Breckinridge Memorial Nursing Facility

F-F656

The findings include:

Review of the facility's policy titled, Assessments, created January 2014, revealed a comprehensive assessment was to be completed within 14 days of a resident's admission. Per review, the comprehensive assessment was also to be completed quarterly, and when there was a significant change in a resident's physical or mental condition that was not normally resolved without further intervention by staff or by starting standard disease related clinical interventions. Continued review revealed the policy addressed the care area of wandering; however, not elopement.

In interview on 12/19/2024 at 1:20 PM, the Assistant Director of Nursing (ADON) stated the facility did not have a policy for Elopement or Wandering Assessments.

Review of the facility's policy titled, Code [NAME] (Missing Patient/Resident), last revised 09/2023, revealed

the policy described the procedure for staff to follow when a resident went missing from their department.

Review of the facility's policy titled, Resident Rights and Responsibilities, with an effective date of 01/01/2000, revealed the resident had the right to a safe and secure environment safeguarded by clinical and non-clinical personnel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 20 185285 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185285 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breckinridge Memorial Nursing Facility 1011 Old Highway 60 Hardinsburg, KY 40143

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the Adult Transmitter manual (for the resident monitoring devices) revealed it contained information regarding the use of the device, transmitter testing, and how to place the device on a resident. Level of Harm - Immediate jeopardy to resident health or Review of the electronic medical record (EMR) for Resident R1 revealed the facility admitted the resident on safety 08/10/2022 with diagnoses that included: diabetes type II, aphasia, hemiplegia/hemiparesis, hypertension, hyperlipidemia, and depression. Residents Affected - Few Continued review of Resident R1's EMR revealed Wandering Risk Assessments dated 08/10/2022 and 05/04/2023.

Review of the Wandering Risk assessment dated [DATE REDACTED], revealed the facility assessed Resident R1 as not independently mobile, not having exit seeking behaviors, not exhibiting wandering behaviors, and not having

the ability to exit the facility. Review of the Wandering Risk assessment dated [DATE REDACTED], revealed the facility again assessed Resident R1 as not being independently mobile, not demonstrating exit seeking behaviors, not having wandering behaviors, not having a history of elopement. Continued review of the 05/04/2023, Wandering Risk Assessment for Resident R1 revealed the resident had the ability to exit the facility. Further review of Resident R1's EMR revealed an additional Elopement Risk assessment dated [DATE REDACTED], which noted Resident R1 as having no elopement attempts, no wandering behaviors, and as being independently mobile.

Review of the Activities of Daily Living (ADLs) documentation charted by the Certified Nurse Aides (CNA's)

on 04/28/2024, revealed Resident R1 had ADL care performed at 9:02 AM and 7:59 PM on 04/28/2024.

In interview on 12/19/2024 at 1:20 PM, the ADON stated the CNAs did not have an area to chart resident checks on their flowsheets.

Review of the Quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/24/2024, revealed the facility assessed Resident R1 as having a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident had been unable to complete the assessment. Per review of the MDS, the facility assessed Resident R1 as not exhibiting any behaviors of wandering. Continued review revealed the facility assessed Resident R1 as having impairment to both the upper and lower extremities on one side and to use a wheelchair. Further review revealed the facility also assessed Resident R1 as needing assistance for chair to bed transfers, and for moving from sitting to standing. In addition, review revealed the facility assessed Resident R1 as not having the ability to walk.

Review of Resident R1's Comprehensive Care Plan (CCP) dated 02/14/2024, revealed the facility had not care planned the resident for wandering or exit seeking behaviors. Continued review of Resident R1's CCP revealed the facility care planned the resident on 04/28/2024 (the date of her elopement from the facility), for being an elopement risk and wanderer.

Review of the Nursing Narrative Note for Resident R1 dated 04/28/2024 at 5:49 PM, electronically signed by Registered Nurse (RN) 4, revealed the Certified Nurse Aide (CNA, no specific aide identified) came to get Registered Nurse (RN) 4 to tell her the resident had been found by housekeeping in an elevator on the first floor, of the hospital in which the SNF was located. Per review, the housekeeper brought Resident R1 back up to the unit (facility). Continued review revealed the Medical Director was notified, and a wander guard (monitoring device) was placed on Resident R1's left ankle, and the resident's family also notified. Further review revealed Resident R1 was educated on the purpose of the wander guard.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 20 185285 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185285 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breckinridge Memorial Nursing Facility 1011 Old Highway 60 Hardinsburg, KY 40143

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the Facility's Incident Report dated 04/28/2924 at 4:22 PM, revealed RN 1, from the acute care on

the first floor, found Resident R1 in her wheelchair in the lobby of the building. Per review, CNA 5 went to the lobby Level of Harm - Immediate and brought Resident R1 back to the unit (facility). Review revealed the ADON, resident's Family Member (FM) 3, and jeopardy to resident health or Medical Director were notified and an order received for a wander guard (monitoring device) According to safety review of the Report, the investigation noted the facility's security cameras were reviewed, and showed Resident R1 leaving the unit (facility) at 3:58 PM via the elevator. Continued review revealed Resident R1 was observed on the Residents Affected - Few video exiting the elevator at 3:59 PM where she propelled herself into the lobby and down the hallway toward Radiology. Continued review revealed at 4:22 PM a nurse (RN 1) from the acute care floor was seen with Resident R1. Review revealed CNA 5 was notified and was seen on the video attending to Resident R1 at 4:24 PM and returning her to the facility on the second floor. Per continued review, interviews with staff revealed Resident R1 had been self-propelling in the hallway as she normally did, and a CNA (not identified by name) reported after

she returned from her lunch break, she had not seen Resident R1 in the hallway and checked the resident's room, but had not found Resident R1 there either. Further review revealed the CNA also reported while she was walking to ask

the other CNA where Resident R1 was, they received the call notifying them that the resident was downstairs (in the lobby). Additionally, review revealed Resident R1 was assessed and found to have no injuries, and had been assessed as not wandering aimlessly nor being considered an elopement risk. Review further revealed Resident R1, was interviewed; however, due to her expressive aphasia, when asked about leaving the facility she shook her head back and forth as if to indicate no.

Observation of Resident R1 on 12/16/2024 at 4:56 PM, revealed the resident was seated in her wheelchair in the hallways and was rolling herself about the unit (facility).

The State Survey Agency (SSA) Surveyor attempted to interview Resident R1 on 12/16/2024 at 4:56 PM; however,

the resident only answered yes to the Surveyor's question regarding her name. All the other questions the SSA Surveyor asked were met with silence.

In interview with RN 1 on 12/17/2024 at 3:58 PM, she stated she worked in acute care in the hospital where

the SNF unit was located. RN 1 stated she found Resident R1 in the first-floor lobby, pushing on the exit door trying to get out the door which led to the parking lot. She said Resident R1 was in a wheelchair when she found her, and had a coke and snacks with her. RN 1 reported she approached Resident R1 and asked what the resident what she was doing and what unit she was from. She stated Resident R1 told her she was trying to leave. RN 1 said she had a cafeteria staff member call the SNF unit (where Resident R1 resided) to let them know Resident R1 was in the lobby. She said

she stayed with Resident R1 until a staff member from the SNF unit came to take her back to the unit. RN 1 stated she thought the elopement occurred around 4:00 to 5:00 PM, and no one was in the business office located near

the lobby. She further stated she had never seen any other residents in the lobby unless they were with staff or family and had never seen Resident R1 back in the lobby since.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 20 185285 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185285 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breckinridge Memorial Nursing Facility 1011 Old Highway 60 Hardinsburg, KY 40143

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In interview with FM 3 (Resident R1's POA) on 12/17/2024 at 7:03 PM, she stated she had been notified the resident got off the unit; however, could not remember how long it took them to tell her after the incident occurred. Level of Harm - Immediate She stated she did not think there was a lapse of time between when her mother (Resident R1) got off the unit and jeopardy to resident health or when the facility notified her. FM 3 said Resident R1 rolled up and down the hallways (of the facility) in her wheelchair, safety but she had never got off the unit before that incident. She reported Resident R1 had been virtually non-verbal since her stroke [AGE] years prior. The Family Member stated family frequently took Resident R1 outside for fresh air, so Residents Affected - Few the resident knew the way out of the building prior to her elopement. She said since the incident however,

they had not taken Resident R1 out of the facility. FM 3 reported after Resident R1 got off the unit, staff kept a close eye on her and the resident now had a wander guard in place to prevent her from getting off the unit again.

In a follow up interview on 12/19/2024 at 11:54 AM with FM 3, she stated no one had been to visit Resident R1 on 04/28/2024, the day the resident eloped. She stated she could not remember if anyone had taken Resident R1 out of

the facility (either outside, to eat or to shop) in the month preceding her elopement either.

In interview with CNA 2 on 12/18/2024 at 9:18 AM, she stated she had worked part time at the facility for two to three years, and in that time had never seen Resident R1 exhibit exit seeking behaviors. She stated however, in the past when Resident R1's daughters or sister came for a visit the resident seemed like she wanted to leave with them because she would become more unsettled after their visits.

In interview with CNA 8 on 12/19/2024 at 11:27 AM, she stated she remembered Resident R1 having a lot of exit seeking behaviors in the month prior to her elopement. CNA 8 reported she had been physically assaulted by Resident R1 when the resident was trying to get off the unit and she (the CNA) tried to stop Resident R1 from getting on the elevator. She stated she told nursing staff, RN 4 and the former DON/RN 6, and management (the present ADON and former DON) had been aware of Resident R1's exit seeking behaviors prior to her elopement. The CNA said staff were told they had to watch Resident R1 closely to prevent her from leaving the unit. She reported in the month (April) Resident R1 tried to get off the unit at least three to four times, but staff had been able to retrieve her most of the times. CNA 8 stated however, twice Resident R1 had gotten on the elevator, one being the day she eloped. She explained the day of the week or time of day that Resident R1 attempted to get out was not a factor because she had tried to leave on different shifts and on different days. CNA 8 further stated she thought if Resident R1 had an opportunity to get off the unit she would try and leave now.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 20 185285 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185285 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breckinridge Memorial Nursing Facility 1011 Old Highway 60 Hardinsburg, KY 40143

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In interview with CNA 7 on 12/19/2024 at 10:56 AM, she stated on the day of Resident R1's elopement, she had been going on break when she saw Resident R1 rolling down the hallway towards the nurses' station. CNA 7 said she had Level of Harm - Immediate not thought anything about Resident R1 rolling down the hallway towards the nurses' station and consequently the jeopardy to resident health or elevators, so she left for lunch. She reported when she returned from lunch she did not see Resident R1 in the hallway safety and asked CNA 5 if Resident R1 had gone to her room, then went to the resident's room to look for her. The CNA stated housekeeping called and spoke with CNA 5, and told her Resident R1 was downstairs in the lobby. She Residents Affected - Few reported she had not seen Resident R1 when she exited the building for lunch or upon her return from lunch. CNA 7 said she did not recall what time she went to lunch but remembered CNA 6 (who was scheduled to work until 2:00 PM) had left already for the day. She stated her lunch break had lasted 30 minutes on the day Resident R1 eloped. The CNA explained she did not recall any issues with Resident R1 occurring on 04/28/2024; however, did remember the resident had been having a tough week that week. She said Resident R1 had been hitting staff and having exit seeking behaviors. CNA 7 stated she had been told in report on 04/28/2024, that the resident had tried to get out of the unit, the day before (04/27/2024). She could not recall the CNA who gave her that report though and did not know whether that CNA notified the RN of Resident R1's exit seeking behaviors (on 04/27/2024). CNA 7 further stated Resident R1 was not able to walk and could only move about the unit/facility in her wheelchair.

In interview with RN 5 on 12/19/2024 at 11:37 AM, she stated Resident R1 had no exit seeking behaviors before the elopement that she had witnessed or had been told about. RN 5 stated Resident R1 went up and down the hallway in her wheelchair, but did not try to get on the elevator. She said she and her CNAs watched Resident R1 just like they did all the other residents, making sure they were safe and accounted for. RN 5 explained she did not recall anything occurring around the time Resident R1 eloped which might have upset her. She reported Resident R1 liked to exert control and would often throw a fit if she did not get her needs met in the way she wanted. RN 5 stated Resident R1 had not tried to get out since the elopement, and she had never seen Resident R1 hanging out by the elevators.

In interview with the [NAME] Clerk (WC) on 12/18/2024 at 9:54 AM, she said she sat at the desk at the entrance to the unit and Resident R1 would have had to have gone past her to get to the elevators (when she eloped).

She stated she also took care of residents' laundry and so, was sometimes away from the desk. The WC explained she only worked Monday through Friday 7:00 AM to 3:00 PM, and had not been at work when Resident R1 eloped, as the incident occurred on a Sunday afternoon. She said she was the only WC for the unit and there was not a WC on nights and weekends. She further stated after Resident R1's elopement she had observed the resident at the elevator trying to get on it and then being removed from the elevator area by CNAs and taken back to her room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 20 185285 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185285 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breckinridge Memorial Nursing Facility 1011 Old Highway 60 Hardinsburg, KY 40143

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In an interview on 12/19/2024 at 10:42 AM, the Safety and Compliance Director (SCD) stated he had been

the person viewing the camera video footage of Resident R1's elopement with the ADON. He said however, the facility Level of Harm - Immediate no longer had that video footage because it got taped over after about a month. The SCD stated on the jeopardy to resident health or video, Resident R1 rolled down the hallway towards Radiology on the first floor of the building, but had not tried to safety access any doors along the way. Per the SCD in interview, Resident R1 was then observed to turn around and roll back the way she came from, towards the exit doors. He stated he could not recall which door in the lobby Residents Affected - Few Resident R1 had been trying to exit through. The SDC stated all the doors on the left side of the building's main corridor and the right side of the main corridor, except the main cafeteria door were locked on nights and weekends. He reported the Radiology Department, which Resident R1 passed by, had two doors located on the main hallway, one of which was always locked. The SCD said the other door to Radiology was always closed, but might not be locked if staff were working in Radiology. He stated radiology staff ensured both doors were locked if they had to go to the Emergency Department (ED). The SCD said he was not sure if staff had been

in the Radiology Department at the time the event occurred (on 04/28/2024).

In interview with the ADON on 12/19/2024 at 1:20 PM, she stated she had been the MDS Coordinator at the time of Resident R1's elopement and the SNF unit had not had a ADON at the time of Resident R1's elopement. The ADON stated Resident R1 had not had exit seeking behaviors prior to that elopement. She said Resident R1 wheeled up and down the hallway only, and never tried to get on the elevator. The ADON reported she had never been made aware of Resident R1 exhibiting exit seeking behaviors by any staff member prior to the elopement. She stated nor had she been informed of anything that went on during that day (04/28/2024) that might have upset Resident R1. Per the ADON in interview, she had been the on call for the former DON (RN 6), who was on vacation at the time of Resident R1's elopement. She said the former DON now worked full time in the hospital's Medical Surgical Unit; however, still worked Pro Re Nata (PRN) for the SNF unit. The ADON stated when she arrived at the facility

on the day of Resident R1's elopement, staff had already brought Resident R1 back upstairs and talked to the Medical Director, who ordered the wander guard device.

In continued interview on 12/19/2024 at 1:20 PM, the ADON stated she observed the camera video footage of the elopement with the SCD, Resident R1 had not tried to access any doors in the downstairs hallways. Per the ADON in interview, on the video Resident R1 had rolled down the hallway towards Radiology, then turned around and came back to the lobby prior to where she pushed on the exit door, trying to get out. The ADON said the lobby had two exit doors, but she did not remember which door in the lobby Resident R1 had been pushing on to try and exit the building. She stated Resident R1 could read and did word puzzles, and it was thought she read signs and that was why she had not tried opening other doors in the hallways. The ADON reported Resident R1 was the only resident who wandered and had tried to elope.

In interview with the DON on 12/19/2024 at 1:41 PM, she stated she had only been the DON since 06/30/2024, and had worked in the acute care unit of the hospital prior to that. The DON stated her expectations of her staff regarding residents who wandered was for staff to keep those residents safe by redirecting the resident when they were exhibiting exit seeking behaviors. She said she also expected staff to notify the nurse, ADON, DON, Administrator, Medical Director, and resident's family of those types of behaviors. According to the DON in interview, if a resident got out of the facility, she expected staff to also alert the police. She reported interventions to prevent further elopement were expected to be implemented, providing constant supervision. The DON further stated she would want someone constantly with the individual one on one (1:1) for the first few days after the elopement. She additionally said she expected staff to make sure they knew where to find all residents on an hourly basis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 20 185285 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185285 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breckinridge Memorial Nursing Facility 1011 Old Highway 60 Hardinsburg, KY 40143

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 In interview with the Administrator on 12/19/2024 at 1:50 PM, she stated the elopement of Resident R1 occurred on a weekend. The ADON called her to let her know that Resident R1 went downstairs where she was found by a staff Level of Harm - Immediate member from another department and had not sustained any injuries. She said the ADON told her staff had jeopardy to resident health or brought Resident R1 upstairs to the unit and assessed her and placed a wander guard device on her. Per the safety Administrator in interview, the ADON said she would make a report about the incident to the proper authorities and start the investigation. She stated her expectations of facility staff, regarding a resident Residents Affected - Few exhibiting exit seeking behaviors, was that they would report such information up the chain of command to

the ADON. The Administrator said she also expected staff to report the incident to the resident's family and

the Medical Director. She said the ADON would alert her and the DON. The Administrator reported interventions staff should put in place to prevent further elopements were to put the resident on closer supervision, and it would depend on the resident's mobility and condition that would dictate how often the resident should have eyes laid on them. The Administrator stated staff should keep the at risk resident in line of sight at all times after an elopement, and place a wander guard device on resident. She stated immobile residents should be seen by staff hourly and mobile residents more frequently. The Administrator further stated if Resident R1 was out of her room, staff should keep an eye on her regularly and should take her to where they were providing care for other residents care in order to observe her more often.

The facility provided an acceptable IJ Removal Plan on 12/31/2024:

Resident affected by the IJ:

The facility took immediate action on 4/28/2024, to remove the IJ. Immediately following the elopement of Resident R1 that occurred on 4/28/2024, the resident was returned to the facility without any injury/harm sustained, as determined by an assessment performed by the RN on duty. Per MD order, a wander guard was placed on Resident R1's person to ensure staff would be alerted if she tried to enter the elevator/exit the 2nd floor facility again. Her family was notified, and they agreed with the plan in place. Resident R1 was able to continue to self-propel in her wheelchair throughout the facility while she worked on her crossword puzzles, as she normally did. Staff continued to complete a weekly elopement risk assessment, per the facility's assessments policy. As documentation shows, Resident R1 was not previously identified as an elopement risk, with no documentation of wandering or exit-seeking behaviors. Policy was followed and continues to be followed. Additional policy has been created to ensure a consistent plan following an elopement.

Other residents affected:

All residents are assessed weekly per assessments policy. No other residents were considered to be an elopement risk.

Training:

Upon receiving the IJ, education on wandering and exit-seeking behavior was provided to all staff of the nursing facility by the ADON. Education began on 12/23/2024 and was completed on 12/30/2024 for all actively working staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 185285 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185285 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Breckinridge Memorial Nursing Facility 1011 Old Highway 60 Hardinsburg, KY 40143

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The education was added to the orientation check list for new hires of the facility as of 12/23/2024 by the ADON. The training was an in-person verbal educational format in which employees received a copy of the Level of Harm - Immediate material presented. It described wandering and exit-seeking behaviors, and the steps that were to be taken jeopardy to resident health or should those behaviors occur within the facility. safety Monitoring: Residents Affected - Few

The MDS Coordinator completed audits to ensure the wander guard transmitter was in place for Resident R1 and elopement assessments were completed on the resident as per policy. Audits were done 04/28/2024 through 06/29/2024, with 100% compliance.

The ADON will conduct random interviews with staff to ensure understanding of the education provided. A minimum of 2 interviews will be conducted at least once weekly for six months. If staff give any indication

they were unclear of education provided, they will be reeducated immediately. Interviews began on 12/30/2024 and will continue until 100% compliance is maintained for 90 days.

The ADON will monitor resident charts weekly to ensure completion of elopement risk assessment. The audit began on 12/30/2024 and will continue until 100% compliance is maintained for 90 days. Information from all audits and interviews will be taken to quarterly QAPI meetings.

Action:

Assessments policy was revised to change the wording from wander risk assessment to Elopement Risk Assessment by ADON on 12/23/2024.

Policy named assessments was already in place for assessing residents for elopement and wandering.

A new policy titled, Elopement was created on 12/30/2024, to address steps to be completed upon an elopement occurring. Input for the policy was provided by QAPI members: CEO, DON, ADON, Safety Office, and Quality Officer. The new policy was provided to all Nurses on 12/30/2024.

Per policy, care plans are updated immediately following a change in care by the nurse on duty. Resident R1's care plan was updated on 4/28/2024, after her elopement by the RN on duty. It was not updated prior because the facility was not aware of any wandering/exit-seeking behaviors by the resident. All staff received education (see prior training section) on reporting behaviors. Care plans continue to be updated immediately by the nurse on duty and reviewed quarterly by the MDS Coordinator.

IJ removal date: 01/01/2025

Attached you will find:

1. Education sign in sheet

2. Assessments Policy

3. Elopement Policy

(The attachments referenced above are on file with the State Survey Agency.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 185285

F-F689, and Substandard Quality of Care (SQC) at 42 CFR 483.25.

The facility provided an acceptable Immediate Jeopardy Removal Plan, on 12/31/2024, alleging removal of

the IJ on 01/01/2025. The State Survey Agency (SSA) validated the IJ was removed on 01/01/2025, prior to exit on 01/03/2025. Remaining non-compliance continued at a S/S 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.

Refer to