**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the website www.weather.gov, and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received the electronic monitoring devices to prevent unsafe wandering and elopement, for 1 of 18 sampled residents, Resident (R) 1.Review of R1's Investigation Report revealed R1 was found by State Tested Nurse Aide (STNA) 2 outside the building, approximately 84 feet from the employee entrance/exit, on 08/07/2025 at 11:10 PM as she was getting out of her car from the back parking lot of Household B. Per the report, STNA2 brought R1, who appeared to be confused and was unstable with ambulation, back into the facility to get warm. During interviews conducted with facility staff who were on duty during the time of the 08/07/2025 elopement, they stated they had last seen the resident at approximately 9:30 PM and were unaware R1 left the building unsupervised until they received notice from Registered Nurse (RN) 1.The facility's failure to have an effective system in place to ensure residents' safety is likely to cause serious injury, impairment, or death, if immediate action is not taken. Immediate Jeopardy (IJ) was identified on 08/21/2025 and was determined to exist on 08/07/2025 in the area of 42 CFR 483.25. Substandard Quality of Care (SQC) was identified at 42 CFR 483.25 Quality of Care, F689. The facility was notified of IJ on 08/21/2025.The facility provided an acceptable Immediate Jeopardy Removal Plan, on 08/22/2025, alleging removal of the IJ on 08/23/2025. The State Survey Agency (SSA) validated the IJ was removed on 08/23/2025, prior to exit. Remaining non-compliance continues at a Scope and Severity of a D while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes.The findings include:Review of the facility's policy titled, Elopements and Wandering Residents, dated 08/12/2022, revealed the facility must establish and utilize a systematic approach to monitoring and managing residents at risk for elopement and or unsafe wandering, including identification and assessment risk, evaluation and analysis of hazards and risk, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. The policy also stated the IDT (Interdisciplinary Team) would evaluate the unique factors contributing to risk in order to develop a person-centered care plan, including if a resident should wear a Wander Gard bracelet.Review of R1's admission Record, located in the resident's electronic medical record (EMR), revealed the facility admitted the Resident on 07/23/2025 with diagnoses which included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, other sequelae following unspecified cerebrovascular disease, and Alzheimer's disease with late onset. Review of R1's Comprehensive Care (CCP), dated 07/25/2025, located in the resident's EMR, revealed the Resident was an elopement risk/wanderer related to impaired safety awareness and wandered aimlessly. The goal stated the resident would not leave the facility unattended. Interventions included: engage resident in purposeful activity and schedule regular walks and appropriate activity.Review of R1's Elopement Assessment, completed on admission on [DATE], revealed R1 had a history of elopement or an attempted elopement while at home as communicated by her family. Per the assessment, R1, having a history of elopement and R1's wandering behaviors were likely to affect the safety or wellbeing of self/others and was determined to be at high risk. Review of R1's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 07/25/2025, located in the resident's EMR, revealed the facility assessed R1 to have a Brief Interview for Mental Status [BIMS] score of three out of 15, which indicated she had severe cognitive impairment.Review of R1's Facility Investigation, 08/07/2025, revealed on 08/07/2025 at approximately 11:10 PM as State Trained Nurse Aide (STNA) 2 was getting out of her car to walk into the back door entrance of Household B, she found R1 sitting alone in the grass near a tree. STNA2 approached R1 and asked R1 if she was okay and did she need any help. STNA2 stated R1 appeared to be confused because R1 stated she did not know where she was. STNA2 stated she told R1 she would be okay, and she was going to take her inside so she could get warm. STNA2 assisted R1 into the building, holding her close as R1 was unstable when walking. Per the investigation, STNA2 asked R1 if she was hurt anywhere, and R1 stated she did not know. STNA2 stated once she got inside the building, she asked staff, including the DON (who was working at the time), why R1 was outside, and no one knew how or why R1 was outside the building.Review of the website www.weather.gov revealed the temperature at the facility on the evening of 08/07/2025 was 78 degrees Fahrenheit with clear skies. Review of the distance taken by R1 when she exited the facility on 08/07/2025 in a measurement taken by a measuring wheel on 08/20/2025 at 2:00 PM by the facility's Physical Therapy Assistant 1 and the State Survey Agency (SSA) Surveyor revealed from Household C to the employee entrance/exit door was 18.9 feet. A second measurement taken on 08/20/2025 at 2:58 PM with the same participants revealed, from the tree where STNA2 saw R1 to the building, was 84.4 feet.Review of the facility provided security video with the Executive Director on 08/23/2025 at 12:12 PM revealed on 08/07/2025, time unknown, Security Officer 1 was observed walking to the employee entrance door and pressed the code to unsound the alarm. Further review of the video revealed Security Office 1 did not make any observations outside the facility or complete a perimeter check to verify any resident had left the facility. Observation of R1 on 08/19/2025 at 4:27 PM revealed R1 was sitting in her wheelchair. The Resident showed no acknowledgement of the State Survey Agency (SSA) Surveyor.During an interview with STNA2 on 08/20/2025 at 2:47 PM, she stated on 08/07/2025 she was reporting to work for her shift. She stated after parking her car, she exited the vehicle and started walking toward the facility from the back parking lot of Household B. She stated she saw a person sitting alone under a tree. At first glance, she stated she thought it was an employee; then at second glance, she realized it was an older resident. She stated she had not worked in Household C and had not had a chance to get acquainted with R1, but she instantly knew the person did not belong outside. She stated she asked R1 if she was okay or hurt, and R1 stated she did not know. She stated she was able to get R1 up from the ground; however, R1 was unstable. She stated she held on close to her, hugging her to keep R1 from falling. She stated she entered the building with R1 and asked staff on Household B if they were aware R1 was outside.During an interview with STNA3 on 08/20/2025 at 2:09 PM, she stated she was working on Household C with R1 on 08/07/2025. She stated the last time she saw R1 she was sitting quietly in her wheelchair. She stated during her shift she had not seen R1 wandering or having exit seeking behaviors. STNA3 stated after R1 was found outside and was back on Household C, she got the resident ready for bed, and she stayed in bed all throughout her shift. She stated she kept a closer eye on her that night due to her exiting the facility earlier that evening. Per the interview, she stated when the door alarms sounded, staff checked immediately to see if anyone got out. She stated she did not hear the alarm go off or see a Security Officer come to the unit and turn off an alarm. The STNA stated she checked on residents every two hours to make sure everyone was in the building and did not need anything. She stated a nurse from Household B told her R1 had been outside over on their unit and had no signs of distress except for being cold, so R1 was given a blanket.During an interview with STNA1 on 08/20/2025 at 2:24 PM, she stated R1 was sitting in her wheelchair in the dining area of Household C, and she saw the resident get up to walk. She stated she asked the resident to sit down, and the resident sat down. She stated she went to Household B and came back past the dining room, and the resident was gone. She stated she thought R1's aide had put the resident to bed. She stated she did not hear the alarm and never saw a Security Officer come to Household C to turn off an alarm. She stated if a resident tried to open the door, the alarm went off. She stated the alarms only sound if a resident had a Wander Gard. She stated the employee entrance/exit door required a code or badge to enter and exit. She stated all doors were fire doors, so if one held the door handle for 15 seconds, the door would automatically open.During an interview with Security Officer 1 on 08/20/2025 at 6:33 AM, he stated he reviewed the facility's videotape of the incident, the day of R1's elopement. Per interview, he stated 30 minutes prior to the resident getting out, a family member of another resident was trying to get out and triggered the alarm. He stated when he went back 30 minutes after the prior triggered alarm, he did not think a resident had gotten out and that maybe an employee or family member set off the alarm. Security Office 1 stated he reset the alarm by entering the code. He stated he looked out the glass panels of the door, did not see anyone, and left the unit. He stated the exit door employees used to come and go were right outside of the Household C where the resident resided. He stated he reviewed the security video feed after he was informed of the elopement and got the timeline of the events with R1 that night. He stated at 10:08 PM R1 was seen at the exited door, reading the sign that stated if you press on the door handle and hold for 15 seconds the alarm would sound and the door would open. He stated the resident held the door handle for 15 seconds, and she was out of the facility. He stated he had multiple people, family members, and staff who sounded the alarm on the door. He stated R1 was escorted back to Household C at 11:19 PM. He stated he had never had any specific procedures in place for him or the security team when the alarms were triggered. During an interview with Registered Nurse (RN1) on 08/20/2025 at 3:04 PM, she stated she was the admitting nurse the night R1 came to the facility on [DATE]. She stated she completed the Elopement Assessment on admission on [DATE], and R1 scored as a high risk. She stated if the resident who scored as high risk did not want to be at the facility, they could be confused and wander. She stated she added wandering/elopement to the Resident's Baseline Care Plan, so staff was aware to keep an eye on the resident. She stated with R1 being high risk, the nursing staff would document the resident's whereabouts and put a Wander Gard on the resident. She stated the night of 07/23/2025 with R1, she did not know why she did not apply the Wander Gard to the resident. She stated it was nighttime, and she figured R1 would just stay in bed. In an interview with the Director of Nursing (DON) on 08/19/2025 at 4:43 PM, she stated the resident was not wearing a Wander Gard at the time she was found outside the facility. She stated due to R1's behaviors and being high risk for wandering and elopement, R1 should have been given a Wander Gard. She stated the resident was last seen by STNA3 on 08/07/2025 at approximately 9:30 PM sitting in her wheelchair in the dining room. The DON stated she was working as an RN for the shift and did not have any recollection of the resident wandering or exit seeking behaviors. She stated the resident was able to exit the building by going out the Household C employee entrance/exit. Per the DON, the Resident was found outside in the parking lot alone sitting under a tree at the back door of Household Entrance B around 11:10 PM. The DON stated there were many system failures by the facility. She stated R1 was not given a personal safety device due to her scoring on the Elopement Assessment on admission. She stated the admitting RN1 had received disciplinary action due to not applying a Wander Gard to R1. She stated Security Officer 1 also received disciplinary action as he was aware the door alarm was going off, cut off the door alarm by entering the code, but failed to do a security check on the perimeter to verify no resident left the facility through the door. She stated anytime an alarm was triggered it needed to be treated as if a resident could have possibly left the facility. During an interview with the Executive Director on 08/22/2025 at 3:03 PM, she stated R1 did get out of Household C where she was residing and exited the employee entrance/exit of the facility. She stated R1 should have been given a Wander Gard bracelet considering her family informed RN1, the admitting nurse, the night of 07/23/2025 that R1 had wandered/eloped from her residence and was assessed to be an elopement risk. She stated under no circumstances was it okay for an admitting nurse to think the resident would just go to bed and ignore facility policy to implement interventions to keep residents safe.The facility's IJ Removal Plan verbatim:The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 8/13/2025) The DON, ADON, SOC, and RN Manager re-evaluated all residents for risk of wandering/elopement using N Adv - Elopement Evaluation in Point Click Care. Completed 8/13/2025 All residents were reassessed using the N Adv - Elopement Evaluation. 18 residents scored at 1+ on the N Adv - Elopement Evaluation as possible elopement/wandering risk. Completed 8/13/2025 The MOS Coordinator and ADON reviewed and updated care plans for the 18 identified elopement/wandering risk individuals as needed. Completed 8/13/2025 DON/RN Managers completed an audit to confirm all Wanderguards were functioning properly and in place for all residents care-planned for Wanderguards. Completed 8/13/2025 DON/RN Managers audit that nurses test the function of the wanderguard daily and placement each shift. Audit results are communicated by the DON/RN Manager at QAPI meetings until substantial compliance is achieved. All staff on all shifts received education on wandering, elopement, and resident safety from the DON, SOC, RN Manager, and ADON. 169 staff received education. 6 staff are on LOA, 47 staff are on vacation or are PRN and have not worked yet. Any staff on leave, PRN or vacation will receive education on their next scheduled work day by RN Manager/DON/ED. [NAME] Manor does not use agency staff. Completed 8/13/2025 or by their next scheduled shift. DON/Nurse Managers/ED administer quizzes to all staff. DON/Nurse Managers/ED follow up with all staff if a question was answered incorrectly, education was provided immediately. Completed 8/13/2025 or by their next scheduled shift. DON/RN Managers provided education for all licensed nurses regarding assessment and developing care plans and interventions for residents who are at risk for elopement. The Director of Facilities tested the Doors, Locks, & Alarms on both 8/7/2025 and 8/13/2025. All functioning properly. Doors, Locks & Alarms will continue to be tested weekly. An Elopement Drill was conducted on day shift and night shift on 8/22/2025 to assure staff understanding of proper process during an elopement.[NAME] Manor took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 8/13/2025 Elopements and Wandering Residents policy was reviewed by ED, VP of Operations, and SOC. Completed. No changes were made to the policy. 8/8/2025. Elopements and Wandering Residents policy was reviewed again by ED, VP of Clinical, VP of Operations and DON. No changes were made to the policy. Completed 8/11/2025. The admitting nurse completes an admission N Adv - Elopement Evaluation assessment and places interventions as appropriate. Starting on admission after 8/13/2025. The DON/Nurse Managers will audit all new admissions for elopement risk and ensure appropriate interventions are in place. Starting with admissions after 8/13/2025 until substantial compliance is achieved. The DON/Nurse Managers will audit all new admission care plans to ensure it reflects individual needs identified. Starting with new admissions after 8/13/2025 until substantial compliance is achieved. Newly hired employees will receive education on wandering, elopement, and resident safety by the DON/Nurse Managers in orientation starting 8/13/2025. An Adhoc QAPI with Medical Director, Director of Social Services, DON, and Executive Director was completed on 8/13/2025 to review QAPI plan created on 8/8/2025 Medical Director agrees with QAPI plan. DON/Nurse Managers will report results of audits, follow up and trends to QAPI committee on 8/22/2025 and will continue to report data to QAPI weekly for 4 weeks and then every other week until we are in substantial compliance. An Elopement Drill was held on 8/22/2025 at approximately 11:30am. An additional Elopement Drill will be held 8/22/2025 for night shift (after7pm) An Ad Hoc QAPI meeting is scheduled for 8/22/2025 at 8pm to discuss the results of the Elopement Drills and the IJ Abatement plan progress.Date facility alleges IJ removal: 8/23/2025

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's physician of a significant change in the resident's physical status for 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 12/01/2024, in the early hours of the morning, R3 was observed by Registered Nurse (RN) 2 to have a significant change in mental status. Despite this critical finding, RN2 failed to notify the physician about the resident's condition. At 7:00 AM, during the shift change report, RN2 relayed to Licensed Practical Nurse (LPN) 1 that the resident's mental status had deviated from the baseline during the night. However, neither nurse assessed R3 or notified the physician of his change in mental status. At approximately 11:30 AM, R3's family alerted LPN1 that R3 was febrile, unresponsive, and had tremors. The family requested the nurse to call emergency medical services (EMS) for transfer to the local emergency department (ED). R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR §483.10 Resident Rights, F580 at a Scope and Severity (S/S) of a J related to KY00044335. The facility was notified of the IJ on 12/20/2024 at 1:08 PM. On 12/20/2024 at 1:08 PM, the facility's Executive Director, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility failed to ensure the physician was notified of a change in condition for Resident (R) 3 when the resident experienced a significant altered mental status and life-threatening deterioration. This failure to notify the physician of the need to alter treatment is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM as alleged, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a G (isolated actual harm that is not immediate jeopardy) at F580. 2. In addition, on 10/18/2024, an unstageable wound to R2's left heel was found by the physical therapy (PT) staff. The nursing staff was notified. However, the nursing staff failed to notify the physician of a change in condition (CIC) immediately. A review of a progress note dated 10/23/2024 by the Wound Care Physician revealed the provider noted a newly acquired unstageable deep tissue injury (DTI) measuring (length (L) x width (W) x depth (D)): 5.0 x 8.0 x 0.1 centimeter (cm) with etiology (cause) noted from pressure. Refer to F655, F684, F686 The findings include: Review of the facility's policy titled, Notification of Change of Condition, undated, revealed the facility would consult with the resident's medical provider when there was a significant change in the resident's physical health. 1. Closed Record Review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord); post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact. Continued review revealed R3 was assessed as being independent with activities of daily living (ADL), and R3 ambulated per self via wheelchair and walker. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit R3 on 12/01/2024 at 11:10 AM, they found R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of R3's CIC, and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated R3 was admitted to the local hospital's critical care unit (CCU) for several weeks. She stated R3 had returned home and required an additional 10 weeks of intravenous [IV] antibiotic therapy. Additionally, F2 stated LPN1 admitted she was made aware of R3's CIC at 7:00 AM, during the shift change report. F2 stated LPN1 told her LPN1 had not seen R3 or assessed him that morning. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated she received in report from RN2 that R3 was lethargic and had an altered mental status overnight, but RN2 reported to her that R3 was fine after aides changed him. She further stated she did not assess R3's condition at the beginning of her shift. Furthermore, LPN1 stated she did not chart or notify the physician of the resident's CIC. LPN1 stated at the time the family made her aware of his CIC at around 11:00 AM, she had not seen R3 and had not given him his 9:00 AM dose of IV antibiotics. During an interview with the Advanced Practice Registered Nurse (APRN) on 12/20/2024 at 1:15 PM, she stated she expected the nursing staff to notify the provider of any changes in the resident's mental or physical condition. The APRN stated nursing staff should notify the provider immediately when a resident's mental status changed. She further stated that making the provider aware of a CIC was necessary for the resident's safety and well-being. During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated the nurse on duty should have communicated changes in the resident's condition immediately to the providers. He stated nurses were to use their nursing judgment and notify the provider on-call in emergency situations. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure the safety of the residents. 2. Closed Record Review of R2's Face Sheet, located in the resident's EMR, revealed the facility admitted the resident on 10/09/2024 with diagnoses to include idiopathic hydrocephalus, peripheral vascular disease, and chronic total occlusion of artery of the extremities. Review of R2's admission MDS, with an ARD of 10/14/2024, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated R2 was moderately cognitively impaired. Continued review revealed R2 was assessed as being dependent (helper did all the effort) with mobility, toileting, and transfers. R2 was assessed as needing substantial/maximal assist (helper did more than half the effort) with positioning in bed. Review of R2's Physical Therapy Treatment Encounter Note, dated 10/18/2024 at 5:11 PM, revealed the Physical Therapist (PT) noted an unstageable wound to R2's left heel. According to the note, PT notified nursing staff and educated them to float R2's heels when in bed. Review of R2's EMR revealed there was no documentation by nursing on 10/18/2024 related to the wound found by PT. Additionally, there was no documentation indicating the facility notified the physician about R2's change in physical condition. Review of R2's Occupational Therapy (OT) Treatment Encounter Note, dated 10/19/2024 at 11:16 AM, revealed R2 attempted activities of daily living (ADL) tasks but could not continue due to a wound that caused a barrier to OT treatment. The note stated the resident is struggling to move the left leg. Review of R2's EMR revealed there was no documentation by nursing on 10/19/2024 related to the wound found by PT. Additionally, there was no documentation indicating the facility notified the physician about R2's change in physical condition. Review of R2's Occupational Therapy (OT) Treatment Encounter Note, dated 10/21/2024 at 4:01 PM, revealed the resident had a new wound on her left lower extremity and nursing instructed OT not to stand [R2] this date. Review of R2's EMR revealed no documentation regarding the wound's worsening condition or an order for non-weight bearing status by nursing on 10/21/2024. Review of R2's Physical Therapy Treatment Encounter Note, dated 10/21/2024 at 4:58 PM, revealed the PT noted, after attempting gait training, that nursing entered the therapy gym and examined R2's left heel ulcer. According to PT, the ulcer appeared to have grown in size since 10/18/2024 and was secreting bloody drainage. Nursing instructed PT to hold gait training. Review of R2's EMR revealed no documentation regarding the wound's worsening condition by nursing on 10/21/2024. Additionally, there was no documented evidence nursing staff informed the physician about R2's change in physical condition. Review of R2's EMR revealed new orders were given by the Advanced Practice Nurse Practitioner (APRN) on 10/21/2024 at 11:39 AM, for bilateral pressure boots and new skin treatment orders. Review of Wound Evaluation and Management Summary, dated 10/23/2024, revealed the wound specialty physician noted R2 to have developed an unstageable deep tissue injury to her left heel measuring (L x W x D): 5.0 x 8.0 x 0.1 cm, with etiology noted from pressure. New treatment and medication orders were given. During an interview with F1 on 12/16/2024 at 9:26 AM, she stated R2 was currently receiving treatment at another facility for an unstageable pressure ulcer (PU) on her left heel, which she developed while at the facility. F1 expressed concern that the former Director of Nursing (DON) did not listen to the family's concerns or notify the medical provider when physical therapy discovered the pressure ulcer. During an interview with the PT Manager on 12/17/2024 at 10:55 AM, she stated she observed a change in R2's heel on 10/18/2024. The PT Manager stated the wound was closed and had a slight discoloration to the skin, but the area was red and blanchable. She stated she collaborated with the nursing staff to offload pressure and apply boots to both feet. According to the PT Manager, the wound status changed significantly from Friday (the 18th) to Monday (the 21st). She stated, on 10/21/2024, the area on R2's left heel was an open blister, and she could not complete her therapy session due to pain in R2's left foot. She stated she requested nursing staff to assess R2's left heel wound. She stated, upon assessment, the wound had grown in size and was secreting blood and drainage. During an interview with the Infection Preventionist/Wound Care Nurse (IP/WCN) on 12/19/2024 at 10:17 AM, she stated, on 10/22/2024, she completed a skin assessment on R2 and found an open area on the resident's left heel. She stated she notified the Wound Care Physician, who provided new treatment orders. During an interview with the Wound Care Physician on 12/19/2024 at 12:06 PM, she stated on 10/23/2024, she examined R2's wound and found that the resident had an unstageable deep tissue injury on the left heel caused by pressure. She stated she ordered a new treatment regimen and prescribed an oral antibiotic. Additionally, she stated she instructed the staff to have the resident wear pressure-relieving boots and to ensure the wound was offloaded. During an interview with the former DON on 12/16/2024 at 1:45 PM, she stated R2 had not been at the facility for long, and her daughter had some medical background. She stated R2 developed a wound on her left heel while at the facility and was seen by the wound care team. She stated she could not state who called the physician, but she was confident nursing staff had notified the physician immediately when the wound was discovered. She stated the nurses on duty at the time of the discovery of the wound no longer worked at the facility. During an interview with the Interim Director of Nursing (IDON) on 12/19/2024 at 9:38 AM, she stated it was her expectation for all nursing staff to follow the facility's policies and procedures regarding a resident's CIC. She stated nursing staff should notify the physician immediately of any injury, fall, or decline in status as per the policies and procedures. The IDON stated following procedures related to a resident's CIC ensured the resident received appropriate and timely care. During an interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy to notify the physician to ensure safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 was discharged from [Facility Name] on 12/1/24. Identification of Residents Affected or Likely to be affected: All residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: l. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussing IJ regarding Notification of Changes for Medical Director input. 2. Notification of Changes policy was reviewed immediately by the Director of Clinical Risk Management. Completed 12/20/24 3. The Director of Clinical Risk Manager provided education for the Director of Nursing, Executive Director and Nurse Managers regarding the Notification of Changes policy. Completed 12/20/24. 4. The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Notification of Changes policy and the plan for the abatement. Completed 12/20 5. Education was provided by Nurse Managers for all nurses and KMAs regarding Notification of Changes policy. Agency nurses were educated prior to their shift by DON/Nurse Managers. 25/28 completed = 93%, 1 nurse on leave will be educated by DON/Nurse Managers prior to her return to work., 2 staff still to complete prior to their next shift. 6. Starting 12/21/24 all nurses and KMAs who are hired will be educated by the DON/Nurse Managers regarding the Notification of Changes policy prior to working. 7. All progress notes were reviewed from 11/26/24 to current by DON/Nurse Manager for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate. Completed 12/20/24 8. Information was given to STNAs, housekeepers and dietary staff regarding what to do when you notice a change in a residents' condition. Information sent by ED via text. Completed 12/20/24. 9. Beginning 12/21/24 - The 24 hour report sheet and the 24 hour summary in Point Click Care {PCC) will be reviewed by DON/Nurse Manager daily 7 times per week for appropriate notification of changes in the morning Clinical Meeting. 10. Starting DON/Nurse Managers administer quizzes to nurses and KMAs regarding Notification of Changes in Condition and report results to QAPI team. If a question is missed, DON/Nurse Managers will educate the nurse immediately and document the education. 11. DON reported audit results regarding notification of changes missed at the 12/27 QAPI meeting and will continue to report audit results and how findings were resolved to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 12. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Managers, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed. 13. Next QAPI meeting scheduled for 1/3/25. Date facility alleges IJ removal: 1/2/2025

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 11/26/2024, the facility admitted R3 with an intrathecal (the space between the spinal cord and the membranes that protect it) pain pump infection, which was being treated with intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC) line. The facility failed to develop a person centered baseline care plan with interventions to address R3's infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR §483.21 Baseline Care Plan, F655 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 12/20/2024 at 1:11 PM. On 12/20/2024 at 1:11 PM, the facility's Executive Director, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility's failure to ensure a baseline person-centered care plan was developed based on R3's admission assessment to ensure resident safety is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM as alleged, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a G (isolated actual harm that is not immediate jeopardy) at F655. 2. Additionally, the facility admitted R2 on 10/09/2024 and assessed the resident to be at risk for developing pressure injuries. On 10/18/2024 an unstageable wound to R2's left heel was identified by the Physical Therapy staff, with nursing staff notified by them. R2's baseline care plan, still in effect, did not address or revise for R2's existing skin issues or breakdown. Refer to F580, F684, F686, and F760 The findings include: Review of the facility's policy titled, Baseline Care Plan, dated 02/27/2023, revealed it was developed and implemented to include the minimum healthcare information necessary to properly care for a resident. Per the policy, baseline care plans would be developed and implemented within 48 hours of a resident's admission. 1. Review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord), post-surgical infection of the intrathecal pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated R3 was cognitively intact. Continued review revealed R3 was assessed as having a wound infection, was taking antibiotics, and had a PICC line to receive the antibiotics at time of admission. Review of R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, R3 was ordered cefepime (an antibiotic), 2 grams (gm) intravenous (IV) twice daily at 9:00 AM and 9:00 PM for the treatment of infections. Additionally, on the same date, R3 was prescribed metronidazole (antibiotic), 500 milligrams (mg) one oral tablet taken every eight hours for infections. Continued review revealed scheduled PICC line flush using heparin (an anti-coagulant) 10 units/milliliter (u/ml); use 5 ml IV every 12 hours then flush the PICC with 10 ml normal saline and follow with 5 ml of 10 units/ml heparin in a 10 cubic centimeter (cc) syringe. Additionally, per the orders, nurses were to monitor and document any signs and symptoms of infection every shift. Review of R3's Baseline Care Plan, dated 11/26/2024, located in the resident's EMR, revealed there was no documented evidence showing the facility had created a baseline care plan with treatments and interventions to address R3's current infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by Licensed Practical Nurse (LPN) 1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated the nurse was responsible for the resident's admission. She stated she had not been aware she was responsible for initiating baseline care plans for residents. LPN1 stated further the MDS Nurse initiated and revised care plans as needed. 2. Closed Record Review of R2's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 10/09/2024, with diagnoses to include idiopathic hydrocephalus, peripheral vascular disease, and chronic total occlusion of artery of the extremities. Review of R2's admission MDS, with an ARD of 10/14/2024, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated R2 was moderately cognitively impaired. Continued review revealed R2 was assessed as being at risk for developing pressure ulcers/injuries. Review of R2's Baseline Care Plan, dated 10/09/2024, located in the resident's EMR, revealed there was no documented evidence showing the facility had created a baseline care plan to address impaired skin. Further review indicated R2's baseline care plan did not include any documentation regarding actual skin breakdown, nor were there any treatments or interventions implemented to prevent further worsening. During an interview with F1 on 12/16/2024 at 9:26 AM, she stated R2 was currently receiving treatment at another facility for an unstageable pressure ulcer (PU) on her left heel, which she developed while at the facility. F1 stated the family requested a transfer to a local facility on 10/25/2024. During an interview with the PT Manager on 12/17/2024 at 10:55 AM, she stated she observed a change in R2's heel on 10/18/2024. The PT Manager stated the wound was closed and had a slight discoloration to the skin, but the area was red and blanchable. She stated she collaborated with the nursing staff to offload pressure and apply boots to both feet. According to the PT Manager, the wound status changed significantly from Friday (the 18th) to Monday (the 21st). On 10/21/2024 the area on R2's left heel was an open blister, and she could not complete her therapy session due to pain in her left foot. She stated she requested nursing staff to assess R2's left heel wound. Upon assessment, she stated the wound had grown in size and was secreting blood and drainage. During a telephone interview with the Wound Care Physician on 12/19/2024 at 12:06 PM, she stated on 10/23/2024, she examined R2's wound and found that the resident had an unstageable deep tissue injury on the left heel caused by pressure. She stated she ordered a new treatment regimen and prescribed an oral antibiotic. Additionally, she stated she instructed the staff to have the resident wear pressure-relieving boots and to ensure the wound was offloaded. During an interview with Registered Nurse (RN) 4 on 12/18/2024 at 12:51 PM, she stated the admitting nurse or Unit Manager initiated the baseline care plan based on the resident's diagnoses and discharge paperwork. RN4 stated interventions were initiated by nursing staff that addressed the resident's current needs to prevent decline such as infections or skin breakdown. RN4 stated care plans needed to be initiated the day of admission and reviewed by the Supervising Nurse or MDS Nurse within 48 hours. She stated nursing staff or nursing leadership should revise the plan of care to include services to prevent pressure ulcers. During an interview with RN6 on 01/03/2025 at 3:34 PM, she stated the baseline care plan should include nurse-initiated interventions based on diagnoses and discharge paperwork and be completed on the day of admission. She stated the baseline care plan should be reviewed by the MDS Nurse within 48 hours. She stated each care plan should be resident-centered. RN6 stated resident assessments and diagnosis codes helped the nursing staff ensure that interventions addressing the resident's current needs were initiated, which was crucial for improving care and preventing declines in health. During an interview with the Infection Preventionist/Wound Care Nurse (IP/WCN) on 12/19/2024 at 10:17 AM, the IP/WCN stated that R2's care plan should have identified the existing skin breakdown upon admission due to her diagnosis of an arterial pressure injury to the left calf. She stated interventions should have been included to prevent further deterioration of the wound or the development of new wounds. During an interview with the MDS Nurse on 01/03/2025 at 11:06 AM, she stated baseline care plans should be initiated within 48 hours of a resident's admission. She stated if she was in the building when a newly admitted resident arrived at the facility, she assisted the admitting nurse with assessments and documenting a baseline care plan. The MDS Nurse stated, however, sometimes residents were admitted late on the evening shift or on a weekend, and in those cases, the process was for nursing management to review the baseline care plans within 48 hours. The MDS Nurse stated the baseline care plan should include health and safety concerns to prevent a decline in the resident's health. She stated the baseline care plan should also include any special needs such as antibiotic therapy, IV therapy, or PICC line care. According to the MDS Nurse, she stated she did not know why R2 and R3's baseline care plans were not completed to include interventions to reflect the residents' needs at the time of admission. During an interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated the facility's process for initiating a new resident's baseline care plan was for the admitting nurse to initiate it within 48 hours, with interventions that addressed the resident's immediate needs. The IDON stated those interventions should include health and safety concerns to prevent a decline in the resident's health. She stated the baseline care plan should also include any special needs such as antibiotic therapy, IV therapy, or PICC line care. The IDON was unable to identify the process breakdown in ensuring that R2 and R3's baseline care plans were completed. During an interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policies. She stated it was her expectation that the admitting nurse, or member of the nursing management present for an admission, entered a baseline care plan within 48 hours of a new resident's admission. She stated it was important to ensure safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 discharged from [Facility Name] on 12/1/24. Identification of Residents Affected or Likely to be affected: Residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: 1. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussing IJ regarding Baseline Care Plans for Medical Director input. 2. The Director of Clinical Risk Management educated the DON and Nurse Managers on the Baseline Care Plan Policy. Completed 12/20/24 3. The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Baseline Care Plan policy and the plan for the abatement. Completed 12/20 4. The Director of Clinical Reimbursement and the MDS nurse audited all baseline care plans for completion and accuracy. If the baseline care plan was missed during this time frame, comprehensive care plans from admissions dated 11/1/24 through 12/20/24 have been completed. 12/20/24. 5. Education was provided by DON/Nurse Managers for all nurses and KMAs regarding the Baseline Care Plan policy. Agency nurses are educated prior to their shift by the DON/Nurse Managers. 100% of nurses educated ( 1 nurse on leave will be educated prior to returning to work by the DON/Nurse Managers.) 6. Starting on 12/26/24 DON/Nurse Managers administer quizzes to nurses and KMAs regarding Baseline Care Plans and report results to the QAPI team weekly. Any nurses/KMAs not receiving a 100% correct will receive 1:1 education provided by the DON/Nurse Managers. 7. Beginning 12/21/24 - DON/Nurse Managers will audit Baseline Care Plan daily 7 days per week in morning clinical meetings. 100% Baseline Care Plans have been completed per policy. 8. DON/Nurse Managers reported results of the audit of baseline care plans, issues that needed resolution and how resolution was achieved to the QAPI committee on 12/27/24 and will continue to report to QAPI weekly for 4 weeks and then every other week until substantial compliance is achieved. 9. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed. 10. The next QAPI meeting is scheduled for 1/3/25 and will review Baseline Care Plan completion. Date facility alleges IJ removal: 1/2/2025

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to promptly identify and intervene with a significant change in a resident's condition, for the resident to receive treatment and care in accordance with professional standards of practice for 1 of 11 sampled residents, Resident (R) 3. R3 was admitted to the facility on [DATE] with diagnoses to include post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was to receive two weeks of intravenous (IV) antibiotic therapy by a peripherally inserted central catheter (PICC) line. However, the resident did not receive four of those ordered doses. In addition, the MAR revealed the physician ordered metronidazole (an antibiotic) to be administered orally every eight hours, but R3 did not receive five of those doses. On 12/01/2024, in the early hours of the morning, R3 was observed by Registered Nurse (RN) 2 to have a significant change in mental status. At 7:00 AM, during the shift change, RN2 communicated to Licensed Practical Nurse (LPN) 1 that the resident's mental status had deviated from baseline during the night. However, neither nurse rounded on R3 to assess his condition and failed to notify the physician or provider. On 12/01/2024 at approximately 11:30 AM, R3's family alerted LPN1 that R3 was febrile, unresponsive, and had tremors. The family requested the nurse to call emergency medical services (EMS) for transfer to the local emergency department (ED). The resident was admitted to the hospital with life-threatening deterioration and spent five days in a critical care unit (CCU) and was in the hospital for 12 days. Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR §483.25, F684 Quality of Care at a Scope and Severity (S/S) of a J related to KY00044335. The IJ at F684 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.25. The facility was notified of the IJ on 12/20/2024 at 1:20 PM. On 12/20/2024 at 1:20 PM, the facility's Executive Director, Director of Corporate Risk Management, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility's failure to have an effective system to ensure residents received treatment and care in accordance with professional standards of practice has caused or is likely to cause serious injury, serious harm, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM as alleged, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a D (no actual harm with a potential for more than minimal harm that is not immediate jeopardy) at F684. Refer to F580, F655, and F760 The findings include: Review of the facility's policy titled, Provision of Quality of Care, dated 12/20/2024, revealed the facility would ensure residents received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person centered care plan, and the resident's choice. Further review revealed each resident would be provided care and services to attain or maintain his or her highest practicable physical mental and psychosocial well-being. Additionally, per the policy, all employees were responsible for following established policies and procedures. Closed record review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024, with diagnoses to include post laminectomy syndrome, post-surgical infection of the intrathecal pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact. Continued review revealed R3 was assessed as having a wound infection and receiving oral and IV antibiotic therapy. Review of R3's Baseline Care Plan, dated 11/26/2024, located in the resident's EMR, revealed there was no documented evidence showing the facility had created a baseline care plan with treatments and interventions to address R3's current infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. Review of R3's EMR clinical documentation revealed, from 11/27/2024 at 11:43 AM until 12/01/2024 at 11:52 AM, no nursing progress notes were documented that showed nursing staff had performed clinical assessments per professional standards of practice to evaluate the resident's condition. Review of R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, R3 was ordered cefepime, 2 grams (gm) IV twice daily at 9:00 AM and 9:00 PM for the treatment of infections. Additionally, on the same date, R3 was prescribed metronidazole, 500 milligrams (mg) one oral tablet taken every eight hours for infections. Review of R3's Medication Administration Record (MAR), dated 11/2024, and located in the resident's EMR, revealed the facility failed to administer three doses of ordered cefepime on 11/26/2024 at 9:00 PM; 11/27/2024 at 9:00 AM; and on 11/29/2024 at 9:00 AM. Further review revealed nursing staff administered IV antibiotics to R3 outside the scheduled parameters according to facility policy on four occasions: 1) on 11/27/2024 the 9:00 PM dose was administered on 11/28/2024 at 12:06 AM, resulting in a delay of two hours and six minutes; 2) on 11/29/2024 the 9:00 PM dose was administered at 10:30 PM, resulting in a delay of 30 minutes; 3) on 11/30/2024 the 9:00 AM dose was administered at 12:36 PM, resulting in a delay of two hours and 36 minutes; and 4) on 11/30/2024 the 9:00 PM dose was administered to R3 at 12:04 AM on 12/01/2024, resulting in a delay of two hours and four minutes. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of ordered cefepime on 12/01/2024 at 9:00 AM. Review of R3's MAR, dated 11/2024, revealed the facility failed to administer the following four doses of metronidazole: 11/26/2024 at 10:00 PM; 11/27/2024 at 6:00 AM or 2:00 PM; and 11/28/2024 at 2:00 PM. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of metronidazole on 12/01/2024 at 6:00 AM. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED upon the request of family. LPN1 stated the resident's family alerted staff that R3 was not responding. LPN1 stated upon her assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024 at 2:47 PM, found in the local hospital records, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. Review of R3's Infectious Disease Progress Note, dated 12/08/2024 at 8:12 AM, found in the local hospital records, revealed R3 was admitted to the hospital and found to have an enterococcus faecium (VRE, a type of bacteria that could cause serious infections) bacteremia (a type of bacteria found in blood). Review of R3's Infectious Disease Progress Note, dated 12/12/2024 at 11:13 AM, found in the local hospital records, revealed R3 presented with a temperature of 102.2 degrees Fahrenheit (F) upon admission to the local hospital. Further review revealed the resident continued on IV and oral antibiotic therapy for an additional six weeks. Review of R3's clinical records, located in the resident's EMR, revealed there was no documentation on 11/30/2024 or 12/01/2024 by RN2 during the 7:00 PM to 7:00 AM shift related to R3's lethargy or change in mental status. Review of R3's Weights and Vitals Summary, dated 11/26/2024 through 11/29/2024, located in the resident's EMR, revealed the last documented completed set of vital signs taken on R3 was on 11/29/2024 at 2:23 PM. Observation and resident interview not conducted due to the resident being discharged from the facility. During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit R3 on 12/01/2024 at 11:10 AM, they found R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of R3's change in condition (CIC), and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated R3 was admitted to the local hospital's CCU for one week. She stated R3 had returned home and required an additional 10 weeks of IV antibiotic therapy. Additionally, F2 stated LPN1 told the family she was made aware of R3's CIC at 7:00 AM, during the shift change report. However, F2 stated LPN1 told F2 she had not seen R3 or assessed him that morning, and he had not received his 9:00 AM dose of IV antibiotic therapy. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated she received a verbal report from RN2 that R3 had been lethargic and had altered mental status overnight, but she stated RN2 stated R3 was fine after aides changed him. LPN1 stated at around 11:00 AM, when the family made her aware of R3's deterioration, she had not seen or assessed the resident and had not given him his 9:00 AM dose of antibiotic. LPN1 stated that particular day (12/01/2024) was busy and got behind on her medication administration. She stated she managed her tasks as best she could. Additionally, LPN1 stated she did not remember if she communicated her need for assistance or asked the unit coordinator (UC) for support. Furthermore, she stated residents should be checked on at least every two hours to ensure their safety, noting that rounding on a resident included entering the resident's room to visually assess their condition. On 12/18/2024 at 11:57 AM and 12/19/2024 at 12:50 PM, the State Survey Agency (SSA) Surveyor left voice messages for RN2 to return the call for an interview. The interview was not conducted because RN2 did not return the calls from the SSA Surveyor. During an interview with RN4 on 12/18/2024 at 12:51 PM, she stated nursing staff should round on every resident every hour. According to RN4, rounding included the nurse laying eyes on the resident, assessing the resident's status, and asking purposeful questions to ensure the resident's needs were met. She stated that hourly rounding was important for the resident's safety and well-being. During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated he expected the nursing staff to administer medications as ordered by the medical provider. The Medical Director stated administering antibiotics on time was important to ensure that all bacteria causing the infection were eliminated and to prevent the infection from recurring. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure quality of care and the safety of the residents. During an interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated per policy, RN2 should have notified R3's physician related to the resident's change in mental status and condition. Additionally, the IDON stated RN2 should have completed an assessment of R3's condition, which included all vital signs, and documented her findings in the resident's EMR. Furthermore, the IDON stated that LPN1 should have assessed R3 immediately after she received report from RN2. The IDON stated nursing staff should check on every resident every hour. She stated clinical rounding involved the nurse visually assessing the resident's condition and asking intentional questions to ensure that the resident's needs were being met. She stated timely assessments, notification of a change in condition, documentation, and hourly rounding were all crucial for the safety and well-being of the residents. The IDON stated her expectation was for nursing staff to follow clinical guidelines and policies and provide quality care according to current nursing care standards. During an interview with the Executive Director (ED) on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy related to quality of care. She stated it was her expectation that the facility's staff provided care according to current nursing care standards. The ED stated it was important to ensure safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 discharged from [Facility Name] on 12/1/24 Identification of Residents Affected or Likely to be affected: Residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: 1 .An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 to discuss quality of care related to Medication Administration, Baseline Care Plans, and Notification of Changes in Resident Condition for Medical Director input. Completed 12/20/24 2. Notification of Changes Policy The Baseline Care Plan Policy and the Medication Administration Policy were reviewed immediately for accuracy by the Director of Clinical Risk Management. Completed 12/20/24 3. The Executive Director, Corporate Clinical Team and DON discussed the Notification of Changes in Condition, Medication Administration, and Baseline Care Plan policies and the plan for abatement. Completed 12/20/24 4. The Executive Director, Corporate Clinical Team and DON discussed the Provision of Quality Care policy. Completed 12/20/24 5. The Director of Clinical Risk Management educated the DON, Nurse Managers and ED regarding Baseline Care Plans, Medication Administration and Notification of Changes in Resident Condition and Provision of Quality Care policies. Completed 12/20/24 6. The DON/Nurse Managers provided education for all nurses and KMAs regarding Notification of Changes, Baseline Care Plan, and Medication Administration policies and provisions of the Quality of Care policy prior to their next shift. Agency nurses received education prior to their shift by DON/Nurse Managers. 100% completion of active staff, 1 nurse on leave will be educated by the DON/Nurse Manager prior to returning to work. Completed 12/20/24. 7. Going forward all newly hired nurses and all agency staff will be educated by the DON/Nurse Managers on the Notification of Changes, Baseline Care Plan, Medication Administration, Provision of Quality Care policies and the Nurse Clinical Binder. 8. On 12/20/24 DON/Nurse Managers completed an audit of all progress notes 11/26/24 through current immediately for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate. Completed 12/20/24 9. STNAs, Housekeepers and Dining staff received information via text regarding: if they notice a change in a residents' condition that they should report it to the nurse immediately. Completed 12/20/24 10. Director of Clinical Risk Management/DON audited all missed meds for identified residents using the Medication Administration Audit Report. Completed 12/20/24 11. DON notified the Medical Director of results of the Medication Admin Audit report and asked for any new orders. No new orders given. DON notified responsible parties of any current affected residents. Completed 12/20/24 12. The Director of Clinical Reimbursement and MDS nurse audited baseline care plans for admissions 11/1/24 through 12/20/24 for completion and accuracy. If incomplete or inaccurate, comprehensive care plans have been completed by the Director of Clinical Reimbursement/MOS nurse. Completed 12/20/24 13. Beginning on 12/21/24 in morning clinical meeting- DON/Nurse Managers review 24 hour report sheet and 24 hour summary report in PCC daily 7 times per week for appropriate notification of changes in resident condition. The DON reported results of the audit to the QAPI committee on 12/27/24 and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 1. Beginning on 12/21/24 - The Medication Admin Audit Report in PCC is completed daily 7 days per week by DON/Nurse Managers. Missed medications will be reported to the MD and responsible party immediately as per policy by the DON/Nurse Manager. Report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 2. Starting on 12/21 Nurse Managers provide daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders and following the nursing process to assure quality care. 14. Beginning on 12/21/24 - Audit of baseline care plans will be by the DON/Nurse Managers daily 7 days per week with immediate follow up. 100% compliance has been achieved to date. DON reported results to QAPI committee on 12/27/24 and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved. 15. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed. 16. Next QAPI meeting scheduled for 1/3/25 (1/3/25).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy, the facility failed to have an effective system in place to ensure residents were free from significant medication errors for 1 of 2 sampled residents receiving intravenous (IV) antibiotic therapy, Resident (R) 3. On 11/26/2024, the facility admitted R3 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord) and post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was scheduled to receive two weeks of intravenous (IV) antibiotic therapy while at the facility. Review of R3's Medication Administration Record [MAR] revealed the physician had ordered cefepime (an antibiotic given for infection) to be administered IV twice daily, but he did not receive four of those ordered doses. In addition, the MAR revealed the physician ordered metronidazole (an antibiotic) to be administered orally every eight hours, but he did not receive five of those doses. On 12/01/2024 at approximately 11:30 AM, R3's family alerted Licensed Practical Nurse (LPN) 1 that R3 was febrile, unresponsive, and had tremors. The family requested the nurse to call emergency medical services (EMS) for transfer to the local emergency department (ED). R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 spent five days in a critical care unit (CCU) and was in the hospital for 12 days. Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR §483.45, F760 Free of Significant Medication Errors at a Scope and Severity (S/S) of a J related to KY00044335. The IJ at F760 also constituted Substandard Quality of Care (SQC) at 42 CFR 483.45. The facility was notified of the IJ on 12/20/2024 at 1:15 PM. On 12/20/2024 at 1:15 PM, the facility's Executive Director, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility failed to have a system to ensure R3's medications were administered as ordered and verified. This failure is likely to cause serious injury, impairment, or death. The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025. The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections. Remaining non-compliance continued at a S/S of a D (no actual harm with a potential for more than minimal harm that is not immediate jeopardy) at F760. Refer to F655 and F684 The findings include: Review of the facility's policy titled, Medication Administration, undated, revealed medications were administered as prescribed by the physician and in accordance with established professional standards of practice. Further review revealed the facility upheld the rights related to medication administration, which included ensuring medications were given at the appropriate times. Per the policy, all medications should be administered within 60 minutes prior to or after the scheduled time. Closed Record Review of R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome, post-surgical infection of the intrathecal pain pump, and idiopathic peripheral neuropathy. Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact. Review of R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, R3 was ordered cefepime, 2 grams (gm) IV twice daily at 9:00 AM and 9:00 PM for the treatment of infections. Additionally, on the same date, R3 was prescribed metronidazole, 500 milligrams (mg) one oral tablet taken every eight hours for infections. Review of R3's MAR, dated 11/2024, and located in the resident's EMR, revealed the facility failed to administer three doses of ordered cefepime on 11/26/2024 at 9:00 PM; 11/27/2024 at 9:00 AM; and on 11/29/2024 at 9:00 AM. Further review revealed nursing staff administered IV antibiotics to R3 outside the scheduled parameters according to facility policy on four occasions: 1) on 11/27/2024 the 9:00 PM dose was administered on 11/28/2024 at 12:06 AM, resulting in a delay of two hours and six minutes; 2) on 11/29/2024 the 9:00 PM dose was administered at 10:30 PM, resulting in a delay of 30 minutes; 3) on 11/30/2024 the 9:00 AM dose was administered at 12:36 PM, resulting in a delay of two hours and 36 minutes; and 4) on 11/30/2024 the 9:00 PM dose was administered to R3 at 12:04 AM on 12/01/2024, resulting in a delay of two hours and four minutes. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of ordered cefepime on 12/01/2024 at 9:00 AM. Review of R3's MAR, dated 11/2024, revealed the facility failed to administer the following four doses of metronidazole: 11/26/2024 at 10:00 PM; 11/27/2024 at 6:00 AM or 2:00 PM; and 11/28/2024 at 2:00 PM. Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of metronidazole on 12/01/2024 at 6:00 AM. Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed. Review of R3's ED Provider Notes, dated 12/01/2024, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile. His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the note revealed the physician stated, Upon my evaluation the patient [resident] had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit R3 on 12/01/2024 at 11:10 AM, they found R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of R3's change in condition (CIC), and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated R3 was admitted to the local hospital's critical care unit (CCU) for several weeks. She stated R3 had returned home and required an additional 10 weeks of intravenous [IV] antibiotic therapy. During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated at the time the family made her aware of R3's CIC at around 11:00 AM, she had not seen R3 and had not given him his 9:00 AM dose of IV antibiotics. LPN1 stated that all medications should be given as ordered. During further interview, LPN1 stated that on 12/01/2024, it was a particularly busy day, and she had fallen behind on her assessments and medication administration. She stated she had tried her best to manage her tasks. Additionally, LPN1 stated she did not recall if she communicated her need for assistance or asked the unit coordinator (UC) for support. During an interview with the Advanced Practice Registered Nurse (APRN) on 12/20/2024 at 1:15 PM, she stated she expected the nursing staff to administer medication as ordered by the medical provider. She stated administering medication on time, every time, was important to ensure that all bacteria causing the infection were eliminated. She stated this was also the best approach to prevent the infection from recurring. During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated he expected the nursing staff to administer medication as ordered by the medical provider. The Medical Director stated administering antibiotics on time was important to ensure that all bacteria causing the infection were eliminated and to prevent the infection from recurring. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure quality of care and the safety of the residents. During an interview with Registered Nurse (RN) 4/Unit Manager (RN/UM) on 12/18/2024 at 12:51 PM, she stated nursing staff should administer antibiotic medication as ordered to treat and prevent the infection from recurring. She stated that administering medication timely was important for the resident's safety and well-being. During an interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated the unit managers were responsible for auditing medication administration on their units; however, there was no formal documentation of those audits. The IDON stated it was her expectation that licensed staff should administer antibiotics as prescribed and timely to ensure the infection was treated and to prevent recurrence. She further stated that timely medication administration was crucial for the resident's safety and well-being. During an interview with the Executive Director (ED) on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff adhered to the facility's medication administration policy. The ED stated following the medical provider's orders was crucial for ensuring safe and appropriate care for all residents. The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim: Resident #3 was discharged from [Facility Name] on 12/1/24. Identification of Residents Affected or Likely to be affected: Residents currently at [Facility Name]. Actions to prevent occurrence/recurrence: l. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussed IJ regarding Medication Administration for Medical Director input. 2. The Corporate Clinical team, VP of Operations, Executive Director and DON discussed the Medication Administration policy and the plan for abatement. 12/20/24 3. The Director of Clinical Risk Management reviewed the Medication Administration policy. Completed 12/20/24. 4. The Director of Clinical Risk Management educated the DON and Nurse Managers regarding the Medication Administration policy. Completed 12/20/24 5. The Director of Clinical Risk Management and the DON audited all missed meds using the Medication Admin Audit Report in PCC and communicated with MD and responsible party as needed. Completed 12/20/24 6. The DON/Nurse Managers provided education for all nurses and KMAs regarding Medication Administration policy and the Nurse Clinical Binder. Agency Nurses are educated prior to their shift. 100% complete with 1 nurse on leave who will be educated prior to her return to work. 7. Nurses were educated by the DON/Nurse Managers on the Nurse Clinical Binder that includes information on Daily Nurse Expectations, pharmacy cut off times, admission/readmission orders, what to do when a medication is unavailable, what to do when someone admits to the facility, what to do when a resident receives new orders, what to do when sending someone to the hospital, what to do when you receive medications from the pharmacy and Medication Administration Special Considerations. Education was initially completed by the DON on [DATE]th and [DATE]th at the Monthly All Staff Clinical Meeting. Beginning 12/21 the DON/Nurse Managers started referencing the Nurse Clinical Binder as education on step by step guides for nurses and KMAs. 8. DON/Nurse Managers administer quizzes to nurses and KMAs regarding Medication Administration. DON/Nurse Managers follow up with Nurse/KMA if a question is missed and reports results to QAPI team weekly. 9. Starting 12/21/24, DON/Nurse Manager completes audit daily 7 days per week using Medication Admin Audit Report in PCC. DON/ Nurse Managers address issues immediately with appropriate nurse or KMA and assures follow up regarding notification policy. 10. Starting on 12/21 Nurse Managers provided daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders. 11. Starting with admissions on or after 1/1/25 DON/Nurse Managers compare the hospital discharge summary to the MD orders in PCC for all new admissions, within 12 hours of admission, to assure accuracy and timeliness of medication administration. Results of the audits will be reported to the QAPI committee weekly for 4 weeks and every other week until substantial compliance is achieved. 12. DON/Nurse Manager reported results of audits, follow up, and trends to QAPI committee on 12/27/24 and will continue to report data to QAPI weekly for 4 weeks and then every other week until we are in substantial compliance. 13. QAPI meeting on 12/27/24 was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IP abatement plan audits, results, and follow up were discussed. 14. The next QAPI meeting is scheduled for 1/3/25. Date facility alleges IJ removal: 1/2/2025