plans of Resident #15 and Resident #7. Resident #15 and Resident #7 were both observed using chewing tobacco. The findings include: 1. Review of the facility's policy titled, Elopements and Wandering Residents, dated [DATE], revealed residents were to be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team (IDT). The interdisciplinary team was to evaluate factors contributing to the risk in order to develop a person-centered care plan. Further interview revealed interventions were to be implemented to modify the resident's behavior, or to minimize risks associated with hazards were to be added to the resident's care plan and communicated to appropriate staff. Review of an Admission Record revealed the facility admitted Resident #20 on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, major depressive disorder, and cognitive communication deficit. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #20 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was cognitively intact. Continued review of the MDS Assessment revealed Resident #20 wandered on one (1) to three (3) days during the seven (7) day assessment period. Review further revealed Resident #20 used a wander/elopement alarm daily. Review of Resident #20's Nursing Admission/Readmission Evaluation, dated [DATE] at 2:30 PM, revealed under Care Planning the resident was checked as a new admission. Further review under the Focus: Rehabilitation Potential/Special Services/Procedures, revealed an intervention for Elopement Risk which had not been selected to be addressed. Review of the Social Service Progress Review for MDS Documentation, dated [DATE] and signed [DATE], revealed the facility identified Resident #20 to have displayed wandering and elopement behaviors and refused care on one (1) to three (3) days during the assessment period. Per review, Resident #20 had been looking for exits in the facility, and had a Wander Guard alarm for safety. Further review revealed Resident #20 had a diagnosis of Dementia and wanted to go home. Interview, with the Social Worker (SW) on [DATE] at 12:04 PM, revealed the family had told her on [DATE], of Resident #20's elopement and wandering history when at home which included the resident wandering outside the home to neighboring houses. The SW stated the family member informed her Resident #20's guardianship had been relinquished to the State because of the resident's wandering and elopement behaviors from the home. She stated the care plan interventions for a Wander Guard alarm, redirection, and anticipating the resident's needs were put in place to address his/her wandering and elopement behavior concerns. Continued interview revealed the SW acknowledged no other supervision was put in place upon Resident #20's admission. The SW stated she had not received any reports from staff of Resident #20 exit seeking or wandering, and she had never seen the resident exit seeking or wandering. Review of Resident #20's Order Summary Report revealed a Physician's Order, with a start date of [DATE], for a Wander Guard alarm to Resident #20's right ankle and for staff to check the functioning and placement of the Wander Guard every shift. Review of Resident #20's Care Plan revised [DATE], revealed the facility care planned the resident as an elopement risk due to disorientation to place and impaired safety awareness. Continued review revealed the interventions included: observing for unmet needs when the resident was wandering/exit seeking; placing the resident's profile in an elopement book; providing structured activities; redirecting the resident when exit seeking or wandering, and checking the placement and function of the resident's Wander Guard. Further review revealed Resident #2's Care Plan did not include additional interventions for monitoring the resident related to his/her elopement and wandering behaviors. An interview was conducted, on [DATE] at 1:39 PM, with an Anonymous Complainant, who called the facility requesting to speak with a State Survey Agency (SSA) Surveyor already on site for the Recertification Survey. The Anonymous Complainant stated Resident #20 had eloped from the facility through a window and got six (6) miles away from the facility. Further interview revealed Resident #20's elopement had not been reported. Telephone interview with Resident #20's Emergency Contact #2, on [DATE] at 4:20 PM, revealed the Emergency Contact had no knowledge of the resident eloping from the facility, and had not been made aware of any exit seeking or wandering behaviors while the resident was residing at the facility. Per interview, Emergency Contact #2 stated guardianship had been sought from the State due to Resident #20's elopement behaviors from the Emergency Contact's home, and the Emergency Contact not being able to provide the level of supervision the resident needed at home. Interview with the Director of Nursing Services (DNS) on [DATE] at 4:42 PM, revealed the facility had no elopements in the past six (6) months. Telephone interview with Licensed Practical Nurse (LPN) #5 on [DATE] at 12:04 PM, Resident #20 had eloped from the facility one (1) day the previous week, on either [DATE] (Tuesday) or [DATE] (Wednesday). She stated the only thing she had been told by LPN #17, the nurse on duty at the time of elopement, was that the resident had been spotted walking down Main Street by facility's State Registered Nurse Aides (SRNA) coming to work. Per LPN #5, she was not working at the time Resident #20 eloped, and when she reported for her shift the day after the elopement, the resident had one-to-one (1:1) staff supervision until he/she was discharged from the facility. Telephone interview was attempted with LPN #17 on [DATE] at 7:20 PM; however, the attempt was unsuccessful. A voicemail was left, with no return call received. Interview with State Registered Nurse Aide (SRNA) #13, on [DATE] at 12:26 PM, revealed on [DATE] around 6:40 PM, a night shift SRNA came to work early and frantically asked her if Resident #20 had left the facility. SRNA #13 told the night shift SRNA no the resident had not left the facility. However, the night shift SRNA told her she and another SRNA had seen Resident #20 on the street. Continued interview revealed the two (2) SRNAs went to Resident #20's room and discovered the resident was not there. She stated a night shift nurse also came in to work and reported also seeing Resident #20 in town. SRNA #13 stated she and the night shift SRNA left the facility to search for Resident #20 and found him/her near a pizzeria. According to SRNA #13, Resident #20 had a blue bag packed and told the staff he/she was going to Interstate 75 to hitchhike. Further interview revealed Resident #20 was returned to the facility; however, she did not know how the resident got out of the facility in the first place. Interview with the Director of Nursing Services (DNS), on [DATE] at 4:26 PM, revealed Resident #20 had left the facility, and acknowledged elopement was when a resident left the facility without authorization or supervision, regardless of his/her cognitive abilities. According to the DNS, residents' care plans should reflect the level of supervision they needed if they were an elopement risk and should be updated for any behavioral changes. A follow-up interview with the Executive Director (ED) on [DATE] at 4:33 PM, revealed residents' care plans should be revised as needed, such as during care plan meetings, when issues were identified, and with any significant changes. Further interview revealed if a resident was exit-seeking, pushing on doors, pacing, stating they wanted to go home, or they had a successful exit, their care plan should be updated to address the behavior. 2. Interview with the ED on [DATE] at 9:37 AM, revealed the facility had no policy or assessment process regarding residents who used chewing tobacco. (a). Review of Resident #15's Admission Record revealed the facility admitted the resident with with diagnoses of Muscle Weakness, Acute Kidney Failure, Diabetes Mellitus, and Methicillin Resistant Staphylococcus Aureus (MRSA) infection. Review of the five (5) day MDS Assessment, dated [DATE], revealed the facility assessed Resident #15 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated intact cognition. Continued review of the MDS Assessment revealed the facility assessed Resident #14 as independent with set-up help when eating. Interview, on [DATE] at 12:25 PM, with Resident #15 revealed he/she chewed tobacco, and had no concerns related to the facility. Observation at the time of interview revealed loose chewing tobacco lying on the resident's bedside table. Review of Resident #15's initial Care Plan, dated [DATE], revealed no documented evidence the facility had care planned the resident for his/her use of tobacco. Further review additionally revealed no documented evidence the facility care planned how Resident #15's tobacco was to be stored or secured, nor of any monitoring to be provided related to the resident's tobacco use. (b). Review of Resident #7's Admission Record revealed the facility admitted the resident with diagnoses which included Dysphagia, Dementia without behaviors, Major Depressive Disorder, and muscle weakness. Review of the Quarterly MDS Assessment, dated [DATE], revealed the facility assessed Resident #7 to have a BIMS' score of six (6),which indicated severe cognitive impairment. Continued review revealed Resident #7 was independent with set-up help only for eating, was on a mechanical soft diet, and was assessed to have no signs or symptoms of a swallowing disorder. Observation of Resident #7, on [DATE] at 9:03 AM, revealed the resident had a large wad of chewing tobacco in his/her mouth with tobacco stains on his/her bed sheets. Further observation revealed loose chewing tobacco on the floor surrounding Resident #7, and a bag of chewing tobacco lying on the resident's bedside table. Review of Resident #7's Care Plan revised on [DATE], revealed no documented evidence the facility developed his/her care plan to address the resident's chewing tobacco use. Additional care plan review revealed no documented evidence the facility care planned how Resident #7's chewing tobacco was to be stored or secured, nor evidence of any monitoring to be provided related to the resident's tobacco use. Telephone interview with Licensed Practical Nurse (LPN) #5 on [DATE] at 12:04 PM, revealed a resident's tobacco use should be addressed on their care plan. Interview, with State Registered Nurse Aide (SRNA) #13, on [DATE] at 12:26 PM, revealed the SRNA Kardex was the closest thing to a care plan the SRNAs had to reference. SRNA #13 further stated residents' chewing tobacco use and habits were not information included on the Kardex. Interview, with the Executive Director (ED) and DNS on [DATE] at 4:29 PM, revealed the DNS stated chewing tobacco use should be included on a resident's care plan. The DNS stated the risks of chewing tobacco and the resident's preferences should also be included as interventions on their care plan. During the interview, the DNS reviewed the residents' care plans and confirmed the facility had not care planned the residents' use of chewing tobacco. The facility provided an acceptable Immediate Jeopardy Removal Plan on [DATE], alleging removal of the Immediate Jeopardy on [DATE]. Review of the Immediate Jeopardy Removal Plan revealed the facility implemented the following: 1(a). Resident #20's wander/elopement assessment and care plan were reviewed with no identified changes needed. This action was completed, on [DATE], by Social Services and Medical Records. (b). Resident #20's MDS and any associated Care Area Assessments (CAAs) were reviewed with no identified changes needed. This action was completed on [DATE] by Social Services. (c). The Physician and responsible party were notified, and no new orders were received. The physician was notified on [DATE] and attempts to contact the responsible party were made on [DATE]. On [DATE], the responsible party was notified via telephone. This action was completed on [DATE] by the Executive Director. (d). The physician stated Resident #20 was alert and oriented x 4 and seemed able to make the resident's own informed decisions. This action was completed on [DATE]. The physician was aware the resident had a court appointed guardian. However, guardianship was appointed while the resident was in the hospital and the resident's daughter was refusing to provide care. The Medical Director had multiple visits with the resident and felt the resident was more than capable of making his/her own decisions. (e). The facility placed Resident #20 on 1:1 until the investigation was completed. This action was completed on [DATE]. The Executive Director initiated 1:1 supervision until the investigation was completed. The ADNS/DNS reeducated the SRNAs, along with all staff, on the policy and procedures related to alarm sounding and checking outside. 2(a). An immediate head count of all residents in the facility was completed and all residents were accounted for. This action was completed by the LPN on duty on [DATE]. (b). New Elopement Risk Assessments were completed, and care plans updated for current residents. This was initiated and completed on [DATE], for anyone identified by the IDT to be at risk. The Director of Nursing, Medical Records, and Social Services completed the elopement risk assessments and reviewed the care plans. There was one resident who was identified at risk and a WanderGuard device was placed on the resident. (c). All code alert alarm bracelets currently in use on [DATE] were checked for placement and function and the expiration date. No issues were found. This audit was completed by Medical Records and a licensed nurse, on [DATE]. (d). Audits of the Elopement Binders were completed by the SSD/Executive Director to validate that all current residents at risk have a picture that accurately reflects the resident's current appearance and their identification information. This action was completed on [DATE] by the SSD and Executive Director. (e). Maintenance completed assessment of all exit doors to verify the doors, windows, door alarms, and panels were functioning appropriately. This action was completed on [DATE]. (f). On [DATE], the Maintenance Director completed assessments of the alarm systems and doors to determine if they all were functioning as per manufacturer's guidelines. (g). The facility's ED/DNS/Maintenance completed an elopement drill on different shifts to evaluate staff on response to the WanderGuard alarms on [DATE]. All staff were involved in elopement drills and no issues were identified beginning on [DATE]. (h). On [DATE], the IDT audited all elopement assessments, elopement books, and photos to ensure they were complete and accurate. This action was completed on [DATE] by the IDT. (i). All code alert alarm bracelets currently in use, on [DATE], were checked for placement and function by Medical Records, who was a licensed nurse. (j). All residents were reassessed for elopement and new wandering assessments were completed by the IDT clinical team on [DATE]. (k). Each resident that was found to be at risk for elopement had appropriate interventions in place. This was completed by the SSD on [DATE]. (l). SSD reviewed the care plan to ensure those at risk were reflected on the comprehensive care plan and KARDEX Care plans; and the Kardex was reviewed by Social Services on [DATE] (m). If a Code Alert Bracelet was appropriate, the order was reviewed for accuracy. Medical Records completed an audit on all code alert bracelets and no issues were identified. This was completed on [DATE]. 3(a). All staff including contract team members (Nurses, SRNAs, Dietary, Housekeeping, Laundry, Therapy, Maintenance, Administrative Office Staff) were re-educated to the Elopement Policy Procedure and the new policy regarding supervision and monitoring on [DATE] by the ADNS/DNS/ED . The training included: code alert placement and function, elopement risk evaluations to identify residents at risk of leaving the facility unattended. Education was provided to staff that included: the elopement books, care plans, Kardex and reporting. Upon admission, the IDT will contact the resident's guardian requesting approval or denial to allow the resident to leave the facility unsupervised and chart approval or denial from the guardian in the medical record. (b). Staff were checked off to a master list generated by payroll by the Nursing Home Executive Director to ensure all staff had been reeducated. As of [DATE], no team member, to include agency, worked without being educated. Based on the elopement risk audit and guardianship status, the IDT will determine which residents will be safe to leave the facility unsupervised. (c). The IDT will review all nursing notes and all new admissions during the Daily Clinical Start-up meeting five (5) days a week (M-F) and on weekends ongoing for three (3) months to ensure there were no new findings related to exit seeking behaviors and that all elopement assessments were completed per policy. If new findings were noted during the reviews, those residents' care plans will be reviewed to ensure revisions have been made appropriately. This review began on [DATE] and will be continued by the Director of Nursing and Assistance Director of Nursing for three (3) months. (d). VP [Vice President] of Clinical Operations educated the Regional Director of Operations on the most current elopement definition on [DATE]. (e). The Regional Director of Operations educated the ED, DNS, and ADNS regarding the most current elopement definition, elopement guidelines, policy and procedure and required reporting, the necessity to follow and update the care plan following the identification of at-risk residents per the elopement assessments; how to complete the elopement assessments; elopement signs, supervision of the residents and necessity of staff to be available and respond to alarms. This action was completed on [DATE] by the Regional Director of Operations. (f). The ADNS completed education with all staff regarding the most recent definition of elopement, elopement drill response and procedure; signs of potential elopement risk and supervision of residents, necessity to update the care plan following the identification of at-risk residents per the elopement assessments; how to complete the elopement assessments; and necessity of staff to be available and respond to alarms. Staff education to be continued until complete with no staff working that was not educated after [DATE] to include agency. 4(a). The Director of Nursing Services and Assistant Director of Nursing will audit the residents at risk on the elopement assessment to determine appropriate interventions were in place for every resident identified at risk seven (7) days a week for the next three (3) months. This action will be ongoing for three (3) months and will be completed by Director of Nursing, Assistant Director of Nursing. (b). Code alert alarm bracelets were checked for placement, expiration date, and function each shift beginning on [DATE]. This was checked every shift by the nurse on duty and recorded on the TAR. Additionally, checks will be conducted weekly by DNS and ADNS for three (3) months. Results will be provided to the ED and reviewed in QAPI at least monthly. (c). Each resident identified by IDT as at risk for elopement had a code alert bracelet in place, which was fully functioning and not expired. Code alerts were checked by Medical Records on [DATE]. The results of continuing audits will be brought to QAPI, and results will be discussed. (d). Each resident at risk for wandering/exit seeking/elopement risk has a current care plan and reflects the resident person-centered interventions. Nine (9) residents were identified to be at risk. The SSD reviewed current care plans and results of the audits were brought to QAPI for review. (e). Maintenance performed function and expiration date checks on all code alert bracelets on [DATE]. The DNS/ADNS/Nurse Management Team will continue to do so weekly for three (3) months, then monthly x four (4) months. Function checks, expiration date, and placement will be documented by the Director of Nursing on a form not part of the medical record. This action was completed on [DATE] by the Maintenance Director. Nurses on shift will check placement, expiration, and function each shift on weekdays and weekends and document completion on the MAR. (f). Elopement drills will be conducted by the ED/DNS/ADNS or Maintenance 3 x per week for 4 weeks on alternating shifts and weekends, then monthly indefinitely, until the staff's response was satisfactory. This action was completed on [DATE] by maintenance. (g). Door alarm functioning audits will be conducted 3 x a week for 4 weeks, then weekly x 4 weeks, including weekends, if no issues are noted by the Maintenance Director/ED. The DNS/ADNS will conduct weekly audits for three (3) months, which will include observation of placement, expiration date, and checking of function for all residents with WanderGuard orders, ongoing. This action was completed on [DATE] by the Maintenance Director and will be ongoing. (h). The DNS/ADNS/Floor Nurse and/or Nurse Management team will conduct 1 x a week audits of the code alert system. The audit will include weekends and observation of placement, expiration date, and checking of function for all residents with orders. (i). All audits will be forwarded to the Executive Director after completion of audits for review by the Center's QAPI (Quality Assurance Performance Improvement) committee (Executive Director, Medical Director, Director of Nursing Services, and a minimum of three {3} department managers) weekly for four (4) weeks, then bi-weekly for four (4) weeks and monthly for three (3) months. (j). A QAPI Meeting was held to discuss all audit results and corrective actions on [DATE], and again on [DATE], with the Medical Director, Director of Nursing, Assistant Director of Nursing and Executive Director, with no concerns noted. (k). All audit results were reviewed and will continue to be reviewed in monthly QAPI until the Immediate Jeopardy has been abated. (l). The Director of Nursing Services/Assistant Director of Nurses/Medical Records will audit the residents at risk of elopement to determine the following items will be in place. She reviewed: Each resident at risk for elopement has an appropriate intervention. The Care Plan to ensure those at risk were reflected on the comprehensive care plan and Kardex. Each resident was care planned with interventions to monitor their whereabouts with appropriate interventions such as redirecting resident or offering activities. If a Code Alert Bracelet was appropriate, the order was reviewed. This action was completed by the Director of Nursing/Assistant Director of Nursing and Medical Records on [DATE]. (m). An Ad Hoc QAPI [Quality Assurance/Performance Improvement] meeting was held with the Executive Director, Director of Nursing, Social Services and Assistant Director of Nursing and Medical Director to review the incident, action plan, and findings. This action was completed by the Executive Director on [DATE]. (n). All audits will be forwarded to the Executive Director after completion of the audits for review by the Center's QAPI committee (Executive Director, Medical Director, Director of Nursing Services, and a minimum of three {3} department managers) weekly for four (4) weeks and then bi-weekly for four (4) weeks and monthly x three (3) months. (o). A QAPI Meeting was held on [DATE] to discuss all audit results and corrective actions with the Medical Director, Director of Nursing, Assistant Director of Nursing and Executive Director, with no concerns noted. (p). All audits will be forwarded to the Executive Director for review by the Center's QAPI committee (Executive Director, Medical Director, Director of Nursing Services, and a minimum of 3 department managers) monthly at a minimum of 3 months to ensure that solutions were sustained, beginning [DATE] and ongoing. (q). QA meetings will continue once a week for four (4) weeks and then will occur bi-weekly for four (4) weeks and monthly thereafter. The State Survey Agency (SSA) verified the facility implemented the following corrective actions with the removal of the Immediate Jeopardy on [DATE]: 1(a). On [DATE], after Resident #20 was returned to the facility, a wander/elopement assessment was completed for him/her and all other others that wandered. This was completed the night of [DATE] by Social Services and Medical Records. Resident #20's care plan was updated on [DATE], after the resident's elopement on [DATE]. Resident #20 was discharged on [DATE]. (b). Review of Resident #20's MDS, dated [DATE], revealed the resident was a wander risk and had a wander guard in place. No changes were made to the resident's MDS after the elopement on [DATE]. (c). During a follow up interview with Resident #20's State appointed Guardian, on [DATE] at 9:31 AM, he stated the facility notified him of the resident exiting the facility and being found in the downtown area. He stated he held full guardianship over Resident #20 which included, medical, financial, and legal decision making. He stated the resident could refuse care, medications, and treatment while in the facility but, he/she could not decide where to live or make any decisions about his/her care or treatment. (d). A Physician's Note, dated [DATE], revealed the resident had a high BIMS' score, was alert and oriented, and could make decisions for himself/herself. However, according to the Court papers the resident had a State Appointed Guardian and could not make his/her decisions. (e). Review of a Body Audit form and documentation of one on one (1:1) supervision revealed Resident #20 was checked for injury upon his/her return to the facility on [DATE]. The facility provided 1:1 supervision for Resident #20, until the resident was discharged and transported to another facility on [DATE] at 6:15 PM. Review of the Record of Inservice, dated [DATE], revealed nursing staff, on the day and night shift on [DATE] were re-educated related to the facility's elopement policies and procedures and participated in an elopement drill. Interviews, with nursing staff on [DATE] and [DATE] revealed once a resident was missing, a Code Silver would be called over the intercom, staff would initiate a head count and a search, and management would be notified. If the resident was not found, the police, the physician, and the resident's representative would be notified, and the search would be expanded into the community. Interviews, with SRNA #11, SRNA #12, and SRNA #13 on [DATE] revealed they were present the night of the elopement. They stated they received training about the facility's policy and procedure regarding resident elopements and participated in an elopement drill the night Resident #20 eloped. LPN #18, the LPN on shift during the elopement, was not able to be reached by telephone and was not present during survey activity as she worked for the facility on an as needed basis. During interviews with the DNS and ED on [DATE] they stated all staff on shift received training and participated in an elopement drill the night Resident #20 eloped, after the resident returned to the facility. They stated no injury was found to the resident. The resident was put on 1:1 supervision. A facility wide audit was completed, and the door alarms were found to be in working order. 2(a). LPN #18, the LPN on Day Shift during the elopement and was not able to be reached by telephone and was not present during survey. (b). Review of the nine (9) residents the facility assessed to be at risk had current elopement assessments completed [DATE]. During interviews with the Medical Records Nurse, SSD, DNS, and ED, on [DATE], they stated elopement risk assessments were completed upon admission and any time a nurse needed to initiate one. Continued interview revealed any time a resident displayed wandering or exit seeking behavior an assessment could be completed. The Medical Records Nurse stated she completed new elopement assessments of all residents on [DATE] after Resident #20 eloped. The SSD stated she reviewed and updated all residents' Care Plans who were an elopement risk. During the Care Plan and Elopement assessment review Resident #45 was identified as an elopement risk and required a wander guard. No other concerns were identified. (c). Review of the Resident Monitoring System logs, revealed no concerns were identified related to the wander guard bracelets or the door alarm systems on [DATE] after Resident #20 eloped. During an interview with the Medical Records Nurse, on [DATE], she stated the wander guard bracelets were checked every shift and after the elopement all the brace [TRUNCATED]

Based on observation, interview, record review, facility document and policy review, it was determined, the facility failed to ensure adequate and necessary supervision was provided for one (1) of five (5) sampled residents reviewed for elopement (Resident #20). Resident #20 eloped from the facility on 01/04/2023, without staff's knowledge and was found approximately 1.6 miles from the facility. Even though the facility's door alarmed when Resident #20 exited, facility staff failed to investigate and determine why the door alarm was sounding or initiate a search outside to ensure no residents had exited the facility without staff's knowledge. The facility failed to identify Resident #20's exiting the facility as an actual elopement due to the resident's intact cognition, and therefore, no investigation was conducted and documented. Staff had not been trained regarding what to do when there was no identified reason for a door alarm sounding. At the time of the Survey, there were nine (9) residents identified as at risk for elopement residing in the facility. The facility's failure to ensure adequate supervision and necessary monitoring were provided for residents with behaviors of wandering, who were at risk for elopement, has caused or is likely to cause serious injury, serious harm or death to residents in the facility. Immediate Jeopardy was identified on 01/23/2023 and determined to exist on 01/04/2023 in the areas of 42 CFR 483.25 Quality of Care, F689; and 42 CFR 483.21 Comprehensive Centered Care Plans, F656 both at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy on 01/23/2023. The facility provided an acceptable Immediate Jeopardy Removal Plan on 01/25/2023, alleging removal of the Immediate Jeopardy on 01/25/2023. The State Survey Agency validated the facility's IJ Removal Plan and found the facility removed the immediacy on 01/25/2023, as alleged, prior to exit on 01/25/2023. The facility remains out of compliance in the area of 42 CFR 483.25 Quality of Care, F689, at a Scope and Severity (S/S) of D while the facility developed and implemented a Plan of Correction and monitored for the effectiveness of the systemic changes. In addition, the facility failed to provide adequate supervision of residents using smokeless tobacco for two (2) sampled residents, Resident #7 and Resident #15, who used smokeless tobacco, Resident #7 and Resident #15. The facility failed to assess Resident #15 and Resident #7 for their ability to safely use smokeless (chewing) tobacco. In addition, the facility failed to ensure the smokeless tobacco was stored in a secure location and the use, storage, and necessary monitoring related to the tobacco use was addressed on the care plans for Resident #15 and Resident #7. The findings include: 1. Review of the facility's policy titled, Elopements and Wandering Residents, dated October 2022, revealed the facility ensured residents who exhibited the behavior of wandering and/or were at risk for elopement received adequate supervision to prevent accidents, and received care in accordance with their person-centered plan of care addressing the unique factors contributing to the wandering or elopement risk. Review of the policy revealed the facility was to monitor and manage residents at risk for elopement or unsafe wandering through evaluation and analysis of hazards and risks, implementing interventions to reduce the hazards and risks, and monitoring for the effectiveness and modify interventions when necessary. Continued review revealed residents were to be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. Review further revealed the interdisciplinary team (IDT) was to evaluate the unique factors contributing to residents' risk in order to develop a person-centered care plan, and interventions to increase staffs' awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards were to be added to the resident's care plan and communicated to appropriate staff. Further review revealed adequate supervision was to be provided to help prevent accidents or elopements. Review of an Inservice sheet and In-Service Attendance Record: Signature Sheet, dated 11/23/2022 at 2:00 PM, revealed twenty-nine (29) employees attended a training that covered multiple topics which included elopement. Review of Resident #20's Admission Record, revealed the facility admitted the resident on 09/16/2022 with diagnoses that included Vascular Dementia with behavioral disturbance, Major Depressive Disorder, and Cognitive Communication Deficit. Review of Resident #20's medical record revealed a Disability Judgment, notarized on 08/23/2022, which noted the resident had been judged to be wholly disabled in managing both his/her financial and personal affairs, and a guardian and a conservator were to be appointed. Continued review of the record revealed an Order of Appointed Guardian, notarized on 08/23/2022, which noted a State Agency had been appointed as Resident #20's guardian. Per review of the order, the guardian's powers and duties included determining the resident's living arrangements, and consenting to medical procedures, with an expiration date of the ruling as indefinite. Review of the Social Service Progress Review for MDS Documentation, dated 09/17/2022 and signed 09/23/2022, revealed the facility identified Resident #20 as displaying wandering behaviors and refusing care on one (1) to three (3) days during the assessment period. Continued review revealed Resident #20 had been looking for exits within the facility, and the resident had a Wander-Guard alarm (a device worn to alert staff when a resident was in close proximity to an exit door equipped with a Wander-Guard sensor) placed for his/her safety. Further review revealed Resident #20 was noted to have a diagnosis of Dementia and wanted to go home. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/21/2022, revealed the facility assessed Resident #20 as having a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed Resident #20 to have rejected care and noted he/she wandered on one (1) to three (3) days during the seven (7) day assessment period. The MDS review further revealed the facility assessed Resident #20 to require supervision with locomotion and ambulation and to use a wander/elopement alarm daily. Review of the Wandering/Elopement Risk Scale document, dated 12/20/2022, revealed the facility assessed Resident #20: at high risk to wander; ambulatory; able to follow directions; able to communicate; to have a history of wandering; and diagnoses of Dementia and cognitive impairment. Review of Resident #20's Care Plan, dated 09/22/2022, revealed the facility care planned the resident as an elopement risk due to disorientation to place and impaired safety awareness. Continued review revealed the interventions included observing Resident #20 for unmet needs when wandering/exit seeking; placing the resident's profile in the elopement book; providing structured activities; redirecting the resident when exit seeking or wandering and checking the placement and function of the resident's wander alert bracelet. Further review revealed however, the facility had not addressed Resident #20's need for monitoring and supervision of the resident to prevent elopement. Review of an Order Summary Report for Resident #20 revealed a Physician's Order, dated 09/17/2022, for a Wander-Guard bracelet to be placed on the resident's right ankle. Continued review revealed the order included to check the functioning and placement of the Wander-Guard every shift. Interview, on 01/11/2023 at 1:39 PM, with an anonymous complainant, who called the facility requesting to speak with the State Survey Agency (SSA) Surveyor, who was on site for the Recertification Survey, revealed Resident #20 had eloped from the facility and had gotten six (6) miles away from the facility. They stated the resident was caught smoking in his/her room the day before the elopement. The Anonymous Complainant stated the elopement was not reported as required. Review of the Progress Notes for Resident #20 for dates from 12/20/2022 through 01/05/2023, revealed no documented evidence of the resident having eloped from the facility. Additional review of Resident #20's Care Plan revealed a revision, dated 01/04/2023, which noted the resident exhibited behavioral symptoms of refusal to shower, to take medication, to allow staff to change linens, and to be weighed. Continued review of Resident #20's Care Plan revealed the resident exhibited signs of cognitive impairment related to the diagnosis of Dementia, and exhibited a psychosocial well-being problem related to ineffective coping skills. Review of the Wandering/Elopement Risk Scale, dated 01/04/2023, revealed the facility assessed Resident #20 as a high wander risk who: had a history of wandering; could follow directions; was ambulatory; could communicate; and had diagnoses of Dementia and cognitive impairment. Review of the facility's, Record of Inservice, dated 01/04/2023 at 11:30 PM, revealed staff had received training on elopement. Continued review revealed the training on elopement included an elopement drill and review of the facility's policy. Further review revealed the Record of Inservice listed twenty-two (22) staff as having attended the training. Observation of five (5) residents' rooms, on 01/11/2023 at 2:11 PM, on the hallway where Resident #20 previously resided, revealed the outside window frame of Resident #20's former room had a screw inserted to prevent the window from opening. Continued observation revealed the window screen was present, and no screw was located on the inside of the window of Resident #20's former room. Observation revealed however, a hole was observed in the window frame, two (2) to three (3) inches from the sliding window panel. Per observation, Resident #20's former room was on ground level, and the sidewalk outside the window was approximately three (3) feet below the window ledge. Observation of the other four (4) rooms revealed each window had a screw on the inside window frame, allowing the window to be opened two (2) to three (3) inches. Telephonic (Phone) interview with Resident #20's Emergency Contact #2, on 01/11/2023 at 4:20 PM, revealed Emergency Contact #2 had no knowledge of Resident #20 having eloped from the facility. Continued interview revealed Emergency Contact #2 had sought State guardianship due to Resident #20's elopement behaviors when residing in the Emergency Contact's home. Per interview, the Emergency Contact was unable to provide the level of supervision Resident #20 needed for his/her safety. Further interview revealed the facility had not made Emergency Contact #2 aware of any exit seeking or wandering behaviors by Resident #20 while he/she had been residing there. Interview with the Director of Nursing Services (DNS) on 01/11/2023 at 4:42 PM, revealed the facility had no elopements in the past six (6) months. Telephone interview with the Ombudsman, on 01/12/2023 at 10:15 AM, revealed she had not been notified of any resident elopements from the facility. She stated the nursing staff guarded the doors pretty well. Per the Ombudsman, on her last visit to the facility on [DATE], she knew the code for the exit doors. Further interview revealed however, when she visited the facility again on 01/10/2023, the code to the exit doors had been changed, and the nurse told her they would have to let her out of the facility. Interview with Resident #20's State Appointed Guardian, on 01/12/2023 at 11:02 AM, revealed the Guardian had no knowledge of the resident eloping from the facility. Further interview revealed the Guardian had been in the facility the previous week (week of 01/01/2023) to check on Resident #20's billing matters, and had no concerns at the time of that visit. Telephone interview with Licensed Practical Nurse (LPN) #5 on 01/12/2023 at 12:04 PM, revealed Resident #20 had eloped from the facility one (1) day the previous week (week of 01/01/2023 through 01/07/2023). Per LPN #5, Resident #20 had eloped on either 01/03/2023 (Tuesday) or 01/04/2023 (Wednesday). She stated the only thing she was told by LPN #17 (the nurse on duty at the time of the incident) was that Resident #20 had been spotted walking down Main Street by a couple of the facility's State Registered Nurse Aides (SRNA), as they were coming in to work their shift. Continued interview revealed LPN #5 had been told different things from different staff as to how Resident #20 exited the facility; first it was through a window, and then she was told the resident exited through the front door. According to the LPN, she had been told no injuries were sustained by Resident #20 during the time he/she was out of the facility. She stated Resident #20 was identified as a wander/elopement risk from the wandering assessment and had a Wander-Guard in place. Further interview revealed LPN #5 had not been at work when Resident #20 eloped. She stated when she reported to work for her shift the day after the elopement occurred, the resident had one-to-one (1:1) staff supervision until he/she was discharged from the facility. LPN #5 stated she was not provided the reason for the facility discharging Resident #20. Telephone interview was attempted with LPN #17 on 01/12/2023 at 7:20 PM; however, this was unsuccessful. A voicemail was left and no return call received. Interview with Maintenance #1, on 01/11/2023 at 3:58 PM, revealed Maintenance #1 stated a window audit had been requested through the facility's TELS system (a computerized system to communicate maintenance concerns). Maintenance #1 stated the TELS system which was used for all work orders and requests for maintenance services. Per Maintenance #1, he completed the window audit when it was requested and found no concerns with the windows, screens, or screws in the window frames that restricted the window opening further than three (3) inches. According to Maintenance #1, the screws had been in the window frames ever since he started his employment at the facility in September 2022. Maintenance #1 stated no concerns of a resident being able to remove the screws had been brought to his attention. Continued interview revealed Maintenance #1 stated a few of the facility's windows had been sealed completely by the former Maintenance Director, but he did not know why. Maintenance #1 stated he checked the Wander-Guard sensors and doors weekly and had no concerns regarding the functioning of the system. Maintenance #1 further stated he knew Resident #20 and that the resident had been discharged from the facility, but he did not know why. Review of the facility's, Resident Monitoring System logs, dated 11/15/2022, 11/21/2022, 11/28/2022, 12/09/2022, 12/14/2022, 12/23/2022, 12/28/2022, and 01/04/2023, revealed inspections had been completed to check the operation of the door monitors and the patient wandering system (Wander-Guard system). Continued review of the logs, revealed the system had passed all the inspections. Further review of the logs revealed the locations checked included the ambulance (front) entrance, downstairs elevator, downstairs exit, downstairs stairwell, upstairs elevator, upstairs stairwell, and workers' entrance. Interview, with LPN #10 on 01/12/2023 at 1:49 PM, revealed she had worked at the facility for three (3) years. She stated Resident #20 had been a wanderer and elopement risk, when he/she came from the previous facility with those behaviors documented. Per LPN #10, Resident #20 had eloped from the facility during the month of January 2023; however, she was not sure of the specific date and had not working at the time of the incident. She stated the facility was not sure how Resident #20 got out. LPN #10 stated the resident had been discharged when she returned to work again. Further interview revealed Resident #20 had not had previous elopement attempts, and she had never witnessed the resident lingering near the doors. Interview, with SRNA #8 on 01/12/2023 at 3:05 PM, revealed Resident #20 was no longer residing in the facility and had been discharged elsewhere after an elopement a couple of weeks ago. She stated Resident #20 had been found five (5) or six (6) miles away from the facility. Per SRNA #8, she had been told Resident #20 left the facility either through a door or a window; however, no one was sure. Continued interview revealed SRNA #8 had not been working when Resident #20 eloped from the facility, but heard the resident was found at a pizza restaurant on the outskirts of town. She further stated staff coming in to work for the night shift had called the facility to check on whether Resident #20 had been discharged because they had seen the resident walking along the road. Review of map directions revealed the distance from the facility to the pizza restaurant was 1.6 miles from the facility. Review of the route from the facility to the pizza restaurant included a road that had several steep hills and sharp curves. Telephone interview was attempted with Resident #20 on 01/12/2023 at 3:35 PM; however, this was unsuccessful. A voicemail was left the resident, with no return call received. Interview with SRNA #11, on 01/13/2023 at 10:45 AM, revealed she had worked at the facility for five (5) years. She stated she knew Resident #20 was an elopement/wander risk and that he/she had successfully eloped from the facility. Per SRNA #11, she had been working another area of the facility the day of the elopement, which was on either 01/04/2023 or 01/05/2023. She stated around 6:35 PM to 6:40 PM, the day of Resident #20's elopement, a night shift worker reported for night shift, and told the day shift staff they had seen Resident #20 walking the streets on their way to the facility. Continued interview revealed SRNA #11 stated staff searched for Resident #20 and contacted the DNS and Executive Director (ED). She stated two (2) SRNAs left the facility to go retrieve Resident #20, and after the resident was returned to the facility, he/she was shown to his/her room, where vital signs were taken, and no injuries were found. According to SRNA #11, Resident #20 was then to 1:1 supervision by a staff member. Interview revealed she had been told Resident #20 eloped through a door; however, no one was 100% sure how the resident eloped. She stated Resident #20 remained in the facility the night of the elopement and the following day until around 6:00 PM, when the resident was discharged and transferred to a different facility. SRNA #11 revealed Resident #20 had a Wander-Guard alarm bracelet in place the day of his/her elopement and it had been working to her knowledge. Further interview revealed if a door alarm was triggered the evening of the elopement, she did not hear it sounding, nor had she heard any door alarms go off that day. She further stated she had not observed/witnessed Resident #20 lingering at the doors the evening of his/her elopement. Telephone interview was attempted with LPN #18 on 01/13/2023 at 2:15 PM; however, the phone rang for three (3) minutes with no answer, and there was no option to leave a voicemail. Interview with SRNA #12, on 01/13/2023 at 11:32 AM, revealed she had worked at the facility since December 2008. She stated, I reckon Resident #20 did successfully elope. Per SRNA #12, she had been working in the lobby area by the front entrance around supper time, the day of Resident #20's elopement, picking up trays after residents had finished eating. She stated she saw a group of staff gathered at the nurse's station and could tell something was wrong. Continued interview revealed she went to ask what was wrong and was informed Resident #20 was gone and could not be found. She stated staff started a search for Resident #20 after the nurse received a call from a night shift staff member coming to work stating they saw Resident #20 walking downtown as they made their way in to work. SRNA #12 stated she did not recall the exact day of Resident #20's elopement; however, she knew it was within the last two (2) weeks on a weekday. She stated she had a family member waiting to pick her up from work in the facility's parking lot, and had asked her family member if they had seen a resident in a plaid shirt walk by the vehicle. Per SRNA #12, her family member confirmed seeing such a person and told her the person had been carrying a bag. Interview revealed SRNA #12's family member stated the person had walked up the facility driveway from the parking lot on the side of the facility, and onto the road heading towards the hospital. According to SRNA #12, her family member told her it was still daylight when they witnessed the resident walking by their car. She stated SRNA #13 and another SRNA left the facility to search for Resident #20 in town, and she recalled hearing the resident was found by a pizza restaurant. Further interview revealed SRNA #12 denied having heard any door alarms sounding the evening Resident #20 eloped, until she opened the front door to speak to her family member who had been waiting in the parking lot. The SRNA stated Resident #20 had to have planned his/her escape because he/she had a bag packed. Interview, with SRNA #13 on 01/13/2023 at 12:26 PM, revealed she had worked at the facility since April 2022. SRNA #13 stated on 01/04/2023 around 6:40 PM, a night shift SRNA showed up early for work and frantically asked her if Resident #20 had left the facility, and she told the other SRNA No. Per SRNA #13, the night shift SRNA then told her they had seen Resident #20 on the street. According to SRNA #13, she and the night shift SRNA then went to Resident #20's room and the resident was not there. She stated a night shift nurse came in to work and also reported seeing Resident #20 in town. Continued interview revealed she and the night shift SRNA left the facility to drive into town and search for Resident #20. Per interview, they found Resident #20 at a karate studio next to the pizza restaurant. The SRNA stated Resident #20 had a blue bag packed with him/her and told the SRNAs he/she was going to Interstate 75 (I-75) to hitchhike. She stated she offered Resident #20 a ride, and the resident accepted it and Resident #20 was taken back to the facility. Interview revealed Resident #20 had been a little upset upon being returned to the facility and told staff he/she thought he/she was going to I-75. She stated she did not know how Resident #20 got out of the facility; however, she recalled the resident had been moved to a different room the day before the elopement which had been at ground level with a window that opened a couple of inches. SRNA #13 revealed she and another staff member went into Resident #20's room to check the window, and the screw was missing from the window which allowed the window to open all the way. She stated the window screen was also missing when she observed the window, and she was pretty sure the screen had been in place before Resident #20 eloped. Further interview revealed however, a screen had not been found outside the facility, so it could have already been missing when Resident #20 moved into that room. According to SRNA #13, since Resident #20's admission, the resident had not wanted to be there at the facility, and would beg his/her family to take him/her out of the facility. She further stated the door alarms at the front of the facility went off anytime those doors were opened, even if the code was entered; however, she had not heard alarms sounding the evening of Resident #20's elopement. In addition, she stated Resident #20 was discharged before the end of her shift the day after the elopement. Interview with the Medical Records Nurse, on 01/13/2023 at 2:38 PM, revealed she had worked at the facility for almost thirteen (13) years. She stated Resident #20 had eloped from the facility the previous week and was transferred to another facility a day or two (2) after the elopement. Continued interview revealed she received a call at home about Resident #20's elopement, and by the time she made it to the facility, the resident had been returned. Per the Medical Records Nurse, facility management started trying to make sense of what happened to see if something needed to be done at the facility. She stated she completed an elopement assessment of Resident #20 upon admission and after the elopement when he/she returned to the facility. Further interview revealed facility staff thought Resident #20 eloped through the facility's front door. The Medical Records Nurse further stated Resident #20 had been moved to a new room prior to the elopement because he/she had not been compatible with his/her roommate. In addition, she stated Resident #20's new room had been closer to the nurse's station so the resident could be observed more closely by staff. Interview, with the ED and DNS on 01/13/2023 at 4:29 PM, revealed the facility had no elopements in the past six (6) months. Per the ED, she had not considered Resident #20's exit from the facility to be an elopement. She stated an elopement was when a resident exited the facility without intent or purpose and did not have the ability to make the decision to go. The ED stated she considered Resident #20's elopement a leave of absence violation because he/she wanted to leave, had been alert and oriented, and knew what he/she was doing. Interview revealed Resident #20 had been alert and oriented, and had known his/her rights as a resident and chose to leave without informing staff, even though the resident had been asked to inform the facility before leaving. However, she acknowledged Resident #20 was not his/her own responsible party and had a State Appointed Guardian. Continued interview revealed the ED stated Resident #20 had a right to go outside. The ED stated the investigation had not determined how Resident #20 got out, and none of the staff recalled if an alarm had sounded. According to the ED, Resident #20 had been able to read and had known the front door would open if held for fifteen (15) seconds. The ED stated Resident #20 had been smart enough to watch and get the door code as people left. Interview revealed the ED stated she did not know if the door alarms had failed to sound when Resident #20 eloped, so a Wander Guard sensor check had been completed, and everything was found to be in working order. She stated the screen in Resident #20's new room had been reported as missing after a storm which preceded the resident's elopement. Per the ED, the ledge of the window in Resident #20's new room was high off the ground, and it was unlikely the resident exited through the window without sustaining a scratch or injury. Further interview revealed Resident #20 told her that he/she had eloped out of the front door. The ED stated she had no reason to believe the resident had been lying. Interview revealed the facility had no documentation of the investigation that was completed because Resident #20 leaving the facility had not been considered an elopement. Follow-up interview with Resident #20's State-Appointed Guardian, on 01/17/2023 at 9:31 AM, revealed the guardian held full guardianship over Resident #20, which included medical, financial, and legal decision making. Per interview, Resident #20 could not decide where to live or make any decisions about his/her care or treatment. The Guardian stated Resident #20 was now residing in a State Psychiatric hospital. Further interview revealed Resident #20 had the cognitive ability to fabricate a story to meet his/her wants and needs. In addition, the Guardian denied Resident #20 had a Wander-Guard during his/her stay at the facility and denied being notified regarding the resident had a violation of leave. Review of an encrypted email sent from the DNS to the Surveyor on 01/18/2023 at 6:43 PM, revealed the DNS noted Resident #20 had been alert and oriented and exited the facility with the intent to go outside to smoke and walk around. Per review of the email, Resident #20 had a BIMS score of fourteen (14) and made the decision on his/her own to exit the facility without signing out or notifying staff. According to the email, the resident's primary Physician stated Resident #20 had been alert and oriented and capable of making his/her own decisions. Review of the email revealed Resident #20 failed to alert staff he/she was exiting the facility which resulted in a failure to follow the facility's leave of absence policy. Continued review of the email revealed Resident #20 had been fully mentally and physically capable of exiting the facility, without supervision and competent to make decisions inside and outside the facility. Review of the email revealed Guardianship allowed Resident #20 to vote, and he/she would have to be competent to vote. The email review revealed Guardianship gave permission for medical procedures; however, did not state that Resident #20 could not go outside if he/she chooses. Further review of the email revealed Resident #20 had intent and wanted to leave the facility and could easily have exited the door by entering the code by figuring out the pattern by watching staff or family. In addition, review further revealed Resident #20 had been alert and oriented and had a right to exit the building, and the email was signed by the ED. Telephone interview with the DNS on 01/18/2023 at 1:42 PM, revealed no formal investigation of Resident #20's exiting the facility had been found, it had been scribbled onto various notes, and that was why the ED wrote the email she sent to the Surveyor. The DNS stated the facility investigated all avenues of possible exit by Resident #20, and as the resident had been alert and oriented and showed facility staff which door he/she went out of, which was the front door. Continued interview revealed the SRNAs told management the front door alarm went off the day of the incident, and they had seen a staff member reset the code; however, the DNS had not been able to identify which staff member reset the door code. She stated the door alarm to the front door went off and no reason for the alarm was found at that time. Per the DNS, Resident #20 had a Wander-Guard at the time the resident exited the facility; however, it would not have set the alarm off on that door. She stated the front door alarm triggered any time the door was opened, whether a code was entered or not. Interview revealed the DNS did not know if the Medical Director (MD) could overrule the State Guardianship's parameters, but the Medical Director had assessed Resident #20 as alert and oriented and last saw the resident on either 01/01/2023 or at the end of November 2022. According to the DNS, if a resident with a Wander-Guard got close to a sensor on the other doors, the alarm started beeping, and if someone without a Wander-Guard went out the front door, it sounded the loud alarm. She stated she understood a Guardian had been appointed to make Resident #20's decisions after an acute illness and hospitalization , as the resident had not been capable of making decisions at that time. Further interview revealed if Resident #20 had remained residing in the facility, they would have petitioned for the resident to regain his/her decision-making rights to be his/her own responsible party. Interview with the ED on 01/24/2023 at 10:22 AM and at 11:02 AM, revealed Resident #20 and his/her family had requested the resident reside closer to family, therefore, the facility had transferred him/her to be closer to his/her family. She stated she had no knowledge that Resident #20 had a history of elopement prior to his/her admission. Further interview revealed Resident #20's family had shared nothing with her about the resident having a history of wandering or elopement. However, interview with the Social Worker (SW), on 01/24/2023 at 12:04 PM, revealed Resident #2 [TRUNCATED]

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the resident and the resident's representative in writing of a transfer to the hospital and provide a copy of the written notice to the Long-Term Care (LTC) Ombudsman for one (1) of one sampled residents reviewed for hospitalization (Resident #45). The findings include: Review of the facility's policy titled, Discharge Plan and Notice of Transfer, dated 07/2018, revealed the Notice of Transfer or Discharge and Ombudsman Notification for facility-initiated transfers or discharges of a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand. Additionally, the facility must send a copy of the notice of transfer or discharge to the State LTC (Long Term Care) Ombudsman. Continued review revealed the medical record of a resident being transferred or discharged must contain evidence that the notice was sent to the LTC Ombudsman. Per review of the policy, Emergency Transfers, when a resident was temporarily transferred on an emergency basis to an acute care facility, this was considered a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable. The policy further revealed Copies of notices for emergency transfers must also still be sent to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. Review of Resident #45's Admission Record revealed the facility admitted the resident with diagnoses that included Dementia with Behavioral Disturbance and COVID-19. Further review of the Admission Record revealed Resident #45 had a Responsible Party - Guardian noted with contact information listed. Review of Resident #45's Progress Notes revealed the facility transferred the resident to the hospital via emergency medical services (EMS) on 11/25/2022 at 6:49 PM. However, review of Resident #45's electronic health record (EHR) revealed no documented evidence that a written notice was provided to the resident or his/her representative regarding the resident's transfer to the hospital. Interview, on 01/10/2023 at 10:14 AM, with the District (LTC) Ombudsman revealed the facility had not notified her when a resident was transferred or discharged from the facility. She stated the only notification she had received from the facility was related to an involuntary discharge of a resident. Further interview revealed the LTC facilities within the State were required to notify the State Ombudsman when a resident was transferred or discharged , and the State Ombudsman then forwarded the information to the District Ombudsman. Interview, on 01/12/2023 at 11:15 AM, with Licensed Practical Nurse (LPN) #5 revealed when a resident was transferred to the hospital, the family and/or guardian were notified via telephone only, not through written documentation. LPN #5 further stated she was not aware of any letter that was sent to the resident's representative regarding a transfer. Interview, on 01/12/2023 at 12:51 PM, with LPN #9 revealed when a resident was transferred to the hospital, the facility notified the resident's family via telephone. The LPN stated the facility did not notify the resident's representative in writing. Further interview revealed LPN #9 did not know how to go about sending such a letter. Interview, on 01/13/2023 at 3:59 PM, with the Director of Nursing Services (DNS) revealed when a resident was transferred to the hospital, the facility notified the responsibility party who was listed on the resident's Admission Record via telephone. The DNS stated if the responsible party was in the facility, the facility verbally informed a resident's responsible party of the transfer. Further interview with the DNS revealed the facility had not ever notified the responsible party or the Ombudsman in writing of a resident's transfer. Interview, on 01/13/2023 at 5:42 PM, with the Executive Director (ED) revealed when a resident was transferred to the hospital, if the resident had a responsible party the facility notified the responsibly party. The ED stated the responsible party was either notified via telephone or, if they were in the facility, they notified the responsible party verbally. Further interview revealed the ED stated she did not think the facility ever notified the Ombudsman of transfers.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide written information regarding the facility's bed-hold policy to a resident and their representative when the resident was transferred to the hospital for one (1) of one (1) residents sampled for hospitalization (Resident #45). The findings include: Review of the facility's policy titled, Discharge Plan and Notice of Transfer, dated 07/2018, revealed emergency transfers, when a resident was temporarily transferred on an emergency basis to an acute care facility, was considered to be a facility-initiated transfer. Further review revealed for emergency transfers a notice of transfer must be provided to the resident and the resident's representative as soon as practicable. Review of the policy further revealed a copy of the facility's Bed Hold Policy was also to be provided. Review of the medical record for Resident #45 revealed the facility admitted the resident with diagnoses which included COVID-19 and Dementia with Behavioral Disturbance. Continued review revealed Resident #45 had a responsible party noted and the contact information was listed for the responsible party. Review of Resident #45's Progress Notes revealed on 11/25/2022 at 6:49 PM, the resident was transferred to the hospital via emergency medical services (EMS). Further review of Resident #45's medical record revealed no documented evidence the facility provided the resident and his/her representative with written information of the facility's bed-hold policy before or at the time of Resident #45's transfer to the hospital. Interview, on 01/12/2023 at 12:51 PM, with Licensed Practical Nurse (LPN) #9 revealed the facility had not provided a copy of the facility's bed hold policy to the resident and/or resident representative when the resident was transferred to the hospital. Interview, on 01/13/2023 at 3:59 PM, with the Director of Nursing Services (DNS) revealed the Business Office Manager sent the resident's representative a bed hold letter when a resident was transferred to the hospital. Interview, on 01/13/2023 at 5:21 PM, with the BOM revealed she only went over the bed hold policy with a resident and their representatives upon the resident's admission to the facility. Further interview revealed she did not send out a copy of the policy to a resident and/or his/her representative when a resident was transferred to the hospital. Interview, on 01/13/2023 at 5:42 PM, with the Executive Director (ED) revealed when a resident was transferred to the hospital, the facility did not provide a copy of the bed hold policy to the resident and/or resident representative.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure staff changed their gloves that were contaminated during incontinent and wound care for one (1) of three (3) sampled resident reviewed for pressure ulcers (Resident #13). Additionally, the facility failed to ensure wound care supplies were not contaminated to reduce the risk of infection for Resident #13. The findings include: Review of the facility's policy titled, Clean Dressing Change, undated, revealed the policy did not indicate what staff should do if their gloves or wound care supplies became contaminated during a dressing change. Review of Resident #13's medical record revealed the facility admitted the resident with diagnoses that included Parkinson's Disease, Dementia, Polyosteoarthritis (arthritis in multiple joints), and palliative care (care given to improve quality of life for individuals with a serious or life-threatening disease). Review of the Annual Minimum Data Set (MDS) Assessment, dated 12/13/2022, revealed the facility assessed Resident #13 as severely cognitively impaired, and required extensive assistance for bed mobility and personal hygiene. Further review of the MDS Assessment revealed the facility assessed Resident #13 to be at risk for pressure ulcer/injury; to have one (1) unstageable pressure ulcer, and skin tear(s); and moisture associated skin damage (MASD). Review of Resident #13's care plan, dated 01/11/2023, revealed the facility care planned the resident as at risk for impaired skin integrity. Continued review of the care plan revealed on 12/06/2022, it was revised to include Resident #13 having a skin tear and MASD to his/her gluteal fold and an unstageable pressure wound to the coccyx. Further review revealed the interventions included to complete Resident #13's treatments as ordered, observe his/her skin daily, and notify the nurse of any changes. Review of the Order Summary Report for Resident #13 revealed a Physician's Order to cleanse the MASD to the resident's left gluteal fold with wound cleanser, apply hydrogel gauze, and cover with a bordered gauze daily and as needed. Observation, on 01/11/2023 at 11:52 AM, revealed the Assistant Director of Nursing Services (ADNS) and State Registered Nurse Aide (SRNA) #19 provided wound care for Resident #13. Observation revealed the ADNS and SRNA #19 both washed their hands and donned (put on) gloves prior to providing the wound care for Resident #13. Continued observation revealed SRNA #19 removed pillows from underneath Resident #13's legs and rolled the resident over onto his/her left side, with a small amount of light brown feces observed around the resident's anus. Per observation, no dressing was in place to the MASD area. Interview with the ADNS, at the time of he observation, revealed she had completed a dressing change for the area on Resident #13 yesterday, (01/10/2023) and stated sometimes the dressing fell off when staff provided care. Observation revealed the ADNS, using gauze and wound cleanser, removed the feces from the resident's anal skin, changed her gloves, then measured the wound to Resident #13's left buttock. The ADNS was observed to apply Hydrogel to a gauze and place the gauze on the wound bed of Resident #13's wound area. Continued observation revealed Resident #13 started having a bowel movement, and feces got on the gauze the ADNS had just covered the wound bed with. Further observation revealed the ADNS removed the gauze, changed her gloves, and checked Resident #13's room for perineal wipes to cleanse the bowel movement from the resident. Additional observation revealed while searching for perineal wipes the ADNS hit the overbed table that contained the wound care supplies, causing the wound cleanser bottle and the Hydrogel bottle to fall to the floor. Continued observation revealed at 11:58 AM, the ADNS removed her gloves, sanitized her hands, and left the room to get obtain perineal wipes. Observation revealed at 12:01 PM, the ADNS returned to the room with the perineal wipes and fresh gauze, and again donned gloves and cleaned the bowel movement off of Resident #13's skin. The ADNS was observed to apply a clean incontinence pad underneath Resident #13, while wearing the same gloves. She was then observed to change her gloves and pick up the uncapped Hydrogel bottle and the wound cleanser bottle up off the floor. Observation revealed without cleansing the wound cleanser bottle or Hydrogel bottle or getting new bottles from the treatment cart, she again applied Hydrogel to a gauze and applied the gauze to the resident's wound, and then applied a bordered dressing. Further observation at 12:10 PM, revealed after completing the treatment, the ADNS noticed a new, reddened area on Resident #13's leg, measured the area, then cleansed the wound cleanser bottle and hydrogel bottle with wipes. Interview at 12:19 PM with the ADNS revealed she acknowledged knocking the wound treatment supplies off the overbed table onto the floor and stated she should have gotten all new stuff. Continued interview revealed the ADNS stated she should have cleansed the Hydrogel bottle after she picked it up off the floor. The ADNS further stated she should have changed her gloves when performing incontinent care and before changing the resident's brief. Interview, on 01/13/2023 at 3:59 PM, with the Director of Nursing Services (DNS) revealed staff should always change their gloves when going from dirty to clean tasks. She stated if wound supplies fell to the floor, the staff should dispose of those supplies, unless it was something that could be cleaned, such as wound cleanser bottle or scissors. Interview, on 01/13/2023 at 5:42 PM, with the Executive Director (ED) revealed staff should always change their gloves when the gloves got dirty or were potentially contaminated. The ED stated if treatment supplies fell to the floor, staff should pick them up and cleanse them, depending on the treatment. She further stated if the item was something like an open Band-Aid, staff should get a new Band-Aid.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to implement the comprehensive care plan for one (1) of thirteen (13) sampled residents. The facility had identified Resident #6 as being at high risk for falls and had developed a care plan addressing falls. The care plan included an intervention, dated 01/20/2020, which stated to keep the resident's pathways in his/her room decluttered as the resident will allow. An intervention dated 10/24/2019 also stated to keep pathways clear and well lit. However, observations of the resident's room on 01/29/2020 and 01/30/2020 revealed the floor fan positioned directly on the right side of the bed with the electrical cord plugged into the opposite wall. The cord was stretched across the room, approximately three (3) feet off the floor, in front of the resident's recliner. The findings include: Review of the facility policy, Falls, dated (MONTH) (YEAR), revealed the purpose of the policy was to identify risk and establish interventions to mitigate the occurrence of falls. The policy further revealed when a risk factor is identified a corresponding intervention, addressing that risk factor, is developed and the identified intervention is initiated. Observation of Resident #6 on 01/29/2020 at 9:02 AM revealed the resident was lying in bed with his/her head covered with a blanket. Further observation revealed a fan close to the right side of the bed. The observation also revealed the cord to the fan was stretched to the opposite wall, where it was plugged into the outlet and the cord was suspended approximately three (3) feet off the floor. An observation on 01/30/2020 at 9:19 AM, revealed the fan beside the resident's bed with the cord plugged into the opposite wall and the cord suspended across the room, in front of the resident's recliner. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/14/2019, revealed a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident required supervision without staff support for the activities of bed mobility, transfer, and ambulation. Review of Resident #6's progress note's incident note, dated 01/20/2020, revealed an investigation of a fall that occurred on 01/17/2020. The investigation also revealed the resident was ambulating in his/her room and the resident stated he/she tripped over the fan and fell on to the bed. Further review of the note revealed an immediate intervention of de[DIAGNOSES REDACTED] the room, and the staff were to continue to assist the resident with de[DIAGNOSES REDACTED] the room. The investigation also revealed the resident suffered no injury related to the fall. Review of the comprehensive care plan for Resident #6, dated 10/10/2019, revealed the resident was at risk for falls. Further review of the care plan revealed an intervention dated 10/24/2019, which stated to keep pathway clear and well lit and an intervention dated 01/20/2020, which stated to keep resident's pathways in room decluttered as resident will allow. Interview with the Director of Nursing (DON) on 01/30/2020 at 10:18 AM, revealed Resident #6's room did not have clear pathways. The DON stated the facility was trying to find a fan to mount on the wall but due to the time of year they were difficult to find. The DON also stated there was not a safe pathway for the resident to be able to ambulate to the recliner, as the electric cord to the fan was stretched in front of the recliner. Further interview with the DON at 1:56 PM revealed the cord should have been addressed and the pathways in the room were not clear.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure the resident environment remained free of accident hazards for one (1) of thirteen (13) sampled residents (Resident #6). Resident #6 had a history of [REDACTED]. Observations of the resident's room on 01/29/2020 and 01/30/2020 revealed a floor fan positioned directly on the right side of the resident's bed and with the electrical cord plugged into the opposite wall. The cord was stretched across the room, approximately three (3) feet off the floor, in front of the resident's recliner. The findings include: Review of the facility policy, Falls, dated (MONTH) (YEAR), revealed the purpose of the policy was to identify risk and establish interventions to mitigate the occurrence of falls. The policy further revealed when a risk factor is identified a corresponding intervention, addressing that risk factor, is developed and the identified intervention is initiated. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 10/14/2019, revealed a Brief Interview for Mental Status (BIMS) score of six (6), which indicated the resident had severe cognitive impairment. The MDS also revealed the resident required supervision without staff support for the activities of bed mobility, transfer, and ambulation. Review of Resident #6's progress note's incident note, dated 01/20/2020, revealed an investigation of a fall that occurred on 01/17/2020. The investigation also revealed the resident was ambulating in his/her room and the resident stated he/she tripped over the fan and fell on to the bed. Further review of the note revealed an immediate intervention of de[DIAGNOSES REDACTED] the room, and the staff were to continue to assist the resident with de[DIAGNOSES REDACTED] the room. The investigation also revealed the resident suffered no injury related to the fall. Observation of Resident #6 on 01/29/2020 at 9:02 AM, revealed the resident was lying in bed with his/her head covered with a blanket. Further observation revealed a fan close to the right side of the bed. The observation also revealed the cord to the fan was stretched to the opposite wall, where it was plugged into the outlet and the cord was suspended approximately three (3) feet off the floor. An observation on 01/30/2020 at 9:19 AM, revealed the fan beside the resident's bed with the cord plugged into the opposite wall and the cord suspended across the room, in front of the resident's recliner. Interview with Maintenance staff on 01/30/2020 at 2:04 PM, revealed he did not remember anyone telling him about the fan cord in the room of Resident #6. He further stated he had not noticed the cord suspended above the floor stretching across the room prior to this day. Interview with the Director of Nursing (DON) on 01/30/2020 at 1:56 PM, revealed Resident #6 would not often allow the staff to move the fan from the side of the bed. She further stated the facility should have addressed the electrical cord to the fan in the resident's room as it was a hazard. She also stated a cord stretched like that, across a room, would be a hazard in any resident room.

Based on interview, record review, review of the Resident Assessment Instrument (RAI) User's Manual, and review of the facility's policy and investigation, it was determined the facility failed to develop a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). The facility identified that Resident #1 was at risk for wandering and developed interventions that included ensuring the resident was wearing a Code Alert Bracelet (the bracelet triggers an alarm when a resident is near an exit that is equipped with a Code Alert). However, the facility failed to develop a care plan with interventions to address the resident's safety when taking the elevator to the lower level of the facility unsupervised. On 07/05/19 at approximately 11:10 AM, Resident #1 was observed outside of the facility unsupervised. According to the facility's investigation, Resident #1 took the elevator to the lower level of the facility without staff knowledge, then took the stairs back to the upper level and exited the facility through a door in the stairwell. Resident #1 was outside without staff knowledge for approximately ten (10) minutes. The facility's failure to ensure a comprehensive care plan was developed and implemented to address resident wandering has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate jeopardy was identified on 07/18/19, and was determined to exist on 07/05/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 07/18/19. An acceptable Allegation of Compliance was received on 07/29/19, which alleged removal of the Immediate Jeopardy on 07/11/19. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. The State Survey Agency verified the corrective actions were implemented as alleged and it was determined Immediate Jeopardy was removed and deficient practice corrected on 07/11/19, as alleged by the facility. The findings include: Interview with the Administrator on 07/19/19 at 3:15 PM revealed the facility did not have a Care Plan policy, but utilized the Resident Assessment Instrument (RAI) Manual when developing care plans. Review of the RAI Manual revealed when planning care for a resident who wandered, the plan should consider the impact of wandering on resident safety and should be focused on minimizing these issues. Review of the facility's Elopement policy, dated (MONTH) (YEAR), revealed if a newly admitted or readmitted resident was determined to be at risk for elopement, an individualized care plan would be established with interventions to mitigate elopement. The policy stated the interventions would be documented on the resident's care plan and on the caregiver guide. Review of Resident #1's medical record revealed the facility admitted the resident on 11/04/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Clinical Health Status dated 11/04/18 revealed the facility determined the resident was at risk for elopement because he/she was physically able to leave the building and was cognitively impaired, had impaired decision-making skills, had a history of [REDACTED]. According to the assessment, a code alert bracelet was implemented on 11/05/18. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment, required physical assistance of one person with transfers, ambulation, and locomotion on the unit, and required staff supervision while off the unit. In addition, the facility assessed the resident to have unsteady balance during transitions and walking and exhibited wandering behavior daily (Wandering is the act of moving from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to his or her physical or safety needs). Interview with State Registered Nurse Aide (SRNA) #4 on 07/17/19 at 10:15 AM and on 07/18/19 at 9:00 AM revealed Resident #1 was routinely confused and agitated. The SRNA stated that it was not unusual for Resident #1 to go to the basement area to talk to staff. She stated that even though there was no resident supervision on the lower level and the resident was confused, she only monitored Resident #1's whereabouts every two hours, the same as all other facility residents. Interview with Registered Nurse (RN) #1 on 07/17/19 at 2:48 PM revealed it was not uncommon for residents, including Resident #1, to take the elevator to the lower level to go to the beauty shop or to get money from their accounts. Interview with RN #2 on 07/17/19 at 4:15 PM revealed Resident #1 was at risk for elopement because he/she was ambulatory, confused, and wandered daily. RN #2 stated SRNAs were expected to monitor Resident #1 and routinely check on all residents every (2) two hours. According to RN #2, only residents who were alert and oriented routinely went to the facility's basement unsupervised. Review of Resident #1's comprehensive care plan dated 11/04/18, revealed the facility identified that the resident wandered and developed interventions that included a Code Alert Bracelet, observing for mood and behavior issues, attempting to find out what the resident was looking for, and assisting Resident #1 with reorientation to his/her room and the facility, with verbal cues as needed. Further review revealed that although the facility developed an intervention for the resident to receive one-to-one observation and/or hourly monitoring as needed due to exit-seeking behavior, there was no documented evidence that the facility had developed interventions to address the resident's safety regarding taking the elevator unassisted to the lower level of the facility. Review of a Facility Investigation dated 07/05/19 revealed the Activities Director observed Resident #1 outside the front lobby window and assisted the resident back inside the facility. Resident #1 stated, I don't know where I was going or where I have been. According to the investigation, Resident #1 got on the elevator, went to the ground floor, and took the stairs back to the second floor. When the resident came to the top of the stairs, he/she exited the emergency exit door to the outside, rather than taking the door that led to the second floor. Continued review revealed the alarm on the emergency exit door was sounding in the stairwell, but failed to sound inside the facility to alert staff that the door had been opened. Interview with Registered Nurse (RN) #3 on 07/18/19 at 2:50 PM, revealed she assessed Resident #1 on 07/05/19 after the Activities Director assisted the resident inside the facility, and the resident had no injuries. The interview revealed RN #3 was not aware the resident had taken the elevator to the lower level of the facility. Interview with the Administrator on 07/16/19 at 4:45 PM revealed she saw Resident #1 on the lower level with another resident on 07/05/19 at approximately 11:00 AM. However, the interview revealed she did not intervene when she saw the resident. Interview with the Social Services Director on 07/18/19 at 3:10 PM revealed that she completed the MDS assessment section regarding wandering and was responsible for developing care plans with interventions to address wandering. She stated she was aware Resident #1 wandered, but was not aware the resident wandered off the unit, and had not developed any interventions to address this behavior. **The facility alleged the following actions were implemented to correct deficient practice on 07/11/19: 1. On 07/05/19, Resident #1 was assessed for injury by the Assistant Director of Nursing Services (ADNS) after being returned to the facility by the Activities Director. The resident was immediately put on one-on-one supervision, and the resident's care plan was revised. The Physician, Nurse Practitioner, and the resident's Power of Attorney were all informed of the incident. 2. A 100% head count was conducted immediately and all residents were accounted for. 3. Each door of the facility was checked for proper functioning related to the code alert bracelet and for fire egress by the Director of Nursing Services (DNS) on 07/05/19. 4. All residents' Code Alert Bracelets were checked for placement and function by the ADNS on 07/05/19 and no negative findings were identified. 5. On 07/05/19, signs were posted at all entrance/exit doors reminding visitors to ask team members before assisting residents out of the facility unsupervised. 6. On 07/05/19, the DNS and ADNS completed elopement risk assessments and the elopement book was reviewed to ensure accuracy. An audit of elopement care plans for all residents determined to be at risk for elopement was completed by the DNS and Regional MDS RN on 07/05/19. 7. The Administrator contacted the alarm company on 07/05/19, and a temporary keypad was installed by the Maintenance Director on 07/05/19 on the door to the stairway on the lower level. A sign was also placed on the stairway door restricting the use of the stairway to emergencies only. 8. A keypad with alarms was installed on the door at the bottom of the stairwell, both inside and outside the door. The alarm installation was completed on 07/10/19 and all team members received education related to its usage. 9. The ADNS began education regarding Elopement Care Guidelines, including conducting an hourly head count which began on 07/05/19 for all team members. The DNS or ADNS was responsible for ensuring all new staff received the trainings upon orientation. 10. The Quality Assurance Performance Improvement (QAPI) committee held an impromptu meeting on 07/05/19 with the Administrator, ADNS, Medical Director, Regional Vice President, and the Director of Clinical Operations. The Administrator, DNS, or designee will conduct elopement drills once per shift per month for three (3) months and as needed if it was determined the team needed them. 11. Door alarms were being tested by the Maintenance Director on a daily basis beginning on 07/05/19 and will continue for two (2) weeks and then revert to weekly if no issues were found on daily checks. 12. Audits will be conducted for residents determined to be at risk for elopement to ensure that the care plan and caregiver guide reflect any changed/updated/new interventions. This audit will be conducted daily (five days a week) and will continue indefinitely to ensure accuracy. ***The facility implemented the following actions to ensure deficient practice was corrected on 07/11/19: 1. Review of Resident #1's medical record revealed on 07/05/19, staff assessed the resident to have no injuries and the resident's vital signs were within normal limits. Staff supervised the resident one on one until 07/11/19, until all alarms were installed and tested , at which time hourly supervision was initiated. Further review revealed staff documented that the resident's Physician, Nurse Practitioner, and the Power of Attorney were all informed of the incident. Continued review revealed the facility revised the resident's care plan to include the supervision that the resident required. Interview with the Administrator on 07/31/19 at 1:24 PM, revealed stairwells were not accessible for residents and hourly monitoring was being conducted for Resident #1. 2. Review of facility documentation and interview with the ADNS on 07/31/19 at 12:00 PM, revealed a 100% head count was conducted immediately on 07/05/19 and all residents were accounted for. 3. Review of facility documentation and interview with the DNS on 07/30/19 at 4:31 PM revealed on 07/05/19, she checked the code alert system and fire egress doors for proper functioning and no other concerns were identified. 4. Review of facility documentation and interview with the ADNS on 07/31/19 at 12:00 PM revealed on 07/05/19, she checked all residents' Code Alert Bracelets and no concerns were identified. 5. Observation of facility doors on 07/16/19 at 10:45 AM revealed signs were posted at all entrance/exit doors reminding visitors to check with staff before assisting residents out of the facility. 6. Interview with the DNS and ADNS on 07/30/19 at 4:31 PM, and review of Elopement Risk Assessments revealed they assessed all residents at risk for elopement including Resident #1, reviewed/revised the elopement book, and audited all elopement care plans. 7. Interview with the Administrator on 07/31/19 at 1:24 PM revealed she contacted the alarm company on 07/05/19 regarding installing a code alert alarm system to the stairwell doors. In addition, a sign was observed on the door that stated the stairs were only to be used in case of emergency. 8. Observation on 07/31/19 at 9:55 AM revealed a code alert alarm key pad was beside the door to the stairway. Interviews on 07/31/19 at 11:00 AM with Laundry staff, at 11:38 AM with the DNS, at 12:00 PM with the ADNS, and at 1:24 PM with the Administrator revealed all team members were educated regarding the usage of the doors/alarms and staff were monitoring to ensure correct functioning. 9. Review of in-service records and interview with the ADNS on 07/31/19 at 12:00 PM revealed she educated staff regarding the facility's Elopement Care Guidelines. The ADNS stated she would also ensure all new staff received the training during orientation. Interview with State Registered Nurse Aide (SRNA) #2 on 07/30/19 at 1:53 PM revealed she was educated regarding the Elopement Care Guidelines. She stated residents were not permitted to go to the lower level unassisted. She stated if residents were seen going toward the elevator, staff would go with them. Further interview revealed that she checked on residents at risk for elopement hourly and more often, if needed. Interview with SRNA #1 on 07/30/19 at 2:56 PM revealed she was educated on the elopement care guidelines on her first day back to work after Resident #1 eloped. She stated residents at risk for elopement did not normally attempt to get on the elevator, but if she saw someone go in that direction, she would assist them to the lower level as needed. Interview with the Administrator on 07/31/19 at 1:24 PM revealed all employees had received the Elopement Care Guidelines Training. 10. Review of QA minutes dated 07/05/19 and interviews with the ADNS at 12:00 PM, the Medical Director at 12:15 PM, and the Administrator at 1:24 PM, revealed the facility had a QAPI meeting on 07/05/19 and discussed the resident's elopement and developed a plan of correction. Review of elopement drills and interviews with the DNS on 07/30/19 at 4:31 PM revealed an elopement drill was conducted on 07/06/19 and no concerns were identified. 11. Review of facility audits, observation of drill, and interview with the Maintenance Director on 07/31/19 at 10:57 AM revealed door alarms were being tested on a daily basis and alarms were functioning as required. 12. Interview with the DNS on 07/31/19 at 11:38 AM revealed care plans for residents assessed to be at risk for elopement would be audited daily (five days a week) and would continue indefinitely to ensure accuracy.

Based on observation, interview, record review, and review of the facility's policies and investigations, it was determined the facility failed to supervise one (1) of three (3) sampled residents (Resident #1) to prevent accidents. On 07/05/19, Resident #1 took the elevator to the lower level of the facility, without staff knowledge or supervision. According to the facility's investigation, the resident took the stairs back to the upper level and exited the facility through a door in the stairwell. At approximately 11:10 AM, a resident alerted the Activities Director that Resident #1 was outside. The Activities Director assisted the resident back inside the facility. The facility assessed the resident to have no injuries, but the facility documented that the resident appeared upset that he/she had been outside. The facility's failure to ensure residents were supervised to prevent accidents/elopement has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate jeopardy was identified on 07/18/19, and was determined to exist on 07/05/19 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656) and 42 CFR 483.25 Quality of Care (F689). The facility was notified of the Immediate Jeopardy on 07/18/19. An acceptable Allegation of Compliance was received on 07/29/19, which alleged removal of the Immediate Jeopardy on 07/11/19. The facility implemented corrective action which was completed prior to the State Survey Agency's investigation. The State Survey Agency verified the corrective actions were implemented as alleged. It was determined Immediate Jeopardy was removed and deficient practice corrected on 07/11/19, as alleged by the facility. The findings include: Review of the facility's Elopement policy, dated (MONTH) (YEAR), revealed if a newly admitted or readmitted resident was determined to be at risk for elopement, an individualized care plan would be established with interventions to mitigate elopement. In addition, the policy stated that team members would be knowledgeable on how to respond to all door/exit alarms. Once the door/exit alarm was activated, a resident search would be completed ensuring there was no missing resident. Review of Resident #1's medical record revealed the facility admitted the resident on 11/04/18 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident had severe cognitive impairment. Further review revealed the resident required the physical assistance of one person with transfers, ambulation, and locomotion on the unit. According to the MDS, Resident #1 required supervision while off the unit. In addition, the facility assessed the resident to have unsteady balance during transitions and walking and to exhibit wandering behavior daily. Review of Resident #1's Admission Clinical Health Status dated 11/04/18, revealed the facility determined the resident was at risk for elopement because he/she was physically able to leave the building and was cognitively impaired, had impaired decision-making skills, had a history of [REDACTED]. According to the assessment, a Code Alert Bracelet was implemented on 11/05/18. Review of Resident #1's comprehensive care plan dated 11/04/18, revealed the facility identified that the resident wandered and implemented a Code Alert Bracelet upon admission to the facility. Further review revealed that although the facility developed an intervention for the resident to receive one-to-one observation and/or hourly monitoring as needed due to exit-seeking behavior, there was no documented evidence that the facility had assessed the resident's wandering to the lower level of the facility and developed interventions to address the resident's safety. Review of a Facility Investigation dated 07/05/19, revealed the Activities Director observed Resident #1 outside the front lobby window. She immediately assisted the resident back inside the facility and the resident was assessed to have no injuries. Further review of the investigation revealed Resident #1 stated, I don't know where I was going or where I have been. The investigation stated that the resident appeared upset that he/she was outside. The resident's Code Alert Bracelet was in place on his/her ankle and was determined to be functional. According to the investigation, Resident #1 got on the elevator, went to the ground floor, and took the stairs back to the second floor. When the resident came to the top of the stairs, he/she exited the emergency exit door to the outside, rather than taking the door that led to the second floor. Continued review revealed the alarm on the emergency exit door was sounding in the stairwell, but failed to sound inside the facility to alert staff that the door had been opened. Observation on 07/17/19 at 11:45 AM, of the lower level of the facility revealed staff offices, the kitchen, the maintenance department, the therapy department, laundry, and etc., were located on the lower level. Observation revealed resident rooms were located on the upper level. Further observation of the upper level revealed an elevator was located across the hallway and to the right of the nurses' station. The elevator was not equipped with a code alert system. The door to the stairwell was also located beside the elevator. Observation of the stairwell revealed an exit door that was located inside the stairwell of the upper level that led to a patio with stairs to the facility's parking lot. Further observation revealed the front lobby of the facility was located approximately one hundred (100) feet from the exit door. Observation of Resident #1 on 07/16/19 at 11:02 AM revealed the resident was standing in the doorway to his/her bedroom. A Code Alert Bracelet was observed to the resident's left ankle. Resident #1 stated he/she had not been outside. The resident stated it was .too hot to go anywhere. Interview with the Activities Director on 07/17/19 at 11:00 AM revealed on 07/05/19, at approximately 11:10 AM, she was in the front lobby on the upper level playing cards with residents, when a resident pointed out that Resident #1 was outside unattended. The Activities Director stated she immediately went outside and escorted the resident back into the facility. According to the Activities Director, Resident #1 told her that he/she did not know how he/she got outside and that he/she was happy to be back. The Activities Director stated she took the resident to the nurses' station and informed Registered Nurse (RN) #3 of what happened. Continued interview with the Activities Director revealed she took the stairs to the lower level to inform the Administrator of the incident, and while in the stairwell, she heard the exit door alarming, and therefore determined that was how the resident exited the facility without staff knowledge. Interview with State Registered Nurse Aide (SRNA) #4 on 07/17/19 at 10:15 AM, and on 07/18/19 at 9:00 AM revealed she was caring for Resident #1 on 07/05/19 and had last seen the resident at approximately 11:00 AM. SRNA #4 stated Resident #1 was confused and agitated on 07/05/19, as was usual for the resident, but did not appear to be actively exit seeking. The SRNA stated that it was not unusual for Resident #1 to go to the basement area to talk to staff. She stated that even though there was no resident supervision on the lower level, she only monitored Resident #1's whereabouts every two (2) hours, the same as all other facility residents. SRNA #4 stated she believed the resident's confusion resulted in the resident taking the stairs, instead of the elevator, and then taking the exit door. She stated the temperature was in the 80's outside on 07/05/19. Interview with Registered Nurse (RN) #3 on 07/18/19 at 2:50 PM, revealed she assessed Resident #1 on 07/05/19 after the Activities Director assisted the resident inside the facility, and the resident had no injuries. The interview revealed RN #3 was not aware the resident had taken the elevator to the lower level of the facility. Further interview with RN #3 revealed anytime an exit door was opened, an alarm sounded at the nurses' station. However, according to RN #3, she did not hear any alarms sounding prior to the resident being found outside. RN #1 stated after the resident's assessment, she contacted RN #1 about the incident for further instructions. Interview with RN #1 on 07/17/19 at 2:48 PM revealed on 07/05/19 staff notified her that Resident #1 was found outside unsupervised. RN #1 stated the exit doors could be opened after pushing and holding the bar on the door. She stated she had SRNAs to check the stairwell once the resident was inside and the exit door alarm was sounding Please Exit. She stated the alarm volume was low and could not be heard outside the stairwell. RN #1 stated all alarms were supposed to sound at the nurses' station, but it was not functioning properly and was not sounding. RN #1 further stated she had not seen the resident on the lower level recently, but stated it was not uncommon for residents to take the elevator to the lower level to go to the beauty shop or to get money from their accounts. Interview with RN #2 on 07/17/19 at 4:15 PM revealed Resident #1 was at risk for elopement because he/she was ambulatory, confused, and wandered daily. RN #2 stated SRNAs were expected to monitor Resident #1 and routinely check on all residents every two (2) hours. According to RN #2, only residents who were alert and oriented routinely went to the facility's basement unsupervised. Interview with the Maintenance Director on 07/16/19 at 4:14 PM revealed on 07/05/19, facility staff called him at approximately 12:30 PM, informing him of the incident, and he came to the facility. The Maintenance Director stated he assumed Resident #1 got onto the elevator on the upper residential floor, came to the basement, and then walked up the stairs to go back to the upper residential floor. The Maintenance Director further stated he believed the resident mistakenly exited through the wrong door that led outside to the patio. Continued interview with the Maintenance Director revealed that although the door that it was believed the resident exited through had an alarm which was heard sounding on 07/05/19 at the door, it had malfunctioned and was not audible at the nurses' station. Interview with the Administrator on 07/16/19 at 4:45 PM revealed alert and oriented residents routinely went down to the lower level to talk to social workers or business office staff, or for activities/physical therapy. She stated the behavior was not encouraged. Further interview revealed the facility did not have a policy related to supervising residents; however, she stated nursing staff had been educated that when they saw a resident get on the elevator, they should intervene and see why the resident was on the elevator. She stated staff were responsible for knowing a resident's whereabouts. However, according to the Administrator, she saw Resident #1 on the lower level with another resident on 07/05/19 at approximately 11:00 AM, and she did not intervene when she saw the resident. The Administrator stated she was then informed that Resident #1 was found outside unsupervised. **The facility alleged the following actions were implemented to correct deficient practice on 07/11/19: 1. On 07/05/19, Resident #1 was assessed for injury by the Assistant Director of Nursing Services (ADNS) after being returned to the facility by the Activities Director. The resident was immediately put on one-on-one supervision, and the resident's care plan was revised. The Physician, Nurse Practitioner, and the resident's Power of Attorney were all informed of the incident. 2. A 100% head count was conducted immediately and all residents were accounted for. 3. Each door of the facility was checked for proper functioning related to the code alert bracelet and for fire egress by the Director of Nursing Services (DNS) on 07/05/19. 4. All residents' Code Alert Bracelets were checked for placement and function by the ADNS on 07/05/19 and no negative findings were identified. 5. On 07/05/19, signs were posted at all entrance/exit doors reminding visitors to ask team members before assisting residents out of the facility unsupervised. 6. On 07/05/19, the DNS and ADNS completed elopement risk assessments and the elopement book was reviewed to ensure accuracy. An audit of elopement care plans for all residents determined to be at risk for elopement was completed by the DNS and Regional MDS RN on 07/05/19. 7. The Administrator contacted the alarm company on 07/05/19, and a temporary keypad was installed by the Maintenance Director on 07/05/19 on the door to the stairway on the lower level. A sign was also placed on the stairway door restricting the use of the stairway to emergencies only. 8. A keypad with alarms was installed on the door at the bottom of the stairwell, both inside and outside the door. The alarm installation was completed on 07/10/19 and all team members received education related to its usage. 9. The ADNS began education regarding Elopement Care Guidelines, including conducting an hourly head count which began on 07/05/19 for all team members. The DNS or ADNS was responsible for ensuring all new staff received the trainings upon orientation. 10. The Quality Assurance Performance Improvement (QAPI) committee held an impromptu meeting on 07/05/19 with the Administrator, ADNS, Medical Director, Regional Vice President, and the Director of Clinical Operations. The Administrator, DNS, or designee will conduct elopement drills once per shift per month for three (3) months and as needed if it was determined the team needed them. 11. Door alarms were being tested by the Maintenance Director on a daily basis beginning on 07/05/19 and will continue for two (2) weeks and then revert to weekly if no issues were found on daily checks. 12. Audits will be conducted for residents determined to be at risk for elopement to ensure that the care plan and caregiver guide reflect any changed/updated/new interventions. This audit will be conducted daily (five days a week) and will continue indefinitely to ensure accuracy. ***The facility implemented the following actions to ensure deficient practice was corrected on 07/11/19: 1. Review of Resident #1's medical record revealed on 07/05/19, staff assessed the resident to have no injuries and the resident's vital signs were within normal limits. Staff supervised the resident one on one until 07/11/19, until all alarms were installed and tested , at which time hourly supervision was initiated. Further review revealed staff documented that the resident's Physician, Nurse Practitioner, and the Power of Attorney were all informed of the incident. Continued review revealed the facility revised the resident's care plan to include the supervision that the resident required. Interview with the Administrator on 07/31/19 at 1:24 PM, revealed stairwells were not accessible for residents and hourly monitoring was being conducted for Resident #1. 2. Review of facility documentation and interview with the ADNS on 07/31/19 at 12:00 PM, revealed a 100% head count was conducted immediately on 07/05/19 and all residents were accounted for. 3. Review of facility documentation and interview with the DNS on 07/30/19 at 4:31 PM revealed on 07/05/19, she checked the code alert system and fire egress doors for proper functioning and no other concerns were identified. 4. Review of facility documentation and interview with the ADNS on 07/31/19 at 12:00 PM revealed on 07/05/19, she checked all residents' Code Alert Bracelets and no concerns were identified. 5. Observation of facility doors on 07/16/19 at 10:45 AM revealed signs were posted at all entrance/exit doors reminding visitors to check with staff before assisting residents out of the facility. 6. Interview with the DNS and ADNS on 07/30/19 at 4:31 PM, and review of Elopement Risk Assessments revealed they assessed all residents at risk for elopement including Resident #1, reviewed/revised the elopement book, and audited all elopement care plans. 7. Interview with the Administrator on 07/31/19 at 1:24 PM revealed she contacted the alarm company on 07/05/19 regarding installing a code alert alarm system to the stairwell doors. In addition, a sign was observed on the door that stated the stairs were only to be used in case of emergency. 8. Observation on 07/31/19 at 9:55 AM revealed a code alert alarm key pad was beside the door to the stairway. Interviews on 07/31/19 at 11:00 AM with Laundry staff, at 11:38 AM with the DNS, at 12:00 PM with the ADNS, and at 1:24 PM with the Administrator revealed all team members were educated regarding the usage of the doors/alarms and staff were monitoring to ensure correct functioning. 9. Review of in-service records and interview with the ADNS on 07/31/19 at 12:00 PM revealed she educated staff regarding the facility's Elopement Care Guidelines. The ADNS stated she would also ensure all new staff received the training during orientation. Interview with State Registered Nurse Aide (SRNA) #2 on 07/30/19 at 1:53 PM revealed she was educated regarding the Elopement Care Guidelines. She stated residents were not permitted to go to the lower level unassisted. She stated if residents were seen going toward the elevator, staff would go with them. Further interview revealed that she checked on residents at risk for elopement hourly and more often, if needed. Interview with SRNA #1 on 07/30/19 at 2:56 PM revealed she was educated on the elopement care guidelines on her first day back to work after Resident #1 eloped. She stated residents at risk for elopement did not normally attempt to get on the elevator, but if she saw someone go in that direction, she would assist them to the lower level as needed. Interview with the Administrator on 07/31/19 at 1:24 PM revealed all employees had received the Elopement Care Guidelines Training. 10. Review of QA minutes dated 07/05/19 and interviews with the ADNS at 12:00 PM, the Medical Director at 12:15 PM, and the Administrator at 1:24 PM, revealed the facility had a QAPI meeting on 07/05/19 and discussed the resident's elopement and developed a plan of correction. Review of elopement drills and interviews with the DNS on 07/30/19 at 4:31 PM revealed an elopement drill was conducted on 07/06/19 and no concerns were identified. 11. Review of facility audits, observation of drill, and interview with the Maintenance Director on 07/31/19 at 10:57 AM revealed door alarms were being tested on a daily basis and alarms were functioning as required. 12. Interview with the DNS on 07/31/19 at 11:38 AM revealed care plans for residents assessed to be at risk for elopement would be audited daily (five days a week) and would continue indefinitely to ensure accuracy.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to revise the care plan for one (1) of twenty-eight (28) sampled residents (Resident #4) after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/29/18 at 10:15 AM, the interdisciplinary team met to discuss the falls and determined that the falls were the result of [CONDITION(S)] (low blood pressure), but did not develop interventions or revise the care plan to address the concern of [CONDITION(S)] to prevent further falls. On 10/29/18 at 4:30 PM, Resident #4 fell again and sustained a non-displaced left acetabular fracture (hip fracture). The findings include: Review of the facility's Care planning/RAI Process policy dated October 2017 revealed the comprehensive care plan is an interdisciplinary communication tool. The care plan should include measurable objectives and timeframes. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy further stated the care plan should be revised on an ongoing basis to reflect changes in the resident. Review of the facility's policy titled Falls, dated April 2017, revealed when a risk factor for falls was identified, a corresponding intervention addressing that risk factor was developed. Further review revealed that a fall huddle was called to help in investigating circumstances around the fall and to help determine immediate interventions post fall. The policy indicated that the Interdisciplinary Team (IDT) reviewed post fall investigations and summarized the team's recommendations. Review of Resident #4's medical record revealed the facility admitted the resident on 09/29/15 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) indicating the resident was cognitively impaired. Further review of the MDS revealed the resident was assessed to be at risk for falls. Review of Resident #4's comprehensive care plan with a projected goal date of 01/27/19 revealed the facility developed interventions to prevent falls that included wearing non-skid socks, encouraging the resident to use call light for assistance, educating the resident to sit on the side of the bed before ambulating, and encouraging the resident to ask for assistance with ambulation. Review of a nursing note dated 10/28/18 at 12:59 PM and review of the Resident Fall Analysis RCA [Root Cause Analysis] Worksheet dated 10/28/18 (no time) revealed Resident #4 sustained a fall at 12:59 PM and another fall at 9:00 PM on 10/28/18. There was no evidence of interventions to prevent further falls after the fall at 12:59 PM. The interventions to be implemented to minimize the risk of recurrence that was documented after the 9:00 PM fall was to encourage the resident to use the call light prior to standing and wait for assistance. However, this was already an intervention on the care plan. Review of an IDT note dated 10/29/18 at 10:16 AM revealed that the root cause of the fall that occurred on 10/28/18 at 12:59 PM and on 10/28/18 at 9:00 PM was determined to be [CONDITION(S)] and the new intervention was to notify the resident's brother of the need for a recliner. There was no evidence that the IDT developed interventions and revised Resident #4's care plan to prevent further falls related to the [CONDITION(S)]. Review of a Resident Incident Report dated 10/29/18 at 4:30 PM revealed a nurse aide called staff to Resident #4's room. The report stated that Resident #4 was sitting in a chair in the room and lost his/her balance and fell . The resident was noted to have disorientation and complained of pain to the left side. The resident was transferred to the hospital. Review of the emergency room nursing assessment record dated 10/28/18 at 5:32 PM revealed Resident #4 was nonweight-bearing upon arrival to the Emergency Department. Further review of the physical exam revealed the resident had mild to moderate pain with movement affecting the left hip and iliac crest. Review of the hospital radiology report dated 10/29/18 at 6:39 PM revealed Resident #4 had a non-displaced left acetabular fracture (hip fracture). Interview with Registered Nurse (RN) #3 on 11/08/18 at 2:15 PM revealed that she was part of the IDT and was responsible for updating resident care plans during the morning meetings. RN #3 acknowledged that no immediate interventions were put in place for Resident #4 after the falls on 10/28/18. RN #3 stated that the intervention to obtain a recliner for Resident #4 was discussed in the morning meeting on 10/29/18; however, this intervention was not added to the care plan and was not implemented. She stated the purpose of the recliner was to assist the resident in changing positions to help with the resident getting lightheaded. However, the recliner was not implemented until after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator and Director of Nursing (DON) on 11/08/18 at 7:25 PM revealed all incidents/accidents were reviewed daily in the morning meeting. The DON reported that care plans were updated at that time to reflect any changes to the resident's status. The DON stated the IDT decided that Resident #4 needed a recliner to help prevent further falls; however, the intervention was not implemented until after the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, record review, and review of a facility policy, it was determined the facility failed to ensure one (1) of twenty-eight (28) sampled residents (Resident #4) received adequate assistance and supervision to prevent accidents. Resident #4 sustained three (3) falls from 10/28/18 at 12:59 PM through 10/29/18 at 4:30 PM. Review of the record revealed that Resident #4's blood pressure after the first fall was 59/42. There was no evidence the facility developed interventions to prevent further falls at that time. Further review of the record revealed the resident fell again on 10/28/18 at 9:00 PM and his/her blood pressure was documented to be 70/68. The intervention implemented after the fall was to encourage the resident to use the call light and wait for assistance, which was already an intervention on the care plan. On 10/29/18 at 4:30 PM, Resident #4 fell again and was transferred to the hospital on 10/29/18 at 5:10 PM and diagnosed with a non-displaced left acetabular fracture (hip fracture). In addition, Resident #1's (#34) care plan required two staff members to transfer the resident to prevent falls. Interview with staff revealed two staff members were required when utilizing a mechanical lift to ensure the resident's safety. However, observation on 12/05/18, revealed one staff member transferred Resident #1 (#34) from a wheelchair to bed utilizing a mechanical lift. The findings include: Review of the facility's policy titled Falls, dated April 2017, revealed that when a risk factor for falls was identified a corresponding intervention addressing that risk factor was developed. Further review revealed that a fall huddle was called to help in investigating circumstances surrounding the fall and to help determine immediate interventions post fall. The policy indicated that the Interdisciplinary Team (IDT) reviewed post fall investigations and summarized the team recommendations. 1. Observation of Resident #4 on 11/06/18 at 10:20 AM revealed the resident sitting on the deck smoking with staff present. Additional observations on 11/06/18 at 1:45 PM, 2:20 PM, and 4:40 PM revealed the resident lying in bed. Review of Resident #4's medical record revealed the facility admitted the Resident on 09/29/15 with diagnoses that included muscle weakness, abnormal posture and other abnormalities of gait and mobility, and Type 1 diabetes. Review of Resident #4's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6), indicating the resident was cognitively impaired. Further review of the MDS revealed the resident was assessed to be at risk for falls. Review of Resident #4's comprehensive care plan with a projected goal date of 01/27/19 revealed interventions to prevent falls that included non-skid socks, encourage to use call light for assistance, educate the resident to sit on the side of the bed before ambulating, and encourage the resident to ask for assistance with ambulation. Review of a nursing note dated 10/28/18 at 12:59 PM revealed Resident #4 was ambulating in the hallway and ambulated approximately 50 feet and fell . The documentation stated that the fall was not witnessed and the resident was assessed and noted to have a blood pressure of 59/42. The note further revealed that the physician was notified and an order for an x-ray of the left femur was obtained. Review of a radiology report dated 10/28/18 at 7:15 PM revealed the conclusion of the mobile x-ray obtained on 10/28/18 was that the resident did not have a fracture of the left hip. Review of the Resident Fall Analysis RCA [Root Cause Analysis] Worksheet dated 10/28/18 (no time) revealed the cause of the fall was loss balance and in the area for interventions to be implemented to prevent recurrence the document stated used w/c [wheelchair] to transport back to room. There was no evidence of interventions to prevent further falls. Phone interview with Licensed Practical Nurse (LPN) #1 on 11/08/18 at 5:00 PM revealed she was assigned to Resident #4 on 10/28/18. She stated she did not witness the fall that occurred at 12:59 PM. LPN #1 stated when a resident sustained a fall, the nurse was required to assess the resident for injury, complete an incident report, notify the physician and family, and contact the Director of Nursing who gave instructions on what staff should do. LPN #1 stated that she called Registered Nurse (RN) #3 after the fall because the Director of Nursing (DON) was unavailable. LPN #1 stated she was not instructed to put any new interventions in place to prevent future falls. Review of Post Fall/Trauma documentation dated 10/28/18 revealed Resident #4 fell again at 9:00 PM on 10/28/18. The documentation stated the resident fell from the bed to the floor due to getting lightheaded and had a blood pressure of 70/68. The document stated that the interventions to be implemented to minimize the risk of recurrence was to encourage the resident to use the call light prior to standing and wait for assistance; however, this intervention had already been implemented prior to the resident's falls on 10/28/18. Attempts were made on 11/08/18 at 4:00 PM and 6:04 PM to interview the nurse working at the time of the fall on 10/28/18 at 9:00 PM, but she was unavailable and did not return calls. The facility provided an IDT note dated 10/29/18 at 10:16 AM that revealed the root cause of the falls that occurred on 10/28/18 at 12:59 PM and 10/28/18 at 9:00 PM was determined to be [CONDITION(S)] and the new intervention was to notify the resident's brother of the need for a recliner. Review of a Resident Incident Report dated 10/29/18 at 4:30 PM revealed that staff was called to Resident #4's room by the aide. The resident was sitting in a chair in the room and lost his/her balance and fell . The resident was noted to have disorientation and complained of pain to the left side. The resident was transferred to the hospital. Review of the emergency room nursing assessment record dated 10/28/18 at 5:32 PM revealed Resident #4 to be nonweight-bearing upon arrival to the Emergency Department. Further review of the physical exam revealed the resident to have mild to moderate pain with movement affecting the left hip and iliac crest. Review of the hospital radiology report dated 10/29/18 at 6:39 PM revealed Resident #4 to have a non-displaced left acetabular fracture (hip fracture). Interview with SRNA #1 on 11/08/18 at 2:50 PM revealed she provided care for Resident #4 on 10/28/18 and was present on the unit when both falls occurred. Per SRNA #1, on 10/28/18 around noon she witnessed Resident #4 lying in the hallway on his/her left side. She stated the nurse assessed the resident and staff assisted the resident to stand. SRNA #1 reported that Resident #4 was complaining of left hip pain after he/she stood up. SRNA #1 reported that she placed Resident #4 in a wheelchair and took him/her out for a smoke break. SRNA #1 reported that she was not instructed to implement any new interventions after the fall and did routine checks every two (2) hours as usual the rest of the day. SRNA #1 reported that around 9:00 PM on 10/28/18, she heard a noise coming from Resident #4's room. Upon entering the room she witnessed Resident #4 sitting on the floor, facing the door, with a small cut above his/her right eye. After assisting Resident #4 to the bed, the resident became pale and clammy, and his/her blood pressure was low. SRNA #1 reported that the resident was still complaining of left hip pain. SRNA #1 stated she reported to the nurse and the nurse assessed the resident. SRNA #1 stated the staff were instructed to do neuro checks and vital signs per protocol and no new fall interventions were put into place. Interview with the DON on 11/07/18 at 12:02 PM revealed attempts are made to determine the root cause when a fall occurs. She stated that the management staff meets daily, Monday through Friday, and discusses any resident issues during the meeting. The DON stated that all falls were evaluated for a root cause during the meeting, and the plan of care was updated during the meeting. She further stated that when a fall occurs, the nurse assigned to the resident contacts the DON, and immediate interventions are put into place to prevent further falls. The DON was unable to recall any immediate interventions that were put in place for Resident #4 when the two (2) falls occurred on 10/28/18. Interview with RN #3 on 11/08/18 at 2:15 PM revealed she was a member of the IDT and that she was responsible to update the care plan during the morning meetings. RN #3 acknowledged that no immediate interventions were put in place for Resident #4 after the falls on 10/28/18. RN #3 reported that an intervention to obtain a recliner for Resident #4 was discussed in the morning meeting on 10/29/18; however, this intervention was not added to the care plan at that time. Further, RN #3 acknowledged that immediate interventions should have been put in place and documented on the care plan to prevent further falls for Resident #4. Interview with the Assistant Director of Nursing (ADON) on 11/08/18 at 10:30 AM revealed any resident incidents were discussed in the morning meeting daily. New interventions were discussed and put in place on the care plan. It was expected that staff would put immediate interventions in place when a fall occurred. The ADON stated she had not identified any concerns with fall interventions or care plans not being updated. Interview with the Administrator and DON on 11/08/18 at 7:25 PM revealed all incidents/accidents were reviewed daily in the morning meeting. The DON reported that care plans were updated during the meeting to reflect any changes to the resident's status. The DON stated the intervention implemented to prevent further falls for Resident #4 should have been added to the comprehensive care plan and the SRNA care plan. 2. A review of the facility's mechanical lift policy titled Lift Care Safe for All (not dated) revealed residents were assessed on admission to determine what type of assistive transfer equipment was needed. The policy did not address the number of staff required to safely utilize a mechanical lift. However, an interview with the Director of Nursing (DON) on 12/18/18 at 1:30 PM revealed two staff were required to transfer residents when a mechanical lift was used to prevent accidents. Review of Resident #1's (34) medical record revealed the facility admitted the resident on 09/02/10. The resident had diagnoses that included Unspecified [CONDITION(S)] Disease, Anxiety Disorder, [CONDITION(S)] Disorder, and Contractures to Bilateral Upper and Lower Extremities. Observation on 12/05/18 at 1:08 PM revealed one staff member, SRNA #10 utilized a mechanical lift to transfer Resident #1 (#34) from a wheel chair to the bed. However, a review of Resident #1's (#34) most recent Minimum Data Set (MDS) assessment completed on 09/10/18 revealed Resident #1 (#34) required extensive assistance of two (2) staff members to transfer the resident. In addition, the facility developed a care plan for the resident that stated the resident required total assistance of two staff for transfers with a mechanical lift to prevent falls and injury. Interview with State Registered Nurse Aide (SRNA) #10 on 12/05/18 at 1:17 PM, revealed the SRNA was aware that Resident #1 (#34) required two staff and the use of a mechanical lift to transfer the resident. However, SRNA #10 stated she transferred the resident by herself because other staff were not available. Interview with Licensed Practical Nurse (LPN) #3 on 12/05/18 at 1:39 PM, revealed two staff were required to assist residents when transferring the resident with a mechanical lift to ensure the safety of the resident. Continued interview with the DON on 12/18/18 at 1:30 PM revealed one staff member transferring Resident #1 (#34) in a mechanical lift was a safety hazard for the resident.

Based on observation, medical record review, facility policy review, and interview it was determined the facility had a medication administration error rate greater than five (5) percent. Observation of medication administration on 12/05/18 revealed the facility had a medication administration error rate of thirty-four (34) percent. The findings include: The facility did not have a policy regarding medication administration; however, interview with the facility Director of Clinical Operations on 12/07/18 at 11:30 AM revealed the facility uses Clinical Nursing Skills and Techniques, 9th Edition by Perry and Potter for their medication administration protocol. 1. Observation of Resident #42 on 12/05/18 at 11:01 AM revealed Licensed Practical Nurse (LPN) #3 administered [MEDICATION NAME] Extended Release (ER) 25 milligrams (mg) (blood pressure medication) one (1) tablet by mouth. LPN #3 obtained Resident #42's blood pressure and pulse after administering the [MEDICATION NAME] Extended Release. Further observation at this time revealed [MEDICATION NAME] XL 5 mg was not administered. Review of Resident #42's physician orders [REDACTED]. The order further stated if the systolic blood pressure was less than 100 or the pulse was less than 60, hold the medication and call the physician. Further review of the physician orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. 2. Observation of Resident #8 on 12/05/18 at 11:09 AM revealed LPN #3 administered [MEDICATION NAME] 20 mg one (1) tablet by mouth, [MEDICATION NAME] 10 mg one (1) tablet by mouth, and [MEDICATION NAME] 100 mg one (1) tablet by mouth. Review of Resident #8's physician orders [REDACTED]. Review of Resident #8's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. 3. Observation of Resident #11 on 12/05/18 at 11:29 AM revealed LPN #3 administered Potassium Chloride ER 20 milliequivalents (meq) one (1) tablet by mouth, [MEDICATION NAME] 875/125 mg one (1) tablet by mouth, and [MEDICATION NAME] ER 25 mg three (3) tablets by mouth. LPN #3 did not administer a Breo LI Inhaler. LPN #3 obtained Resident #11's blood pressure and pulse after administering the medications. Review of Resident #11's physician orders [REDACTED]., and call the physician, and Breo Ellipta 100-25 micrograms (mcg) Inhaler, administer one (1) puff by mouth twice a day. Review of Resident #11's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the MAR for (MONTH) (YEAR) revealed the residents did not receive the Potassium Chloride ER 20 meq, [MEDICATION NAME] 875/125 mg, [MEDICATION NAME] 25 mg three (3) tablets were not administered at 7:00 AM, and the Breo Ellipta 100-25 mcg Inhaler was not administered at 8:00 AM. Interview with LPN #3 on 12/05/18 at 2:22 PM revealed medications being administered to Resident #42 at 11:01 AM, Resident #8 at 11:09 AM, and Resident #11 at 11:29 AM were the medications the residents were to be administered during the 7:00 AM medication pass. LPN #3 revealed she was substantially late administering the medications due to being busy taking care of residents. However, LPN #3 revealed she knew the medications should have been administered between the hours of 6:00 AM and 8:00 AM and she had fallen behind during the medication administration pass. LPN #3 also revealed she had not informed a coworker or the Director of Nursing (DON) that she was late administering medications. Interview with the DON on 12/18/18 at 1:30 PM revealed she was not aware LPN #3 was late administering the 7:00 AM medication pass on 12/05/18. The DON revealed the 7:00 AM medication administration pass can be started at 6:00 AM and should be finished by 8:00 AM. The DON further revealed medication administration pass audits and education are done annually. The DON also revealed she had not previously identified any concerns with the medication administration pass being done timely or concerns with medication errors.

Based on observation, interview, facility policy review, and medical record review the facility failed to ensure that three (3) of twenty-eight (28) sampled residents were free of any significant medication errors. Observation of the medication administration on 12/05/18 revealed seven (7) significant medication errors were observed for Residents #42, #8, and #11. The findings include: The facility did not provide a policy in regard to significant medication errors. Interview with the Director of Clinical Operations on 12/07/18 at 11:30 AM revealed the facility currently uses Clinical Nursing Skills & Techniques, 9th Edition, for their medication administration protocol. 1. Observation of Resident #42 on 12/05/18 at 11:01 AM revealed Licensed Practical Nurse (LPN) #3 administered [MEDICATION NAME] Extended Release 25 milligrams (mg) one (1) tablet by mouth that was due to be given at 7:00 AM. LPN #3 obtained Resident #42's blood pressure and pulse after administering the [MEDICATION NAME] ER. Review of Resident #42's physician orders [REDACTED]. 2. Observation of Resident #8 on 12/05/18 at 11:09 AM revealed LPN #3 administered [MEDICATION NAME] 10 mg one (1) tablet by mouth and [MEDICATION NAME] 20 mg one (1) tablet by mouth that were due to be given at 7:00 AM. Review of Resident #8's physician orders [REDACTED]. Review of Resident #8's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the MAR indicated [REDACTED]. 3. Observation of Resident #11 on 12/05/18 at 11:29 AM revealed LPN #3 administered Potassium Chloride Extended Release 20 milliequivalents (meq) one (1) tablet by mouth, [MEDICATION NAME] Extended Release 25 mg three (3) tablets by mouth, and [MEDICATION NAME] 875/125 mg one (1) tablet by mouth that were due to be given at 7:00 AM. LPN #3 did not administer the Breo LI Inhaler. LPN #3 obtained Resident #11's blood pressure and did not obtain the pulse after administering the medications. Review of Resident #11's physician orders [REDACTED]. and call the physician, and Breo Ellipta 100-25 mcg Inhaler, administer one (1) puff by mouth twice a day. Review of Resident #11's (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of the MAR for (MONTH) (YEAR) revealed the residents did not receive the Potassium Chloride ER 20 meq, [MEDICATION NAME] 875/125 mg, [MEDICATION NAME] 25 mg three (3) tablets were not administered at 7:00 AM, and the Breo Ellipta 100-25 mcg Inhaler was not administered at 8:00 AM. Interview with LPN #3 on 12/05/18 at 2:22 PM revealed medications being administered to Resident #42 at 11:01 AM, Resident #8 at 11:09 AM, and Resident #11 at 11:29 AM were the medications the residents were to be administered during the 7:00 AM medication pass. LPN #3 revealed she was substantially late administering the medications due to being busy taking care of residents and she had not asked for assistance from other staff. However, LPN #3 revealed she knew the medications should have been administered between the hours of 6:00 AM and 8:00 AM and had fallen behind during the medication administration pass. LPN #3 also revealed she had not informed a coworker or the Director of Nursing (DON) that she was late administering medications. Interview with the DON on 12/18/18 at 1:30 PM revealed she was not aware LPN #3 was late administering the 7:00 AM medication pass on 12/05/18. The DON revealed the medications should have been given on time due to the significance of the medication and possible effect on the resident. The DON further revealed medication administration pass audits and education are done annually. The DON also revealed she had not previously identified any concerns with the medication administration pass being done timely.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to ensure approaches for resident care were revised to address infections for two (2) of fourteen (14) sampled residents (Resident #12 and Resident #13). Resident #12 was diagnosed with [REDACTED]. Resident #13 was diagnosed with [REDACTED]. The facility's failure to ensure resident care plans were reviewed and revised placed Resident #12 and the other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 09/23/16, was determined to exist on 09/09/16, and is ongoing in the areas of 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.30 Nursing Services (F353), 42 CFR 483.65 Infection Control (F441), and 42 CFR 483.75 Administration (F490, F493, F502, and F520). The facility was notified of the Immediate Jeopardy on 09/23/16. The findings include: Interview with the Acting Administrator on 09/23/16 at 1:15 AM revealed the facility did not have a policy on reviewing/revising comprehensive plans of care. She stated the facility used the Resident Assessment Instrument (RAI) to develop comprehensive care plans. Review of the facility's policy, Infection Control with a revision date of August 2012 revealed The objectives of the facility's infection control policies and practices were to: prevent, detect, investigate, and control infections in the facility; establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions. 1. Review of the medical record for Resident #12 revealed the facility admitted the resident on 10/24/01 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of nine (9) indicating moderate cognitive impairment. Further review of the MDS assessment revealed the resident was not identified to have an infection. Review of the physician's orders [REDACTED]. Review of laboratory results revealed no culture was obtained on 09/11/16. Review of the physician's orders [REDACTED]. Review of the laboratory results revealed a culture was obtained on 09/13/16 and it was noted the resident [MEDICAL CONDITION] to his/her right index finger. Further review of the laboratory report revealed the laboratory received the [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. index finger for seven (7) days. Review of the Comprehensive Care Plan dated 09/20/16, revealed the facility developed a care plan [MEDICAL CONDITION] of the resident's right index finger; however, no interventions were put into place to ensure necessary precautions were used to prevent the spread of infection to staff and residents. Interview with Licensed Practical Nurse (LPN) #1 on 09/22/16 at 6:50 PM revealed she was aware Resident #12 [MEDICAL CONDITION] of the right index finger. She stated when the infection first started, Resident #12's finger was red around the nail of the right index finger and had a pustule, with a small amount of serosanguinous (yellowish fluid with small amount of blood) drainage. Further interview with LPN #1 revealed she spoke with the Director of Nursing (DON)/Infection Control Coordinator regarding Resident #12's [DIAGNOSES REDACTED]. Interview with the Medical Director on 09/23/16 at 5:05 PM revealed she ordered Resident #12 to have a wound culture of his/her right index finger if there was no improvement by 09/11/16. She stated she was not aware the culture was not obtained until 09/13/16. She further stated that the resident's finger should have been covered while awaiting the culture results and the resident should have been in contact precautions. 2. Review of the medical record for Resident #13 revealed the facility admitted the resident on 01/13/15 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS score of three (3) indicating severe cognitive impairment. Further review of the MDS assessment revealed the resident was not identified to have an infection. Review of the Comprehensive Care Plan dated 09/17/16, revealed the facility developed a care plan for Impetigo Rash (contagious skin infection) to the resident's buttocks. However, no interventions were put into place to ensure necessary precautions were used to prevent spread of infection to staff and residents. Interview with the MDS Coordinator on 09/23/16 at 11:45 PM revealed she was responsible for developing the comprehensive care plans and reviewing/revising them. She further stated that she did not put interventions related to contact precautions because Resident #12 was not in contact precautions at any time prior to the [DIAGNOSES REDACTED]. Further interview revealed she should have put interventions for extra precautions for Resident #12 and Resident #13. Interview with the Director of Nursing (DON) on 09/23/16 at 11:57 PM revealed the Comprehensive Care Plans should have had interventions to direct staff to ensure precautions were in place to prevent the spread of both infections to other residents or staff. Interview with the Medical Director on 09/23/16 at 5:05 PM, revealed the DON called her on 09/17/16 and described the rash to Resident #13's buttocks and that the DON's best guess was that the resident had Impetigo. She stated that she ordered the resident to start Keflex 500 mg 4 (four) times a day for 10 (ten) days. Further interview revealed that the Medical Director chose not to put Resident #13 into contact precautions and continue standard precautions because she was not sure if the resident truly had Impetigo since she did not visually assess the resident until 09/21/16.

Based on interview, record review and facility policies, it was determined the facility failed to provide sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by the residents' needs, physician's orders [REDACTED].#1, #12, #13 and #14) and one (1) unsampled resident (Resident A). The facility failed to ensure that sufficient qualified nursing staff was available to meet the residents' needs as evidenced by interviews with facility staff. Nursing staff failed to practice safe and acceptable infection control practices related to ensuring residents with infections received proper treatment to reduce the spread of infection to other residents in the facility, ensuring cleaning/sanitizing of glucometer machines through training and ensuring adequate supplies were available, and following established policies/procedures for handwashing and glove changes during wound care, indwelling catheter care, and skin assessments. On 09/09/16, Resident #12 was observed to have redness and a draining pustule to the right index finger. physician's orders [REDACTED]. However, the facility failed to obtain the wound culture until 09/13/16 and failed to follow up on the results until 09/19/16 when the resident was diagnosed with [REDACTED]. Resident #13 was assessed to have a [DIAGNOSES REDACTED]. In addition, Licensed Practical Nurse (LPN #1) failed to disinfect a glucometer (machine used to monitor blood glucose levels) according to facility guidelines and manufacturer's recommendations to sanitize and prevent the spread of infections. the Director of Nursing, the Minimum Data Set Nurse, and the Medical Records Nurse were required to work extra shifts due to nursing shortage to provide direct resident care as well as attempt to be responsible for their normal duties. As a result, there was limited monitoring and supervision to ensure safe and acceptable infection control practices and techniques were followed to protect residents from the potential spread of infectious disease. The facility's failure to provide sufficient staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/23/16, was determined to exist on 09/09/16, and is ongoing in the areas of 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.30 Nursing Services (F353), 42 CFR 483.65 Infection Control (F441), and 42 CFR 483.75 Administration (F490, F493, F502, and F520). The facility was notified of the Immediate Jeopardy on 09/23/16. (Refer to F441, F490, F493, and F520). The findings include: Interview with the Acting Administrator, who did not hold a license or permit in the state, on 09/23/16, at 2:30 PM revealed the facility did not have a formal written policy/procedure regarding staffing and how sufficient staffing would be provided. The Administrator stated the facility provided staffing according to the regulations. Review of the Census and Condition Report dated 09/20/16, revealed the facility had forty-one (41) residents in the facility. According to the list of nurses employed by the facility, the facility employed three (4) Registered Nurses full time and one (1) part-time. The Director of Nursing (DON) and the Minimum Data Set (MDS) Nurse were included in the full time list of RNs employed by the facility. In addition, the facility also employed four (4) Licensed Practical Nurses (LPNs). The medical record staff was included in the list of LPNs. Review of the weekly staffing schedule revealed during the week of 09/01-07/16, the DON worked the 7:00 PM to 7:00 AM two (2) shifts and the MDS nurse covered one (1) 7:00 PM to 7:00 AM shift. During the week of 09/15-21/16, the DON and the MR staff worked the 7:00 AM to 7:00 PM shift one (1) shift and the 7:00 PM to 7:00 AM shift one (1) shift. The MDS nurse also covered the 7:00 AM to 7:00 PM shift one (1) shift. The medical record LPN covered the 7:00 PM to 7:00 AM shift on 09/22/16. Interview with the MDS Nurse on 09/21/16, at 9:35 AM, revealed the facility was having a problem with a nursing shortage. The MDS Nurse stated she often had to work the floor to provide direct care for the residents, but then also had to work her shift as the MDS Nurse as well in order to keep the MDS assessments caught up. Interview with the Medical Record (MR) LPN on 09/21/16, at 4:00 PM, revealed she also was required to cover the floor schedule at least once and sometimes two (2) to three (3) times each week. The MR staff stated several of the nurses had quit at the facility and left the facility short staffed. She stated she was also responsible for ordering the nursing supplies for the facility as well as to maintain the residents' medical records. When interviewed how this affected her job performance, the MR staff stated she was not as thorough as she normally was and knew she probably missed things. The MR staff stated she was not aware the nurses had no Sani-wipes available. The MR staff further stated she had not had an opportunity to check the inventory of supplies to know if the Sani-wipes needed to be reordered because she had been working the extra shifts as a floor nurse at night. Further interview revealed staff had not made her aware of being out of any other supplies. Interview with the DON on 09/23/16 at 9:00 PM revealed she had been required to cover the floor as a staff nurse at least weekly since she started working as the DON in April 2016. The DON stated she had worked either as a staff nurse or DON for three (3) consecutive weeks without a day off and sometimes would split the 7:00 PM to 7:00 AM shift with the MDS Nurse or the MR Nurse. The DON stated the facility also did not have nursing supervisors available to assist her with the supervisory needs of the facility. As a result, the DON stated this practice affected her responsibility as the DON a lot since she could not provide monitoring to ensure residents received the services and care they should. The DON stated she had not been able to provide the staff supervision to ensure infection control practices/techniques were followed and that staff performed their duties correctly. In addition, the DON stated she had not been able to track the lab orders to ensure the labs were obtained as ordered, to ensure the physician was called as indicated, and to provide staff education/in-services to ensure staff competencies. Interview with the Acting Administrator, on 09/23/16, at 9:25 PM, who did not hold a license or permit, revealed she believed the issues/problems that had been identified were a result of the recent nursing shortage at the facility. The Acting Administrator also confirmed the facility did not have any floor supervisors and stated it was difficult for the DON to perform her duties related to monitoring and supervision since she also was required to provide coverage on the floor for resident care. The Administrator further stated several nurses had quit at the facility to go to another facility to receive higher wages and she had tried to recruit nurses through newspaper and radio ads, offering sign on bonus, and through contract staffing agency.

Based on observation, interview, record review, policy and procedure review, and Centers for Disease Control Guidelines it was determined the facility failed to have an effective Infection Control Program in place to provide a safe environment to prevent the development and transmission of disease and infection for five (5) of fourteen (14) sampled residents (Resident #1, Resident #2, Resident #9, Resident #12 and Resident #13) and one (1) unsampled resident (Resident A). Resident #12 was noted to have redness and draining pustule to the right index finger on 09/09/16. Review of the physician's orders [REDACTED]. The facility failed to obtain the wound culture as ordered; it was not obtained until 09/13/16. The culture was positive for Methicillin Resistant Staphylococcus Aureus (MRSA). The laboratory had the results of the test on 09/17/16; however, the facility failed to follow-up on the results of the culture and did not get the results until 09/19/16. According to staff, Resident #12 was out of his/her room daily throughout the facility without the wound being covered and without any type of contact precautions from 09/09/16 through 09/19/16. The facility failed to ensure contact precautions were in place to prevent the spread of infection. Resident #13 was noted to have blisters with pustules on his/her buttocks on 09/11/16. Review of the physician's orders [REDACTED]. Staff stated they were not aware of the resident having Impetigo Infection and did not use any additional precautions. The facility failed to initiate contact precautions after the resident was diagnosed and physician's orders [REDACTED]. In addition, the facility failed to ensure resident multi-use blood glucose monitors were disinfected between each resident use according to the facility's policy and manufacturer's recommendations. On 09/22/16, Licensed Practical Nurse (LPN) #1 disinfected the blood glucose monitor utilizing alcohol instead of the recommended Super Sani-Cloth germicidal wipes and proceeded to perform blood glucose monitoring for Resident #1 and Unsampled Resident A. The facility failed to have the appropriate disinfectant to ensure the blood glucose monitors were disinfected to prevent the spread of infection. The facility failed to ensure staff followed appropriate infection control procedures to prevent the spread of infections. Observations of LPN #1 revealed she provided care to Resident #1 after handling trash and without washing/sanitizing her hands. LPN #1 was further observed to throw a used lancet (sharp object utilized to obtain a blood sample for blood glucose monitoring) in the trash can and place the used blood glucose monitor back into the medication cart without disinfecting it. In addition, LPN #1 was observed to not wash her hands or use hand sanitizer between glove changes during wound care, the skin assessment on 09/20/16, and during blood glucose monitoring on 09/21/16. Certified Nursing Assistants (CNA) #1 and #2 were observed to not wash their hands between glove changes when providing indwelling catheter care for Resident #2 and Resident #9. LPN #2 and Kentucky Medication Assistant (KMA) #1 were observed during a skin assessment of Resident #13 to not wash their hands and change gloves. The facility's failure to have an effective infection control program placed residents at risk for serious injury, harm, impairment, and death. Immediate Jeopardy was identified on 09/23/16, was determined to exist on 09/09/16, and is ongoing in the areas of 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.30 Nursing Services (F353), 42 CFR 483.65 Infection Control (F441), and 42 CFR 483.75 Administration (F490, F493, F502, and F520). The facility was notified of the Immediate Jeopardy on 09/23/16. The findings include: Review of the facility's policy, Multidrug - Resistant Organisms with a revision date of August 2012 revealed, Appropriate precautions will be taken when caring for individuals known or suspected to have infection with a multidrug-resistant organism (MDROs). MDROs are bacteria and other microorganisms that have developed resistance to one or more classes of antimicrobial drugs. Common examples of MDROs in long-term care facilities include Methicillin Resistant Staphylococcus Aureus (MRSA). Risks for transmission including uncontrolled secretions, stool incontinence, draining wounds, diarrhea, and total dependence for activities of daily living or behaviors that may increase the risk of transmission may indicate the need for Contact Precautions. Review of the facility's policy, Infection Control with a revision date of August 2012 revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the facility's infection control policies and practices were to: prevent, detect, investigate, and control infections in the facility; establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions; provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. The Quality Assessment and Assurance Committee, through the Infection Control Committee, shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they were implemented and followed. All personnel will be trained on our 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. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. Review of the facility's policy Contact Precautions, with a revision date of August 2012 revealed In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether precautions are necessary will be evaluated on a case by case basis. Examples of infections requiring Contact Precautions include, but are not limited to: Infections with multi-drug resistant organisms (determined on a case by case basis). 1. Review of Resident #12's medical record revealed the facility admitted the resident on 10/24/01 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have a Brief Interview of Mental Status (BIMS) score of nine (9) indicating the resident had moderate cognitive impairment. Review of the physician's orders [REDACTED].#12) fingernails with warm soapy water daily due to Paronychia. If no improvement noted by 09/11/16, then obtain a culture from the nailbed. Review of laboratory results revealed no culture was obtained on 09/11/16. Review of the physician's orders [REDACTED]. Review of the laboratory results revealed a culture was obtained on 09/13/16 and it was noted the resident had MRSA to his/her right index finger. Further review of the laboratory report revealed the laboratory received the [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. index finger for seven (7) days. Interview with Resident #12 on 09/23/16 at 12:32 PM revealed that he/she was not sure when the infection on his/her finger started or when the facility began to cover the area with a dressing. Interview with Certified Nursing Assistant (CNA) #1 on 09/22/16 at 7:05 PM revealed she provided care for Resident #12 and was not aware that the resident had MRSA on his/her right index finger. She stated she gets resident care information from the CNA Care Card and during shift report. CNA #1 stated the resident had a bandage on his/her finger but she did not know why. Interview with CNA #5 on 09/23/16 at 1:00 PM revealed she provided care for Resident #12 and was not aware that he/she had MRSA to his/her right index finger. She stated that she gets information related to residents with infections/contact precautions at shift report when she starts her shift and also on the CNA Care Card. However, she was not informed the resident had MRSA during shift report or after reviewing the resident's CNA Care Card. Interview with CNA #6 on 09/23/16 at 1:05 PM revealed she was aware Resident #12 had MRSA of the right index finger, but there were no special precautions in place for providing care for Resident #12. Interview with Licensed Practical Nurse (LPN) #1 on 09/22/16 at 6:50 PM revealed she was aware Resident #12 had MRSA of the right index finger. She stated when the infection first started, Resident #12's finger was red around the nail of the right index finger and had a pustule, with a small amount of serosanguinous (yellowish fluid with small amount of blood) drainage. Further interview with LPN #1 revealed she spoke with the Director of Nursing (DON)/Infection Control Coordinator regarding Resident #12's [DIAGNOSES REDACTED]. LPN #1 further stated that the resident was in the hallway every day; he/she liked to sit close to the elevator and talk to other residents and staff. Interview with the DON on 09/22/16 at 6:46 PM revealed she was also the Infection Control Coordinator. The DON stated that normally the Registered Nurse (RN) Supervisor was responsible for monitoring to ensure labs were obtained on residents as ordered by the physician, but the facility currently did not have a RN Supervisor. She stated she was also responsible for ensuring labs were obtained and received as ordered. Further interview revealed she was not sure why Resident #12's culture was not obtained until 09/13/16 when the physician's orders [REDACTED]. The DON stated she did not consider initiating contact precautions for Resident #12 from 09/11/16 until 09/19/16 or covering his/her right index finger with a bandage although she observed redness and a pustule in the middle of the wound. Furthermore, she stated Resident #12 should have been put in contact precautions on 09/11/16 until an official [DIAGNOSES REDACTED]. She stated that she used a tracking sheet to monitor infections every month and monitors for trends. The DON stated she was unable to adequately monitor infection control concerns and laboratory values because she was also working night shift as a staff nurse when there was not a night shift nurse available. Interview with the Medical Director on 09/23/16 at 5:05 PM revealed she ordered Resident #12 to have a wound culture of his/her right index finger if there was no improvement by 09/11/16. She stated she was not aware the culture was not obtained until 09/13/16. She further stated that the resident's finger should have been covered while awaiting the culture results and the resident should have been in contact precautions; however she chose not to follow contact precautions procedures. 2. Review of Resident #13's medical record revealed the facility admitted the resident on 01/13/15 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed the resident was assessed to be absent of skin infections, rashes, etc. Further review of the MDS revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of three (3) which indicated severe cognitive impairment. Observation of Resident #13 on 09/20/16 at 9:48 AM revealed the resident was on the bed on his/her right side. Observation on 09/22/16 revealed a bedpan inside of a clear plastic bag under the resident's bed. No signage or personal protective equipment was observed outside of the resident's room throughout the survey. Review of the physician's orders [REDACTED]. Review of a Nursing Note dated 09/17/16, revealed an assessment of the buttocks revealed multiple small yellow fluid filled blisters. Review of the physician's orders [REDACTED]. Interview with CNA #1 on 09/22/16 at 7:05 PM revealed she had worked with Resident #13 and that she knew the resident had some blisters on his/her buttocks, but she was not aware that Resident #13 had Impetigo Infection. Further interview revealed the resident had not been on contact precautions. She stated she received resident care information during shift report and from the CNA Care Card. However, she was not informed of the Impetigo in report. Interview with CNA #3 on 09/22/16 at 7:25 PM revealed he was not aware that Resident #13 had Impetigo infection on his/her buttocks. He stated that he had provided incontinent care for the resident multiple times during his shift. CNA #3 further stated that the resident did not wear a brief currently because he/she has some kind of blisters to his/her buttocks and that he was told to leave the resident open to air. Further interview revealed he received information related to resident care from the CNA Care Card and during shift report. However, he was not informed of the Impetigo in report or from the CNA Care Card. Interview with CNA #5 on 09/23/16 at 1:00 PM revealed she was not aware of Resident #13's [DIAGNOSES REDACTED]. She stated she relied on the CNA Care Card and shift report to know if a resident had a change in condition or required contact precautions. She stated she was not told of any infections; however, she was told by the nurse on shift to make sure she wore gloves while providing care to Resident #13. She stated she always wore gloves when providing care to all residents whether or not they had an infection. Interview with LPN #1 on 09/23/16 at 7:56 PM revealed she was aware Resident #13 had Impetigo. She stated the resident was not put in contact precautions after the [DIAGNOSES REDACTED]. She further stated that the DON was responsible for education and in services provided and that she had not received any in services since she was hired. Further interview revealed she was not familiar with the facility's policy and procedure on contact precautions. Interview with the DON/Infection Control Coordinator on 09/22/16 at 5:59 PM revealed she assessed the rash on Resident #13's buttocks and called the Medical Director on 09/17/16 to describe what she observed. She stated the resident was diagnosed with [REDACTED]. Further interview with the DON/Infection Control Coordinator revealed she was unaware the resident was contagious for up to 24 (twenty-four) hours after starting antibiotic therapy. She stated the CNAs should have been made aware of residents with infections so they could take the necessary precautions to prevent spread of infection to other residents. Interview with the Medical Director on 09/23/16 at 5:05 PM, revealed the DON called her on 09/17/16 and described the rash to Resident #13's buttocks and that the DON's best guess was that the resident had Impetigo. She stated that she ordered the resident to start Keflex 500 (five hundred) mg 4 (four) times a day for 10 (ten) days. Further interview revealed that the Medical Director chose not to put Resident #13 into contact precautions and continue standard precautions because she was not sure if the resident truly had Impetigo since she did not visually assess the resident until 09/21/16. 3. (A) Review of the Maintenance Cleaning & Disinfecting Guidelines for the Assure Platinum Meter (glucometer machine), not dated, revealed guidelines included cleaning and disinfecting the meter between patient tests to avoid cross-contamination issues. The policy further stated Super Sani-Cloth and Super Sani-Cloth HB Germicidal Disposable Wipes were pre-moistened towelettes that were acceptable to use to disinfect glucometer machines. According to the Centers for Disease Control (CDC) Guidelines, updated March 23, 2011, Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Review of the facility's policy for cleaning the glucometer machines titled Super Sani-Cloth Germicidal Disposable Wipes, not dated, revealed staff were to disinfect the glucometer machines with a single use Super Sani-Cloth Germicidal Disposable Wipe after each resident use and allow machines to dry for 2 (two) minutes. Review of the facility's policy Disposal of Medications, Syringes, and Needles (not dated) revealed used syringes and needles are disposed of safely and in accordance with applicable laws and safety regulations. Immediately after use, syringes and needles are placed into puncture resistant, one-way containers specifically designed for that purpose. Review of Resident #1's medical record revealed the facility readmitted Resident #1 on 09/02/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS assessment dated [DATE] revealed the facility assessed Resident #1 to have a Brief Interview of Mental Status (BIMS) score of five (5) which indicated severe cognitive impairment. Review of the physician's orders [REDACTED].#1 was ordered blood glucose monitoring four (4) times a day and sliding scale insulin ([MEDICATION NAME]) 100 (one hundred) units/milliliter was also ordered four (4) times daily. During observations of the noon medication pass conducted on 09/21/16 at 11:40 AM, Licensed Practical Nurse (LPN) #1 was observed to obtain Resident #1's blood glucose via finger stick. LPN #1 entered Resident #1's room and donned one glove and asked another nurse to obtain another glove. She then obtained a trash can with the ungloved hand and moved it close to the bedside. When the other glove was given to her she put it on the hand she used to handle the trash can and obtained the blood glucose without washing her hands. After obtaining the blood glucose, LPN #1 left Resident #1's room to obtain the insulin [MEDICATION NAME] to administer Resident #1's insulin. When returning to Resident #1's room, LPN #1 did not wash her hands. Observation of Blood Glucose Monitoring on 09/23/16 at 4:51 PM revealed LPN #1 cleaned two (2) glucometer machines with alcohol prep pads prior to use and then placed them on top of the medication cart while she gathered the remaining supplies. She then proceeded to check Resident #1's blood glucose level. After checking Resident #1's blood glucose, she placed the used lancet inside of a paper towel and discarded it into the trash can in Resident #1's room. (B.) During observations of the noon medication pass conducted on 09/21/16 at 12:06 PM, Licensed Practical Nurse (LPN) #1 was observed to obtain Unsampled Resident #A's blood glucose via finger stick. After obtaining the blood glucose from Unsampled Resident A, LPN #1 left the room to obtain the insulin [MEDICATION NAME] without washing her hands. After administering the Humalog five (5) units, LPN #1 threw the lancet from the blood glucose monitoring test into the trash can. LPN #1 left Resident #1's room and put the glucometer back into the medication drawer without cleaning it. Observation of Blood Glucose Monitoring on 09/23/16 at 5:00 PM revealed LPN #1 used a glucometer machine that she had previously cleaned with alcohol prep pads to monitor Unsampled Resident A's blood glucose. After checking Unsampled Resident A's blood glucose, she place the used lancet inside of a paper towel and discarded it into the trashcan in Unsampled Resident A's room. Review of Unsampled Resident A's medical record revealed the facility admitted Unsampled Resident A on 09/23/15 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Unsampled Resident A to have a Brief Interview of Mental Status (BIMS) score of nine (9) which indicated moderate cognitive impairment. Review of the physician's orders [REDACTED]. Interview with LPN #1 on 09/23/16 at 7:56 PM revealed she usually used Super Sani-Cloth Germicidal Disposable Wipes to disinfect the glucometer machines between each resident use. She stated that since she could not locate any of the wipes she used the alcohol prep pads to clean the machines. LPN #1 stated she had not been trained by the facility on how to disinfect the glucometer machines, but she realized through her nursing education that alcohol prep pads were not an effective disinfectant and would not prevent spread of infections. Further interview revealed she was required to notify the Medical Records Coordinator, who ordered supplies, when she was low on Super Sani-Cloth Germicidal Disposable Wipes. LPN #1 stated she had not informed the Medical Records Coordinator and that she ran out of the disinfecting wipes on 09/23/16 after performing the 7:00 AM blood glucose monitoring. Furthermore, she stated she should not have discarded the glucose testing lancets in the trashcans in Resident #1 and Unsampled Resident A's room. She stated she was not trained by the facility on discarding lancets but by using her nursing judgement and education, she knew she should have discarded the lancets in the red sharps container. Further interview revealed she was trained to wash her hands before and after providing resident care, and when entering and exiting a resident's room. Interview further revealed she did not know why she put the glucometer back into the medication drawer without cleaning it. Interview with the Medical Record Coordinator on 09/23/16 at 9:00 PM revealed she was responsible for ordering supplies for the staff to use to provide care. She stated she ordered the Super Sani-Cloth Germicidal Disposable Wipes to clean the glucometer machines after each resident use and was not aware that the nurses had run out of the wipes. She stated she tried to go to the floor daily to check the inventory of supplies, but she did not always get to because she also worked as a staff nurse on the floor on night shift after she worked all day as the Medical Records Coordinator. The Medical Records Coordinator stated she was unable to fulfill all of her duties because of the number of hours she works at the facility. Interview with the DON/Infection Control Coordinator on 09/22/16 at 5:59 PM revealed she was not aware that the facility was out of Super Sani-Cloth Germicidal Disposable Wipes. She stated staff was supposed to inform her or the Medical Records Coordinator if they were running low on the disinfecting wipes. She stated the Medical Records Coordinator was responsible for ordering the wipes. Further interview revealed staff should not use alcohol prep pads to clean the glucometer machines because they do not disinfect and prevent possible spread of infections. Further interview with the DON/Infection Control Coordinator, on 09/22/16 revealed there was a resident with MRSA (Resident #12) and a resident with Impetigo (Resident #13) that were both Diabetics and were monitored daily using the glucometer machines that were observed being cleaned with alcohol prep pads. She stated she was not aware of nursing staff disposing of lancets in resident trashcans after use. Further interview revealed lancets should always be disposed of after use in a sharps container. She further stated that she had not provided any staff trainings since starting as the DON/Infection Control Coordinator in April 2016 because she was also working night shift on the floor due to inadequate staffing. Further interview revealed staff were expected to wash their hands between glove changes and when entering and exiting residents' rooms. Furthermore she stated staff had been overworked and she thought that was causing a lot of the infection control issues. 4. Review of the facility's policy Handwashing/Hand Hygiene with a revision date of August 2012 revealed This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Employees must wash their hands for at least 15 (fifteen) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: before and after direct resident contact (for which hand hygiene is indicated by acceptable professional practice); before and after performing any invasive procedure (e.g., finger stick blood sampling); before and after changing a dressing; after handling soiled or used linens, dressings, bedpans, catheters and urinals; after removing gloves or aprons. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% [MEDICATION NAME] or [MEDICATION NAME] for all the following situations: before and after direct contact with residents; before preparing or handling medications; before handling clean or soiled dressings, gauze pads, etc.; before moving from a contaminated body site to a clean body site during resident care; after handling used dressings, contaminated equipment, etc.; after removing gloves. Hand hygiene is always the final step after removing and disposing of personal protective equipment. The use of gloves does not replace handwashing/hand hygiene. Review of the facility's policy Care System Guideline Skin Care, not dated, did not address how to perform skin assessments. A.) Review of Resident #2's medical record revealed the facility admitted the resident on 04/02/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) of 7 (seven) indicating severe cognitive impairment. Review of the facility's policy Dressings, Dry/Clean with a revision date of August 2011 revealed, the purpose of this procedure was to provide guidelines for the application of dry, clean dressings. Wash and dry your hands thoroughly, put on clean gloves, loosen tape and remove soiled dressing. Pull glove over dressing and discard into plastic or biohazard bag. Wash and dry your hands thoroughly. Put on gloves. Cleanse the wound, use dry gauze to pat the wound dry, and apply ordered dressing and secure with tape. Discard disposable items into the designated container, remove disposable gloves, and discard into designated container. Wash and dry your hands thoroughly Observation on 09/20/16 at 3:48 PM revealed Licensed Practical Nurse (LPN) #1 conducted a skin assessment of Resident #2. LPN #1 washed her hands and donned gloves. The LPN started the skin assessment at the resident's feet, looking between the resident's toes and proceeded to continue the skin assessment. She then assessed the resident's perineal area and continued the skin assessment up the resident's body to the resident's head. Observation revealed LPN #1 examined the resident's feet and perineal area and did not wash her hands and change gloves before touching the rest of the resident's body. After the skin assessment was performed LPN #1 was then observed providing wound care. LPN #1 washed her hands and donned gloves, after removing the dressing from the resident's sacral area LPN #1 removed her gloves and donned clean gloves without washing or sanitizing her hands. She then was observed to clean the resident's wound and removed her gloves and donned clean gloves, again without washing or sanitizing her hands. She then proceeded to put the clean dressing on the resident's sacral area and then looked under the resident's breasts and arms. She then removed her gloves and washed her hands after she finished the skin assessment and wound care. Interview conducted with LPN #1 on 09/23/16 at 7:56 PM, revealed she learned how to do a skin assessment in nursing school, and she knew a skin assessment should start at the resident's head. LPN #1 stated she had been trained to wash her hands and change gloves before, after, and during resident care/assessment if she was going from a dirty area to a clean area. She also stated, I realize I didn't change my gloves after touching the resident's genital area. LPN #1 stated she has not been trained on handwashing/hand hygiene while working at this facility. Further interview revealed she should have washed her hands or sanitized her hands in between each glove change while providing wound care and after applying the clean dressing to the resident's sacral area. She stated she was trained on hand hygiene during wound care in nursing school and that she had not had any training at this facility. B.) Review of Resident #13's medical record revealed the facility admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS dated [DATE] revealed the facility resident was assessed to be absent of skin infections, rashes, etc. Further review of the MDS revealed the facility assessed the resident to have a BIMS of 3 (three) which indicated severe cognitive impairment. Observation on 09/23/16 at 2:19 PM revealed LPN #2 and Kentucky Medication Assistant (KMA) #1 conducted a skin assessment of Resident #13. LPN #2 and KMA #1 washed their hands and donned gloves. The LPN started the skin assessment at the resident's buttocks by resident request. She then proceeded to assess the resident's perineal area and then continued the skin assessment from the resident's feet and continuing to the resident's head without washing their hands or changing their gloves. KMA #1 helped to assess the resident's perineal area and then continued to help position the resident while LPN #2 finished the skin assessment. LPN #2 and KMA #1 then repositioned Resident #13 before removing their gloves. They were then observed to remove their gloves and wash their hands prior to leaving the resident's room. Interview with LPN #2 on 09/23/16 at 6:55 PM revealed she was trained to start skin asses

Based on observation, interview, record review, the facility's Administrator Job Position Description, and the Kentucky Revised Statute (KRS) it was determined the administrator 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 well-being for four (4) of fourteen (14) sampled residents (Residents #1, #12, #13, and #14) and one (1) unsampled resident (Resident A). The administrator failed to ensure its infection control policies and procedures were effectively and efficiently implemented to ensure residents were protected from the spread of infection. Resident #12 was noted to have redness and a draining pustule to the right index finger on [DATE]. A Physician's Order was obtained to clean the wound daily and collect a culture of the wound if it was not improved by [DATE]. The facility failed to obtain the wound culture as ordered ([DATE]); it was not collected until [DATE]. However, the facility failed to follow-up on the results until [DATE] when the resident was diagnosed with [REDACTED]. Resident #13 also had a [DIAGNOSES REDACTED]. Furthermore, Licensed Practical Nurse (LPN #1) failed to disinfect a glucometer (machine used to monitor blood glucose levels) according to facility guidelines and manufacturer's recommendations to sanitize and prevent the spread of infections. In addition, the Director of Nursing, the Minimum Data Set Nurse, and the Medical Records Nurse were required to work extra shifts due to a nursing shortage to provide direct resident care as well as attempt to be responsible for their normal duties. As a result, there was limited monitoring and supervision to ensure safe and acceptable infection control practices and techniques were followed to protect residents from the potential spread of infectious disease. The facility's failure to have effective administrator in place to assure the facility was administered in a manner that promoted, protected and enhanced the health and safety of each resident, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE], was determined to exist on [DATE], and is ongoing in the areas of 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.30 Nursing Services (F353), 42 CFR 483.65 Infection Control (F441), and 42 CFR 483.75 Administration (F490, F493, F502, and F520). The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Review of the Administrator Job Position Description (dated [DATE]) revealed the administrator was accountable to direct, oversee, and manage the twenty-four/seven day to day operations of the facility. The job description identified the administrator's responsibilities to include: to ensure compliance with state and federal regulations, to ensure quality care and services would be provided to all residents, to lead an effective Quality Assurance and Process Improvement (QAPI) Program, and to ensure an effective program for recruitment, retention, orientation, and training of staff. Review of the facility policy Infection Control with a revision date of [DATE] revealed This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the facility's infection control policies and practices were to: prevent, detect, investigate, and control infections in the facility The Quality Assessment and Assurance Committee, through the Infection Control Committee, shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they were implemented and followed. Review of KRS 216A.080 revealed no person shall be eligible to practice long-term care administration in this state unless: he or she shall make written application to the board on such forms as are provided therefor, he or she provides proof satisfactory to the board that he or she is of good moral character and is otherwise suitable, he or she has passed an examination approved by the board by promulgation of an administrative regulation. When an applicant has met the requirements as provided herein, the board shall issue the applicant a license to practice long-term care administration in this state. Interview on [DATE] at 9:25 PM with the Acting Administrator, revealed when she initially came to the facility approximately two (2) years ago, she had a temporary administrator's license that was good for six (6) months (which expired [DATE]). She stated she had taken and failed the administrator's test twice, and currently did not have a permit or license to serve as administrator. However, this Acting Administrator, who did not have a license or permit to practice in the state, stated she had been designated by the governing body as the acting administrator of the facility and was responsible to oversee the day-to-day operations of the facility. The Acting Administrator stated that she attended the QAPI meetings and was responsible for staffing the facility in addition to making sure all policies/procedures were being implemented and followed by staff, and ensuring the residents received the care they should receive. She stated she had tried to recruit nurses through newspaper and radio ads, offering sign on bonus, and through contract staffing agency. The Acting Administrator stated she had reported staffing concerns/shortage to the Governing Body (RVP #1) and after a wage comparison analysis had been done; a wage increase had been improved for starting salary for nurses. In addition, the Acting Administrator stated she also communicated with RVP #1 through emails, text messages, and weekly financial reports. The Acting Administrator stated she was not aware Resident #12 and #13 had been diagnosed with [REDACTED]. Interview with Regional Vice President (RVP) #1 on [DATE] at 9:40 AM, and on [DATE] at 6:20 PM, confirmed she was aware the Acting Administrator's temporary permit had expired [DATE] and that the Acting Administrator had not successfully completed the Administrator's test to be a licensed administrator for the facility. RVP #1 stated she served as governing body for the facility and as the licensed administrator for the facility and was responsible for providing oversight/supervision for the Acting Administrator. However, RVP #1 stated she had not been in the facility since [DATE]. RVP #1 stated she had received a promotion within the corporation in [DATE] and designated RVP #2 to provide supervision to the Acting Administrator. According to RVP #1, RVP #2 had been coming to the facility every other week and an administrator from another facility, Administrator #3, had been coming one (1) day each week to provide supervision/assistance with administrative duties. However, review of documentation provided by the facility of RVP #2 and Administrator #3 visits' revealed RVP #2 was at the facility only one (1) day in July and [DATE] and three (3) days in [DATE]. Administrator #3 visited the facility one (1) day in [DATE], five (5) days in [DATE], and three (3) days in [DATE].

Based on interview, review of the facility's policies, and review of the Kentucky Revised Statutes (KRS) 216A.080 was determined the Governing Body failed to establish and implement policies and procedures regarding the management and operation of the facility; and the governing body failed to appoint an administrator who was licensed by the state and responsible for the management of the facility. Review of the facility's compliance history revealed the State Survey Agency identified on [DATE] that the facility did not have a licensed administrator. The facility's [DATE] plan to correct the identified deficient practice revealed the Regional Vice President (RVP) was serving as a mentor to the Acting Administrator and would serve in the role of Administrator at the facility. Interview with the Acting Administrator revealed that although she had taken the licensing examination on two (2) occasions since the deficient practice was identified on [DATE], she failed to pass the examinations and was still acting as the administrator of the facility without the appropriate license. (Refer to F353, F441, F490, F520.) The facility's failure to ensure an effective governing body was in place and to appoint a licensed administrator to assure the facility was administered in a manner that promoted, protected and enhanced the health and safety of each resident, has caused or is likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE], was determined to exist on [DATE], and is ongoing in the areas of 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.30 Nursing Services (F353), 42 CFR 483.65 Infection Control (F441), and 42 CFR 483.75 Administration (F490, F493, F502, and F520). The facility was notified of the Immediate Jeopardy on [DATE]. The findings include: Interview with the Acting Administrator on [DATE], at 7:30 PM, revealed the facility did not have a policy related to Governing Body for the facility. Review of KRS 216A.080 revealed no person shall be eligible to practice long-term care administration in this state unless: he or she shall make written application to the board on such forms as are provided therefor, he or she provides proof satisfactory to the board that he or she is of good moral character and is otherwise suitable, he or she has passed an examination approved by the board by promulgation of an administrative regulation. When an applicant has met the requirements as provided herein, the board shall issue the applicant a license to practice long-term care administration in this state. A post-survey interview with a representative from the Kentucky Board of Licensure for Long-Term Care Administrators on [DATE] at 11:00 AM revealed a temporary permit was issued when someone applied for a long term care administrator's license in the state and the permit was valid for six (6) months. The representative further stated if the person requesting the license did not pass the licensing exam within the six (6) month time frame, they could reapply for another temporary permit and could take the licensing exam four (4) times per calendar year. Interview with the Acting Administrator on [DATE], at 9:45 AM, revealed, she had been the Acting Administrator during the survey conducted in [DATE]. The Acting Administrator stated she had failed the administrator test twice, but had not rescheduled to take the test again due to being busy at the facility, no time to study, and due to personal issues. The Acting Administrator further stated the Regional Vice President (RVP) #1 provided oversight through emails, text, phone calls, and weekly reports. Further interview revealed, since the RVP #1 had received a promotion within the corporation in [DATE], another RVP (#2) had been coming to the facility every other week, and an administrator (#3) from another facility had been coming one (1) day each week to provide assistance with administrative duties. Interview with the RVP #1 on [DATE] at 9:40 AM, and on [DATE], at 6:20 PM, revealed she served as the governing body for the facility and was responsible to appoint a licensed administrator for the facility. RVP #1 stated the Acting Administrator was originally transferred to the facility as the Acting Administrator in training with a temporary work permit that was effective for six (6) months and the permit expired in [DATE]. After the Acting Administrator unsuccessfully attempted the administrator's test twice, RVP #1 stated the Acting Administrator was sent for additional training in [DATE] for preparation to retake the test. RVP #1 stated she was aware the Acting Administrator had not successfully completed the Administrator's test for licensure. RVP #1 also confirmed she had received a promotion within the corporation in [DATE] and had not been in the facility since [DATE]. RVP #1 stated after she was promoted, she assigned other corporate staff (RVP #2) and Administrator #3 to go to the facility to occasionally provide oversite for the Acting Administrator, but never appointed a licensed administrator to oversee the facility. However, RVP #1 stated she did correspond with the Acting Administrator through weekly reports and phone calls and was aware the facility was experiencing staffing issues with nurses. When questioned why RVP #2 had not been assigned the role of licensed administrator, RVP #1 replied, (RVP #2) was in the process of evaluating the Acting Administrator's progress and we were hoping she would have her license by now. Documentation was provided by the facility of the visits from RVP #2 and Administrator #3. The RVP #2 was at the facility to provide oversight to the Acting Administrator one (1) day in July and [DATE] and three (3) days in [DATE]. Administrator #3 visited the facility one (1) day in [DATE], five (5) days in [DATE], and three (3) days in [DATE] to provide oversight to the Acting Administrator. RVP #1 had not been at the facility since [DATE].

Based on interview, record review, and facility policy review it was determined the facility failed to obtain laboratory services to meet the needs of three (3) of fourteen (14) sampled residents (Residents #1, #2 and #12). The facility identified Resident #12 as having a draining pustule with a physician's orders [REDACTED]. The facility failed to obtain the culture on 09/11/16 as ordered; the culture was collected on 09/13/16. Furthermore, the facility failed to follow up and get the results of the culture. Record review revealed the culture was complete on 09/17/16, but the facility did not get the results until 09/19/16 that showed Resident #12 had [MEDICAL CONDITION] (MRSA) (a contagious infection that is resistant to the usual antibiotics) in the right index finger. Resident #1 and Resident #2 had physician's orders [REDACTED]. However, there was no evidence the laboratory tests had been obtained as ordered by the physician. The facility's failure to have an effective system in place to ensure laboratory service to meet the needs of each resident placed residents at risk for serious injury, harm, impairment, and death. Immediate Jeopardy was identified on 09/23/16, was determined to exist on 09/09/16, and is ongoing in the areas of 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.30 Nursing Services (F353), 42 CFR 483.65 Infection Control (F441), and 42 CFR 483.75 Administration (F490, F493, F502, and F520). The facility was notified of the Immediate Jeopardy on 09/23/16. The findings include: Interview on 09/23/16 at 4:03 PM with the Administrator #3 (an administrator from a sister facility) revealed the facility did not have a policy concerning laboratory services. 1. Review of Resident #12's medical record revealed the facility admitted the resident on 10/24/01 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS) score of nine (9) indicating the resident had moderate cognitive impairment. Review of the physician's orders [REDACTED]. Review of laboratory results revealed no culture was obtained on 09/11/16. Review of the physician's orders [REDACTED]. Review of the laboratory results revealed a culture was obtained on 09/13/16 and it was noted the resident had [MEDICAL CONDITION] (MRSA) infection to his/her right index finger. Further review of the laboratory report revealed the laboratory received the [DIAGNOSES REDACTED]. Post survey interview with the Diagnostic Laboratory Supervisor on 09/28/16 at 11:07 AM revealed the laboratory received the results of the culture on 09/17/16 but the facility was not notified until 09/19/16. He stated 09/17/16 was on a Saturday and the laboratory was closed on the weekends. He further stated the laboratory has someone that works on-call on the weekends and is responsible for notifying the facilities of any critical lab values or results. Further interview revealed he was not sure why the on-call laboratory technician did not notify the facility on 09/17/16. He stated he was not sure of the procedure for notifying the facility [MEDICAL CONDITION] infections. 2. Review of the medical record revealed the facility readmitted Resident #1 on 09/02/16 with [DIAGNOSES REDACTED]. Further review of the medical record for Resident #1 revealed physician's orders [REDACTED]. However, the laboratory test for the BMP level was obtained on 11/11/15, 12/03/15, 09/15/16, and 09/16/16. The lab test for HbA1c level was obtained on 11/11/15 and 12/03/15. 3. Review of the medical record for Resident #2 revealed the facility admitted the resident on 04/02/10 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the laboratory reports revealed the facility obtained the BMP on 06/10/16 but failed to obtain a Magnesium level. Interview with the Director of Nursing (DON) on 09/23/16 at 11:57 PM revealed normally the Registered Nurse (RN) Supervisor was responsible to ensure laboratory tests were conducted as ordered. However, she stated the facility did not have a RN Supervisor at this time. Further interview revealed the DON tried to ensure the lab slips were put into the lab book. She revealed she did not always have time to follow-up on all the lab tests due to also having to work as a staff nurse on the floor. Interview further revealed when the physician calls for a lab test to be repeated, the night shift nurse was responsible to fill out the lab sheet. She stated the staff nurses were usually as needed (PRN) staff and labs were being missed.

Based on interview, record review, facility policy review, and guidelines from the Centers for Disease Control (CDC) it was determined the facility failed to identify issues for which quality assessment and assurance activities were necessary, and failed to develop and implement appropriate plans of action to correct these quality deficiencies for four (4) of fourteen (14) sampled residents (Residents #1, #12, #13, and #14) and one (1) unsampled resident (Resident A). The facility identified Residents #12 and #13 to have potentially contagious infections. However, the facility failed to ensure infection control policies were implemented and direct care staff was aware of the necessary precautions to be utilized when providing care for these residents. The Quality Assurance and Performance Improvement (QAPI) Committee failed to identify these quality issues to ensure the necessary precautions to prevent the potential spread of infection to other residents and staff was addressed. The facility's failure to identify quality issues related to infection control and failure to develop and implement appropriate plans of action to correct identified quality deficiencies placed Resident #12 and the other residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 09/23/16, was determined to exist on 09/09/16, and is ongoing in the areas of 42 CFR 483.20 Resident Assessment (F280), 42 CFR 483.30 Nursing Services (F353), 42 CFR 483.65 Infection Control (F441), and 42 CFR 483.75 Administration (F490, F493, F502, and F520). The facility was notified of the Immediate Jeopardy on 09/23/16. (Refer to F353, F441, F490, and F493.) The findings include: Review of the facility's QAPI policy dated August 2015, revealed the purpose of the team was to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of the interventions. According to the Acting Administrator/QAPI Coordinator, the following committee members met monthly: Acting Administrator, DON, Social Services Director (SSD), Maintenance Supervisor, Therapy Manager, Medical Records Licensed Practical Nurse (LPN), Dietary Manager, and Minimum Data Set (MDS) Nurse. Quarterly Meetings were held with these same committee members along with the Medical Director. On 09/09/16, the facility assessed Resident #12 to have a reddened, swollen finger with drainage. Staff reported the concern to the physician and treatment was ordered. If there was no improvement, a culture was to be obtained on 09/11/16. The facility failed to obtain the culture until 09/13/16. The culture results were available 09/16/16; however, the facility failed to follow up with the laboratory and did not receive the results until 09/19/16. The resident had [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA- a type of staph bacteria). However, no further precautions were implemented and the direct care staff was not informed of the infection. The facility failed to address this issue with the QAPI Committee. On 09/17/16, the facility identified Resident #13 had multiple small yellow fluid-filled blisters on the buttocks. According to physician's orders [REDACTED]. No further precautions were implemented and the direct care staff was not informed of the infection. The facility failed to bring this issue to the QAPI Committee. Interview conducted with the Infection Control Nurse (ICN) on 09/22/16 at 5:59 PM, and on 09/23/16 at 1:10 PM, revealed she also served as the Director of Nurses for the facility and had been at the facility since 08/31/16. She stated she had tracked/trended the infections for any common factors and was aware Resident #12 [MEDICAL CONDITION] and Resident #13 had impetigo. The ICN further stated the staff nurses should make the Certified Nurse Aide (CNA) direct care staff aware of infections or special precautions for the residents when the CNA reported to work. However, the ICN stated she had not had an opportunity to monitor or provide training related to infection control practices/techniques to ensure infection control policy and procedures were implemented because she was working as the DON and a staff nurse two (2) to three (3) shifts each week. She stated these issues had not been brought to the QAPI Committee. Interview with the Acting Administrator on 09/23/16 at 9:25 PM revealed she also served as the QAPI Coordinator. The QAPI Coordinator stated the committee met monthly and infection control trend reports were provided by the DON and reviewed by the committee. She stated she was unaware of the infection control concerns related to the facility's failure to follow established infection control policies/procedures to prevent the spread of infections. Further interview revealed the QAPI committee should have identified the problems related to infection control, but she believed the failure was related to staffing issues which had resulted in a lack of monitoring and supervision to ensure infection control practices/techniques were being followed.

Based on observations, interviews, and review of facility policy, it was determined the facility failed to ensure the resident's environment remained as free from accident hazards as possible for four (4) unsampled residents (Residents C, D, E, and F) that the facility identified as residents who exhibit the behavior of wandering. The men's shower room which was unlocked, had a file cabinet underneath the sink area that was unlocked that contained two (2) curling irons, razors, shaving cream, body spray, and skin and hair cleansers. Deficient practice was cited on 08/25/16 at F323 with scope and severity at a G level; therefore, the continued noncompliance will remain at a G level. The findings include: Review of the facility's policy titled, Chemical Storage, (not dated) revealed the facility would store chemicals in a safe manner and if possible, doors would be locked for security purposes. Observations on 09/21/16 at 10:15 AM of the men's shower room on the Old Hall revealed the men's shower room which was unlocked, had a file cabinet underneath the sink area that was unlocked that contained two (2) curling irons, razors, shaving cream, body spray, and skin and hair cleansers. Interview with the Maintenance Supervisor on 09/21/16 at 10:35 AM revealed the men's shower room door did not lock. However, the file cabinet in the men's shower room used to have a padlock on it. Further interview revealed he had not received a work order from staff requesting a lock on the file cabinet.

Based on interview and record review it was determined the facility failed to review and revise the plan of care with interventions to prevent falls for one (1) of three (3) sampled residents (Resident #1). Resident #1 had an increase in falls in June 2016 related to transferring unassisted and throwing self on the floor. There was no evidence the facility revised the plan of care with interventions to prevent falls from self-transfer or behaviors and Resident #1 sustained a fall on 06/29/16 that resulted in fractured ribs. The findings include: Interview with the Assistant Administrator on 08/24/16 at 11:00 AM revealed the facility did not have a written policy for the revision of care plans for residents but utilized the Minimum Data Set (MDS) assessment process to identify needs and develop care plans for residents and it was facility practice to review and revise the plan of care after each fall. Review of the record revealed the facility admitted Resident #1 on 02/12/16. The resident had [DIAGNOSES REDACTED]. Review of the Admission Comprehensive assessment dated [DATE] revealed the facility assessed the resident to be moderately impaired for cognition with a brief interview for mental status (BIMS) score of 8. According to a quarterly MDS Assessment for Resident #1 dated 05/19/16 revealed the resident had improved in cognition to a BIMS score of 12. Further review of the quarterly assessment revealed Resident #1 was also assessed to require the extensive assistance of two staff persons for transferring and the extensive assistance of one staff person for ambulation. The resident was assessed to be continent of bowel and bladder. Review of the comprehensive care plan developed for Resident #1 based on an assessment completed on 02/19/16 revealed the resident was at risk for falls related to the problems of having a history of falls, weakness, needing assistance with activities of daily living, decreased mobility, and utilizing [MEDICAL CONDITION] medications. Interventions were added to the plan of care for staff to remind the resident to ask for assistance for all ambulation, monitor for changes in condition that may warrant the need for increased supervision/assistance, to keep the call light within reach, and to keep the room and area free of clutter. Review of facility fall investigations revealed on 06/06/16 at 11:28 AM Resident #1 was found on the floor in the resident's bathroom. According to the investigation the resident stated he/she was ambulating to the bathroom and fell . The resident was assessed to have no injuries. The resident did not use the call light for assistance and was ambulating unassisted. The interventions utilized for the resident after the fall included reminding the resident to use the call light, and a bedside commode was placed in the room at the request of the resident. Further review of the care plan revealed no evidence the facility revised the care plan or developed interventions after the 06/06/16 fall for the noncompliance with the use of a call light and getting up unassisted to prevent further falls. Additional review of facility fall investigations revealed on 06/24/16 at 8:58 AM Resident #1 told a Certified Nurse Aide (CNA) that the resident was going to throw him/her self onto the floor so the resident could go to the emergency room . The resident was found sitting on the floor and stated that he/she wanted to go to the emergency room because he/she was short of air. The resident was assessed with [REDACTED]. According to the investigation the resident had increased anxiety and agitation. A review of the care plan interventions revealed no evidence of interventions added to the care plan to address the resident's behavior or the fall on 06/24/16. Further review of fall investigations revealed on 06/28/16 at 9:00 AM Resident #1 was found lying on the floor on his/her left side with his/her pants down around the ankles with no injury. According to the investigation the resident stated, I was going to sit in that chair, and pointed toward the wheelchair. Additional review of the investigation revealed the resident was difficult to redirect with a history of purposefully falling to the floor. According to the investigation, the resident's alarm was in place and functioning properly, and a carbon [MEDICATION NAME] level was drawn for increased confusion. A review of the nurse's notes dated 06/28/16 at 9:40 AM revealed according to the note the resident had been more confused lately with increased anxiety and was difficult to redirect. Review of the care plan revealed no evidence the care plan was revised to include interventions to address the behaviors of noncompliance with the use of a call light, transferring unassisted, or the history of purposefully falling to the floor. Additional review of fall investigations revealed on 06/29/16 at 10:45 PM Resident #1 was found on the floor with injuries of skin tears to the right forearm and abrasions to the right elbow. The resident was transferred to the hospital and diagnosed with [REDACTED]. According to the investigation the resident was attempting to transfer unassisted from the wheelchair to the bed. A review of the nurse's notes dated 06/29/16 at 10:56 PM revealed the resident had altered mental status, severe confusion, and increased tremors. According to the note the resident was transferred to the hospital and returned at 6:44 AM on 06/30/16. The interventions implemented after the fall with injury included wheelchair mobility education and frequent redirection, and interventions were added to the care plan to move the resident's bed against the wall and a fall mat was placed on the floor. There was no evidence of any interventions to address the resident's altered mental status, anxiety, noncompliance with asking for assistance, or transferring unassisted. Interview with the MDS Coordinator on 08/24/16 at 9:30 AM revealed she completed the MDS assessments and developed a comprehensive assessment for residents when they were admitted to the facility following the guidelines and timeframes of the MDS assessment process. According to the MDS Coordinator, when a resident sustained [REDACTED]. The fall was reviewed the next working day at the morning meeting and the interventions were reviewed to ensure the interventions were appropriate and if additional interventions were needed to prevent further falls. The MDS Coordinator did not know why the care plan for Resent #1 was not revised after the falls on 06/24/16 and 06/28/16. Additional interview revealed the resident did use alarms to prevent the resident from transferring unassisted but the alarms were not added to the plan of care for Resident #1 because there was no doctor's order for the use of [REDACTED] An interview with the Assistant Administrator on 08/24/16 at 11:00 AM revealed if a resident had a fall they were assessed by the nurse, and an incident report and fall investigation were initiated. The Assistant Administrator stated the nurse was to try to determine the cause of the fall and implement an intervention to try and prevent further falls. The fall was reviewed the next working day in the morning meeting and interventions were reviewed by the team to ensure the intervention was appropriate and additional interventions were added to the care plan by the MDS Coordinator if needed. The Assistant Administrator could not remember and did not provide documentation to explain if the care plan for Resident #1 was reviewed and revised to prevent further falls after Resident #1 sustained falls on 06/24/16 and 06/28/16.

Based on interview, record review, and a review of the facility falls policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistive devices to prevent accidents. Resident #1 had a history of [REDACTED]. The facility failed to investigate the falls to determine the cause of the falls, and to prevent further falls. Resident #1 fell on [DATE] and sustained fractured ribs as a result of the fall. The findings include: Review of the facility falls policy titled Care System Guideline Falls, undated, revealed after a resident sustained [REDACTED]. Further review of the policy revealed the interdisciplinary team reviewed the fall investigation and summarized the team recommendations for interventions. Further review of the policy revealed patterns or trends in falls, such as numbers, locations, and time of day, were reviewed by the Quality Assurance Performance Improvement (QAPI) Committee. Review of the medical record for Resident #1 revealed the facility admitted the resident on 02/12/16 with [DIAGNOSES REDACTED]. The resident was assessed to be at risk for falls on the admission Minimum Data Set (MDS) assessment with a reference date of 02/19/16 and sustained three falls within five days of admission to the facility. Review of the admission comprehensive MDS assessment dated [DATE] revealed Resident #1 was assessed to have a brief interview for mental status (BIMS) score of 8 which indicated the resident was moderately impaired for cognition. According to a quarterly MDS assessment dated [DATE] Resident #1 was assessed by the facility to have improved cognition to a BIMS score of 12. The MDS further revealed the resident required the extensive assistance of two staff persons to transfer and the extensive assistance of one staff person for ambulation. According to the assessment the resident was assessed as being continent of bowel and occasionally incontinent of urine. Further review of the assessment revealed the resident did not have a history of falling prior to admission but had a history of [REDACTED]. Review of the comprehensive care plan developed for Resident #1 based on an assessment completed on 02/19/16 revealed the resident had problems of being at risk for falls related to having a history of falls, weakness, needing assistance with activities of daily living, having decreased mobility, and utilizing psychotropic medications. Interventions were developed for staff to remind the resident to ask for assistance for all ambulation, to monitor for changes in condition that may warrant the need for increased supervision/assistance, to keep the resident's call light within reach, and to keep the resident's room and area free of clutter. Review of nursing notes revealed on 06/06/16 at 11:28 AM Resident #1 was found on the floor in the resident's bathroom. A review of the investigation of the fall revealed the resident stated he/she was ambulating to the bathroom and fell . The resident was assessed to have no injury and it was determined the resident did not use the call light for assistance according to the investigation. The resident was reminded to use the call light and a bedside commode was placed in the room at the request of the resident. Review of the care plan revealed no evidence the facility developed interventions to prevent further falls or to address the resident's noncompliance with the use of the call light. Review of nursing notes revealed on 06/24/16 at 8:58 AM Resident #1 told a Certified Nurse Aide (CNA) that the resident was going to throw self onto the floor so the resident could go to the emergency room . The CNA reported the information to the nurse. According to the note, when the nurse entered the resident's room the resident was sitting on the floor and stated that he/she wanted to go to the emergency room because he/she was short of air. A review of the fall investigation revealed the resident was assessed with [REDACTED]. The resident was assisted back to bed and the filter on the oxygen concentrator was cleaned. The resident was currently on an antibiotic and had increased confusion and agitation according to the fall investigation. Review of the care plan revealed no evidence the facility developed interventions to prevent further falls or interventions to address behaviors that led to the fall. Review of the nursing notes revealed on 06/28/16 at 9:00 AM Resident #1 was lying on the floor on his/her left side with his/her pants down around the ankles. According to the notes the resident stated, I was going to sit in that chair, and pointed toward the wheelchair. Further review of the note revealed the resident was difficult to redirect with a history of purposefully falling to the floor. Review of the fall investigation revealed the resident was assessed to have no injury, the resident's alarm was in place and functioning properly, and a carbon dioxide level was drawn due to increased confusion. Review of the care plan revealed no evidence the facility developed interventions to prevent further falls or addressed Resident #1's noncompliance related to transferring without assistance and not utilizing the call light. Review of the nurse's notes revealed on 06/29/16 at 10:45 PM, Resident #1 was found on the floor with injuries of skin tears to the right forearm and abrasions to the right elbow. According to the nurse's note Resident #1 had an altered mental status, severe confusion, and increased tremors. The resident was transferred to the hospital and diagnosed with [REDACTED]. Review of the fall investigation revealed the resident was attempting to transfer unassisted from the wheelchair to the bed. The interventions implemented after the fall on 06/29/16 were wheelchair mobility education and frequent redirection. A review of the falls care plan revealed the resident's bed was moved against the wall and a fall mat was placed on the floor. There were no interventions to address the resident's altered mental status, severe anxiety, noncompliance with using the call light, or transferring without assistance. Interview conducted with Licensed Practical Nurse (LPN) #1 on 08/23/16 at 12:50 PM revealed the LPN had provided care and assessed Resident #1 after the resident had fallen on 06/24/16 and 06/28/16. According to LPN #1 when the resident fell the resident was assessed and if injuries were identified the physician was notified for orders and if needed the resident was sent to the hospital. According to LPN #1, a CNA reported to her that the resident was going to throw him/her self on the floor because the resident wanted to go to the hospital. Further interview revealed the LPN went to the resident's room and found the resident sitting on the floor stating he/she wanted to go the hospital because the oxygen wasn't working. The LPN stated she checked the resident's oxygen level and the level was normal for the resident. Further interview revealed she changed the filter on the oxygen concentrator. The resident became calmer and didn't want to go to the hospital. Further interview revealed the resident was on the floor on 06/28/16 and was attempting to transfer to the wheelchair. The resident was confused and a carbon dioxide level was ordered for the resident due to increased confusion. Further interview with the LPN revealed Resident #1 had a history of [REDACTED]. The LPN stated she completed the post fall investigation. She stated she talked with the resident and the resident was anxious about his/her oxygen. The LPN stated she did not consider the need for increased supervision for the resident. Interview with the MDS Coordinator on 08/24/16 at 9:30 AM revealed Resident #1 had a risk of falls upon admission to the facility and a care plan was developed for the resident with interventions to try and prevent falls. Further interview revealed when the resident had a fall on 06/06/16, a bedside commode was added as an intervention to the care plan to prevent further falls. Further interview revealed the resident did have an alarm as an intervention but the alarm was not care planned due to the alarm not being ordered by the physician. The MDS nurse stated when a resident had a fall, the fall was discussed in the morning meeting and interventions were reviewed for appropriateness and changed or new interventions added to address the needs of the resident. The MDS nurse did not consider interventions of increased supervision due to transferring unassisted or fall mat and placing the bed against the wall until the resident sustained [REDACTED]. Interview with the Assistant Administrator on 08/24/16 at 11:00 AM revealed that if a resident had a fall, the resident was assessed by the nurse and an incident report and fall investigation were initiated. The nurse was to try to determine the cause of the fall and implement interventions to try and prevent further falls. The Assistant Administrator stated the fall was reviewed the next working day in the morning meeting and interventions were reviewed. According to the Assistant Administrator there was no evidence that the facility had tracked or trended falls for Resident #1.