Every finding on record at Avir at Arbor Terrace

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #18) and (Resident #13) of three residents reviewed for PASRR Level 1 screenings.The facility failed to ensure the accuracy of the PASRR Level 1 Screening for Resident #18. The PASRR Level 1 Screening did not indicate a diagnosis of mental illness, although the diagnosis of schizophrenia was present on admission.The facility failed to refer Resident #13 for a PASARR Level II review when she was newly diagnosed with schizophrenia.This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needs.Resident #18 A record review of Resident #18's face sheet, dated 4/30/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder (chronic mental health condition characterized by a combination of symptoms, hallucinations, delusions, disorganized speech, mood disorder symptoms), depression (mental health condition that causes a persistent low mood and loss of interest in activities), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable, persistent worry about daily life events), insomnia (persistent difficulty falling asleep, staying asleep, or waking too early resulting in poor sleep quality). A record review of Resident #18's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #18's active diagnoses included anxiety, depression and schizophrenia. A record review of Resident #18's PASRR Level 1 Screening completed on 6/11/2025 by the referring hospital revealed Resident #18 did not have a primary diagnosis of dementia and no indicator of mental illness. During an interview on 4/30/2026 at 12:00PM with Resident #18 he stated he has been at the facility since May 2025 but has had several hospital stays. Resident #18 stated he has been transferred to multiple facilities per his choice. He was unsure if he ever received PASRR services prior to admitting to this facility.Resident #13A record review of Resident #13's face sheet, dated 4/30/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included depression (mental health condition that causes a persistent low mood and loss of interest in activities), vascular dementia with psychotic disturbance (cognitive decline caused by vessel damage, accompanied by delusions or hallucinations), and vascular dementia with anxiety (cognitive decline caused by vessel damage that features panic like episodes). A record review of Resident #13's comprehensive MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #13's active diagnoses included non Alzheimer's dementia (cognitive decline caused by brain diseases other than Alzheimer's), depression and schizophrenia. A record review of Resident #13's PASRR Level 1 Screening completed on 4/11/2019 by the referring hospital revealed Resident #13 had no indicator of mental illness. During an interview on 4/30/2026 at 12:15PM with Resident #13 she stated she has been at the facility since last year. Resident #13 stated she has not received services through PASRR before.During an interview on 4/30/2026 at 4:40 PM, the MDS Coordinator stated Resident #18 had a mental illness diagnosis, thus the PASRR screening was positive, not negative as reflected on the screening form. She stated a corrected screening should have been completed and sent to the local authority for evaluation. The MDS Coordinator stated Resident #13 had just received the diagnosis of schizophrenia on 3/5/2026 and she was unaware of the diagnosis. MDS Coordinator stated she needed to fill out a form to notify the Local Authority of the diagnosis. The MDS Coordinator stated PASRR was her responsibility and she would correct the issue. She stated the risk of PASRR not being accurate could be lack of services for the resident. During an interview on 4/30/26 at 4:49PM, the DON stated she expected the PASRRs to be accurate and timely. She stated if an error in a PASRR was later found, a corrected form was sent. DON stated the MDS Coordinator was responsible for the accuracy of PASRR documents. She stated residents may not have received the benefits or treatments they needed or were entitled to if the PASRR screening was inaccurate. During an interview on 4/30/2026 at 5:00PM with the Administrator she stated it was the MDS Coordinator's responsibility to update and follow through with PASRR. She stated the risk in not doing so could lead to decrease in quality of life and not receiving services that could be beneficial to the resident. During a record review of facility's policy dated 11/2023 titled PASRR revealed:6. Follow the Texas PASRR Policy for all mandatory meetings and care coordination including any changes that may require a change in residents' PASRR status.Review of the Texas Health and Human Services Detailed Item by Item Guide for Local Authorities and Nursing Facilities to Complete the PASRR Level 1 Screening Form, revised June 2023, and accessed at PASRR Forms and Instructions | Texas Health and Human Services revealed in part, The PASRR Level I (PL1) Screening Form is designed to identify individuals who are suspected of having mental illness (MI), intellectual disability (ID) or a developmental disability (DD). Developmental disabilities are also referred to as related conditions.If documentation entered on the PL1 Screening Form indicates a suspicion of MI, ID, or DD, a PASRR Evaluation (PE) must be completed to confirm PASRR eligibility. The PE is designed to confirm the suspicion of MI, ID, or DD and ensure an individual is placed in the most integrated residential setting receiving the specialized services needed to improve and maintain an individual's level of functioning.Examples of MI diagnoses are:SchizophreniaMood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder)Paranoid DisorderSevere Anxiety DisorderSchizoaffective DisorderPost-Traumatic Stress SyndromeWhat is not considered an MI:Neurocognitive Disorders, such as Alzheimer's disease, other types of dementia, Parkinson's disease, and Huntington's. (DSM-5*), Depression, unless diagnosed as Major Depression; and Anxiety, unless diagnosed with severe anxiety disorder.*Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

Based on observation, interview, and record review, the facility failed to ensure residents received reasonable accommodation of needs for 2 of 20 residents (Resident #10 and #55) reviewed for resident rights activities of daily living, received reasonable accommodation of needs . The facility failed to place Residents #10 and #55's call lights within reach. This deficient practice could affect all residents who need assistance with activities of daily living of not having needs met.Findings Include: Record review of Resident #10's admission record dated 04/30/2026 indicated he was admitted to the facility on [DATE] with diagnoses of stroke and heart failure. He was [AGE] years of age. Record review of Resident #10's MDS assessment dated [DATE] indicated in part: BIMS score of = 10 indicating resident was moderately cognitively impaired. Mobility devices = used were walker and wheelchair. Record review of Resident #10's care plan revised on 04/20/2026 indicated in part: Focus: The resident is at risk for falls related to gait/balance problems. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Record review of Resident #55's admission record dated 04/30/2026 indicated she was admitted to the facility on [DATE] with diagnoses of anxiety and unsteadiness of feet. She was [AGE] years of age. Record review of Resident #55's MDS assessment dated [DATE] indicated in part: BIMS score of= 15 indicating resident was cognitively intact. Mobility devices =used was a wheelchair. Record review of Resident #55's care plan revised on 09/27/2025 indicated in part: Focus: I am at risk for Falls/Safety. Resident will remain free of injuries related to falls and will remain in a safe environment. Assess resident's footwear for proper fit and nonskid soles. Encourage use of call light. Keep call light in reach. Observation and interview on 04/28/2026 at 11:45 AM the rest room call light string in resident room was wrapped around the grab bar by the toilet. Surveyor tried to pull the call light string but it did not trigger the call light due to the string wrapped around the grab bar. Resident #10 said he used the restroom by himself and at times he would use the call light. The resident said that the call light was hard to use due it being tied to the grab bar and sometimes it would not trigger the call light. Observation and interview on 04/30/2026 at 2:48 PM the rest room call light string in resident room was wrapped around the grab bar by the toilet. Resident #55 said she would use the toilet on her own and that if she had to use the call light she would not be able to use it as it was wrapped up on the bar. Interview on 04/30/2026 at 5:04 PM the interim DON said the call light string was supposed to be within reach at all times. She said if the call lights were not within reach then the resident's would not be able to call for help if they needed something. Interview on 04/30/2026 at 5:22 PM the Administrator said it was expected for the call lights to be within reach of the residents. The Administrator said if the call light was not at reach then the resident's would not be able to call for help. Record review of the facility policy titled Resident call system dated 01/2025 indicated in part: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance form his/her bed, from toileting/bathing facilities and from the floor.

Based on interview and record review the facility failed to develop and implement a comprehensive person -centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 3 of 9 residents (Resident #13, #18, and #26) reviewed for care plans.1. The facility failed to ensure a care plan was developed to address Resident #13's psychotropic medication use and schizophrenia diagnosis.2. The facility failed to ensure a care plan was developed to address Resident #18's psychotropic medication use and schizophrenia diagnosis.3. The facility failed to ensure a care plan was developed to address Resident #26's psychotropic medication use and PTSD diagnosis.These failures could place residents at risk for not receiving necessary care and services or having important care needs identified.Findings include:Resident #13A record review of Resident #13's face sheet, dated 4/30/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included depression (mental health condition that causes a persistent low mood and loss of interest in activities), vascular dementia with psychotic disturbance (cognitive decline caused by vessel damage, accompanied by delusions or hallucinations), and vascular dementia with anxiety (cognitive decline caused by vessel damage that features panic like episodes). A record review of Resident #13's comprehensive MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #13's active diagnoses included non Alzheimer's dementia (cognitive decline caused by brain diseases other than Alzheimer's), depression and schizophrenia. Section N-Medications revealed Resident #13 received antidepressant and antianxiety medications.A record review of Resident #13's order summary dated 4/30/2026 revealed Resident #13 was prescribed buspirone (an antianxiety medication) with an order date of 11/12/2025, duloxetine (an antidepressant medication) with an order date of 11/12/2025.A record review of Resident #13's care plan initiated on 3/19/2026 revealed no evidence of psychotropic medication usage or schizophrenia diagnosis.Resident #18 A record review of Resident #18's face sheet, dated 4/30/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included schizoaffective disorder (chronic mental health condition characterized by a combination of symptoms, hallucinations, delusions, disorganized speech, mood disorder symptoms), depression (mental health condition that causes a persistent low mood and loss of interest in activities), generalized anxiety disorder (mental health condition characterized by excessive, uncontrollable, persistent worry about daily life events), and insomnia (persistent difficulty falling asleep, staying asleep, or waking too early resulting in poor sleep quality). A record review of Resident #18's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15 which indicated no cognitive impairment. Resident #18's active diagnoses included anxiety, depression and schizophrenia. Section N-Medications revealed Resident #18 takes antipsychotic, antianxiety, and antidepressant medications.A record review of Resident #18's order summary dated 4/30/2026 revealed Resident #18 was prescribed amitriptyline (an antidepressant medication) since 11/10/2025, ariprazole (an antipsychotic medication) since 11/10/2025, buspirone (an antianxiety medication) since 11/10/2025, duloxetine (an antidepressant medication) since 3/18/2026, and trazodone (an antidepressant medication) since 1/18/2026.A record review of Resident #18's care plan revised on 3/12/2026 revealed no evidence of psychotropic medication usage or schizophrenia diagnosis.Resident #26Record review of Resident #26's electronic face sheet, dated 04/30/2026, revealed a [AGE] year-old male who was admitted initially to the facility on [DATE] with a readmission on [DATE]. His diagnoses include Chronic Obstructive Pulmonary Disease (a progressive long term lung disease that causes obstructed air flow, making it hard to breathe), Post Traumatic Stress Disorder (PTSD) (a mental health condition triggered by experiencing or witnessing terrifying, life threatening, or traumatic events), anxiety disorder (mental health condition characterized by excessive, uncontrollable, persistent worry about daily life events), and suicidal ideations (thinking about, considering, or planning suicide).Record review of Resident #26's quarterly MDS Assessment, dated 02/23/2026, revealed Resident #26 had a BIMS score of 15 which indicated no cognitive impairment. Resident #26 active diagnoses included anxiety, depression, and PTSD. Section N-Medications included antipsychotic and antidepressant usage.Record review of Resident #26's order summary dated 4/30/2026 revealed he was prescribed duloxetine (an antidepressant medication) since 12/8/2025, olanzapine (an antipsychotic medication) since 11/10/2025, and trazadone (an antidepressant medication) since 4/29/2026.Record review of Resident #26's Care Plan, initiated 02/13/2025, revealed no evidence of antipsychotic medication use or diagnosis of PTSD.During an interview on 4/30/2026 at 3:01 PM, the Interim DON stated her expectation was that medications and diagnoses are care planned. The DON stated the effect on the resident for their care plans not being accurate could have caused the resident to have care needs not met. The DON stated that the MDS Coordinator was responsible for updating the care plans based on resident needs. The DON stated what led to this failure was that the facility was transitioning from one electronic health record program to another in October of 2025 and all the care plans have not been completed.During an interview on 4/30/2026 at 3:33 PM with the MDS Coordinator she stated she was responsible for completing care plans with the Interdisciplinary Team. She stated some of the care plans are not complete because in October of 2025 they changed electronic health records. She stated the risk in care plans not being completed and individualized could be a failure to have needs met.During an interview on 4/30/2026 at 5:00PM with the Administrator, she stated they have changed electronic health record programs. The Administrator stated she only had 1 MDS Coordinator right now to enter all care plans. The Administrator agreed that the MDS Coordinator needs to focus on completing care plans. The Administrator stated that the risk of care plans not being completed could be a decreased quality of life by not having needs met.Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated March 2022, revealed: The comprehensive, person-centered care plan includes measurable objectives and timeframes; to meet the residents highest practicable physical, mental, and physical psychosocial well-being.2. The comprehensive, person-centered care plan is developed within 7 days of the completion of the required MDS assessment.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, functional, and comfortable environment for residents in 5 of 6 halls (A, B, C, D and F) in that: Resident rooms and other areas accessible to the residents had drywall damage, lose baseboards, exhaust fan vents with lint built up and restrooms in need of repair. These failures affected the residents and placed them at risk of living in an unsafe and uncomfortable environment . Findings included: Observation on 04/28/2026 at 10:56 AM in resident room A-2 there was lint built up on the exhaust fan vent located in the restroom. Observation on 04/28/2026 at 10:58 AM in resident room A-5 there was lint built up on the exhaust fan vent located in the restroom. Observation on 04/28/2026 at 11:02 AM in resident room B-3 there was lint built up on the exhaust fan vent located in the restroom. Observation on 04/28/2026 at 11:08 AM in resident room C-7 there was lint built up on the exhaust fan vent located in the restroom. Observation on 04/28/2026 at 11:12 AM in resident room D-6 there was lint built up on the exhaust fan vent located in the restroom. Observation on 04/30/2026 at 8:30 AM in resident room F-7A and B the following issues were seen in the restroom. There were some holes in the walls behind the toilet and sink and the baseboard was hanging off the wall. Also, the sheetrock was deteriorating and crumbling in spaces and there were visible holes around plumbing pipes. There was lint built up on the exhaust fan vent. Interview on 04/30/2026 at 4:50 PM the Maintenance Director said they were in the process of cleaning the vents in the restrooms. The Director said they did that periodically but had not done it recently. The Director said he understood how those issues could affect the quality of life for the residents as those issues did not appear to be homelike. Interview on 04/30/2026 at 5:24 PM the Administrator said she understood how the issues with the environment could lead to the residents feeling sad and not having a homelike environment. The Administrator said they would work with getting those issues repaired. Record review of the facility's Maintenance Director job description dated 08/2024 indicated in part: Supervise and coordinate activities of workers (including self) engaged in maintaining and repairing physical structures and contents of buildings and maintaining grounds. Keeps the interior in good repair which includes drywall repair, painting, cleaning carpets and miscellaneous other duties.

Based on interviews and record review the facility failed to develop a baseline care plan within 48 hours of admission that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 5 residents (Resident #80) reviewed for baseline care plans.The facility failed to develop the baseline care plan for Resident #80 within 48 hours following his admission on [DATE].This failure could place residents at risk for complications due to the potential for their immediate needs not being identified so interventions could be planned and initiated.Findings included: A record review of Resident #80's Resident Face Sheet, dated 4/30/2026, revealed a [AGE] year old male admitted to facility on 4/27/2026 with diagnoses of Chronic Kidney disease stage 5 (most advanced stage of chronic kidney disease requiring dialysis), dependence on renal dialysis (medical treatment that filters waste, toxins, and excess fluids from the blood when the kidneys have failed), neuromuscular dysfunction of the bladder (occurs when nerve damage interrupts signals between brain, spinal cord, and bladder muscles, causing loss of control, urinary retention or overactive bladder symptoms), and anxiety (mental health condition characterized by excessive, uncontrollable, persistent worry about daily life events).A record review on 4/30/2026 of Resident #80's electronic clinical records revealed the facility had not developed an initial baseline care plan within 48 hours of his admission.During an interview on 4/30/2026 at 3:50PM, the Interim Director of Nursing (DON) confirmed that a baseline care plan had not been developed within the 48-hour timeframe. DON stated she started the baseline care plan today. She said her expectation was for the baseline care plans to be completed within the first 48 hours after admission by an RN. Interim DON stated the risk of not completing the baseline care plan was staff not knowing how to care for the resident.During an interview on 4/30/2026 at 5:00PM with the Administrator she stated her expectation was for nursing to complete the baseline care plan upon admission. She stated the risk in not completing the baseline care plan timely could affect the residents' quality of care by staff not knowing how to care for the resident.Baseline care plan policy requested from DON on 4/30/2026 at 3:00pm. No policy for baseline care plans was received prior to exit.

Based on observation, interviews, and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 of 8 (Resident #45) reviewed for respiratory care in that: Resident #45's oxygen nasal cannula were bagged when not in use. These failures could place all residents who use respiratory equipment at risk for respiratory infections. Findings included: Record review of Resident #45's admission record dated 04/30/2026 indicated he was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and weakness. He was [AGE] years of age. Record review of Resident #45's MDS quarterly assessment dated [DATE] indicated in part: BIMS =score of 11 indicating resident was moderately cognitively impaired. Section O: Special Treatments, Procedures, and Programs = Oxygen therapy. Observation and interview on 04/30/2026 at 2:25 PM the Resident #45's oxygen nasal cannula tubing was seen wrapped around the back of the oxygen tank with no protective cover or bagged on the back of the wheelchair. Resident #45 said the staff had taken his nasal cannula off after they moved him from his wheelchair to his bed and placed it on the oxygen tank. Interview on 04/30/2026 at 5:12 PM the Administrator was made aware of the observations of the oxygen nasal cannula not stored in the bags. The Administrator said that it was expected for staff to store the cannulas in the bags when they were not in use. The Administrator said if the cannulas were not stored in the bags then that could possibly lead to the residents acquiring respiratory infections. There was no policy provided regrading regarding oxygen administration or storage of nasal cannula tubing .

Based on interviews and record review, the facility failed to report allegations of abuse, neglect, exploitation, or mistreatment that did not result in bodily injury within 24 hours. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 2 (Residents #2 and #3) of 3 residents reviewed for abuse, neglect, and misappropriation of property, in that; The facility staff failed to report Resident #2 inappropriately touching Resident #3 that did not result in any bodily injury. This failure could place residents at risk for not having incidents investigated and reported as required and continued abuse and neglect which could result in diminished quality of life.The findings were: Record review of Resident #2's face sheet, dated 10/16/25, revealed that Resident #2 had a admission date 12/26/18 and an readmission date of 12/6/23, with diagnoses that included: dementia (mental decline caused by different diseases), Chronic obstruction pulmonary disease (damage to lungs), irritable bowel syndrome (uncomfortable or painful abdominal), atherosclerotic heart disease (plaque in the arteries), lack of coordination, congestive heart failure (heart unable to pump enough blood to meet body's needs). Record review of Resident #2's MDS, dated [DATE] revealed BIMS score of 00 (severely cognitively impaired). Resident does not have the ability to make self-understood or the ability to understand others. Ambulates using wheelchair, resident is always incontinent bowl and bladder. Smoker. Record review of Resident #2's Care Plan dated 9/18/25, revealed a focus area, I have cognitive loss, which affects my Short-term/Long-term memory and decision-making skills. I am at risk of further decline as my disease progresses. Interventions include encourage activities, plan frequent rest periods during ADLs, observe for signs of frustration and anxiety, provide cueing, prompting, use eye contact. Behavioral symptoms, resident exhibits sexual inappropriateness during showering and bathing and showering activities. He makes gestures to wash and dry private areas which has been assessed as capable of performing that part of care. Resident has attempted to inappropriately touch female residents. Approach to behavior, redirect when resident acts out, praise when resident displays appropriate behavior. SW is attempting to find better placement for resident to a men's unit. Record review of Resident #3's face sheet, dated 10/17/25, revealed that Resident #3 had a admission date 8/31/12 and an readmission date 7/28/25, with diagnoses that include: intracranial injury (brain injury caused by external force), intellectual disabilities (limitations in functioning, skills and learning abilities), dementia (mental decline), pseudobulbar affect (uncontrolled episodes of crying or laughing), muscle weakness, repeated falls. Record review of Resident #3's MDS dated [DATE], revealed BIMS score of 00 (severely cognitively impaired), extensive assistance (staff provides weight bearing support) with transfers, bed mobility, and toileting. Record review of Resident #3's Care Plan dated 8/29/25, revealed a focus area, I have a history pulling on peoples(male/female) clothing and pinch them on the bottom, But I generally gravitate to male residents. Interventions, verbally redirect when displaying inappropriate behavior with male residents. Face resident when speaking, never assume resident knows what/or understands what was said. I have behavior symptoms. As evidenced by my wandering, related to my DX of Dementia. Interventions, assist me in reorientation to room and facility with verbal cues, encourage group activities. Record review of Resident #1's face sheet dated 10/16/25, admission on [DATE] with diagnoses that include pneumonia (inflames air sacs in lungs), severe obesity (excess body fat), chronic obstructive pulmonary disease (damaged lungs). Record review of Resident #1's MDS dated [DATE], revealed BIMS score of 14 (cognitively intact). Record review of Resident #14's face sheet dated 9/13/25, admission on [DATE], with diagnoses that include malignant neoplasm of prostate (skin cancer), cerebral infarction (stroke). Record review of Resident #14's MDS dated [DATE], revealed BIMS score of 15 (cognitively intact). During a interview on 10/17/25 at 1:30pm, Resident #14 stated he could not recall date or time but sometime last month, he was coming in from smoking and was in the dining room when he saw Resident #2 who was coming in from smoking also and was about 15 feet in front of Resident #14, going over to Resident #3 who was sitting next to the coffee bar. Resident #2 placed his hand between the legs over the clothing of Resident #3. Resident #14 told him to stop that, and Resident #2 removed his hand. Resident #14 stated that the incident lasted only a few seconds. Resident #14 told LVN M, who was sitting at the nurses' station, that Resident #2 was inappropriately touching Resident #3 and LVN M got up and went into the dining room immediately. Resident #14 stated that he thought Resident #1 witnessed the incident also. Resident #14 stated that he knows residents' rights and to report any concerns to the staff. Interview on 10/17/25 at 1:45pm, Resident #1 stated he could not recall date or time, sometime last month, that they were all coming in from smoke break and Resident #1 observed Resident #2 roll over next to Resident #3 and put his hand between her legs. Resident #1 stated that Resident #2's hand was above cloths. Resident #1 stated that Resident #14 yelled at Resident #2 to stop, and he did. Resident #1 stated that Resident #14 told the nurse. The nurse came into the dining room and removed Resident #2. Resident #1 stated that the incident happened fast, and Resident #3 did not seem to mind. Interview on 10/21/25 at 1:05pm, LVN M stated that Resident #14 told her that Resident #2 was inappropriately touching a female resident in the dining room, LVN M stated she walked into the dining room and found residents #2 and #3 sitting next to one another but was not touching. LVN M stated that she removed Resident #2 from the dining room and back to his room. LVN M stated she did not recall date or time, but stated it was earlier this month, stating it was after dinner and residents were returning from smoke break. LVN M did not document the incident in progress notes. LVN M stated that she assessed Resident #3 and found no injury. LVN M stated she did not report the incident to Admin/DON, LVN stated she did not know why she did not report. LVN M stated she has been in-serviced to recognize, prevent, and report ANE to Admin/DON. LVN M stated that she knows how to report and allegation of ANE. LVN stated no other staff witnessed the incident. Interview on 10/21/25 at 2:00pm, Administrator stated that she was unaware of any incident involving Resident #2 and Resident #3 until surveyor informed her. Administrator stated that Resident #2 was removed from the facility on 9/29/25 because of his behaviors towards female staff and attempt to grab other residents. Administrator stated if known, the allegations of inappropriate touching would be investigated and reported to HHS. Administrator stated that LVN M failed to report and will be in-serviced and disciplined accordingly. Record review on 10/21/25 revealed that Resident #2 was transferred to a all-male facility on 9/29/25. Interview on 10/21/25 at 2:15pm, the DON stated she was not aware of the incident between Resident #2 and Resident #3. The DON stated expectation was that staff report all allegations to Administrator and/ or DON, so allegations can be investigated and reported if needed. The DON stated that Resident #3 did not appear to be withdrawn, harmed or had any change of character. The DON stated that all staff have been in-serviced in reporting alleged abuse and neglect. The DON stated that LVN M will be re-in-service 1:1 with DON on reporting allegations of abuse and neglect. Record review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 04/2021. Policy Interpretation and Implementation,8. Identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident's property.9. Investigate and report any allegations within timeframes required by federal requirements.

Based on interviews and record review, the facility failed to report allegations of abuse, neglect, exploitation, or mistreatment that did not result in bodily injury within 24 hours. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported no later than 24 hours after the allegation is made to the administrator of the facility and to HHSC, if the events that cause the allegation do not involve abuse and do not result in serious bodily injury for 2 (Residents #2 and #3) of 3 residents reviewed for abuse, neglect, and misappropriation of property, in that; The facility staff failed to report Resident #2 inappropriately touching Resident #3 that did not result in any bodily injury. This failure could place residents at risk for not having incidents investigated and reported as required and continued abuse and neglect which could result in diminished quality of life.The findings were: Record review of Resident #2's face sheet, dated 10/16/25, revealed that Resident #2 had a admission date 12/26/18 and an readmission date of 12/6/23, with diagnoses that included: dementia (mental decline caused by different diseases), Chronic obstruction pulmonary disease (damage to lungs), irritable bowel syndrome (uncomfortable or painful abdominal), atherosclerotic heart disease (plaque in the arteries), lack of coordination, congestive heart failure (heart unable to pump enough blood to meet body's needs). Record review of Resident #2's MDS, dated [DATE] revealed BIMS score of 00 (severely cognitively impaired). Resident does not have the ability to make self-understood or the ability to understand others. Ambulates using wheelchair, resident is always incontinent bowl and bladder. Smoker. Record review of Resident #2's Care Plan dated 9/18/25, revealed a focus area, I have cognitive loss, which affects my Short-term/Long-term memory and decision-making skills. I am at risk of further decline as my disease progresses. Interventions include encourage activities, plan frequent rest periods during ADLs, observe for signs of frustration and anxiety, provide cueing, prompting, use eye contact. Behavioral symptoms, resident exhibits sexual inappropriateness during showering and bathing and showering activities. He makes gestures to wash and dry private areas which has been assessed as capable of performing that part of care. Resident has attempted to inappropriately touch female residents. Approach to behavior, redirect when resident acts out, praise when resident displays appropriate behavior. SW is attempting to find better placement for resident to a men's unit. Record review of Resident #3's face sheet, dated 10/17/25, revealed that Resident #3 had a admission date 8/31/12 and an readmission date 7/28/25, with diagnoses that include: intracranial injury (brain injury caused by external force), intellectual disabilities (limitations in functioning, skills and learning abilities), dementia (mental decline), pseudobulbar affect (uncontrolled episodes of crying or laughing), muscle weakness, repeated falls. Record review of Resident #3's MDS dated [DATE], revealed BIMS score of 00 (severely cognitively impaired), extensive assistance (staff provides weight bearing support) with transfers, bed mobility, and toileting. Record review of Resident #3's Care Plan dated 8/29/25, revealed a focus area, I have a history pulling on peoples(male/female) clothing and pinch them on the bottom, But I generally gravitate to male residents. Interventions, verbally redirect when displaying inappropriate behavior with male residents. Face resident when speaking, never assume resident knows what/or understands what was said. I have behavior symptoms. As evidenced by my wandering, related to my DX of Dementia. Interventions, assist me in reorientation to room and facility with verbal cues, encourage group activities. Record review of Resident #1's face sheet dated 10/16/25, admission on [DATE] with diagnoses that include pneumonia (inflames air sacs in lungs), severe obesity (excess body fat), chronic obstructive pulmonary disease (damaged lungs). Record review of Resident #1's MDS dated [DATE], revealed BIMS score of 14 (cognitively intact). Record review of Resident #14's face sheet dated 9/13/25, admission on [DATE], with diagnoses that include malignant neoplasm of prostate (skin cancer), cerebral infarction (stroke). Record review of Resident #14's MDS dated [DATE], revealed BIMS score of 15 (cognitively intact). During a interview on 10/17/25 at 1:30pm, Resident #14 stated he could not recall date or time but sometime last month, he was coming in from smoking and was in the dining room when he saw Resident #2 who was coming in from smoking also and was about 15 feet in front of Resident #14, going over to Resident #3 who was sitting next to the coffee bar. Resident #2 placed his hand between the legs over the clothing of Resident #3. Resident #14 told him to stop that, and Resident #2 removed his hand. Resident #14 stated that the incident lasted only a few seconds. Resident #14 told LVN M, who was sitting at the nurses' station, that Resident #2 was inappropriately touching Resident #3 and LVN M got up and went into the dining room immediately. Resident #14 stated that he thought Resident #1 witnessed the incident also. Resident #14 stated that he knows residents' rights and to report any concerns to the staff. Interview on 10/17/25 at 1:45pm, Resident #1 stated he could not recall date or time, sometime last month, that they were all coming in from smoke break and Resident #1 observed Resident #2 roll over next to Resident #3 and put his hand between her legs. Resident #1 stated that Resident #2's hand was above cloths. Resident #1 stated that Resident #14 yelled at Resident #2 to stop, and he did. Resident #1 stated that Resident #14 told the nurse. The nurse came into the dining room and removed Resident #2. Resident #1 stated that the incident happened fast, and Resident #3 did not seem to mind. Interview on 10/21/25 at 1:05pm, LVN M stated that Resident #14 told her that Resident #2 was inappropriately touching a female resident in the dining room, LVN M stated she walked into the dining room and found residents #2 and #3 sitting next to one another but was not touching. LVN M stated that she removed Resident #2 from the dining room and back to his room. LVN M stated she did not recall date or time, but stated it was earlier this month, stating it was after dinner and residents were returning from smoke break. LVN M did not document the incident in progress notes. LVN M stated that she assessed Resident #3 and found no injury. LVN M stated she did not report the incident to Admin/DON, LVN stated she did not know why she did not report. LVN M stated she has been in-serviced to recognize, prevent, and report ANE to Admin/DON. LVN M stated that she knows how to report and allegation of ANE. LVN stated no other staff witnessed the incident. Interview on 10/21/25 at 2:00pm, Administrator stated that she was unaware of any incident involving Resident #2 and Resident #3 until surveyor informed her. Administrator stated that Resident #2 was removed from the facility on 9/29/25 because of his behaviors towards female staff and attempt to grab other residents. Administrator stated if known, the allegations of inappropriate touching would be investigated and reported to HHS. Administrator stated that LVN M failed to report and will be in-serviced and disciplined accordingly. Record review on 10/21/25 revealed that Resident #2 was transferred to a all-male facility on 9/29/25. Interview on 10/21/25 at 2:15pm, the DON stated she was not aware of the incident between Resident #2 and Resident #3. The DON stated expectation was that staff report all allegations to Administrator and/ or DON, so allegations can be investigated and reported if needed. The DON stated that Resident #3 did not appear to be withdrawn, harmed or had any change of character. The DON stated that all staff have been in-serviced in reporting alleged abuse and neglect. The DON stated that LVN M will be re-in-service 1:1 with DON on reporting allegations of abuse and neglect. Record review of the facility's policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 04/2021. Policy Interpretation and Implementation,8. Identify and investigate all possible incidents of abuse, neglect, mistreatment or misappropriation of resident's property.9. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview and record review, the facility to ensure that the residents had the right to self determination and that the facility promoted and facilitated resident self-determination for 1 (Resident #33) of 7 resident who were reviewed for resident rights. - The facility failed to ensure Resident #33's right to make choices about aspects of his life that were significant to the resident by failing to honor Resident #33's request to be sent to the hospital for evaluation on 05/02/2025 at approximately 3 pm. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and decrease their quality of life. Findings included: Record review of Resident #33's face sheet dated 05/22/2025 revealed the resident was a [AGE] year-old female admitted to the facility 04/11/2019. The resident had diagnosis that included Acute recurrent sinusitis (inflammation of mucous membranes), Shortness of breath, Hemiplegia (one sided paralysis), and hemiparesis (one sided muscle weakness). Record review of Resident #33's Minimum Data Set, dated [DATE] revealed BIMS of 12, suggesting intact cognition. During an interview with CNA A on 05/22/25 at 12:49 pm, CNA A stated that on a day in early May 2025, unable to give exact date, she remembers Resident #33 using her call light and informed CNA A that she wanted to go to the hospital because she was not feeling well. CNA A stated that she informed LVN B after leaving the resident's room. CNA A stated about 2 hours later the resident used her call light again and informed CNA A that the nurse had not been in her room. CNA A stated she then went back to LVN B who informed CNA A that she would assess the resident. An unknown amount of time passed, and the resident used the call light again and CNA A went in and the resident had informed CNA A that the nurse had not been in the room and that she still wanted to go to the hospital. CNA A stated she went to LVN B again to inform her the resident was wanting to be sent to the hospital. CNA A stated that LVN B informed her that she had taken the residents vitals but would go back in to speak with her. CNA A stated that she thought LVN B had assessed and addressed Resident #33's concerns. CNA A stated that the resident did not go to the hospital during her shift but when CNA A returned the next day, she was informed that Resident #33 had gone to the ER. CNA A did not know that the Resident #33 had to call her Significant Other (SO) to take her to the hospital. Record review of Resident #33's progress notes and vital sign log revealed there was no notes regarding the Resident #33's request to go to the hospital, nor vital signs documented on 05/02/2025. During an interview on 05/22/2025 at 1:20 pm the DON stated that she was unaware that the resident had not being sent out to the hospital after requesting to be sent out. The DON stated she knew Resident #33 had gone to the hospital with her SO but did not know she had requested the staff to send her out first. The DON stated if there is a resident that was stating they are not feeling well she would expect her nurses to evaluate the resident, obtain vital signs, and contact the doctor to attempt to treat in house if non-emergent. The DON stated that if a resident is was refusing to be treated in house or insisting to be sent out, the staff are expected to contact emergency services to send them out. The DON stated the emergency services in town have denied nonemergent transfers in the past so they would have to have the van driver transport resident to the emergency room. During an interview with LVN B on 05/22/25 at 2:51 pm, LVN B stated she did not remember being informed of any resident wanting to go to the hospital. LVN B stated that she (LVN B) does not have a good memory. LVN B stated that if a resident was not feeling well, she would assess the resident and obtain vital signs. LVN B stated that if the resident was not stable, she would call 911 but if they were stable, she would call the doctor for treatment orders. LVN B stated that if a resident was wanting to be sent out regardless of the doctors' orders, she would just call for transport to the emergency room. During an interview with Resident #33 on 05/22/2025 at 3:20 pm, when Resident #33 stated that on 05/02/2025 she was not feeling well and wanted to go to the emergency room. Resident #33 stated she informed CNA A about this on multiple occasions that day and that CNA A was informing the resident that she was telling the nurse on shift. Resident #33 stated that no one other than CNA A had returned to check on her during this time. Resident #33 stated that she first asked to go to the hospital around 3 pm and finally called her SO to take her around 8 pm that night. Resident #33 stated she signed out and informed staff she was going to the hospital. Resident #33 stated that she was not admitted to the hospital but was diagnosed with a urinary tract infection and acute inflammation of the air passages. The resident stated that she was prescribed antibiotics for the urinary tract infection. Resident #33 stated that she has never had a situation prior where a nurse did not evaluate her after informing staff that she was not feeling well. Record review of facility policy titled Requesting, Refusing and/or Discontinuing Care or Treatment dated revised February 2021, revealed in part, 4. The resident/representative has the right to request treatment or care that the resident wishes. However, this facility is not obligated to provide medical treatment, or medical services deemed medically unnecessary or inappropriate.

Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 7 residents (Resident #33) reviewed for quality of care. - The facility failed to ensure Resident #33 received treatment immediately after she requested to be sent to the hospital for evaluation on 05/02/2025 at approximately 3 pm. This failure could place residents at risk for a delay in treatment or diagnosis, a decline in the resident's condition, harm and/or the need for hospitalization and prolonged treatment. Findings included: Record review of Resident #33's face sheet dated 05/22/2025 revealed the resident was a [AGE] year-old female admitted to the facility 04/11/2019. The resident had diagnosis that included Acute recurrent sinusitis (inflammation of mucous membranes), Shortness of breath, Hemiplegia (one sided paralysis), and hemiparesis (one sided muscle weakness). Record review of Resident #33's Minimum Data Set, dated [DATE] revealed BIMS of 12, suggesting intact cognition. During an interview with CNA A on 05/22/25 at 12:49 pm, CNA A stated that on a day in early May 2025, unable to give exact date, she remembers Resident #33 using her call light and informed CNA A that she wanted to go to the hospital because she was not feeling well. CNA A stated that she informed LVN B after leaving the resident's room. CNA A stated about 2 hours later the resident used her call light again and informed CNA A that the nurse had not been in her room. CNA A stated she then went back to LVN B who informed CNA A that she would assess the resident. An unknown amount of time passed, and the resident used the call light again and CNA A went in and the resident had informed CNA A that the nurse had not been in the room and that she still wanted to go to the hospital. CNA A stated she went to LVN B again to inform her the resident was wanting to be sent to the hospital. CNA A stated that LVN B informed her that she had taken the residents vitals but would go back in to speak with her. CNA A stated that she thought LVN B had assessed and addressed Resident #33's concerns. CNA A stated that the resident did not go to the hospital during her shift but when CNA A returned the next day, she was informed that Resident #33 had gone to the ER. CNA A did not know that the Resident #33 had to call her Significant Other (SO) to take her to the hospital. Record review of Resident #33's progress notes and vital sign log revealed there was no notes regarding the Resident #33's request to go to the hospital, nor vital signs documented on 05/02/2025. During an interview on 05/22/2025 at 1:20 pm the DON stated that she was unaware that the resident had not being sent out to the hospital after requesting to be sent out. The DON stated she knew Resident #33 had gone to the hospital with her SO but did not know she had requested the staff to send her out first. The DON stated if there is a resident that was stating they are not feeling well she would expect her nurses to evaluate the resident, obtain vital signs, and contact the doctor to attempt to treat in house if non-emergent. The DON stated that if a resident is was refusing to be treated in house or insisting to be sent out, the staff are expected to contact emergency services to send them out. The DON stated the emergency services in town have denied nonemergent transfers in the past so they would have to have the van driver transport resident to the emergency room. During an interview with LVN B on 05/22/25 at 2:51 pm, LVN B stated she did not remember being informed of any resident wanting to go to the hospital. LVN B stated that she (LVN B) does not have a good memory. LVN B stated that if a resident was not feeling well, she would assess the resident and obtain vital signs. LVN B stated that if the resident was not stable, she would call 911 but if they were stable, she would call the doctor for treatment orders. LVN B stated that if a resident was wanting to be sent out regardless of the doctors' orders, she would just call for transport to the emergency room. During an interview with Resident #33 on 05/22/2025 at 3:20 pm, when Resident #33 stated that on 05/02/2025 she was not feeling well and wanted to go to the emergency room. Resident #33 stated she informed CNA A about this on multiple occasions that day and that CNA A was informing the resident that she was telling the nurse on shift. Resident #33 stated that no one other than CNA A had returned to check on her during this time. Resident #33 stated that she first asked to go to the hospital around 3 pm and finally called her SO to take her around 8 pm that night. Resident #33 stated she signed out and informed staff she was going to the hospital. Resident #33 stated that she was not admitted to the hospital but was diagnosed with a urinary tract infection and acute inflammation of the air passages. The resident stated that she was prescribed antibiotics for the urinary tract infection. Resident #33 stated that she has never had a situation prior where a nurse did not evaluate her after informing staff that she was not feeling well. Record review of facility policy titled Requesting, Refusing and/or Discontinuing Care or Treatment dated revised February 2021, revealed in part, 4. The resident/representative has the right to request treatment or care that the resident wishes. However, this facility is not obligated to provide medical treatment, or medical services deemed medically unnecessary or inappropriate.

Based on observation, interview, and record review the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for 2 of 3 medication carts reviewed for labeling/storage of drugs and biologicals. The facility failed to ensure that medication carts 1 and 2 were not left unlocked and unsupervised. These failures could cause access, loss, diversion, or accidental ingestion of medications. Findings included: During observation on 02/04/25 at 5:13 p.m. an unlocked and unsupervised medication cart (cart 1) was found on F Hall. There was no staff in the line of sight of the cart at the time of this observation. There were two residents observed in sight of the medication cart. During an interview on 02/06/25 at 4:47 p.m., the DON stated that it was her expectation that medication and treatment carts would be locked when not in use. During an observation on 02/06/25 at 8:35 p.m. an unlocked and unsupervised medication cart (cart 2) was noted at the nurses' station. There were no staff in line of sight of the cart at the time of this observation. There were no residents or visitors observed within sight of the medication cart. Record review of the facility's Storage of Medications policy dated 11/20 indicated in part .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 (Residents #30, #64, #63 and #331) of 4 residents reviewed for infection control practices. 1. The facility failed to ensure LVN C used appropriate PPE during dressing changes for Residents #30, #64 and #331 who were on Enhanced Barrier Precautions (EBP). 2. The facility failed to ensure CNA G changed her gloves after they became contaminated during incontinent care for Resident #63. 3. The facility failed to ensure LVN C used appropriate infection control principles while performing dressing changes for Resident #331. These failures could place residents at risk for cross contamination and the spread of infection. Finding included: Resident #30 In an observation on 02/06/2025 at 12:30 PM LVN C performed a dressing change on Resident #30's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the abdomen). LVN C did not wear a gown during the dressing change. Review of Resident #30's face sheet dated 02/06/2025 indicated she was admitted to the facility on [DATE] with diagnoses of the presence of urogenital implants-suprapubic catheter, neuromuscular dysfunction of the bladder, and encounter for other orthopedic aftercare (care post-orthopedic surgeries). She was [AGE] years of age. Review of Resident #30's care plan revised 01/22/2025 indicated in part: Focus - Enhanced Barrier Precautions (EBP): Resident #30 requires EBP due to having a wound and catheter. Goal: The resident will have no symptoms of multi-drug resistant organisms (MDRO). Interventions: Staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing, device care or use (central line, urinary catheter, feeding tube, trach care, ostomy care, etc.). Review of Resident #30's Quarterly MDS dated [DATE] indicated in part: the BIMS score is 15, indicating Resident #30 is cognitively intact. She had an indwelling catheter and was always continent of bowel. Review of Resident #30's Order Summary Report dated 8/22/24 revealed the following orders: - Clean Suprapubic site with wound cleanser, pat dry, apply T-drainage dressing - every day and as needed (Order Date: 01/13/2025) - Enhanced Barrier Precautions due to the following: Increased risk of MDRO acquisition due to having an indwelling medical device and a wound (Order Date: 01/16/2025) Resident #63 In an observation on 02/05/2025 at 6:33 PM CNA G performed incontinent care for Resident #63. After washing and drying her hands, CNA G donned gloves and proceeded to perform personal care to Resident #63. CNA G used her right hand to wipe and her left hand to hold and move Resident #63's genitals. Not changing gloves, CNA G rolled Resident #63 onto his right side and used her right hand to wipe and her left hand to hold Resident #63's buttocks apart. Not changing gloves, CNA G removed the dirty brief, placed a clean brief on Resident #63, and rearranged his clothing and bedding. CNA G then removed her gloves. Review of Resident #63's face sheet dated 02/06/2025 indicated he was admitted to the facility on [DATE] with diagnoses of cerebrovascular disease (disease impacting the brain's blood vessels and blood supply), hemiplegia (one-sided muscle paralysis or weakness) affecting the left side, and deafness. He was [AGE] years of age. Review of Resident #63's care plan revised 01/28/2025 indicated in part: Focus - ADL's: Resident is incontinent of bowel/bladder related to stroke. Goal: The resident will achieve maximum functional ability. Interventions: Toileting assistance. Review of Resident #63's Quarterly MDS dated [DATE] indicated in part: BIMS not available related to Resident #63 is rarely understood. Bladder and bowel: Always incontinent. Resident #64 During observation on 02/06/25 at 9:30 a.m., LVN C performed a dressing change on Resident #64's cancerous lesion to his middle back without wearing a gown as required for EBP. The EBP sign was visible on Resident #64's door indicating the need for PPE and a PPE station was noted outside of the resident's room. Review of Resident #64's face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included malignant melanoma (cancer) of the skin and obstructive and reflux uropathy (urine is unable to drain through the urinary tract). Review of Resident #64's Quarterly MDS dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment, he had an indwelling catheter, and he had open lesion(s) other than ulcers, rashes, cuts (e.g., cancer lesion). Review of Resident #64's care plan, revised on 01/14/25, revealed the following: Problem: I require enhanced barrier precautions due to the following: I am at increased risk of a MDRO acquisition due to having a wound and an indwelling catheter. Goal: I will have no signs/symptoms of a MDRO. Approach: A sign will be posted on my door that says 'contact nurse before entering'; Discard PPE inside my room in the appropriate receptacle prior to leaving my room; PPE will be available (including gowns/gloves/face shield or goggles) right outside my room, in the shower room; Staff will wear PPE during high-contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing, device care or use (central line, urinary catheter, feeding tube, trach care, ostomy care, etc.) Review of Resident #64's active physician orders on 02/06/25 revealed the following: Enhanced barrier precautions due to increased risk of MDRO acquisition due to having a wound - Start Date: 01/16/25 Resident #331 In an observation on 02/06/2025 at 1:40 PM LVN C performed wound care on Resident #331's elbows. There was EBP signage outside Resident 331's door. LVN C did not wear a gown during the dressing changes. LVN C washed her hands, donned gloves, removed the dressing on the right elbow, and removed her gloves. LVN C donned clean gloves without hand washing or using hand sanitizer and proceeded to clean the wound. LVN C used the same surface area of a 4 X 4 gauze to wipe half of the wound 4 times. LVN C repeated the same process on the other half of the wound. After LVN C applied the dressing to the right elbow, she removed her gloves and donned another pair of gloves without hand washing or using hand sanitizer, removed the dressing on Resident #331's right elbow, and removed her gloves. LVN C donned clean gloves without hand washing or using hand sanitizer and proceeded to clean the wound. LVN C used the same surface area of a 4 X 4 gauze to wipe half of the wound 3 times. LVN C repeated the same process on the other half of the wound. After cleaning the second half of the wound, LVN C used the same 4 X 4 to wipe a different wound that is 2-3 inches away. LVN C stated this is a new wound. LVN C applied a dressing to this new wound. Review of Resident #331's face sheet dated 02/06/2025 indicated he was admitted to the facility on [DATE] with diagnoses of Parkinson's disease (a disorder of the central nervous system, often including tremors), atherosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on artery walls), chronic obstructive pulmonary disease (COPD-a group of lung diseases that causes persistent airflow limitation and breathing problems), and pulmonary fibrosis (a lung disease that causes scarring in the lungs, making it difficult to breathe). he was [AGE] years of age. Review of Resident 331's Care Plan revealed the Care Plan was in the process of completion. Review of Resident #331's Order Summary Report dated 02/06/2025 revealed the following orders: - Wound Treatment Order-Clean left upper elbow with normal saline/wound cleanser, apply triple antibiotic ointment, cover with bordered dressing - every day until resolved (Order Date: 02/05/2025) - Wound Treatment Order-Clean right elbow with normal saline/wound cleanser, apply triple antibiotic ointment, cover with bordered dressing - every day until resolved (Order Date: 02/05/2025) Review of Resident #331's MDS assessments revealed the Admission MDS was in the process of completion. In an interview on 02/06/2025 at 4:13 PM, LVN C was asked to list the steps to follow when providing wound care and she stated wash hands, put gloves on, remove old dressing, take gloves off and wash or sanitize hands, put new gloves on, clean wound, take gloves off and wash or sanitize hands, put new gloves on then apply clean dressing. When asked how many times a wound should be wiped with the same surface area of a gauze pad, LVN C stated, once. When asked what happened when she wiped a wound repeatedly or wiped different wounds with the same gauze, LVN C stated, Cross-contamination. When asked if she considered cleaning a wound and placing the new dressing with the same gloves on, clean-clean, clean-dirty, dirty-clean, or dirty-dirty, LVN C stated, dirty-clean and I should have changed gloves. When asked about EBP, LVN C asked, What is EBP? When told EBP stood for Enhanced Barrier Precautions LVN C stated the facility did not use the abbreviation and she was aware of the facility policy. When asked if gowns should be worn during direct resident care if on EBP, LVN C said she thought it was only for chronic wounds. LVN C stated she had not had any training on EBP. In an interview on 02/06/2025 at 04:47 PM the DON/Infection Preventionist stated staff have been trained on EBP, the last in-service was conducted on 06/26/2024. The DON stated staff were expected to know which residents are on EBP and to follow the policy. Regarding the wound/dressing changes, DON stated all nurses should have been trained in school on preventing cross-contamination and follow the facility's policies. She staff had been trained on infection prevention and should follow their training. The DON said the staff are expected to change gloves when appropriate to prevent cross contamination and the spread of infection. In an interview on 02/06/2025 at 7:00 PM CNA G was asked to list the steps to follow when performing incontinent care and she stated wash hands, put gloves on, clean resident front first and back second, change gloves if poopy, wash hands if gloves were poopy, put new gloves on, remove soiled brief, place clean brief on resident, and then collect trash. When asked if her gloves were clean or dirty after using her left gloved hand to hold Resident #63's genitals and right gloved hand to wipe the genital area, CNA G stated the gloves would be dirty and she should have changed them. CNA G stated it would be cross contamination to perform tasks without changing soiled gloves. Review of facility policy titled Enhanced Barrier Precautions, revised 04/01/2024, reflected, in part: .PPE for enhanced barrier precautions is only necessary when performing high-contact care activities. High-contact resident care activities include: .Wound care: any skin opening requiring a dressing .Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes. Review of facility policy titled Dressings, Dry/Clean, revised 04/2020, reflected in part Preparation .Review the resident's care plan, current orders, and diagnoses to determine if there are special resident needs. Steps in the Procedure .Perform hand hygiene, put on clean gloves, loosen tape and remove soiled dressing, pull gloves over dressing and discard, perform hand hygiene, put on clean gloves, cleanse the wound with ordered cleanser (if using gauze, use clean gauze for each cleansing stroke), change gloves (perform hand hygiene), apply clean dressing, remove gloves, perform hand hygiene, reposition the bed covers, make the resident comfortable.

Based on interview and record review, the facility failed to immediately consult Resident #1's physician for a decision to discharge the resident after a change in condition for one (Resident #1) of three residents reviewed for notification of changes. The facility failed to immediately notify Resident #1's physician regarding an incident with the resident's change of behavior resulting in Resident #1 being discharged from facility. This failure could place residents at risk of not having their physician informed of medical diagnoses not getting treated and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including sequelae cerebral infarction (pneumonia), diabetes mellitus with circulatory complications (sustained high blood sugar levels), Hemiplegia and hemiparesis (weakness to right dominant side), anxiety disorder due to known physiological condition, type 2 diabetes, acquired absence of left and right leg below the knee. Review of Resident #1's quarterly MDS assessment, dated 11/9/24, reflected a BIMS score of 15, indicating Resident #1 is cognitively intact. Section E-rejects care, GG- manual and motorized wheelchair, impaired on lower extremity both side, H-always incontinent, I-stroke, diabetes, and anxiety. Review of Resident #1's quarterly care plan, dated 11/15/24, behavioral symptoms, exhibits verbally abusive behaviors towards staff. Last reviewed/revised: dated 11/25/24 created by DON J (former DON), category: Physical aggression towards staff causing injury. Record review of incident on 11/25/24 at 9:15pm, Resident #1 physically assaulted CNA. CNA was sent to emergency room and diagnosed with chest wall contusion. Resident #1 was given an immediate discharge notice and was transferred to another nursing facility on 11/26/24 at 3:00pm. Resident #1's primary Physician was not notified of incident on 11/16/24 of Resident#1's change in aggression from verbal to physical aggression. During an interview on 2/4/25 at 2:30pm, the Administrator stated that on 11/25/24 at 9:30pm she was notified by DON J of an incident involving Resident #1. The Administrator stated it was decided by her and DON J that Resident #1 needed to be immediately discharged . The Administrator stated that this was the first time that Resident #1 had physically assaulted staff that she knew of. The Administrator stated that it was Care Planned that Resident #1 was verbally aggressive. The Administrator stated that DON J made a necessary notification and plans for discharge. During an interview on 2/5/25 at 3:10pm, DON J stated that on 11/25/24 at 9:15pm Resident #1 physically assaulted a CNA causing injury. It was decided by her and the Administrator that Resident #1 will be immediately discharged as soon as possible. A nursing facility was found the next morning on 11/26/24 and agreed to take Resident #1 that day. DON J stated that she notified Resident #1, resident's spouse , and resident's Primary Physician that Resident #1 is being discharged . DON J stated she did not notify resident's Primary Physician of the incident on 11/25/24 until the next day on 11/26/24 at 12:05pm. DON J stated she did not think that she needed to notify the Primary Physician on 11/25/24 because the resident was not harmed only staff. DON J stated that Resident #1 had a history of verbal aggressiveness towards staff, yelling, cussing, and threatening but this was the first time resident physically assaulted staff. DON J did agree that becoming physically aggressive could be considered a change in behavior. DON J stated that she did revise Resident #1's Care Plan on 11/25/24 to include physical aggression. During an interview on 2/6/25 at 2:00pm, Resident #1's Primary Physician stated that he was not notified of the incident on 11/25/24 until the next day, 11/26/24. The Primary Physician stated he would expect to be notified if a resident has a change in behavior or condition. Facility Resident's Condition or Status policy, Our facility promptly notifies the resident, his or her attending physician, heath care provider and the resident representative of changes in the resident's medial/mental condition and/or status (e.g., changes in level of care, billing/payments, residents' rights, etc.). Policy Interpretation and Implementation 1. Notifying resident's attending physician, A. accident or incident involving the resident, D. significant change in the resident's physical/emotional/mental condition, G. need to transfer the resident to a hospital/treatment center.

Based on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 1 of 5 residents (Resident #2) reviewed for reasonable accommodations, in that: CNA A and CNA B failed to put Resident #2's call light within reach after performing a transfer. This deficient practice could place residents at risk of not having their needs/preferences met to not being able to use call lights for assistance in to achieve independent functioning, dignity, and well-being. Findings included: Review of Resident #2's Face Sheet dated 2-5-25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stiffness of the right and left knee, abnormal posture, and arthritis. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed: He had long and short-term memory impairment with severely impaired cognitive skills for daily decision making. He had lower extremity impairment on both sides and used a wheelchair. He was dependent for chair to bed transfers. Review of Resident #2's Care Plan updated 1/14/25 revealed: Falls/Safety risk: resident had a fall out of his wheelchair no injuries noted. Long Term Goal Target Date: Resident will remain free of injuries related to falls and will remain in a safe environment. Approaches included: Keep call light in reach. Review of Resident #2's Care Plan updated 1/14/25 revealed: Resident had multiple problems that affects his ability to walk. He has history of and the potential to fall and at risk for injury related to weakness and depression and mental disorder. The long-term goal was Resident will have no injuries related to fall over the next 90 days. Identified interventions included: Make sure his call light is within his reach and respond quickly. Review of Resident #2's Care Plan updated 1/14/25 revealed: Resident is unable to stand for transfers. The identified the goal was Resident may use a mechanical lift for all transfers and will not have falls related to transfers. Approaches included: resident may use mechanical lift for all transfers. Observation on 02/05/25 at 1:18 PM revealed CNA A and CNA B transferred Resident #2 from his wheelchair to the bed. The aides positioned Resident#2 in bed washed their hands and left the room. The call light remained on the floor behind the nightstand. Interview on 02/05/25 at 03:53 PM the DON stated she expected staff to put a resident's call light within reach once care was completed. Observation on 02/05/25 at 04:21 PM with the DON revealed CNA A and CNA B completed a transfer for Resident #2. Resident #2's call light was draped on the night nightstand but still out of reach of the resident if he was in bed. Review of the facility's policy and procedure on Call Lights dated March 2021 revealed: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 3 residents (Resident #28) reviewed for respiratory care. The facility failed to ensure staff remained with Resident #28 while he received his nebulizer treatment. This failure could place residents at risk for respiratory distress. Findings included: Review of Resident #28's Face Sheet dated 2/6/25 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnosis which included pulmonary edema (swelling of the lungs) and Chronic Obstructive Pulmonary Disease (chronic disease affecting the lungs and heart making it difficult to breathe) Review of Resident #28's Quarterly MDS Assessment, dated 1/24/25, revealed: He had a mental status score of 14 of 15 (indicating he was cognitively intact) Review of Resident #28's Continuity of Care Document, dated 2/6/25 revealed he had orders for ipratropium - albuterol 0.5mg - 3 mg solution for nebulization one vial, inhalation four times a day for wheezing and shortness of breath diagnosis of Chronic Obstructive Pulmonary Disease beginning 12/29/24. There was no care plan for the breathing treatments. Observation on 2/4/25 at 2:39 p.m. revealed Resident #28 out of his room. There was a breathing treatment mask on the bed in operation. Review of Resident #28's nurse's notes and Medication Administration Record for the date and time revealed no documentation about Resident #28 refusing the breathing treatment or walking away from it. Interview on 2/6/25 at 1:31 p.m. DON stated if the resident refused a breathing treatment three times in a row the facility notified the doctor. The DON said breathing treatments were administered dependent on the mental status of the resident. The DON explained the nurse would stay with the resident if the resident was actively delusional. The DON said Resident #28's cognition went back and forth. The DON stated Resident #28 did smoke but was not a regular smoker. The DON said if Resident #28 walked away from the breathing treatment in the middle of the breathing treatment it was considered a refusal. The DON stated Resident #28 walking away from breathing treatments was not care planned and the expectation was that nurses would sit with him if there was still medication in the small volume nebulizer. Review of the facility's policy and procedure on Medication Administration, revised December 2019, revealed: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Resident may actively refuse medications. Medication refusal must be reported to the prescriber after (XX) number of doses are refused and there must be documentation of prescriber notification of such.

Based on interviews and record review the facility failed to notify hospice of emergency transfer of 1 (Resident #1) of 1 resident reviewed for discharge. The facility failed to immediately notify resident's hospice provider of discharge to another facility. This failure placed residents at risk of not receiving necessary care and services. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including sequelae cerebral infarction (pneumonia), diabetes mellitus with circulatory, complications (sustained high blood sugar levels), Hemiplegia and hemiparesis (weakness to right dominant side), anxiety disorder due to known, physiological condition, type 2 diabetes, acquired absence of left and right leg below the knee. Review of Resident #1's quarterly MDS assessment, dated 11/9/24, reflected a BIMS score of 15, indicating Resident #1 is cognitively intact. Section E-rejects care, GG- manual and motorized wheelchair, impaired on lower extremity both side, H-always incontinent, I-stroke, diabetes, and anxiety. Review of Resident #1's quarterly care plan, dated 11/15/24, behavioral symptoms, exhibits verbally abusive behaviors towards staff, hospice services. During an interview on 2/6/25 at 10:05am, Hospice RN stated she was notified by DON J that resident had been immediately discharged from facility only after resident had left facility. Hospice RN stated she needed to know about discharge before resident left facility so they can help set-up or coordinate care with the new hospice or facility that resident was going too before resident left facility and make sure resident had at least two weeks supply of medications just to ensure the receiving facility has time to gather needed medications. Hospice RN stated that without this coordination with current facility and receiving facility resident's care could be compromised. During an interview on 2/4/25 at 2:30pm, Administrator stated that on 11/25/24 at 9:30pm she was notified by DON J of incident involving Resident #1. The Administrator stated it was decided by her and DON J that Resident #1 needed to be immediately discharged . The Administrator stated that DON J made all necessary notification and plans for discharge. During an interview on 2/5/25 at 3:10pm, DON J stated that she was responsible for making all notifications to providers of resident's discharge. DON J stated that she had forgot to contact Resident #1's hospice provider before the resident left facility. DON J stated she did contact Hospice RN, but it was after resident was already enroute to receiving facility. Nursing Facility Hospice Services Agreement dated March 20, 2024. Section 3.6 Notifications. The Nursing Facility must immediately notify Hospice in the event of any of the following: C). There is a need to transfer the Resident Patient from the Nursing facility, and the Hospice makes arrangements for, and remains responsible for, any necessary continuous care or patient care related to the terminal illness and related conditions.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents and failed to ensure medications were disposed of when expired for 2 of 3 nurses carts inspected for medication storage. The facility failed to ensure the medication cart 1 did not contain expired docusate sodium and loratadine. The facility failed to ensure the medication cart 2 did not contain expired loratadine. These failures could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: During an observation and interview on 02/06/25 at 11:10 a.m., in the medication cart assigned to LVN E, 1 bottle of docusate sodium 100 mg was found with an expiration date of 01/25 and 1 bottle of loratadine 10 mg was found with an expiration date of 01/25. Surveyor asked LVN E what staff is responsible for checking carts for expired medications. LVN E stated that the nurses and medication aides try to check monthly for expired meds. During an observation and interview on 02/06/25 at 12:49 p.m., in the medication cart assigned to CMA F, 1 bottle of loratadine 10 mg was found with an expiration date of 01/25. Surveyor asked CMA F what staff is responsible for checking carts for expired medications. CMA F stated LVN's and CMA's try to check every few months for expired meds. During an interview on 02/06/25 at 4:47 p.m ., the DON stated all staff assigned to a cart should check for expired medications. The DON stated the contracted pharmacist performs cart inspections monthly and the DON and ADON's perform random cart checks. Record review of the facility's Storage of Medications policy dated 11/20 indicated in part: .Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 2 resident (Resident #2 and #63) reviewed for accidents, hazards, supervision. The facility failed to safely transfer Resident #2 with a mechanical lift transfer by not locking his wheelchair. The facility failed to safely complete a two-person gait belt transfer with Resident #63 by not locking his wheelchair. These failures could place residents at risk for injuries due to not receiving the appropriate level of supervision. Findings included: Review of Resident #2's Face Sheet dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included stiffness of the right and left knee, abnormal posture, and arthritis. Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed: He had long and short term memory impairment with severely impaired cognitive skills for daily decision making. He had lower extremity impairment on both sides and used a wheelchair. He was dependent for chair to bed transfers. Review of Resident #2's Care Plan updated [DATE] revealed: Falls/Safety risk: resident had a fall out of his wheelchair no injuries noted. Long Term Goal Target Date: Resident will remain free of injuries related to falls and will remain in a safe environment. Approaches included: Keep call light in reach. Review of Resident #2's Care Plan updated [DATE] revealed: Resident had multiple problems that affects his ability to walk. He has history of and the potential to fall and at risk for injury related to weakness and depression and mental disorder. The long-term goal was Resident will have no injuries related to fall over the next 90 days. Identified interventions included: Make sure his call light is within his reach and respond quickly. Review of Resident #2's Care Plan updated [DATE] revealed: Resident is unable to stand for transfers. The identified the goal was Resident may use a mechanical lift for all transfers and will not have falls related to transfers. Approaches included: resident may use mechanical lift for all transfers. Observation on [DATE] at 1:18 PM revealed CNA B positioned the mechanical lift around Resident #2's chair while CNA A steadied the wheelchair and Resident #2. CNA A steadied Resident #2 as CNA B lifted the chair and the chair moved as Resident #2 came out of it. Once Resident #2 was clear of the wheelchair, CNA A hooked her foot around the wheelchair and pulled it out the way of the lift. CNA A and CNA B then completed the transfer. Interview on [DATE] at 01:35 PM CNA A stated she thought the transfer with Resident #2 went good. CNA A stated she did the transfer as she was trained to do and there was not anything she would do differently. Interview on [DATE] at 01:43 PM CNA B said she thought the transfer with Resident #2 went ok. CNA B said she did not think there was anything she would do differently in the transfer. Interview on [DATE] at 03:53 PM the DON stated her expectation for a mechanical lift was for there to be two people to use it at all times, make sure the sling was positioned under the resident correctly, make sure the wheelchair is positioned the shortest distance from the bed because it was less stress on the resident, one aide holds the resident's arms. The DON explained she expected one aide to stand behind the resident and control the sling while the other aide operated the lift. The DON stated the wheelchair should absolutely be locked. The DON said the last training on transfers the facility did was approximately 6 - 8 weeks ago and it was a joint in-service between therapy and nursing. The DON said the Regional Nurse recently updated the competencies and the facility did them as people hired on. The DON said the agency staff had their own competency check off list at the nurse's station and transfers were on it. Interview on [DATE] at 04:31 PM the Administrator joined the conversation with DON regarding transfers and stated the ADON needed to start an in-service right away on mechanical lifts. Interview and observation with the DON on [DATE] at 04:21 PM revealed CNA A and CNA B completing a mechanical lift transfer with Resident #2. While explaining to the DON the wheelchair was unlocked while the transfer was completed, CNA B stated Did I not lock it the last time? Sorry. Review of in-services provided by the facility revealed the last in-service on mechanical lift transfers was completed on [DATE]. Review of Resident #63's Face Sheet, dated [DATE], revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included stroke with paralysis on the non-dominant side. Review of Resident #63's Quarterly MDS, dated [DATE], revealed: He had long and short-term memory impairment. He had modified independence with daily decision-making skills. He needed substantial assistance for chair to bed transfer. He used a wheelchair. Review of Resident #63's Care Plan, dated [DATE], revealed: Problem: ADL Function/Rehab potential. Goal: Resident will achieve maximum functional mobility. Approaches included: Ambulation/Transfers amount of assist: Total. Observation on [DATE] at 1:30 p.m. revealed CNA A and CNA B prepared to do a transfer with Resident #63. CNA B put a gait belt on Resident #63. The aides decided they wanted the wheelchair closer to the bed, unlocked the wheelchair, inched the wheelchair closer to the bed. CNA B locked the inside wheel, but CNA A did not lock the outside wheel. The aides completed the transfer from the wheelchair to the bed with the wheelchair unlocked. Interview on [DATE] at 1:35 p.m. CNA A stated she thought the transfer went ok; they took Resident #63's foot pedals off, put the gait belt on, Resident #63 did really well standing, the aides assisted with the pivot and put him to bed. CNA A said there was not anything she would do differently with the transfer. Interview on [DATE] at 1:43 p.m. CNA B stated she insisted on doing the transfer with Resident #63 with two people all the time. CNA B said Resident #63 would not agree to a transfer until there were two people available. CNA B stated she remembered the aide took the foot pedals off Resident #63's wheelchair, moved the wheelchair closer to the bed, put on the gait belt, she (CNA B) got one side while CNA A got on the other side; they (the aides) grabbed the gait belt got under his arms, helped him pivot and helped him sit on the bed. CNA B said there was not anything different she would do with the transfer because she always did a two-person transfer gait belt transfer with him. Interview on [DATE] at 3:53 p.m. the DON stated her expectation for a two-person gait belt transfer was both wheels of the wheelchair be locked. Review of the Clinical Skills Checklist and Competency Evaluation for Transfers from Bed to Wheelchair using Transfer Belt, dated February 2019, revealed: Before assisting to stand, locks wheels on wheelchair. Review of the facility's policy and procedure on Safe Lifting and Movement of Residents, revised [DATE], revealed: In order to protect the safety and well-being of staff and residents, and to promote quality of care, the facility uses appropriate techniques and devices to lift and move residents.

Based on interview and record review, the facility failed to provide documentation for transfer or discharge by resident's physician for 1 (Resident #1) reviewed for discharge requirements. The facility failed to provide reason for discharge by resident's physician which must include specific resident needs the facility could not meet, the facility's efforts to meet those needs and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at current facility. This failure placed residents at risk of not having the needed records when transferring care and services. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including sequelae cerebral infarction (pneumonia), diabetes mellitus with circulatory complications (sustained high blood sugar levels), Hemiplegia and hemiparesis (weakness to right dominant side), anxiety disorder due to known physiological condition, type 2 diabetes, acquired absence of left and right leg below the knee. Review of Resident #1's quarterly MDS assessment, dated 11/9/24, reflected a BIMS score of 15, indicating Resident #1 is cognitively intact. Section E-rejects care, GG- manual and motorized wheelchair, impaired on lower extremity both side, H-always incontinent, I-stroke, diabetes, and anxiety. Review of Resident #1's quarterly care plan, dated 11/15/24, behavioral symptoms, exhibits verbally abusive behaviors towards staff. Last reviewed/revised: dated 11/25/24 created by DON J (former DON), category: Physical aggression towards staff causing injury. Record review of incident on 11/25/24 at 9:15pm, revealed Resident #1 physically assaulted CNA. CNA was sent to emergency room and diagnosed with chest wall contusion. Resident #1 was given an immediate discharge notice and was transferred to another nursing facility on 11/26/24 at 3:00pm. Record review of Resident #1's Physician orders dated 11/26/24 at 12:14pm, stated 'Discharge resident to (other nursing facility). Continue current orders and medications as ordered.' During an interview on 2/6/25 at 2:00pm, Resident #1's Primary Physician stated that he was not notified of the incident on 11/25/24 until the next day 11/26/24. Primary Physician stated he agreed with discharge from the facility for resident's behavior towards staff and in his general order description stated discharge resident. During an interview on 2/4/25 at 2:30pm, Administrator stated that on 11/25/24 at 9:30pm she was notified by DON J of incident involving Resident #1. The Administrator stated it was decided by her and DON J that Resident #1 needed to be immediately discharged . The Administrator stated that DON J made all necessary notification and plans for discharge. During an interview on 2/5/25 at 3:10pm, DON J stated she received a general order from Resident #1's Primary Physician stating to discharge resident. SLP Operations, Transfer and Discharges policy, dated July 2024. Section 12, Emergency Transfer/Discharges,

Based on observations, interviews, and record review the facility failed to protect the confidentiality of personal and medical records for 2 (LVN C and CMA D) of 5 staff reviewed for confidentiality of records. 1. The facility failed to ensure LVN C locked her laptop before she left the treatment cart unattended exposing residents personal and medical records. 2. The facility failed to ensure CMA D locked her laptop while she was in a resident's room administering medication exposing a resident's medication record. These deficient practices could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Observation and interview of a treatment cart on 02/06/25 beginning at 11:30 a.m., revealed the computer on the treatment cart was unlocked and unattended displaying residents' personal and medical records. The computer was unattended for 5 minutes, approximately 25 feet away from the nurse's station and not in a clear line of sight from the nurse's station. Walking to the nurse's station, the surveyor asked which staff member was assigned to the cart. LVN C, standing at the nurse's station, stated the cart belonged to her. Observation of a medication cart in A Hall, on 02/06/25 beginning at 12:38 p.m., revealed the computer on the medication cart was unlocked and unattended which displayed a resident's medication record. The computer was unattended with the computer facing the hall. After 2-3 minutes, CMA D came out of a resident's room. The surveyor asked CMA D if the cart belonged to her. CMA D stated the cart belonged to her. In an interview on 02/06/25 at 11:30 a.m., LVN C stated she knew it (the computer) should be locked and she did not mean to leave it open. LVN C stated she never left it open. LVN C stated that leaving the computer unlocked could give unauthorized people access to private information. In an interview on 02/06/25 at 12:38 p.m., CMA D stated leaving the computer unlocked was not an acceptable practice. CMA D stated This was the first time ever. In an interview on 02/06/25 at 4:47 p.m., the DON stated the staff knew better than to leave their computers unlocked and unattended. The DON stated computers should be locked when unattended. The DON stated she and the ADON's perform random rounds to check for compliance. Record review of the facility's policy entitled Electronic Medical Records, revised in June of 2019, read in part: The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure.

Based on interview and record review the facility failed to ensure residents were free from of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for medication regimen. The facility did not administer physician ordered medications to Resident #1 that included handheld nebulizer breathing treatments, inhalers, nasal sprays, and tablets for diagnosed respiratory diseases. This resulted in the need for Resident #1 to be transferred to ED on 08/04/2024 at 8:55 PM and admitted to hospital with diagnosis of acute exacerbation of chronic obstructive pulmonary disease (lung disease causing breathing problems) and symptoms of shortness of breath. An Immediate Jeopardy was identified on 08/09/2024. The Immediate Jeopardy Template was provided to the Administrator on 08/09/2024 at 3:40 PM. While the Immediate Jeopardy was removed on 08/10/2024 at 5:41 PM, the facility remained out of compliance at a scope of pattern and severity level of potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective actions. This failure placed residents at risk of significant medication errors and a decline in health status, serious injury, and/or death. The findings included: Record review of Resident #1's Admission Record, dated 08/08/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] at 03:38 PM. The resident's diagnoses included chronic obstructive pulmonary disease (lung disease causing breathing problems), anxiety disorder (feelings of worry), essential hypertension (high blood pressure), hypothyroidism (thyroid disorder), type 2 diabetes mellitus (elevated blood sugar), long term (current) use of anticoagulants (use of blood thinner), unspecified asthma (breathing disorder caused by airway restriction), gastro-esophageal reflux disease (stomach digestive disease), pain (discomfort), localized edema (swelling in a specific area), allergic rhinitis (allergic response causing sneezing) and hereditary and idiopathic neuropathy (weakness, numbness, pain from nerve damage). Record review of Resident #1's Medication Administration Record, dated 08/08/2024, revealed in part: Brezti HFA 160-9-4.8ncg 2 puffs inhalation twice a day Dx: COPD, inhaled medication to open airways and decrease breathing difficulties (2 of 2 missed doses) Budesonide 0.5mg/2ml 1 vial twice a day Dx: COPD, (an inhaled medication to open airways and decrease breathing difficulties) (2 of 2 missed doses) Fluticasone 50mcg 1 spray nasal twice a day Dx: Allergic Rhinitis, (a nose spray for nasal allergies). (3 of 3 missed doses) Ipratropium-Albuterol 0.5mg-3mg/3ml 1 vial via HHN twice a day Dx: COPD, (an inhaled medication to open airways and decrease breathing difficulties) (3 of 3 missed doses) montelukast tablet. 10mg. 1 at bedtime Dx: Asthma, (a tablet to decrease allergy symptoms) (2 of 2 missed doses) Losartan 25mg 2 tablets once a day Dx: COPD, HTN, (a tablet to maintain blood pressure and decrease airway difficulties) (1 of 1 missed doses) Prednisone 10mg once a day (AM) Dx: COPD (1 of 1 missed doses) Albuterol Sulfate HFA Inhaler PRN wheezing/SOB (a breathing inhaler medication to decrease airway difficulties) (was not administered) Record review of Resident #1's Nursing Progress Note, dated 08/03/2024 through 08/04/24, revealed: 08/03/2024 at 09:23 PM, LVN A documented resident's arrival to facility on 08/03/2024 at 5:00 PM, admitted from acute care hospital with diagnosis of peripheral vascular disease and transported via facility van. LVN A also documented admission orders entered into matrix care and medication orders sent to pharmacy at 5:00 PM. 08/04/2024 at 03:49 AM, LVN F documented Resident has heart rate of 122, anxiety, problems breathing. (Physician) notified and he ordered one time order of Clonazepam1mg for resident. Administered at this time. Will continue to monitor. 08/04/2024 at 05:46 AM, RN G documented Repeat vitals,BP131/89,SPO2 98,resp26,pulse 92,Temp 97.8. On oxygen 4L/min at this time. pt still having dyspnea. Will continue to monitor. 08/04/2024 at 09:39 PM, LVN B documented transfer resident to Hospital ER. Primary reason for transfer: shortness of breath, anxiety and husband wanted resident transferred. Resident condition upon transfer alert and oriented with oxygen applied at 3liters per minute. Resident left facility at 08/04/2024 at 9:00 PM. Resident did not have medications in facility d/t not received from pharmacy resident admitted after 1600(4:00PM) on 08/03/2024. Record review of Resident #1's hospital medical record ED Provider note, dated 8/4/24 at 2137 (9:37PM), revealed the following [in part]: Chief complaint of shortness of breath. Vital signs: T-98.5, HR 123, R 23, BP 159/104, SpO2 100%. Physical Exam Comments: Abuse. Chronically Ill. On a non-rebreather mask. Diminished in lung bases. Scattered rales. Blood Gas (lab to detect oxygen, acidity, and carbon dioxide in the blood), Venous - Collected 8/4/24 @ 9:30 PM with the following results: Ph Venous - 7.32 (Normal 7.35-7.45), PCO2 Venous 72.0 (Normal 80-100), HCO3 Venous 37.3 (Normal 22-26),CO2- 34 (Normal 23-30). Hospital admitting diagnosis: Acute Exacerbation of Chronic Obstructive Pulmonary Disease. In an interview on 08/08/24 at 10:49 AM with Resident #1's Physician, he stated he was at the facility in Resident #1's room at the time of Resident #1's transfer initiation to the ER. He said the resident complained of difficulty breathing and wanted to be transferred to the ER. He stated, I am sure that the lack of medication could have contributed to exacerbation of COPD. He further said the staff at the nursing home usually notified him if the medications were unavailable so he could Give a new order if needed, he continued to say that the clinical staff was in contact with him regarding Resident #1. In an interview on 08/08/24 at 1:18 PM, LVN A, who was the admitting nurse for Resident #1, stated When I went in to assess (Resident #1), she was fine and not short of breath unless she walked to the restroom. She did have an inhaler that her husband brought from home that she used, but I have no idea what it was, (resident's husband) put it back in his pocket. I think it was blue. I suppose it would be me and (other nurse) that should order medication, I only work a few days, so I am not sure. When I received the order, me and the other nurse put the orders in and as far as I know that is what triggers the pharmacy to deliver the medication. I don't give scheduled medications only controlled medications. I knew (Resident #1) didn't have anything upon arrival for meds, I think they have a thing in the med room that they can pull from. All of the orders were put in, I thought they would be delivered at 12 am. In an interview on 8/08/24 at 1:32 PM, LVN B stated Sometimes admission orders are faxed in advance from the hospital, and sometimes they are sent with the resident in a packet when they arrive at the facility. We cannot enter any orders into the computer until the resident is in the building. We cannot enter orders until the resident is entered in the census to open a chart. When the orders are entered into the chart, they automatically are sent to the pharmacy. As long as orders are entered in the computer before 6:30 PM, they should be delivered that same night, but they're not delivered. The orders aren't received immediately by the pharmacy. If the meds aren't delivered, then the nurse gets them from the emergency box, (EMDS). The medication aide administers new residents' meds, except insulin, breathing treatments of any kind (inhalers, nebulizer treatments, supplemental oxygen), PRN narcotics. Med aides can give routinely scheduled narcotics, just not PRNs. Medication aides reorder routine meds when they get low. There is a column on the right-hand side of each medication on the eMAR that says resupply and the medication aide just clicks on it to reorder. The licensed nurses reorder narcotics because the pharmacy has to be called. LVN B stated she called the doctor to ask if medications have refills or if a prescription could be written to send to the pharmacy. LVN B stated she worked for an agency not the facility, has worked in facility for about 2 weeks averaging 4 days per week and doesn't work weekends. LVN B stated the agency nurse was assigned whatever hall was open, including the Medicare Hall, Hall A. She admitted a resident to the Medicare Hall A, entered meds in the computer, and completed the admission nursing assessment, a standardized form. During the week, the ADONs and the DON would help with the admission process and would sometimes enter the medication orders. In an interview on 08/08/24 at 1:51 PM, ADON H stated the Charge Nurse was responsible for ordering medications and if they could not get the medication after calling the pharmacy, they should have notified administrative staff to give direction on what to do. ADON H stated the failure of Resident #1 not getting her medication could have occurred because of a lack of knowledge maybe. ADON H said the risk of the failure for Resident #1 not receiving her medications was an Exacerbation of her Chronic Diseases. In an interview on 08/08/24 at 2:02 PM, ADON I stated the medication aide should have notified the nurse that Resident #1's medication had not been delivered in the medication cart and the Nurse did not follow through to make sure Resident #1 got her medication. ADON I said she did not realize Resident #1 had not received any of her medications for 08/03/24 or 08/04/24 until the morning of 08/08/24. ADON I said the Charge Nurse and the medication aide lacked initiative to get the medication which caused the failure. She said if it were her, I would have pulled everything possibly from the (EMDS) and then contacted the pharmacy to have the rest delivered from backup. ADON I said that did not occur because, PRN nurses, either didn't know the process or just didn't follow it. ADON I stated it was the responsibility of the med aide, nurse, nurse on call, DON ADM to order medications for a new admission. ADON I stated the failure could include death for a resident. In an interview on 08/08/24 at 3:50 PM the DON, stated training began on 08/05/24 with the anticipated DON, start date of 08/12/24. The DON further stated Resident #1 did not receive any of her medications for 08/03/24 or 08/04/24, but the facility did not realize Resident #1 did not receive any of her medications until after the State Surveyors began the investigation and the facility began a Chart Audit after 6ish Wednesday (6:00PM 08/07/24). The DON said (Resident #1) should have received her medications and the on-call nurse, DON, MD should have been immediately notified if the medications were not available. The DON stated the failure occurred because, lack of communication, agency LVN, and admission process. The DON stated the ADON and the LVN had access to the EMDS, and (facility) were working on getting all facility employed nurses' access to the system. The DON stated nurses were responsible for providing residents with nebulizers, inhalers and nasal sprays. In an interview on 8/08/24 at 4:10 PM, MA D stated the licensed nurses give the initial dose of medications. If a resident is new to the facility, then all their medications are considered initial doses, and the Med Aide doesn't do it. MA D stated I did not give Resident #1 any medications. Medication Aide D said The nurses put the orders in the computer for the pharmacy and the licensed nurses give the initial doses and all the PRN medications. The nurses can get meds from (EMDS) (EMDS), but the med aides cannot. I did not see LVN A give Resident#1 any medications and I don't know if she (LVN A) gave the resident any medications. MA D stated the resident did not have any medications in the med cart because she didn't come with any. MA D also stated Medication Aides do not do any kind of respiratory care or breathing treatments - no inhalers or nebulizer treatments. The med aides can get the oxygen cylinder, but the nurse sets the liters and applies the oxygen. In an interview on 08/08/24 at 4:27 PM the Clinical Resource Nurse stated the medications were ordered, but the pharmacy should have been called to ensure the orders were filled, the medication should have been obtained from (EMDS) and what isn't obtained from (EMDS) the pharmacy should have been called, the physician should have been called, or you could call the family to see if they have home medications, we could have gotten medication from hospital, we could have notified DON. The Clinical Resource Nurse said the nurse didn't administer Resident #1's medications from the EMDS because, I am not sure why she didn't give them, but there were many opportunities for her to seek the assistance to obtain the medication. The Clinical Resource Nurse stated the failure could have occurred because of a lack of education, further stating the nurses were responsible for initial doses of medications, nebulizers or breathing treatments and inhalers. The Clinical Resource Nurse said the failure could have caused the rehospitalization of Resident #1. In an interview on 8/8/24 at 4:44 PM, the Administrator stated, the facility failure was that they did not check the (EMDS) and did not notify nursing management that they were missing all of those medications, as well as the charge nurse. The Administrator stated I know I got a call Sunday about an uber and picking up medication how to pay an uber, I said no the pharmacy orders thru a local pharmacy they take care of it, at that time I called ADON I, at that time I was aware of the clonazepam only. Otherwise, I didn't know of anything else until yesterday . I was not aware of other medications not given until yesterday evening. Record review of the facility's policies/procedures for Medication Orders revealed [in part]: Non-controlled Medication Orders, 12/12 Procedures - Elements of the Medication Orders 4. The prescriber shall be contacted by nursing for direction when delivery of a medication will be delayed or the medication is not available. Documentation of the Medication Order: a. New orders b. Written transfer orders (sent with a resident from a hospital or other health care facility): Implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. 4. Scheduling new medications orders on the Medication Administration Record (MAR)/Treatment Administration Record (TAR): a. Non-emergency medication orders: The first dose of medication is scheduled to be given after the next regularly scheduled pharmacy deliver to the nursing home. b. Emergency/STAT medication orders when medication is available in the emergency kit: From the emergency kit, remove the appropriate number of doses to be administered prior to the regularly scheduled pharmacy delivery. Thereafter, does are scheduled according to nursing care center policy on medication administration. c. Emergency/STAT medication order when medication is not available in the emergency kit: An emergency STAT order is placed with the provider pharmacy and the medication is scheduled to be given as soon as received. Subsequent doses are timed according to nursing care center policy on medication administration schedule. This was determined to be an Immediate Jeopardy on 08/09/2024. The Administrator was provided the Immediate Jeopardy Template on 08/09/2024 at 3:49 PM and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 08/10/2024 at 10:17 AM: 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #1 was sent to the hospital on 8/4/2024. Person(s) Responsible: Charge Nurse/The Physician/The Facility Completion Date: 8/4/2024 2. How the Facility Identified Other Possibly Effected Residents: Action: Facility wide MAR to cart audit to ensure medications on the MAR are available on the medication carts, including recent admissions/readmissions. This has been completed on 8/9/2024 with no other discrepancies noted. Person(s) Responsible: Regional Nurse, Director of Nursing, Assistant Director of Nurses and/or Designee Completion Date: 8/9/2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Director of Clinical Operations and Clinical Resource Nurse educated Director of Nursing and Assistant Director of Nurses regarding the facility's emergency medication dispenser and ordering medications from the pharmacy. Charge Nurses were educated by the Clinical Resource Nurse, Director of Nursing, and/or Assistant Director of Nurses over the facility's emergency medication dispenser, ordering medications from the pharmacy. Charge Nurses and Certified Medication Aides were educated over their responsibilities in administering medications and initial doses and notifying the physician with any medications that are unavailable through the emergency medication dispenser and/or would be delayed in receiving and following MD orders. If the medication is not available in the Emergency (EMDS) the nurse will notify the Pharmacy On Call that the medication is not available in the Emergency (EMDS) and determine if the provider pharmacy will be filling the medication order or they will be sending the order to a local 24-hour pharmacy for fill and arranging delivery or pick up. The nurse will determine an approximate time of delivery and document this is the progress notes. Charge Nurses/Certified Medication Aides will be educated prior to working their next shift. New and temporary Charge Nurses/Certified Medication Aides will be educated prior to working their first/next shift. Person(s) Responsible: Director of Clinical Operations, Clinical Resource Nurse, Director of Nurses, Assistant Director of Nurses, and/or Designee Completion Date: 8/9/2024 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Review all admissions/readmissions to ensure medications are available during clinical meetings, daily. Charge nurses will communicate with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and Doctor if medications are not available immediately from the emergency medication dispenser for the next administration time for all admissions/readmissions regardless of day or time and/or pharmacy is unable to deliver the medications timely/on the next run, immediately through the above education. Person(s) Responsible: Director of Nursing, Assistant Director of Nursing, Charge Nurses, and/or Designee Completion Date: 8/9/2024 Action: Medication unavailable report to be ran and reviewed during clinical meetings, Monday-Friday, staff will know to communicate unavailable medications with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and notification of the MD through the above education if there is a noted issue with medications being unavailable. Any issues noted with medication unavailable/failure to communicate will result in 1:1 education with the Charge Nurse or Certified Medication Aide responsible. Director of Nursing, Assistant Director of Nursing, Charge Nurses, and/or Designee Completion Date: 8/9/2024 Action: Notify the MD/Ad hoc QAPI regarding the deficient practice and the facility's plan to avoid future noncompliance. Person(s) Responsible: Administrator/Director of Nursing Completion Date: 8/9/2024 Monitoring and Verification of the facility's Plan of Removal began 08/10/2024 at 10:19 AM as follows: In an observation on 08/10/2024 at 1:39 PM, 3 medication carts were inspected and 3 of 3 new admission residents medications were available on the cart and were administered as ordered. In an interview on 08/10/2024 at 11:09 AM, LVN N stated Upon admission orders are brought to facility, put in computer, pharmacy is called, then pull medications from EMDS. The CMA should inform the nurse if there are no medications on the cart to be given to the resident, then the nurse would have gone thru the EMDS, called the pharmacy and then administered. If the CMA does not communicate to the nurse the nurse would not know. LVN N further stated, if an issue with a medication, LVN N immediately calls the pharmacy to get the medication. LVN N stated I received training regarding responsibilities of Charge nurse, I have been here three years, we (nursing staff) got another training yesterday (8/9/24) that was provided by DON. Yesterday we reviewed the EMDS, physician orders, notifying physician regarding medications that are unavailable and get a suitable substitute, nurses providing initial doses. DON reviewed this with me one on one and I felt comfortable asking questions. In an interview on 08/10/2024 at 01:21 PM, MA D stated she was in-serviced by ADON I, face to face on Medication Administration, which included if a new admission comes in the initial dose is to be given by the charge nurse and that the nurses set up all of the oxygen stuff as well. MA D further stated If there is a resident on my cart I tell the nurse they do not have medication and to remind them to pull from EMDS. In an interview on 08/10/2024 at 1:39 PM, MA E stated in-service training provided in the past day regarding medication administration, new admission medication, to notify nurses if missing medications, that only nurses initial dose,the EMDS that nurses could retrieve medications from. MA E stated she received one on one training from the DON and was able to ask questions. MA E further stated if there was a medication ordered, MA E immediately told the nurse it was not available. In an interview on 08/10/2024 at 1:52 PM, LVN K stated an in-service by the DON and the ADON one on one with each regarding EMDS use of and what was available, admissions, medication ordering and physician notification. LVN K stated nurses were responsible for the initial dose. LVN K further stated Medications for new admissions, I would order from pharmacy and use EMDS if I need so that no doses are missed and if it's a resident that is already here I would check to make sure overflow and pull from STAT EMDS box to avoid missing a dose. In an interview on 08/10/2024 at 2:13 PM, MA M stated an in-service was given by ADON I, one on one regarding initial doses, and notification to nurse if medication needed was not available. In an interview on 08/10/2024 at 2:17 PM, LVN L stated an in-service completed by ADON I, one on one, regarding EMDS demonstration, initial dosing, HHN, new admission responsibility of orders and medications, procedure if medications were not available in the EMDS, notify pharmacy, physician and clinical staff. In an interview with Clinical Resource Nurse on 08/10/24 at 4:02 PM revealed Resident #1 was transferred to the hospital on 08/04/24 from the facility. The CRN stated she did the chart audits on 08/09/24 and any medications that were low were ordered from the pharmacy and/or restock was completed. The CRN explained in-services completed with staff consisted of ordering medications for admissions and readmissions, accessing and use of EMDS with demonstration, and ordering routine medications for all residents in the facility's new and current, reviewed notification of doctor, DON, ADON and ADM if any medications were unable to be obtained, always including weekends and after hours. The information provided to the licensed nursing staff specified if a medication could not be found in the medication cart it could be found in the EMDS. Charge nurses employed by facility may access the EMDS. Agency staff should ask for assistance obtaining medication needed from the EMDS which included tablet, capsule, liquids, HHN and injectables. A copy of the EMDS manufacturer Quick Reference Guide was reviewed with the nurses and gave specific step-by-step instructions on how to operate the medication dispensing machine with pictures of power-point slides. A printed list of the Active Inventory of medications in the EMDS for the facility. The staff did return demonstration of use of the medication dispense machine. She said, facility DON or designee will run a report Monday thru Friday mornings of medications not given. The DON would then bring the report to morning meeting to discuss with the team. The DON or designee would initiate an investigation, speak with the nurse or CMA who was responsible, find out why the medication wasn't administered, educate them, and follow the discipline policy as needed. In an interview on 08/10/24 at 4:37 PM, the DON stated the DON and both ADON's in-serviced all facility charge nurses regarding log in access to EMDS with demonstration regarding how to use system, initial dosing must be completed by license staff only, admission and re-admission medication process, ordering and dispensing, the CMA scope of practice. The DON explained in further detail the DON and the ADON educated clinical staff regarding upon admission that all resident medications should be reviewed for verification that medications were available for supply, the DON or ADON must be notified if not able to supply for next steps such as notifying the discharge provider for alternate or to send with supply, initial doses were only to be given by licensed nursing staff, the CMA expectation was not to administer initial doses and they were to notify the charge nurse of any medications not available to them. The DON further explained above information was given one on one to each facility nurse and facility CMA. The DON also stated the DON was responsible for education regarding the in-services and education given to clinical staff, she, with the help of the ADONs and the Clinical Resource Nurse completed trainings. The DON stated the process to address all new referrals and new medication orders in the morning meetings, as well as the DON or the on call clinical designee would call in on weekends to verify. The DON stated, medication unavailable report will be reviewed daily Monday thru Friday in morning meeting. If anything is flagged, DON will review, investigate, and determine why medication was missed or not given and then take corrective action as appropriate. She said The process to address all new referrals and new medication orders in the morning meetings, as well as DON or the on call clinical designee will call in on weekends to verify. In an interview on 08/10/2024 at 5:00 PM with the DON, she said they had a QAPI meeting and attendance with the medical director via phone. The Medical director was called by the ADM. Interview also revealed that Medical Director was notified by the DON regarding medications not administered to Resident #1 on 08/08/24 at 10:53AM. In an interview with ADM 08/10/2024 at 5:02PM regarding physician notification of Medical Director regarding IJ and SQC, ADM stated that medical was notified by ADM via phone on 08/09/24 at 5:11PM. Record review of Resident #1 hospital record dated 08/04/24 at 9:42 PM, revealed Resident #1 arrival to the emergency department with symptoms of shortness of breath at 9:15 PM on 08/04/2024. In an interview on 08/10/24 at 10:21am, with Resident #1's family, she said Resident #1 discharged from the hospital on 08/09/24 to a different nursing facility and was feeling much better. Record review of Chart Audit, dated 08/09/24, revealed All Medication Carts were audited and completed as signed by CRN and dated 08/09/24. Record Review of In-services dated, 08/08/24 & 08/09/24, included the following: Initial Dosing-8/9/24Certified Medication Aide (CMA) are not to administer the initial dose of any medication. This includes newly admitted residents and residents who have orders for any new medication. Initial dosing medication is not within the scope of practice of a CMA. This inservice had facility staff signatures and facility staff names and phone numbers indicating nurses and medication aides were inserviced on the information. New Admit Readmit Med Process Med Dispense Machine-Nurse Administrative Staff-8/9/24. 1. New Admission Medication 2. Med Dispense 3. Nebulizer Med Administration dated 8/9/24-Admission/Readmission Medication Process- Always including nights and afterhours-1. Enter orders for residents hospital discharge medication list. 2.Contact the pharmacy to confirm medication time of arrival 3. Enter pharmacy communication information in a nurse's note. Include name of person that was spoken to at pharmacy. 4.Check the medication dispensing machine for available medications. 5. At this time notify doctor, director of nursing, assistant director of nursing, or administrator of any medication that is unavailable, to obtain a substitute medication or in order to DC the medication until it is available from the pharmacy. And alternate pharmacy may be considered (local pharmacy) 6. Communication with director of marketing, to request discharge medication for medication that is unavailable prior to discharge. 7. In the morning meeting review referral documentation. communicate with the director of marketing to request discharge medication for medication that is unavailable prior to discharge. Consider holding admission if it is foreseen that we will be unable to attain medication including after hours or on weekends. 8. The morning following admission the DON or designee will verify the medications were obtained. - Nursing staff signatures reflected they reviewed and acknowledged the information. Accessing medication from med dispense located in the med room at the nurses station medication that cannot be found in the medication cart can be found in the Med dispense. Charge nurses employed by (facility) may access the Med dispense machine agency staff should ask for assistance obtaining medication needed from the medication dispense machine including tablet, capsules, liquids, HHN, injectables. Nursing staff signatures reflected they reviewed and acknowledged the information. 1 The Director of Nursing/designee will review referrals preadmission specifically those that may be admitting after hours/weekends and request potential discharge date and time and discharge orders if these are available.2 The Director of Nursing/designee will determine what medications are needed and specifically note if any medications will not be available in the facility's emergency medication dispenser (review the referral prior to admission, communicate with the discharging entity on potential discharge date (s), proactively request discharge orders from the discharging entity).3. If the Director of Nurses/designee identifies medications that are not in the Emergency medication dispenser and if this medication will be needed prior to the next Pharmacy delivery the Director of Nurse/designee will request the discharging entity to provide medications until the facility can obtain the medications. If the discharging entity is unable to supply the medication{s) the facility will notify the physician and determine further actions or delay the admission until the medication can be obtained.- Nursing staff signatures reflected, they reviewed and acknowledged the information. Medication unavailable report to be ran and reviewed during clinical meetings, Monday-Friday, staff will know to communicate unavailable medications with the Director of Nursing, Assistant Director of Nursing, and/or Administrator and notification of the MD through the above education if there is a noted issue with medications being unavailable. Nursing staff signatures reflected, they reviewed and acknowledged the information. Record review of QAPI Meeting on 8/8/24: Problem-Failure to ensure new resident admission received medications. Attendees included Resident #1's Physician and Medical Director, ADM, CRN, CCM, ADONs, and Social Worker. The Administrator was informed the Immediate Jeopardy was removed on 08/10/24 at 5:41PM. The facility remained out of compliance at a scope o [TRUNCATED]

Based on observations, interview, and record review the facility failed to ensure the environment remained free of accidents hazards and provided adequate supervision to prevent accidents for 5 of 9 (Resident #1, #8, #9, #10 and #11) residents reviewed. 1. The facility failed to ensure Resident #1, #8, #9, and #10 were provided direct supervision of staff when smoking. Residents #1, #8, #9, and #10 were allowed to sign out and go outside to smoke in an undesignated smoking area unsupervised in an area with flammable objects of dry grass and dry wood. Residents #1 and #8 were observed to cross the street in front of the facility to the picnic table at the park and smoke in their wheelchairs unsupervised near a creek with an 8-foot drop off. 2. The facility failed to ensure Resident #1 was safe when smoking with no supervision as evidence by a burn on his clothing, fanny pack and blanket. 3. The facility failed to ensure Residents #1,#8, #9, and #10 complied with the facility's smoking policy that required all smoking paraphernalia to be checked in and out by the nursing staff and stored in a secure location upon return from pass. 4. The facility failed to follow their Nursing Guideline: Out on Pass/Leave Procedure Policy, dated 03/2024, by failing to abide by: - ensure smoking actions were implemented in Residents #1 and #8's Care Plan per policy to correctly identify the residents' smoking safety needs. - obtain physician orders prior to Residents #1, #8, #9, and #10 physically signing out of the facility on pass to smoke. - ensure proper documentation on the Out of Pass Release of Responsibility Form for Resident #1, #8, and #10 was completed accurately and entirely, to include what time the residents left the building, and what time the residents planned to return. - ensure Resident #1, #8, #9, and #10 were assessed by a nurse prior to signing out and leaving the facility and upon return to the facility from pass. 5. The facility failed to ensure a smoking assessment was conducted for Resident #9's to determine his smoking risk when admitted on [DATE]. 6. The facility failed to ensure Resident #11's cigarettes were not stored on his person and kept in a secure area during other times than scheduled, supervised smoking breaks. An IJ was identified on 03/28/2024. The IJ template was provided to the facility on [DATE] at 1:15 p.m. While the IJ was removed on 03/29/2024, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm, severe injury, and possible death to residents who require supervision while smoking. Findings included: Resident #1 Record review on 03/07/2024 at 11:30 a.m. of Resident #1's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Unspecified sequelae (consequence of a previous disease) of cerebral infarction (damage to tissues in the brain due to loss of oxygen to the area), Hemiplegia (paralysis on one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction affecting right dominant side, Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), and surgical amputation of both legs below the knees. Record review on 03/07/2024 at 11:31 a.m. of Resident #1's Doctor's Orders, dated 01/24/2024, revealed Resident #1 had a general order of Nasal Cannula (prn for comfort): o2@ (2-4) L/Min, Every shift - PRN Shift, Shift1, Shift2, Shift3. Record review on 03/07/2024 at 11:32 a.m. of Resident #1's Doctor's Orders, dated 03/07/2024, revealed Resident #1 did not have physician orders that identified Resident #1 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/07/2024 at 11:33 a.m. of Resident #1's Quarterly MDS Assessment, dated 01/26/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which identified an intact cognitive response. Section GG0115 - Functional Limitation in Range of Motion revealed Resident #1 had impairment on both sides of his lower extremity and Section GG0120 revealed Resident #1 ambulated by use of a wheelchair. Review of Section E - Behavior, E0800 revealed Resident #1 had no behaviors or refusals of care. Record review on 03/07/2024 at 11:34 a.m. of Resident #1's Smoking Risk Assessment, dated 09/29/2023, revealed Resident #1 scored high and was deemed an unsafe smoker. The assessment revealed Resident #1 was assessed as a chain smoker, severe problem with smoking in unauthorized area, severe problem with careless with smoking materials, such as drops cigarette on floor or burns fingertips, severe problem smoking used cigarettes butts from ash trays, severe problem giving cigarettes to others, and severe problem with begging or stealing cigarettes. The assessment recommended Resident #1 continue current plan of care and follow facility policy. Record review on 03/07/2024 at 11:36 a.m. of Resident #1's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking, Assessment - Observation Information, Resident #1's name was hand-written in. Review revealed the questions on the assessment were blank and the form was unsigned and not dated. The summary and rating of Resident #1's smoking ability was blank and undetermined. Record review on 03/07/2024 at 11:38 a.m. of Resident #1's Care Plan, dated 12/18/2023, revealed Resident #1 had a Problem/Category area of - Smoking: I am a smoker. I am not always compliant with the smoking policies. I have been found smoking outside of the designated smoking area and I have been known for not returning all of my smoking materials. Review revealed Resident #1's goal was to comply with smoking policies and would smoke in designated area(s) at scheduled times through the next review period. Record review on 03/07/2024 at 11:39 a.m. of Resident #1's Progress Note, dated 2/08/2024 at 8:07 a.m., revealed Resident #1 was observed smoking outside in the smoking area even though he was reminded not to go. Resident #1 said to the staff, stay out of my business and I am not a f__cking child. Resident #1 remained outside and refused to extinguish his cigarette. Record review on 03/07/2024 at 11:40 a.m. of Resident #1's Progress Note, dated 2/10/2024 at 12:35 a.m., revealed Resident #1 was observed going outside with another male resident who pushed Resident #1 in his wheelchair to the smoking area even though he was reminded not to go but he went anyway and smoked. During an observation on 03/07/2024 at 8:30 a.m., Resident #1 was observed outside sitting in his wheelchair and smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed the area where Resident #1 was smoking was located by a side street that intersected with the road that ran in front of the facility. Resident #1 was observed as he smoked by a telephone phone surrounded by yellow, dried weeds approximately two (2) feet in height and a grey wooden pallet, or a flat wooden platform on which goods are stored so that they can be lifted and moved using a forklift truck, was observed lying flat on top of the weeds. During an interview on 03/07/2024 at 9:32 a.m., LVN L said he had observed Resident #1 exit the facility through the front entrance and go to the east side of the facility and smoke unsupervised on multiple occasions. LVN L said he did not know which residents who smoked were assessed as safe or unsafe. LVN L said he had observed Resident #1 across the street at the park at the picnic table smoking on several occasions. LVN L said Resident #1 was independent and he assumed Resident #1 could smoke as long as he was off the property. On 03/27/2024 @8:33 a.m., Resident #1 was observed with a small hole in his fanny packet he wore around his waist, approximately 1/4 inch in diameter, singed and melted around the edges. Observed two small black spots on the blanket Resident #1 had draped over his lap. Resident #1 said he was sitting outside smoking a week prior and the wind blew his blanket up and knock his cigarette out of his hand. Resident #8 Record review on 03/07/2024 at 6:45 p.m. of Resident #8's Face Sheet, dated 03/07/2024, revealed a [AGE] year-old female who was admitted to the facility on [DATE], with diagnoses of Atherosclerotic (thickening or hardening of the arteries) heart disease of native coronary artery with unspecified angina pectoris (occurs when arteries that carry blood to your heart become narrowed and blocked because of thickening or hardening of the arteries or a blood clot); Alcohol dependence; History of methamphetamine dependence, Chronic obstructive pulmonary disease, and Acquired absence of other specified parts of digestive tract-Partial colectomy (surgeon removes the diseased portion of the colon and a small portion of surrounding of heathy tissue). Record review on 03/07/2024 at 6:46 p.m. of Resident #8's Doctor's Orders, dated 09/23/2023, revealed Resident #8 had a general order of Oxygen 2-4 L/Minute PRN As Needed, PRN1, PRN2, PRN3. Record review on 03/07/2024 at 6:47 p.m. of Resident #8's Doctor's Orders, dated 03/07/2024, revealed Resident #8 did not have physician orders that identified Resident #8 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/07/2024 at 6:48 p.m. of Resident #8's MDS Quarterly Assessment, dated 02/22/2024, Section C- Cognitive Response Patterns revealed a BIMS score of 12, which indicates moderate impairment. Section - GG0120 - Mobility Devices, revealed Resident #8 ambulated with the use of a wheelchair. Review of Section E - Behavior, E0800 revealed Resident #1 had no behaviors or refusals of care. Record review on 03/07/2024 at 6:49 p.m. of Resident #8's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking Assessment - Observation Information, Resident #8's name was hand-written in. Under the Section - Observation Detail List Report - the question, Is the resident physically capable of smoking? was blank as well as Section - Evaluation, Smoking Risk, Referral, and Plan of Care. Review revealed the assessment was not signed or dated and was incomplete. The summary and rating of Resident #8's smoking ability was blank and undetermined. Record review on 03/07/2024 at 6:51 p.m. of Resident #8's Smoking Risk Assessment, dated 09/28/2023, revealed Resident #8 had a score that identified her as Potentially Unsafe Smoker and deemed Resident #8 with the need for care plan intervention. The assessment revealed Resident #8 was assessed as a chain smoker, minimum problem with smoking in unauthorized area, moderate problem with careless with smoking materials, such as drops cigarette on floor or burns fingertips, moderate giving cigarettes to others, and moderate problem with begging or stealing cigarettes. The assessment recommended Resident #8continue current plan of care and follow facility policy. Record review on 03/07/2024 at 6:54 p.m. of Resident #8's Care Plan, dated 01/08/2024, revealed Resident #8 had a Problem area of - Res is a smoker; Review revealed Resident #8's goal was to maintain safety while smoking, which included nursing staff to assist and assure Resident #8 removed oxygen before smoking and reviewed/discussed the facility's smoking policy with Resident #8 quarterly. Resident #9 Record review on 03/08/2024 at 9:25 a.m. of Resident #9's Face Sheet, dated 03/08/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Other psychoactive (affecting the mind) substance abuse with substance-induced persisting dementia (loss of cognitive functioning - thinking, remembering, and reasoning- to such an extent that it interferes with a person's daily life and activities), Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance) with hyperglycemia (high blood glucose), Osteomyelitis (infection in the bone) of vertebra (spine), thoracic region (middle of spine), and Paraplegia, incomplete (the injury has not completely severed the spinal cord and some degree of sensation and movement control would be present). Record review on 03/08/2024 at 9:26 a.m. of Resident #9's Doctor's Orders, dated 03/08/2024, revealed Resident #9 did not have physician orders that identified Resident #9 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/08/2024 at 9:27 a.m. of Resident #9's Other Payment MDS Assessment, dated 12/06/2023, Section C- Cognitive Response Patterns revealed a BIMS score of 14, which identified an intact cognitive response. Section G revealed Resident #9 required extensive assistance with two or more persons with toileting and transferring to his wheelchair. Review of Section E - Behavior, E0800 revealed Resident #9 had no behaviors of rejection of care to meet his goals for health and well-being. Record review on 03/08/2024 at 9:30 a.m. of Resident #9's clinical record progress notes, dated 09/18/2023 through 02/13/2024 revealed Resident #9 did not have a Smoking Risk Assessment. Record review on 03/08/2024 at 9:33 a.m. of Resident #9's SLP Smoking Risk Assessment, dated 02/13/2024, revealed a paper copy of an Observation Detail List Report with the identifying information marked out with a black marker. Under the Section - Smoking Assessment - Observation Information, Resident #9's name was hand-written in. Under the Section - Observation Detail List Report - the question, Is the resident physically capable of smoking? was blank as well as Section - Evaluation, Smoking Risk, Referral, and Plan of Care. Review revealed the assessment was not signed or dated and was incomplete. The summary and rating of Resident #9's smoking ability was blank and undetermined. Resident #10 Record review on 03/08/2024 at 10:20 a.m. of Resident #10's Face Sheet, dated 03/08/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses of Osteomyelitis (serious infection of the bone) of vertebra (spine), thoracic (middle section of your spine) region, End stage renal (kidney) disease, Unspecified dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to an extent that it interferes with a person's daily life and activities) , Type II Diabetes (condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) Mellitus (the response to insulin was diminished and defined as insulin resistance), Dependence on renal dialysis (treatment for people whose kidneys are failing), and Chronic kidney disease, Stage 5 (last stage). Record review on 03/07/2024 at 10:22 a.m. of Resident #10's Doctor's Orders, dated 02/16/2023, revealed Resident #10 had a general order of Nasal Cannula (PRN): O2@ 2L/Min, As Needed, PRN 1, PRN 2, PRN 3. Record review on 03/08/2024 at 10:24 a.m. of Resident #10's Doctor's Orders, dated 03/08/2024, revealed Resident #10 did not have physician orders that identified Resident #10 was able to leave the facility, to include the reason, medical or social, and the circumstances (i.e. alone or with family/friends). Record review on 03/08/2024 at 10:25 a.m. of Resident #10's Quarterly MDS Assessment, dated 12/10/2023, Section C- Cognitive Response Patterns revealed a BIMS score of 08, which identified moderate impairment. Section I - Active Diagnoses revealed in I8000 Resident #10 had the diagnosis of Dependence on renal dialysis. Section O - Special Treatments revealed in Section O0110 J1, Resident #10 received the treatment of Dialysis upon admission and while a resident. Section E - Behavior, E0800 revealed Resident #10 had no behaviors of rejection of care. Record review on 03/08/2024 at 10:28 a.m. of Resident 10's Smoking Assessment, dated 12/20/2023, was incomplete as the questions were not answered and the assessment was not dated and signed. Review of the Resident #10's Smoking Assessment, dated 10/06/2023, revealed Resident #10 had a minimal problem of understanding the facility policy and a minimal problem of general behavior and interpersonal interaction. Resident #10's score was a 5, which in the middle of the range of the safe smoker category. Review revealed Plan of Care section recommended to continue current care plan. Record review of Resident 10's Care Plan dated 02/02/2024, revealed the plan did not include a goal or interventions to address smoking. Resident #11 Record review on 03/14/2024 at 5:50 p.m. of Resident #11's Face Sheet, dated 03/14/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] , with diagnoses of Cerebral infarction, unspecified (stroke or not enough blood was getting through certain blood vessels in your brain and the tissue had not received enough blood causing damage); Bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration), Gout (happens when urate, a substance in your body, builds up and forms needle-shaped crystals in your joints), Morbid obesity (have a high body mass index and experience negative health effects due to excessive body weight), and Hypertension (when the pressure in your blood vessels is too high). Record review on 03/14/2024 at 5:53 p.m. of Resident #11's MDS Optional State Assessment, dated 12/06/2023, Section C- Cognitive Response Patterns revealed a BIMs score 15, which identified an intact cognitive response. Review of Section E - Behavior, E0800 revealed Resident #11 had no behaviors or refusals of care. Record review on 03/14/2024 at 5:55 p.m. of Resident #11's Smoking Risk Assessment, dated 09/29/2023, revealed Resident #11 had a score that identified him as Potentially Unsafe Smoker and deemed Resident #11 had the need for care plan intervention. The assessment revealed Resident #11 was assessed as a chain smoker, severe problem with providing smoking material to other residents, severe problems with begging and stealing smoking materials from other residents, and severe problem with behavior and interpersonal interaction. The assessment revealed Resident #11 continue current plan of care and follow facility policy. Record review on 03/14/2024 at 5:58 p.m. Resident #11's Care Plan, dated 03/11/2024, revealed a Problem Area included in Resident #11's Care Plan in the category of smoking, which was started 09/18/2023. The Care Plan revealed under the Category: Smoking: I am a smoker, and I am not always compliant with smoking policies. I have been found smoking in areas that are not designated smoking areas and I do not always comply with returning smoking materials. Review revealed the goal was to comply with smoking policies through the next review period. During an interview on 03/06/2024 at 6:45 p.m., Resident #1 said he could not go more than 30 minutes without smoking a cigarette. Resident #1 said the facility's smoking policy was unfair and he did not agree with the policy that he could not smoke without being supervised. Resident #1 said he signed himself out at the nurses' station, signed his name on the sign book and smoked on the east side of the building. Resident #1 said the staff that was at the nurses' station at the time he signed out would hand him a bag that contained his cigarettes and lighter and he went outside without staff to smoke. During an interview on 03/06/2024 at 7:31 p.m., Administrator F said the nursing home followed facility policy and provided supervision to the residents who were assessed as unsafe smokers. Administrator F said if a resident had a high BIMS score and was assessed as a safe smoker, the resident could sign-out on pass at the nurses' station and smoke outside unsupervised. Administrator F said the facility did not have policy that covered when residents signed out on pass to specifically smoke. During an observation on 03/07/2024 at 11:45 a.m., observed the smoking schedule posted on the door that exited out into the designated smoking area revealed smoking breaks were scheduled for 6:30 a.m., 8:30 a.m., 11:00 a.m., 1:00 p.m., 4:00 p.m., and 7:00 p.m., and were 15 minutes in length or two (2) cigarettes each time. Observed the facility's designated smoking area was located outside a door accessible from the dining room. Observed the door had opened into a secure gated area that contained a table, chairs, ashtrays, and smoking vests that hung on the wall. During an interview on 03/07/2024 at 12:05 p.m., ADON B said the facility had one designated smoking area and the designated smoking space was the area located off the dining room through a non-exit door into the secure fenced area. ADON B said the residents did not smoke outside the facility and there was not a designated smoking area on the East side of the building on the outside of the fenced in location. ADON B said the residents were provided cigarettes during designated smoking times from the staff who provided supervision and when the break was over, the residents returned the cigarettes and lighters to the staff to be secured in a plastic tote that was stored under the nurses' station. ADON B said residents who were assessed as safe smokers signed out on pass and requested cigarettes from the nurses who would get them from the plastic storage box located under the desk area in the nurses' station. ADON B said the nurse would give the resident what the resident had in the box even if it was 2 cigarettes or a pack of cigarettes. During an observation on 03/07/2024 at 12:47 p.m., observed a clear plastic storage tote under the nurses' station that was not locked or secure. Observed the storage tote was under the desk area at the front of nurses' station where the sign out book was located. Observed ADON B open the tote and remove a small tackle box that contained a vape device with three (3) bottles labeled nicotine. Observed approximately 30 large zip lock bags with residents' name written on the side that contained lighters and cigarettes or cigarette packs. During an interview on 03/07/2024 at 12:50 p.m., ADON B said the employee of the facility or person who let the resident in the door was responsible to ensure he/she returned his/her plastic bag including the lighter. ADON B said the reason Resident #1 could sign out and smoke was because Resident #1 had a high BIMS Score and was his own responsible party. During an observation on 03/07/2024 at 12:53 p.m., observed Resident #8 at the front desk, sign out on the facility sign out book, and take her cigarette and lighter from the staff behind the counter. Observed Resident #8 exit the facility and ambulate by use of her wheelchair to the east side of the facility and light her cigarette and smoke unsupervised by the telephone phone and side street. During an interview on 03/07/2024 at 1:15 p.m., DON D said the residents had a right to sign out if they had a high BIMS score and a safe smoking assessment. DON D said once a resident signed out, the facility could not stop them from smoking on the east side of the building unsupervised. DON D said the east side of the building was not a designated smoking area and was not set up to meet the facility's policy as a designated smoking area During an interview on 03/07/2024 at 1:30 p.m., Resident #8 said she knew the facility had a designated smoking area by the dining room and designated smoking break times, but she would rather sign herself out on pass and smoke. Resident #8 said she could not wait for each facility break time to smoke because she needed to smoke more often. During an interview on 03/07/2024 at 1:37 p.m., Resident #9 said he would sign himself out on pass and smoke outside the facility. Resident #9 said he did not need supervision and could push himself outside to the side of the facility because he needed to smoke several cigarettes at a time during his smoke break. During an interview on 03/07/2024 at 1:41 p.m., Hospitality Aide E said the residents that were able to independently sign out would sign out on pass and she would give them their cigarettes and lighters that were stored in a zip lock bag inside the plastic tote container. Hospitality Aide E said the residents would go outside to the east side of the building by the telephone pole and side road curb and smoke. Hospitality Aide E said the residents had to have a high BIMS score and be assessed as a safe smoker. Hospitality Aide E said she did not have a list of which residents were safe smokers and were able to sign out on pass independently. Hospitality Aide E said she had not read the smoking policy or out on pass/leave policy. During an observation on 03/07/2024 beginning at 1:48 p.m., observed Resident #1 and Resident #8 sign out on pass, receive their cigarettes from staff at nurses' station, exit the facility, and go outside to the east side of the building to smoke unsupervised in an undesignated smoking area. Observed Resident #1 was in an electric wheelchair and Resident #8 was in a manual. After smoking, observed both cross the parking lot and observed Resident #1 as he rode his chair on the side of the road next to the sidewalk and Resident #8 as she went up on the sidewalk and enter the handicap low curb. Resident #1 and Resident #8 were observed crossing the road to the sidewalk on the other side of the road at the park. Observed Resident #8 take several minutes to maneuver her wheelchair down the sidewalk as there was a sharp slope down to the picnic table. Observed Resident #9 with his family member sitting at the picnic table ahead of Resident #1 and Resident #8. Resident #9's family member was observed walking up the hill and pushed Resident #8 down to the picnic table. Observed the picnic table was approximately 30 yards from the river that had an 8 foot drop off to the water below. During a group interview on 03/07/2024 at 1:59 a.m., at the picnic table at the park across from the facility, Resident #9's family member said Residents #1, #8, and #9 came to the park just about every day. Resident #1 said prior to the first of February, Residents #1, #8, and #9 smoked whenever they wanted to in the designated facility smoking area. Resident #1 said he was assessed by the fact that if he could get out the door, he did not need supervision. Resident #9 said he had never been assessed for smoking. Resident #1 said prior to the first of February, the group could smoke whenever they wanted to in the facility's designated smoking area unsupervised. Resident #9 said he came to park when his family member could push him over because Resident #9 said he was not strong enough to push himself in his wheelchair by himself all the way across the street, down the hill, and to the picnic tables. Resident #9 said he would sign himself out on pass and smoke on the side of the facility when his family member was not at the facility. Resident #1 said prior to first of February, he kept his cigarettes and lighter with him in his room. Resident #8 said she kept her cigarettes and lighter in her room as well and no one asked Resident #8 to turn her lighter in when Resident #8 came in from pass. Resident #8 said she could not go two (2) or three (3) hours without smoking a cigarette and Resident #8 said the smoking policy should only apply to residents who were unsafe smokers. During an interview on 03/07/2024 at 3:27 p.m., Administrator F said residents were deemed able to sign out of the facility and smoke based on a high BIMs score and if a smoking assessment revealed the resident was a safe smoker. Administrator F said the east side of the building was not a designated smoking area, but the residents smoked in the space when signed out on pass from the facility. During an interview on 03/07/2024 at 4:06 p.m., Social Worker I said she attempted to complete a smoking assessment with Resident #1 on 02/13/20/24. Social Worker I said Resident #1 told her he did not smoke so she did not complete the assessment. Social Worker I said she had not assessed or attempted to assess Resident #9 after learning he was a smoker. During an observation on 03/08/2024 at 8:55 a.m., observed Resident #1 and Resident #10 outside smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed Resident #1 and #10 ambulated by wheelchairs and sat next to a side street by a telephone pole. During an observation on 03/13/2024 at 8:29 a.m., Resident #1 was observed outside sitting in his wheelchair and smoking on the east side of the facility unsupervised in an undesignated smoking area. Observed Resident #1 sitting by a telephone pole and dry grass next to the pole. No ashtrays present. During an observation on 03/13/2024 at 9:15 a.m., observed Resident #11 walk by the nurses' station with the assistance of a rolling walker with a cigarette tucked behind his left ear. During an interview and observation on 03/13/2024 at 9:52 a.m., Resident #11 said he was a smoker and smoked outside in the designated smoking area. Resident #11 said he would rather not answer the question of where he kept his cigarettes or where he was supposed to keep his smoking supplies. Observed a cigarette behind his left ear. During an interview on 03/13/2024 at 10:10 a.m., Administrator F said all resident smoking materials had to be kept stored in a central place and none was allowed in the residents' rooms or on their person. Administrator F said she was not sure why Resident #11 had cigarettes in his room, but she went down and talked to Resident #11, and he gave her three (3) cigarettes he had in his room. Observed Administrator F with three (3) cigarettes in her hand. During an interview and observation on 03/13/2024 at 2:15 p.m., observed Resident #1 and Resident #9 outside sitting in their wheelchairs and smoking on the east side of the facility unsupervised in an undesignated smoking area. During an interview on 03/15/2024 at 12:57 p.m., Administrator F said the facility smoking policy was necessary and should be enforced for the residents' safety. Administrator F said she realized changes to the process were needed in the smoking assessments and how they were completed did not meet her expectations. During an interview on 03/25/2024 at 8:02 a.m., DON D said the residents who were smokers and who checked out on pass to smoke at the side of the building were violating the facility smoking policy. DON D said the residents were at risk smoking near the building if the cigarette was not extinguished properly. DON D said the residents who smoke had be in-serviced and educated on 03/14/2024 on the dos and don'ts of the smoking policy and had been informed that the only designated area for smoking was the facility patio. During an observation on 03/25/2024 at 10:42 p.m., revealed Resident #1 smoking outside unsupervised approximately 10 feet from a parked car. Resident #1 turned his wheelchair with his back facing the building near the exit of Hall A and was observed with a lit cigarette in his hand. Observed Residents #8 and #9 come out of the facility and join Resident #1 to form a circle and smoke. On 03/27/2024 @8:33 a.m., Resident #1 was observed with a small hole in his fanny packet he wore around his waist, appr [TRUNCATED]

Based on interviews, and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 9 residents reviewed for CPR, in that; The facility failed to ensure Resident #1 received life saving measures including CPR (Cardiopulmonary Resuscitation) when she was found unresponsive on [DATE]. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of not receiving life saving measures including CPR and could lead to death. The findings included: Record review of Resident #1's face sheet dated [DATE] revealed an admitted [DATE] with diagnoses which included: unspecified dementia, psychotic disturbance, multiple rib fractures, unspecified side, chronic pain syndrome, weakness, chronic kidney disease, stage 3b, and congestive heart failure. Record review of Resident #1's physician orders revealed an order for Code status: Full Code dated [DATE] placed into the electronic medical record and signed by facility Medical Director. Record review of Resident #1's care plan dated [DATE] revealed The Resident and/or Responsible Party will communicate their wishes regarding Advanced Directives/Advance Care Planning and facility staff will honor their stated preferences with interventions which included: Full Code. Record review of Resident #1's progress note dated [DATE] written by LVN A revealed: Resident #1 was climbing out of bed, pulling off O2 tubing, restless and anxious. LVN A documented administration of Ativan and Lortab at 06:30 a.m. LVN A documented at 0730 a.m., Resident #1 was found deceased . Record review of Resident #1's progress note dated [DATE] at 9:15 a.m., revealed: RN C documented end of life care for Resident #1 provided by hospice and staff. Attempts were made to contact family but no answer. During an interview on [DATE] at 8:00 a.m., the Interim Administrator stated he had only been working at the facility since [DATE] (3 days). During an interview on [DATE] at 9:40 a.m., CNA A stated she was working on the day Resident #1 expired. CNA A stated when she was completing her rounds around 6:00 a.m. Resident #1 was lying peacefully then a little bit later, she noticed Resident #1's feet were off of the bed, and she was touching her face. CNA A asked Resident #1 if she was hurting and she nodded her head, so she went to get the nurse. CNA A reports the night nurse (RN A) stated Resident #1 slept well during the night. CNA A reports she went back to the room later and gave Resident #1 her breakfast and a drink of water. CNA A returned a little later and changed Resident #1's top as her back was sweaty. CNA A reports that she was documenting in Point of Care when she heard the nurse say Resident #1 expired. During an interview on [DATE] at 11:07 a.m., CMA A stated she was working on halls D, C and ,d+[DATE] of B the day Resident #1 expired. CMA A stated, LVN A went to see Resident #1 upon notification and that she was her patient in the past. CMA A stated CNA B informed both she and LVN A she was unresponsive around 7:30 a.m. CMA A was able to identify the process for checking a resident's code status by looking in the Kiosk and the crash cart list. During an interview on [DATE] at 11:30 a.m., CNA B stated she was working with Resident #1 on [DATE] and went into her room and saw her leaning on the right side of her pillow looking up toward the light. CNA B stated she did not see Resident #1's chest move with breathing, and she did not respond to CNA B. CNA B was unable to report an approximate time of her observation. CNA B stated she immediately reported this to LVN A. CNA B was able to state to surveyor how to find a resident's code status by looking in the Kiosk. CNA B stated the nurses and the DON will tell you who has a DNR versus who is a full code. During a phone interview on [DATE] at 12:12 p.m., LVN A stated she was working with Resident #1 on [DATE]. LVN A stated she thought because Resident #1 was on Hospice, she had an Out of Hospice Do Not Resuscitate Order. LVN A stated when she reported for duty on [DATE] at 06:00 a.m., the report she received from RN A was Resident #1 was calm and slept well. LVN A stated about 15 minutes later CNA A reported Resident #1 was restless and taking off her oxygen. LVN A stated she administered Ativan and Lortab for pain at 06:30 a.m. as ordered and a little later (7:25 a.m.), administered Morphine Sulfate sublingual as ordered because her assessment reflected, she was still hurting. LVN A reported she notified Hospice (unsure of time) because Resident #1 was not doing good and getting worse. LVN A reported going back into Resident #1's room after being informed by CNA B that she was unresponsive. LVN A reported she went into Resident #1's room observed she had expired around 07:30 a.m. prior to Hospice arrival. LVN A stated she did not take any vital signs or document any assessment including ones prior to finding the resident unresponsive. LVN A stated she was in a hurry. LVN A stated she was not trained on Hospice protocols. LVN A stated when the Hospice nurse came to the facility after 08:00 a.m., she told me Resident #1 was a full code. A review of LVN A's CPR certification revealed she had Basic Life Provider Certification in accordance with the cirriculum of the American Heart Association and did not expire until [DATE]. During an interview on [DATE] at 12:56 a.m., ADON stated she worked the 2 p.m. to 10 p.m. shift on the day Resident #1 expired. The ADON stated she was aware Resident #1 had an order for a full code even though she was receiving services from a local hospice. The ADON stated the residents code status is on the MAR and also posted on the dashboard. The ADON stated you can confirm a resident's code status by checking the dashboard which is uploaded by the DON. During an interview on [DATE] at 1:29 p.m., the DON stated on [DATE], the Regional Nurse Consultant called her and said Resident #1 had passed (expired). The DON started working at the facility [DATE]. The DON stated she was not aware of Resident #1's code status prior to her passing but she knows now. The DON stated she arrived at the facility on [DATE] after notification and began training on facility policy and procedures including a mock CPR drill. The DON stated she would be responsible for notifying staff of code status including who has a DNR. She stated a resident's code status is placed on the 24-hour report, crash cart list and by each nurse's station. She stated she uploads the information into the electronic health record (Matrix) and staff have easy access to Matrix. During an interview on [DATE] at 2:26 p.m., LVN B stated she received a call from the triage nurse who reported Resident #1 expired on [DATE] at 7:20 a.m. LVN B stated she arrived at the facility at 8:08 a.m. and asked LVN A if she initiated CPR as Resident #1 was a full code. LVN A informed LVN B she did not realize Resident #1 was a full code. LVN B notified the Hospice Medical Director at 8:09 a.m. Resident #1 was pronounced expired at 8:11 a.m. by the Hospice Medical Director. At the direction of the Regional Nurse Consultant, LVN B reported she called a local funeral home to pick up Resident #1 at 8:16 a.m. Resident #1 was taken by funeral home at approximately 9:13 a.m. During an interview on [DATE] at 4:08 p.m., the Lead [NAME] President of Operations (who acquired facility [DATE]) stated there is a code status present for each resident in Matrix (electronic health record) and also present on a list attached to the Crash Cart. She said she was notified on [DATE] along with the Clinical Resource Nurse regarding Resident #1 expiring without CPR and having a full code status. She stated the facility corrective actions on [DATE] included LVN A was placed on administrative leave pending investigation, a mock CPR drill conducted on [DATE], training on Abuse, Neglect, Exploitation, Emergency Management Code Procedure, a DNR audit reviewing the physician orders for DNR/Full code status to ensure it was set up correctly in Matrix, Crash Cart notebook with resident names who have a DNR versus those who are full codes, and audit of orders to care plans to face sheets for code status and lastly an ad hoc QAPI meeting including the Medical Director with regards to the deficient practice. During an interview on [DATE] at 5:16 p.m., RN A stated Resident #1 slept well the night of [DATE]. RN A stated one of the aides asked them to check on Resident #1 while they were conducting shift counts as she was hurting and needing pain medication. RN A stated LVN A went to check on Resident #1. RN A stated that she knew Resident #1 was a full code before hospice but not after until she received the training. RN A stated she knew to look on the MAR and in the record for code status. RN A could confirm the process of a resident's code status during an emergency. RN A stated there was also a code status list on the crash cart. During an interview on [DATE] at 9:40 a.m., RN B stated she admitted Resident #1 to a local hospice on [DATE], with a diagnosis of heart failure and chronic kidney disease. RN B stated Resident #1 did not have any family involvement. RN B stated when residents get placed on services, they are asked if they would like a DNR and Resident #1 chose to remain a full code. RN B stated when nurses go in for routine visits, residents are asked if they would like to remain a full code status. This continued to be Resident #1's choice and was documented with each hospice visit. During an interview on [DATE] at 10:20 a.m., the Medical Director for a local hospice stated he did receive a call from a staff member about Resident #1 expiring. He stated he was aware Resident #1 was a full code and the facility should have called 911. During an interview on [DATE] at 11:54 a.m., the facility Medical Director stated he had been notified of the incident involving Resident #1. He stated he attended the ad hoc QA meeting held by the facility addressing this issue. Others in attendance included the DON, ADON, and Regional Nurse Consultant. The Medical Director stated he recommends starting CPR and calling 911 on residents who are designated as a full code. During an interview on [DATE] at 1:26 p.m., the Regional Nurse Consultant stated the facility requires 2 or more staff to be certified in CPR per shift. On [DATE] there were over 4 CPR certified staff including 3 licensed staff. During interviews on [DATE] from 8:46 a.m. to 5:45 p.m. of licensed staff including 2 RN's and 2 LVN's (DON, RN A, ADON, LVN C) verified they had received in-service training in cardiopulmonary resuscitation, location of DNR and code status, and abuse/neglect. Record review of an Ad Hoc QAPI Code Status document dated [DATE] revealed: Problem Area Identified: Emergency procedures for Cardiopulmonary resuscitation. CPR Baseline: The facility audited for all Code status of current residents. Allowable deviation: There will not be an allowable deviation. Changes Implemented to reach Baseline: Lack of education, training, and leadership. In-services are being completed to obtain a baseline. Impact of change: Successful implementation of changes noted above. Baseline attained on (Date): [DATE] Implementation change did not reach baseline. Continue change for 30 more days to allow additional time for staff to comply with new system. New changes or modifications will be implemented and tested for 30 days to bring measured activity to baseline. Subcommittee will report to QAPI every month regarding movement toward baseline. Record review and observation of Code Status lists by all 3 nurses station computers and at the crash cart revealed all lists were current and reflecting accurate advance directives (Full Code versus Do Not Resuscitate) associated with each resident name. Record review and observation on [DATE], of an in-service training, titled Emergency Procedure-CPR dated [DATE] with attached Emergency Procedures Cardiopulmonary Resuscitation policy revealed 16 licensed staff had signed the training document. Record review of an in-service training, titled Code Blue/Medical Emergency Practice Drill dated [DATE] with attached Code Blue/Medical Emergency Practice Drill checklist revealed 4 licensed staff had participated in the mock drill on A Hall and at the Nurses' Station. Record review of an in-service training, titled Emergency Management Code Procedure dated [DATE] with attached Emergency Management Codes and Procedures policy revealed 16 licensed staff had signed the training document. Record review of an in-service training, titled Abuse Neglect and Exploitation dated [DATE] with attachment Abuse Neglect and Exploitation policy revealed 16 licensed staff had received training and signed the training document. Record review of a facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation revised [DATE] revealed: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis). 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physician's order not to administer CPR. Record review of a facility policy titled Patient Advanced Directives (undated) revealed: The facility will be compliant with the Patient Self-Determination Act (PSDA). We will encourage all patients to make choices and decisions about types and extent of medical care they want to accept, or refuse should they become unable to make decisions due to illness. Staff responsible for patients' care should be made familiar with the contents and requirements of a patients' advance directive. The provision of this information on advance directives, and any provider-patient discussion concerning advance directives, also should be documented in the medical record. The Administrator was notified of the IT on [DATE] at 4:12 pm. The IT Template was provided at that time. Record review of Plan of Removal provided by Regional Nurse Consultant revealed: 1. Immediate Action: LVN was suspended pending investigation. MD and RP of Resident #,d+[DATE] notified. Person Responsible: Director Of Nursing Date: [DATE] @ or by 12 noon 2. Identification Action: All residents received an order, to care plan, to face sheet audit of their Code Status. No discrepancies noted. Person Responsible: Director of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 3. Identification Action: Audited the DNR Book (Do Not Resuscitate) to ensure it is current with the upmost updated status of our resident population. (Crash Cart and Nurses Station) Person Responsible: Director Of Nursing, Assistant Director of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 4. Preventative Action: Audited employee CPR cards to ensure an adequate number of certified employees each shift Person Responsible: Human Resources, Director Of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 5. Preventative Action: Education provided to nursing staff related to Code Status, Initiating CPR for Full-Codes, and Location of the DNRs/Code Statuses. Person Responsible: Human Resources, Director Of Nursing, and/or Designee Date: [DATE] @ or by 6 p.m. 6. Systematic Change Action: New admission and residents with a change in code status will be reviewed in daily meeting/clinical meeting to ensure the chart reflects the appropriate code status. Person Responsible: Director Of Nursing, and/or Assistant Director of Nursing Date: [DATE] @ or by 10 a.m. 7. QA Action: Ad hoc AQPI performed with Medical Director reviewing the deficient practice/template and the plan to correct. Person Responsible: Administrator Date: [DATE] 10:00 a.m. On [DATE] at 4:12 p.m. the Administrator, DON, and Regional Nurse Consultant were informed of the IJ. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 2 residents reviewed for abuse and neglect. The facility failed to timely assess or transfer Resident #2 to the hospital after changes in condition were observed. The resident was found with a pool of blood under her head and on the bed. Resident #2 was not assessed until about 7 hours later. She was transferred to the hospital with presentation of a widespread infection causing organ failure and dangerously low blood pressure and fracture of the cervical nerves. The facility failed to have structure in place to ensure residents with changes in condition receive adequate supervision and assistance timely to prevent injury/death a) LVNB did not notify Resident #2 physician or provide care and treatment to a resident found with puddle of blood on her head and bed. b) CNAC did not notify DON after LVNB forgot to assess Resident #2 timely. An Immediate Jeopardy (IJ) was identified on 04/09/21. While the IJ was removed on 04/10/21, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect other residents requiring timely response by placing them at risk for delays in treatment and care which could result in serious injury, harm and/ or death. The findings were: Review of Resident #2's face sheet, dated 04/03/21, revealed the resident was a 60- year- old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set (MDS) assessment, dated 09/12/20 and 12/17/20 did not record a brief interview for mental status score. She had [CONDITION(S)] which is inherited disorder that causes nerve cells (called neurons) in parts of the brain to gradually break down and die (https://www.ninds.nih.gov/Disorders/All-Disorders/[CONDITION(S)]-Disease-Information-Page). Resident #2 required extensive assistance with bed mobility, transfer, dressing, toilet use, and one person assist with transfer. She has unclear speech but usually understands. Resident #2 was occasionally incontinent of bladder and frequently of bowel. Review of Resident #2 care plan, dated 01/19/21, revealed the resident was planned for risk of falls due to history. Its goal was for the resident to have little injury after fall. Furthermore Resident #2 had a plan for urinary incontinence with intervention to provide incontinent care every 2 hours as her voiding patterns permits. Record review of Resident #2's of history of present illness dated 03/31/21(day of the incident) from the hospital reflected, [AGE] year-old chronically ill female who is a resident at a nursing home with a history of [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)] disorder, history of alcohol dependence in remission, gait disturbance, dysphagia, hypertension, [CONDITION(S)], gastroesophageal reflux, recurrent urinary tract infections. She was previously being hospitalized with subdural hematoma and underwent surgical evacuation. She is presented to emergency room at this time. She was poorly found out of her bed on the floor. Thought that she has suffered a fall with an injury to the back of her head. The report was that she had been unwell for the past 1-2 days. Her friend had reported that had visited the patient yesterday that she was less talkative and responsive than her usual. She reportedly is non-ambulatory. She had indicated that she was feeling cold. In emergency room , she was hypothermic with temperature 90.6. Bradycardic with pulse of 44. Respiratory rate was 14, blood is low as 60/46. She was leukopenic with a white blood cell count of 2.7. Platelets 56. Creatinine elevated 1.2 with CO2 of 38. Sodium elevated at 147. Warming blanket was applied. Patient was started intravenous [MEDICATION(S)]. Cath urine sample appeared to be abnormal with 50 white cells and moderate leukocytes. CT of the cervical spine showed acute mildly displaced fracture of the anterior arch of the atlas. Was cervical spondylosis. There was CT of the head evidence for right posterior convexity soft tissue contusion without acute fracture and thin left frontal lobe hyperdense extra-axial fluid collection is seen to be consistent with postsurgical fluid collection. This is from left frontal craniotomy that she had undergone previously. She is admitted for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review X-ray result dated 03/31/21(the incident date) revealed the following impressions: 1) Right high posterior convexity soft tissue contusion without acute fracture of the skull or [CONDITION(S)] 2) Acute fracture of the anterior arch of the atlas. Recommend CT of the cervical spine 3) Stable appearance of cerebral atrophy 4) Small air-fluid level within the left maxillary [MEDICATION(S)] without evidence of facial fracture. Review of CT cervical spine without contrast dated 03/31/21(the day of the incident) revealed the following impressions: 1) Acute mildly displaced fracture of the anterior arch of the atlas 2) Cervical spondylosis Review of nurse's note dated 03/31/21 at 3:03p.m reflected, During routine round res noted with bright red drainage to bed linen at the head of the bed, res exam responsive to touch without opening eyes, noted dry matted hair to back of the head and large hematoma. No bright red drainage noted. PCP notified with N/O recv'd may send to hospital for [NAME] and TX. DON notified. 911 called and EMT's here. Res remains unresponsive without opening eyes. Res transferred to gurney and exited . Review of nurse's note from the hospital dated 04/01/21(a day after admission) by RNF reflected, Patient was admitted ,d+[DATE] with severe [CONDITION(S)] and hypothermia. She was found to have a C1 fracture and laceration on her face. According to the physicians in the ER, the patient could not have had this accident today due to older signs and symptoms of the injuries and her very low rectal temperature indicating that the patient had been left lying on the floor unattended. She is nonverbal at this time. CM called her friend Caregiver G whom is listed as her emergency contact . He states he visits her daily and noticed that there was old blood on the pillow 03/31 when he visited. He states he uses a wheelchair to get around, but the staff help her a lot with ADLs. He is agreeable for her to go back at the time of d/c given that she stabilizes and is able to return. Her chart indicates that she was on hospice prior to admission . In an interview with CNAC on 04/02/21 at 12:57p.m, she revealed she was responsible for Resident #2 during the morning shift on 03/21/21. She has been employed in the facility since August 2020. CNAC explained she went to Resident #2's room around 7:00-7: 30a.m and saw red blood on the floor and some on resident's fingers. There was puddle of blood on the bed where the resident head was usually supposed to be. CNAC said she immediately went and notified LVNB because she knew resident needed to be assessed for the injury. LVNB asked if the resident was still bleeding. She replied that there was blood on her head. CNAC stated she thought LVNB went to assess the resident. She said she got busy and didn't think about it till the DON called her to the office on end of shift around 2:00p.m. The DON asked when she found the resident with the injury. She told the DON it was in the early morning and that she informed LVNB. She said the DON berated her informing that she should have told someone else if the charge nurse didn't assess the resident immediately. CNAC went to say she learned her lesson and will report to another nurse next time if the resident was not assessed timely. During interview with RNE on 04/02/21 at 1:13p.m, she said she was the treatment nurse for the facility. She said she has been in the facility since September but became Wound Nurse about three weeks ago. RNE explained LVND came to her (on 3/31/21) around 2:00p.m after coming in for the evening shift. LVND told her Resident #2 was bleeding in her head. RNE and LVND went to see Resident #2. She said the resident was lying in reverse head near the footrest and the feet near the headboard. She stated blood was under the resident's head. She could tell it was a hematoma. She began to assess the resident and getting vitals. She explained Resident #2 was unresponsive. She cleaned the head with wash cloth to see the extent of the wound. She said the DON came and assisted in the assessment. The EMS was called, and Resident #2 was transferred to the hospital for evaluation and treatment. She notified hospice. She said Resident #2 did not have any previous skin issues or tear. Interview with LVND on 04/03/12:21 p.m. revealed she was the incoming nurse for the evening shift on 03/31/21 around 2:00p.m. She explained LVNB told her during shift change Resident #2 was bleeding from scalp and asked that she assess her. LVND went to the resident's room and saw her covered up. She shakes her to wake up. Resident #2 moved but didn't wake up. She went to RNE and told her of the resident condition. They both proceeded to assess the resident. The doctor was notified and received order to send Resident #2 to the hospital. LVND said Resident #2 should have been assessed. She said she didn't ask LVNB why the Resident #2 was not assessed. LVND explained it was the policy of the facility to assess resident during change in condition. The charge nurse was supposed to use nursing judgement, notify physician, family and the administration. Surveyor asked if it was fair to conclude that LVND did not follow the facility policy. LVND said it was her conclusion. During interview with LVNB on 04/03/21 at 2:58p.m, she stated she has been employed by the facility since July 2020. She was the nurse for Resident #2 and was working her hall on the day of the incident. LVNB said she did not usually work Resident #2 hall but picked up extra shift that day. She explained that around 10:30-11:00a.m, CNAC ask her to go look at Resident #2 because there was blood on the pillow and head of bed. CNAC said she notified LVNB around 7:30a.m. She asked CNAC if it was new or old blood. LVNB said she asked if the wound was bleeding and CNAC said no. LVNB said she did not go to assess Resident #2 as she intended. She stated she got distracted from blood sugar, giving meds and doctor's appointment. LVNB said she did not have any reason for not timely assessing the Resident #2. It was communication error between her and CNAC. LVNB explained during the shift change, she informed LVND that Resident #2 had a scratch and she did not have time to assess her. She said LVND assessed resident and found she had a head injury and an order was received to transfer Resident #2 to the hospital. She stated the DON called her to the office and told she did have any excuses for not assessing the resident and sent her home. She left the facility and was still on suspension at the time of this interview. In an interview with DON on 04/03/21 at 10:50a.m, she said she was familiar with incident with Resident #2. The DON explained she was bringing some requested paperwork to the surveyor when LVND asked her to come to Resident #2's room. She went and saw LVND and RNE working on Resident #2 and taking vitals. The resident was not responding to verbal cues. There was a puddle of blood on the head of bed. They tried to figure out the extent of the head injury. She directed LVND to call 911. Resident #2 was transferred to the hospital for further evaluation and treatment. Meanwhile she briefly investigated and found out CNAC discovered the injury in the early morning around 7:00a.m and informed LVNB who did not assess the resident. The DON said she told LVNB it was inappropriate and not normal to leave a resident unassessed after she was informed there was blood on the resident. She said LVNB has no excuse, no reason for not assessing Resident #2. She stated if LVNB was busy, she could have informed ADONs or herself to assess the resident. She talked to LVNB and suspended her. The DON explained she also told CNAC to let other nursing staffs, ADON and herself know if the charge nurse did not timely assess the resident after notification. She said Resident #2 had [CONDITION(S)] which involves constant and continuous movement. She believes the resident did not have a fall but may have hit her head because of rapid involuntary movement she makes. She said Resident #2 was on hospice and her disease has getting progressively worse. She was a very independent woman and wanted to do things by herself. Interview with Caregiver G on 04/09/21 at 10:31a.m revealed he was the Caregiver and friend of Resident #2. He said he visits her every day to bring food and give support to the resident. Caregiver G explained he visited Resident #2 on 03/31/21(incident date) at around 9:00a.m. He went into the resident's room and she was covered with a blanket. He lifted the blanket and saw pool of blood on the Resident #2 head and head of bed some of which was dry. He asked the Resident #2 what happened to you because he saw her a day before. Resident #2 did not answer but continued to say I' m cold, I'm cold. He believed Resident #2 fell sometime during the night because some of the blood had dried out. He was horrified and went and notified a nurse (he did not know the name of the nurse). Caregiver G described her as a heavy-set Caucasian female. The nurse (unknown) said she was going to look at the resident. He told the nurse to clean the resident. He said he had to get some supplies for Resident #2. He left the building. Caregiver G explained the facility was nice to him and allowed him to see the resident, but he felt they were not providing Resident #2 the necessary care and services. He said about 3-4 days before day of the incident he came to visit Resident #2, who also said she was cold when he asked her why she looked sick. He looked at the resident and found she was completely soiled and soaked with urine and fecal matter. He went and got an aide to clean Resident #2. Caregiver G said the hospital called and he talked to the physician, they have decided to remove the life support for Resident #2. Further review of Resident #2 hospital stays dated 04/08/21 revealed a very poor prognosis. It reflected the following: Plan: 1) Myxedema coma-Still notably encephalopathic, T3/T4 better, will take some time to improve, if possible. Very high mortality. 2) Severe [CONDITION(S)] with septic shock unclear etiology-Has gotten fluids, still requires [MEDICATION(S)], on abx. Monitor, UC+, BC-X2, has improved, but not much and still critically ill with low chance of recovery 3) Hypothermia. Related to shock and myxedema coma. Warming blanket applied. Determine other measures necessary, has improved some 4) [CONDITION(S)]. Apparently non-diabetic in probably relates to the myxedema. Has stabilized now. Not diabetic. DC accu-cheks. Tube feeds started 5) C1 fracture cervical vertebra. Displaced. Neurosurgical consultation. Hard cervical collar. No surgical intervention at this time. Flexion and extension x-rays of cervical spine if becomes medically stable. Will have to participate to get these images 6) Apparent fall with injury is noted above. 7) [CONDITION(S)]-improving with IVF. 8) [CONDITION(S)] chorea. Underling pathology condition. Supportive care. Resume her medicines when she is able to take orally 9) History of hypertension hold any medicines at this time due to shock 10) [CONDITION(S)]. TSH severely elevated at 168. She apparently has not been receiving [CONDITION(S)] medications and supplement for a long time. Continue her medicines intravenously until she can take orally again 11) Other psychiatric disorders reported in the record as [CONDITION(S)] disorder and [CONDITION(S)] disorder but over unclear relationship to her subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 12) Prognosis, patient is acutely, and profoundly ill-Patient has an underlying always fatal condition, [CONDITION(S)] chorea which only worsens. I addition to this she presented with Myxedema coma, which has high fatality, and after a fall has a C1 Fx. And she is currently pressor dependent for [CONDITION(S)] from Ecoli UTI. Any one of this DX. Would be very difficult for a fragile patient to tolerate and survive. Then recovery will be difficult at best. With this sad preponderance of severe conditions, the patient has terminal set of severe physiologic insults and her condition is irreversible. It would be appropriately to compassionately withdrawal care in accordance with her wishes as she was DNR on hospice as an outpt. 13) Code status-Currently out of hospital DNR, has been DNR in place since admit, Palliative trying to clarify with family. Complex family situation 14) Dispo-Will likely has withdrawal of care this afternoon. During a follow-up call with CNAC on 04/10/21 at 1:02p.m, she was asked if she provided any care and services to Resident #2 from time she reported to LVNB (7-7:30am) and towards the end of shift when LVND assessed the resident. CNAC said she checked on Resident #2 between 10a.m-12: 00p.m after Caregiver G left and she was dry. CNAC was also asked the condition of the resident at that time. Caregiver G noted Resident #2 was cold during his visit on the incident date. CNAC said the Resident #2 has being saying she was cold the past few days and Caregiver G was aware of it. Resident #2 was given extra blanket. A follow up interview with LVNB on 04/09/21 at 3:21p.m revealed she did not provide any care and services from the time she was informed of Resident #2 bleeding (7-7: 30a.m) by CNAC to end of shift about 7 hour later. LVNB also stated she did not know if CNAC provided care during that time (7:00am to end of shift-2:00p.m). Review of Resident #2's nursing notes from 03/24/21-03/30/21 reflected no nurse's notes on resident. The next nursing notes was the documentation of the incident on 03/31/21 by LVND when Resident #2 was transferred to hospital for her change in condition. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview CMA H on 04/10/21 at 3:33p.m revealed she gave medication to Resident #2. She explained the resident was alert and took the medicine without problems on 03/31/21. CMA H said the resident will almost always resist medication before taking it. When asked if there was anything abnormal about Resident #2 that day? CMAH said the resident was normally out of bed at that time but was still in bed covered with blanket. She said Resident #2 took the medication without resistance. She did not notice blood on the resident Interview with Physician J on 04/13/21 at 1:42p.m revealed he was responsible and primary doctor for Resident #2. He explained he last saw the resident in 03/06/21. He was notified of the resident's change in condition and gave order to transfer Resident to the hospital for further evaluation and treatment. Physician J was asked if he was aware that the facility may have taken about 7 hours before the facility responded to Resident #2's changes in condition. He said he was not. He said Resident #2 was oftentimes sitting around the nursing station. He said Resident #2 had a friend that visits every day and pushes her around the halls. Physician J stated his expectations from the nurse's is to thoroughly assess the residents and send them to the hospital during emergencies or changes in condition. Review of the facility policy on change in a resident condition or status revised May 2017 reflected, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The policy interpretation and implementation include: 1) The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a) Accidents or incident involving the resident; b) Discovery of injury of unknown source; c) Adverse reaction to medications; d) Significant change in the resident's physical/emotional/mental condition; e) Need to alter the resident's medical treatment significantly f) Refusal to treatment or medication two (2) or more consecutive times); g) Need to transfer the resident to the hospital/treatment center h) Discharge without proper medical authority; and/or i) Specific instruction to notify the Physician of changes in the resident's condition. 2) A significant change of condition is a major decline or improvement in the resident's status that; . 3) Prior to notify the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the interact SBAR Communication Form . Record review of the facility's policy on accidents and Incidents revised July 2017 reflected this policy statement, All accidents or incidents, involving employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The facility's abuse/neglect policy revised May 2020 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Signs of actual physical abuse includes: a) Welts or bruises; b) Abrasions and lacerations Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Signs of actual physical neglect includes: a) Malnutrition and dehydration . b) Leaving someone unattended who needs supervision. An Immediate Jeopardy was identified on 04/09/21 at 4:42 p.m. The ADM and Regional consultant were notified on 04/09/18 at 4:42p.m of the IJ. The plan of removal was requested at that time. The facility's plan of removal accepted on 04/10/21 at 2:48p.m reflected: The following actions were immediately put in place upon being notified of the immediate jeopardy: Plan of Removal Revision #1 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on April 09, 2021 for failure to 1) provide Freedom from Abuse and Neglect, 2) ensure Competent Nursing Staff. Corrective Actions: 1. Action: On April 1, 2021, an in-service was initiated by the Director of Nursing for all staff regarding reporting Changes of Condition. Staff are to report changes of condition to the resident's nurse immediately. The nurse will assess the change of condition as soon as possible. Changes of Condition will be reported to the resident's physician within 24 hours except in case of a medical emergency per center policy. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 2. Action: On April 1, 2021, an in-service was initiated with staff on abuse and neglect. The in-service will continue each shift to ensure all staff has the training. The Director of Nursing or designee may conduct the in-services in person or on the phone. No staff will be allowed to work until their in-service is completed. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 3. Action: On April 9, 2021, an in-service was initiated with nurses on Resident Examination and Assessment. The in-service will continue each shift to ensure all nurses have the training. The Director of Nursing or Designee may conduct the in-service in person or on the phone. No staff will be allowed to work until their in-service is completed. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 4. Action: On April 9, 2021, an in-service was initiated with nurses on Guidelines for Notifying Physicians of Clinical Problems. The notification of the physician should be immediate or as soon as is possible for change of condition that is sudden in onset or a marked change unrelieved by measures already prescribed. The in-service will continue each shift until all nurses have the training. The Director of Nursing or Designee may conduct the in-service in person or on the phone. No nurses will be allowed to work until their in-service is completed. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 5. Action: On March 31, 2021, the nurse, LVNB, was suspending pending investigation. The nurse continues to be suspended. Her personnel file was sent to Human Resources for license referral. 6. Action: Residents on Halls D and F were screened by nursing staff and no other residents were identified as affected by the LVN's alleged neglect. Completion date 4/10/2021. Identification of Residents at Risk: All residents on Halls D and F have the potential to be affected. One resident has been affected. Systemic Change(s): Administrator, DON, ADON, and/or designee will monitor resident changes of condition, validate by conducting random staff interviews to ensure understanding of procedure. Continue in-services weekly X4, monthly X3 and on-going as needed to ensure compliance is met to continue. Monitoring: Administrator, Director of Nursing, Assistant Director of Nursing will ensure compliance by walking rounds, return demonstration, and education as needed. If issues are identified, the Administrator or Director of Nursing will address at that time and provide training/guidance and /or disciplinary actions as needed. The information will be brought to the Quality Assurance Performance Improvement (QAPI) monthly X3 and as needed. The QAPI will review, at minimum, in-service documentation to validate. To verity the facility implemented their plan of removal, the following observations, interviews and record reviews were conducted: Observations of residents in halls A, B, C, D, E, and F did not revealed any resident with changes in condition. Interviews on 04/10/21 at various times with LVND, RNE, LVNK, RNL, RNF, RNI, LVNK, RNL, LVNP, LVNS, etc. They stated they received abuse/neglect, reporting change of condition, resident examination and timely reporting to physician training. The nursing staffs said they felt comfortable to thoroughly asses the residents during changes in condition and follow the facility policy on reporting to administration, physician and family. Interviews on 04/10/21 at various times with CNAA, CNAC, CMAH, CNAM, CMA N, CNAO, CNAQ, CNAT, CNAU, CNAV, CMAW, CNAX, CNAY, CAN Z, CNAO etc. They said they received in-services on reporting the resident's changes in condition and to report to other nursing staffs including the DON if the residents was not timely assessed. The aides were knowledgeable about the facility policy and abuse/neglect and report to Coordinator immediately. The aides were knowledgeable about the facility policy and abuse/neglect and to report to Coordinator immediately. On 04/10/21 at 2:48p.m, the ADM was notified the IJ was removed. While the IJ was removed on 04/10/21, the facility remained out of compliance at a severity level and a scope of isolated because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal.

Based on observation, interview, and record review the facility failed to ensure the resident's right to be free from abuse and neglect for 1 (Resident #2) of 2 residents reviewed for abuse and neglect. The facility failed to timely assess or transfer Resident #2 to the hospital after changes in condition were observed. The resident was found with a pool of blood under her head and on the bed. Resident #2 was not assessed until about 7 hours later. She was transferred to the hospital with presentation of a widespread infection causing organ failure and dangerously low blood pressure and fracture of the cervical nerves. The facility failed to have structure in place to ensure residents with changes in condition receive adequate supervision and assistance timely to prevent injury/death a) LVNB did not notify Resident #2 physician or provide care and treatment to a resident found with puddle of blood on her head and bed. b) CNAC did not notify DON after LVNB forgot to assess Resident #2 timely. An Immediate Jeopardy (IJ) was identified on 04/09/21. While the IJ was removed on 04/10/21, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility was still monitoring the effectiveness of the Plan of Removal. These failures could affect other residents requiring timely response by placing them at risk for delays in treatment and care which could result in serious injury, harm and/ or death. The findings were: The facility's abuse/neglect policy revised May 2020 defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Signs of actual physical abuse includes: a) Welts or bruises; b) Abrasions and lacerations Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Signs of actual physical neglect includes: a) Malnutrition and dehydration . b) Leaving someone unattended who needs supervision. Review of Resident #2's face sheet, dated 04/03/21, revealed the resident was a 60- year- old female admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Minimum Data Set (MDS) assessment, dated 09/12/20 and 12/17/20 did not record a brief interview for mental status score. She had [CONDITION(S)] which is inherited disorder that causes nerve cells (called neurons) in parts of the brain to gradually break down and die (https://www.ninds.nih.gov/Disorders/All-Disorders/[CONDITION(S)]-Disease-Information-Page). Resident #2 required extensive assistance with bed mobility, transfer, dressing, toilet use, and one person assist with transfer. She has unclear speech but usually understands. Resident #2 was occasionally incontinent of bladder and frequently of bowel. Review of Resident #2 care plan, dated 01/19/21, revealed the resident was planned for risk of falls due to history. Its goal was for the resident to have little injury after fall. Furthermore Resident #2 had a plan for urinary incontinence with intervention to provide incontinent care every 2 hours as her voiding patterns permits. Record review of Resident #2's of history of present illness dated 03/31/21(day of the incident) from the hospital reflected, [AGE] year-old chronically ill female who is a resident at a nursing home with a history of [CONDITION(S)], [CONDITION(S)] disorder, [CONDITION(S)] disorder, history of alcohol dependence in remission, gait disturbance, dysphagia, hypertension, [CONDITION(S)], gastroesophageal reflux, recurrent urinary tract infections. She was previously being hospitalized with subdural hematoma and underwent surgical evacuation. She is presented to emergency room at this time. She was poorly found out of her bed on the floor. Thought that she has suffered a fall with an injury to the back of her head. The report was that she had been unwell for the past 1-2 days. Her friend had reported that had visited the patient yesterday that she was less talkative and responsive than her usual. She reportedly is non-ambulatory. She had indicated that she was feeling cold. In emergency room , she was hypothermic with temperature 90.6. Bradycardic with pulse of 44. Respiratory rate was 14, blood is low as 60/46. She was leukopenic with a white blood cell count of 2.7. Platelets 56. Creatinine elevated 1.2 with CO2 of 38. Sodium elevated at 147. Warming blanket was applied. Patient was started intravenous [MEDICATION(S)]. Cath urine sample appeared to be abnormal with 50 white cells and moderate leukocytes. CT of the cervical spine showed acute mildly displaced fracture of the anterior arch of the atlas. Was cervical spondylosis. There was CT of the head evidence for right posterior convexity soft tissue contusion without acute fracture and thin left frontal lobe hyperdense extra-axial fluid collection is seen to be consistent with postsurgical fluid collection. This is from left frontal craniotomy that she had undergone previously. She is admitted for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review X-ray result dated 03/31/21(the incident date) revealed the following impressions: 1) Right high posterior convexity soft tissue contusion without acute fracture of the skull or [CONDITION(S)] 2) Acute fracture of the anterior arch of the atlas. Recommend CT of the cervical spine 3) Stable appearance of cerebral atrophy 4) Small air-fluid level within the left maxillary [MEDICATION(S)] without evidence of facial fracture. Review of CT cervical spine without contrast dated 03/31/21(the day of the incident) revealed the following impressions: 1) Acute mildly displaced fracture of the anterior arch of the atlas 2) Cervical spondylosis Review of nurse's note dated 03/31/21 at 3:03p.m reflected, During routine round res noted with bright red drainage to bed linen at the head of the bed, res exam responsive to touch without opening eyes, noted dry matted hair to back of the head and large hematoma. No bright red drainage noted. PCP notified with N/O recv'd may send to hospital for [NAME] and TX. DON notified. 911 called and EMT's here. Res remains unresponsive without opening eyes. Res transferred to gurney and exited . Review of nurse's note from the hospital dated 04/01/21(a day after admission) by RNF reflected, Patient was admitted ,d+[DATE] with severe [CONDITION(S)] and hypothermia. She was found to have a C1 fracture and laceration on her face. According to the physicians in the ER, the patient could not have had this accident today due to older signs and symptoms of the injuries and her very low rectal temperature indicating that the patient had been left lying on the floor unattended. She is nonverbal at this time. CM called her friend Caregiver G whom is listed as her emergency contact . He states he visits her daily and noticed that there was old blood on the pillow 03/31 when he visited. He states he uses a wheelchair to get around, but the staff help her a lot with ADLs. He is agreeable for her to go back at the time of d/c given that she stabilizes and is able to return. Her chart indicates that she was on hospice prior to admission . In an interview with CNAC on 04/02/21 at 12:57p.m, she revealed she was responsible for Resident #2 during the morning shift on 03/21/21. She has been employed in the facility since August 2020. CNAC explained she went to Resident #2's room around 7:00-7: 30a.m and saw red blood on the floor and some on resident's fingers. There was puddle of blood on the bed where the resident head was usually supposed to be. CNAC said she immediately went and notified LVNB because she knew resident needed to be assessed for the injury. LVNB asked if the resident was still bleeding. She replied that there was blood on her head. CNAC stated she thought LVNB went to assess the resident. She said she got busy and didn't think about it till the DON called her to the office on end of shift around 2:00p.m. The DON asked when she found the resident with the injury. She told the DON it was in the early morning and that she informed LVNB. She said the DON berated her informing that she should have told someone else if the charge nurse didn't assess the resident immediately. CNAC went to say she learned her lesson and will report to another nurse next time if the resident was not assessed timely. During interview with RNE on 04/02/21 at 1:13p.m, she said she was the treatment nurse for the facility. She said she has been in the facility since September but became Wound Nurse about three weeks ago. RNE explained LVND came to her (on 3/31/21) around 2:00p.m after coming in for the evening shift. LVND told her Resident #2 was bleeding in her head. RNE and LVND went to see Resident #2. She said the resident was lying in reverse head near the footrest and the feet near the headboard. She stated blood was under the resident's head. She could tell it was a hematoma. She began to assess the resident and getting vitals. She explained Resident #2 was unresponsive. She cleaned the head with wash cloth to see the extent of the wound. She said the DON came and assisted in the assessment. The EMS was called, and Resident #2 was transferred to the hospital for evaluation and treatment. She notified hospice. She said Resident #2 did not have any previous skin issues or tear. Interview with LVND on 04/03/12:21 p.m. revealed she was the incoming nurse for the evening shift on 03/31/21 around 2:00p.m. She explained LVNB told her during shift change Resident #2 was bleeding from scalp and asked that she assess her. LVND went to the resident's room and saw her covered up. She shakes her to wake up. Resident #2 moved but didn't wake up. She went to RNE and told her of the resident condition. They both proceeded to assess the resident. The doctor was notified and received order to send Resident #2 to the hospital. LVND said Resident #2 should have been assessed. She said she didn't ask LVNB why the Resident #2 was not assessed. LVND explained it was the policy of the facility to assess resident during change in condition. The charge nurse was supposed to use nursing judgement, notify physician, family and the administration. Surveyor asked if it was fair to conclude that LVND did not follow the facility policy. LVND said it was her conclusion. During interview with LVNB on 04/03/21 at 2:58p.m, she stated she has been employed by the facility since July 2020. She was the nurse for Resident #2 and was working her hall on the day of the incident. LVNB said she did not usually work Resident #2 hall but picked up extra shift that day. She explained that around 10:30-11:00a.m, CNAC ask her to go look at Resident #2 because there was blood on the pillow and head of bed. CNAC said she notified LVNB around 7:30a.m. She asked CNAC if it was new or old blood. LVNB said she asked if the wound was bleeding and CNAC said no. LVNB said she did not go to assess Resident #2 as she intended. She stated she got distracted from blood sugar, giving meds and doctor's appointment. LVNB said she did not have any reason for not timely assessing the Resident #2. It was communication error between her and CNAC. LVNB explained during the shift change, she informed LVND that Resident #2 had a scratch and she did not have time to assess her. She said LVND assessed resident and found she had a head injury and an order was received to transfer Resident #2 to the hospital. She stated the DON called her to the office and told she did have any excuses for not assessing the resident and sent her home. She left the facility and was still on suspension at the time of this interview. In an interview with DON on 04/03/21 at 10:50a.m, she said she was familiar with incident with Resident #2. The DON explained she was bringing some requested paperwork to the surveyor when LVND asked her to come to Resident #2's room. She went and saw LVND and RNE working on Resident #2 and taking vitals. The resident was not responding to verbal cues. There was a puddle of blood on the head of bed. They tried to figure out the extent of the head injury. She directed LVND to call 911. Resident #2 was transferred to the hospital for further evaluation and treatment. Meanwhile she briefly investigated and found out CNAC discovered the injury in the early morning around 7:00a.m and informed LVNB who did not assess the resident. The DON said she told LVNB it was inappropriate and not normal to leave a resident unassessed after she was informed there was blood on the resident. She said LVNB has no excuse, no reason for not assessing Resident #2. She stated if LVNB was busy, she could have informed ADONs or herself to assess the resident. She talked to LVNB and suspended her. The DON explained she also told CNAC to let other nursing staffs, ADON and herself know if the charge nurse did not timely assess the resident after notification. She said Resident #2 had [CONDITION(S)] which involves constant and continuous movement. She believes the resident did not have a fall but may have hit her head because of rapid involuntary movement she makes. She said Resident #2 was on hospice and her disease has getting progressively worse. She was a very independent woman and wanted to do things by herself. Interview with Caregiver G on 04/09/21 at 10:31a.m revealed he was the Caregiver and friend of Resident #2. He said he visits her every day to bring food and give support to the resident. Caregiver G explained he visited Resident #2 on 03/31/21(incident date) at around 9:00a.m. He went into the resident's room and she was covered with a blanket. He lifted the blanket and saw pool of blood on the Resident #2 head and head of bed some of which was dry. He asked the Resident #2 what happened to you because he saw her a day before. Resident #2 did not answer but continued to say I' m cold, I'm cold. He believed Resident #2 fell sometime during the night because some of the blood had dried out. He was horrified and went and notified a nurse (he did not know the name of the nurse). Caregiver G described her as a heavy-set Caucasian female. The nurse (unknown) said she was going to look at the resident. He told the nurse to clean the resident. He said he had to get some supplies for Resident #2. He left the building. Caregiver G explained the facility was nice to him and allowed him to see the resident, but he felt they were not providing Resident #2 the necessary care and services. He said about 3-4 days before day of the incident he came to visit Resident #2, who also said she was cold when he asked her why she looked sick. He looked at the resident and found she was completely soiled and soaked with urine and fecal matter. He went and got an aide to clean Resident #2. Caregiver G said the hospital called and he talked to the physician, they have decided to remove the life support for Resident #2. Further review of Resident #2 hospital stays dated 04/08/21 revealed a very poor prognosis. It reflected the following: Plan: 1) Myxedema coma-Still notably encephalopathic, T3/T4 better, will take some time to improve, if possible. Very high mortality. 2) Severe [CONDITION(S)] with septic shock unclear etiology-Has gotten fluids, still requires [MEDICATION(S)], on abx. Monitor, UC+, BC-X2, has improved, but not much and still critically ill with low chance of recovery 3) Hypothermia. Related to shock and myxedema coma. Warming blanket applied. Determine other measures necessary, has improved some 4) [CONDITION(S)]. Apparently non-diabetic in probably relates to the myxedema. Has stabilized now. Not diabetic. DC accu-cheks. Tube feeds started 5) C1 fracture cervical vertebra. Displaced. Neurosurgical consultation. Hard cervical collar. No surgical intervention at this time. Flexion and extension x-rays of cervical spine if becomes medically stable. Will have to participate to get these images 6) Apparent fall with injury is noted above. 7) [CONDITION(S)]-improving with IVF. 8) [CONDITION(S)] chorea. Underling pathology condition. Supportive care. Resume her medicines when she is able to take orally 9) History of hypertension hold any medicines at this time due to shock 10) [CONDITION(S)]. TSH severely elevated at 168. She apparently has not been receiving [CONDITION(S)] medications and supplement for a long time. Continue her medicines intravenously until she can take orally again 11) Other psychiatric disorders reported in the record as [CONDITION(S)] disorder and [CONDITION(S)] disorder but over unclear relationship to her subsequent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 12) Prognosis, patient is acutely, and profoundly ill-Patient has an underlying always fatal condition, [CONDITION(S)] chorea which only worsens. I addition to this she presented with Myxedema coma, which has high fatality, and after a fall has a C1 Fx. And she is currently pressor dependent for [CONDITION(S)] from Ecoli UTI. Any one of this DX. Would be very difficult for a fragile patient to tolerate and survive. Then recovery will be difficult at best. With this sad preponderance of severe conditions, the patient has terminal set of severe physiologic insults and her condition is irreversible. It would be appropriately to compassionately withdrawal care in accordance with her wishes as she was DNR on hospice as an outpt. 13) Code status-Currently out of hospital DNR, has been DNR in place since admit, Palliative trying to clarify with family. Complex family situation 14) Dispo-Will likely has withdrawal of care this afternoon. During a follow-up call with CNAC on 04/10/21 at 1:02p.m, she was asked if she provided any care and services to Resident #2 from time she reported to LVNB (7-7:30am) and towards the end of shift when LVND assessed the resident. CNAC said she checked on Resident #2 between 10a.m-12: 00p.m after Caregiver G left and she was dry. CNAC was also asked the condition of the resident at that time. Caregiver G noted Resident #2 was cold during his visit on the incident date. CNAC said the Resident #2 has being saying she was cold the past few days and Caregiver G was aware of it. Resident #2 was given extra blanket. A follow up interview with LVNB on 04/09/21 at 3:21p.m revealed she did not provide any care and services from the time she was informed of Resident #2 bleeding (7-7: 30a.m) by CNAC to end of shift about 7 hour later. LVNB also stated she did not know if CNAC provided care during that time (7:00am to end of shift-2:00p.m). Review of Resident #2's nursing notes from 03/24/21-03/30/21 reflected no nurse's notes on resident. The next nursing notes was the documentation of the incident on 03/31/21 by LVND when Resident #2 was transferred to hospital for her change in condition. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview CMA H on 04/10/21 at 3:33p.m revealed she gave medication to Resident #2. She explained the resident was alert and took the medicine without problems on 03/31/21. CMA H said the resident will almost always resist medication before taking it. When asked if there was anything abnormal about Resident #2 that day? CMAH said the resident was normally out of bed at that time but was still in bed covered with blanket. She said Resident #2 took the medication without resistance. She did not notice blood on the resident Interview with Physician J on 04/13/21 at 1:42p.m revealed he was responsible and primary doctor for Resident #2. He explained he last saw the resident in 03/06/21. He was notified of the resident's change in condition and gave order to transfer Resident to the hospital for further evaluation and treatment. Physician J was asked if he was aware that the facility may have taken about 7 hours before the facility responded to Resident #2's changes in condition. He said he was not. He said Resident #2 was oftentimes sitting around the nursing station. He said Resident #2 had a friend that visits every day and pushes her around the halls. Physician J stated his expectations from the nurse's is to thoroughly assess the residents and send them to the hospital during emergencies or changes in condition. Review of the facility policy on change in a resident condition or status revised May 2017 reflected, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.) The policy interpretation and implementation include: 1) The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a) Accidents or incident involving the resident; b) Discovery of injury of unknown source; c) Adverse reaction to medications; d) Significant change in the resident's physical/emotional/mental condition; e) Need to alter the resident's medical treatment significantly f) Refusal to treatment or medication two (2) or more consecutive times); g) Need to transfer the resident to the hospital/treatment center h) Discharge without proper medical authority; and/or i) Specific instruction to notify the Physician of changes in the resident's condition. 2) A significant change of condition is a major decline or improvement in the resident's status that; . 3) Prior to notify the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the interact SBAR Communication Form . Record review of the facility's policy on accidents and Incidents revised July 2017 reflected this policy statement, All accidents or incidents, involving employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. An Immediate Jeopardy was identified on 04/09/21 at 4:42 p.m. The ADM and Regional consultant were notified on 04/09/18 at 4:42p.m of the IJ. The plan of removal was requested at that time. The facility's plan of removal accepted on 04/10/21 at 2:48p.m reflected: The following actions were immediately put in place upon being notified of the immediate jeopardy: Plan of Removal Revision #1 Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on April 09, 2021 for failure to 1) provide Freedom from Abuse and Neglect, 2) ensure Competent Nursing Staff. Corrective Actions: 1. Action: On April 1, 2021, an in-service was initiated by the Director of Nursing for all staff regarding reporting Changes of Condition. Staff are to report changes of condition to the resident's nurse immediately. The nurse will assess the change of condition as soon as possible. Changes of Condition will be reported to the resident's physician within 24 hours except in case of a medical emergency per center policy. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 2. Action: On April 1, 2021, an in-service was initiated with staff on abuse and neglect. The in-service will continue each shift to ensure all staff has the training. The Director of Nursing or designee may conduct the in-services in person or on the phone. No staff will be allowed to work until their in-service is completed. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 3. Action: On April 9, 2021, an in-service was initiated with nurses on Resident Examination and Assessment. The in-service will continue each shift to ensure all nurses have the training. The Director of Nursing or Designee may conduct the in-service in person or on the phone. No staff will be allowed to work until their in-service is completed. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 4. Action: On April 9, 2021, an in-service was initiated with nurses on Guidelines for Notifying Physicians of Clinical Problems. The notification of the physician should be immediate or as soon as is possible for change of condition that is sudden in onset or a marked change unrelieved by measures already prescribed. The in-service will continue each shift until all nurses have the training. The Director of Nursing or Designee may conduct the in-service in person or on the phone. No nurses will be allowed to work until their in-service is completed. Completion date 4/10/2021 except for PRN staff and one nurse on vacation who will be in-serviced upon her return. 5. Action: On March 31, 2021, the nurse, LVNB, was suspending pending investigation. The nurse continues to be suspended. Her personnel file was sent to Human Resources for license referral. 6. Action: Residents on Halls D and F were screened by nursing staff and no other residents were identified as affected by the LVN's alleged neglect. Completion date 4/10/2021. Identification of Residents at Risk: All residents on Halls D and F have the potential to be affected. One resident has been affected. Systemic Change(s): Administrator, DON, ADON, and/or designee will monitor resident changes of condition, validate by conducting random staff interviews to ensure understanding of procedure. Continue in-services weekly X4, monthly X3 and on-going as needed to ensure compliance is met to continue. Monitoring: Administrator, Director of Nursing, Assistant Director of Nursing will ensure compliance by walking rounds, return demonstration, and education as needed. If issues are identified, the Administrator or Director of Nursing will address at that time and provide training/guidance and /or disciplinary actions as needed. The information will be brought to the Quality Assurance Performance Improvement (QAPI) monthly X3 and as needed. The QAPI will review, at minimum, in-service documentation to validate. To verity the facility implemented their plan of removal, the following observations, interviews and record reviews were conducted: Observations of residents in halls A, B, C, D, E, and F did not revealed any resident with changes in condition. Interviews on 04/10/21 at various times with LVND, RNE, LVNK, RNL, RNF, RNI, LVNK, RNL, LVNP, LVNS, etc. They stated they received abuse/neglect, reporting change of condition, resident examination and timely reporting to physician training. The nursing staffs said they felt comfortable to thoroughly asses the residents during changes in condition and follow the facility policy on reporting to administration, physician and family. Interviews on 04/10/21 at various times with CNAA, CNAC, CMAH, CNAM, CMA N, CNAO, CNAQ, CNAT, CNAU, CNAV, CMAW, CNAX, CNAY, CAN Z, CNAO etc. They said they received in-services on reporting the resident's changes in condition and to report to other nursing staffs including the DON if the residents was not timely assessed. The aides were knowledgeable about the facility policy and abuse/neglect and report to Coordinator immediately. The aides were knowledgeable about the facility policy and abuse/neglect and to report to Coordinator immediately. On 04/10/21 at 2:48p.m, the ADM was notified the IJ was removed. While the IJ was removed on 04/10/21, the facility remained out of compliance at a severity level and a scope of isolated because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 of 21 residents reviewed for medications. (Resident #134) The facility failed to review and correctly transcribe Resident #134's medication list to the MAR following readmission from the hospital for [DIAGNOSES REDACTED] on 08/05/19. The facility administered Humalog insulin 9 units per sliding scale for a blood sugar of 272 on 08/05/19. The facility administered Actos and [MEDICATION NAME]/[MEDICATION NAME] on 08/06/19. These medications, which all lower blood sugar, had been changed/discontinued when Resident #134 was discharged from the hospital on [DATE]. Resident #134 developed severe [DIAGNOSES REDACTED] with [MEDICAL CONDITION] activity requiring re-hospitalization in ICU. An Immediate Jeopardy was identified on 08/10/19. It was determined to be past non-compliance immediate jeopardy from 08/05/19 to 08/08/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. These failures could place residents at risk of not receiving the correct medications, assessments, interventions, not having their medical needs met, and hospitalization , and death. Findings included: Review of Resident #134's undated Face Sheet indicated he was [AGE] years old and was most recently admitted to the facility on [DATE]. He was originally admitted on [DATE] and was hospitalized from [DATE] - 08/05/19. [DIAGNOSES REDACTED]. Review of Resident #134's MDS assessment dated [DATE] indicated he was usually able to make himself understood and understand others. He scored 11 on the BIMS, indicating he had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, locomotion on unit, dressing, hygiene and bathing. He utilized a wheelchair. Review of Resident #134's care plan 07/02/19, included the problem of diabetes. The goal was for no complications. Approaches included FSBS checked daily, medications as ordered, and observe for s/s of hypo/[MEDICAL CONDITION]. Review of the hospital Patient Discharge Summary Report dated 08/05/19 at 3:08 PM indicated Resident #134 had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The discharge medication orders included the following, in part: New Medications to Start Taking: Humalog 100 units/ml - Take sq before meals and at bedtime .sliding scale .for blood sugar from 260 to 299, give 4 units (Insulin that lowers blood sugar) Medications to Stop Taking: Actos 45 mg orally daily (lowers blood sugar) [MEDICATION NAME] 5 mg orally daily (lowers blood sugar) Review of the facility MAR beginning 08/05/19 for Resident #134 included the following, in part: Humalog 9 units given on 08/05/19 at 8:00 PM for blood sugar of 272 (incorrect dosage) Actos 45 mg given on 08/06/19 at 8:00 AM (had been discontinued) [MEDICATION NAME]/[MEDICATION NAME] 5-500 mg given on 08/06/19 at 8:00 AM (combination of two drugs that lowers blood sugar) (had been discontinued) Review of nurses notes included the following: 08/06/19 2pm - 10pm Skilled services cont. Contact isolation precautions for [MEDICAL CONDITION]. Accu check - 60 at 8pm. Health shake and sandwich given. Recheck @ 9:30 pm accucheck 75. Health shake and Dr.Pepper given. Recheck @ 10:30 85. Dr. Pepper given. (unsigned by LVN I) 08/06/19 10pm - 6am (No times documented) Remains SNF for [MEDICAL CONDITION]. Accucheck has been going down to 37. Called Dr. _. Got order for [MEDICATION NAME] 1 mg IM. Gave and went to 94 at this time. Will continue to monitor. (Signed by LVN D) Received oral [MEDICATION NAME] from pharmacy. (Initialed by LVN D) There was no documentation of continued monitoring of the resident's blood glucose level by LVN D. There was no documentation of the resident's reported [MEDICAL CONDITION] activity (which may occur in relation to [DIAGNOSES REDACTED]), no documentation of assessment of vital signs, neurologic status, level of consciousness, or details of the [MEDICAL CONDITION] activity as specified in the facility's policy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. 08/07/19 5:30 AM Resident (#134) is lethargic - Large BM tarry dark. He is able to open eyes on request. Respirations 20 labored. Bathed, incontinent care with PPE - isolation for [MEDICAL CONDITION]. Crash cart @ door if needed. 911 per staff nurse. RN stayed with (Resident #134) awaiting EMS for transport. EMS with PPE, report per staff nurse. Full Code status - face sheet and orders sent with EMS. (signed by RN E) Review of the Provider Investigation Report dated 08/07/19 included the following; Report Details: Resident (#134) arrived back from hospital on 08/0519 during the 2pm - 10pm shift. Admitting nurse (LVN C) failed to check physician's orders [REDACTED]. ADON (B) printed MARS from H&P that listed home medications (not current discharge orders). Due to this oversight, medications were left on the MAR and given by AM (6-2 shift) nurse. These included two anti-hyper glycemic medications. On 08/06/19, 2pm - 10pm nurse charted hypoglycemic episodes with resident. Nurse treated with oral intake and remonitored blood glucose. Resident's blood sugar at 2230 (10:30 PM) was documented as 85 and oral intake was given and report provided to 10pm - 6pm nurse. The 10pm - 6pm nurse charted blood sugar down to 37 (time undocumented) and Dr. called. At that time, order received for [MEDICATION NAME] 1mg IM. Med administered as ordered. 10pm - 6pm nurse notified ADON (B) at approximately 0515 (5:15 AM) that resident was hypoglycemic and had two [MEDICAL CONDITION]. ADON (B) arrived to the facility shortly thereafter and met RN (E) who had already arrived and assessed resident and was in process of arranging transportation to ER. Resident was transported via ambulance to hospital and is presently in ICU. In an interview with the DON on 08/08/19 at 4:30 PM she said ADON B put in orders for Resident #134's readmission on 08/05/19 based on the hospital H&P (which listed home medications). The DON said that on 08/05/19 the 2p - 10p nurse (LVN C) got the hospital discharge packet when Resident #134 arrived back from the hospital, but did not review the discharge orders. She said that Actos and Glypizide/[MEDICATION NAME] were given the morning of 08/06/19, but should not have been given as they were discontinued on the discharge orders. She said Resident #134 was basically getting all the same medications as he was before he went to the hospital. The DON said the nurses have been inserviced on admissions/re-admissions, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation and abuse/neglect. In an interview with ADON B on 08/09/19 at 11:40 AM she said when she was notified that Resident t#134 was returning from the hospital on [DATE] she printed new MARs following the home medication list. She said she told the 2pm - 10pm nurse (LVN C) to be sure to compare the MARs with orders in the hospital packet when Resident #134 returns to the facility. ADON B said Resident #134 returned to the facility around 3:30 PM and had the hospital discharge packet with him. She said that what was in the packet was not transcribed to the MARs. She said a bunch of meds were highlighted in red to stop. ADON B said they have changed the procedure for when a resident is readmitted to the facility. She said they are not printing MARs based on home medications anymore. In an interview with LVN C on 08/09/19 at 12:05 PM she said the norm was for an ADON to put in the orders for new or readmitted residents. She said ADON B did that when Resident #134 was coming back from the hospital. She said Resident #134 came back with a packet from the hospital. LVN C said, I did not check the orders, and that's on me. She said that on Monday (08/05/19) they told us (charge nurses) we would be doing our own admission orders [REDACTED]. LVN C said she has been employed at the facility for two months. She said since ADON B did the MARs the day Resident #134 (08/05/12) was returning, she did not think charge nurses were doing their own admissions yet. In an interview with the DON on 08/09/19 at 5:00 PM she said that LVN D told her that CNA G reported that Resident #134 was acting weird and she (LVN D) checked his blood sugar. The DON said that LVN D's story changed between interviews about what times the [MEDICAL CONDITION] occurred, and LVN D did not document any of these events. The DON said that Resident #134's physician said he received a call at approximately 2:00 AM regarding the [DIAGNOSES REDACTED], but he wasn't told anything about [MEDICAL CONDITION]. The DON said that LVN D called ADON F on 08/06/19 at approximately 5:15 AM regarding Resident #134's low blood sugar and [MEDICAL CONDITION]. RN [NAME] arrived as usual at 5:30 AM (before ADON F) and assessed the resident and immediately arranged for him to be transported to the ER by EMS. The DON said her expectation is for nurses to completely document all symptoms and care given. She said LVN D was suspended 08/07/19, but she resigned immediately. ADON B and LVN C were both given written warnings on 08/08/19. In an interview with CNA G on 08/10/19 at 11:20 AM she said she had just gotten back from break at approximately 2am and there were two nurses in Resident #134's room. They told me he had just had a [MEDICAL CONDITION] and they had given him a shot. CNA G said she passed by his room around 4am and he was shaking and I hollered for the nurses. After he stopped having the [MEDICAL CONDITION] they gave him some sugar stuff. He had a large, loose bowel movement that was real dark. He was gurgling and I didn't want to put his head down because I was afraid he would choke. He was sitting up at about a 45° angle. Me and LVN D were trying to clean him up but he was sitting up and gurgling. RN [NAME] came in and helped me clean him up and an ambulance came and took him to the hospital. In a telephone interview with LVN D on 08/10/19 at 11:40 AM she said she came on at 9:45 PM (08/06/19) for her 10p-6am shift. She said she got report and the nurse (LVN I) that had (Resident #134) said 'I have a low blood sugar' and went to his room. Medications were delivered from the pharmacy. LVN I said she gave Resident #134 a health shake .she said she was going to take care of him while she was there doing charting. She rechecked his blood sugar and it was up to 80. She (LVN I) was there until 12:00 or 12:30 AM. LVN D said she gave some prn meds to other residents and Resident #134 was sleeping. LVN D said, I had a funny feeling, it was a little before 2:00 AM, and checked Resident #134's blood sugar and it was 27! He was still alert and talking! I called the doctor and he ordered [MEDICATION NAME]. It looked like he was having a [MEDICAL CONDITION] and I gave it ([MEDICATION NAME] injection) and he came out of it. I looked at his chart and saw he had a history of [REDACTED].#134's blood sugar about an hour later and it was 94. She said he went to sleep and looked normal. LVN D said she went back to the nurses desk and did a little bit of charting and gave more prn medications. LVN D said she looked in on Resident #134 frequently and he looked normal. Around 4:30 AM CNA G was doing rounds and hollered for me. I went to his room and he had another [MEDICAL CONDITION]. His blood sugar was in the low 30's. I tried to give him oral glucose but he couldn't swallow. He said he felt bloated and he had a history of [REDACTED]. I still had to do early morning meds, blood sugars, etc. I stayed until around 7:30 AM. My back was hurting so bad! When I got halfway home I started thinking, Did I chart?, did I chart? I thought surely I did, I always do. In a telephone interview with LVN I on 08/10/19 at 12:55 PM she said she stayed late (on 08/06/19) after a double shift. She said that around 8:00 PM Resident #134's blood sugar was 60. She said this was her first time to care for him. She said he told her he felt bad. She said she got him a health shake and a 1/2 sandwich. She said she rechecked his blood sugar and it was still low so she gave him another health shake and a DR. Pepper. She said he told her her he felt better, but his blood sugar was still on the low side. She said when she gave report to the oncoming 10pm - 6am shift she told them everything she had given him to raise his blood sugar. In an interview with the DON on 08/09/19 at 4:15 PM she said that she has only been with the facility since 08/05/19 and has not yet had the time/opportunity to review all of the clinical systems. She said that since this incident occurred with Resident #134 they are not generating MARs without current orders any longer. But, she said, even if a MAR was done prematurely, the charge nurse should have reviewed and compared the hospital discharge orders with the MAR and made any/all changes to reflect the current orders. Review of facility policy, Reconciliation of Medications on admitted d (MONTH) (YEAR), included the following, in part: General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications .for the purpose of preventing unintended changes or omissions at transition points of care. Steps in Procedure: 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 5. Review the list carefully to determine if there are discrepancies/conflicts. For example; a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; 6. If there is a discrepancy or conflict in medications, dose, route, or frequency, determine the most appropriate action to resolve the discrepancy. For example: b. Contact the physician from the referring facility; d. Contact the resident's primary physician in the community; g. Contact the admitting and/or Attending Physician. It was determined these failures placed Resident #134 in an Immediate Jeopardy situation from 08/05/19 through 08/07/19. The facility took the following actions to correct the non-compliance on 08/08/19: - Suspended LVN (D) responsible for care of this resident pending investigation with intent to terminate after investigation. During interview the LVN (D) resigned effective immediately. Refer employee file to Legal counsel and CNO for licensure referral of LVN (D). - Inservices were conducted on the following policies: 1. admission orders [REDACTED] 2. Medication Errors 3. Abuse and Neglect Prevention 4. Change of condition 5. Notification of MD on change 6. [MEDICAL CONDITION] activity 7. Documentation on accuracy 8. Documentation on dating/timing entry 9. Assessment after episode of Low Blood Sugar readings 10. Hypoglycemic Policy and Procedure - Reviewed past 90 days admission orders [REDACTED] - Generated Medication Error Reports - Reviewed all Medication errors past 90 days - Reviewed past 90 days of glucometer readings on all diabetic residents - Assessed all residents for change of condition - Reviewed resident with [MEDICAL CONDITION] medication or history of [MEDICAL CONDITION] - Reviewed lab on all diabetic residents - Reviewed glucometer machine calibration - Competency check on admitting a resident on license staff - Out of Cycle QAPI - Monitor: Competencies on licensed nurse on admissions. DON/designee will review each admission within 24 hours of admission to ensure accuracy. 24 hour report daily review for significant change Complete rounds alternating every 2 hours Review glucometer readings daily before noon. Interviews from 08/08/19 - 08/15/19 with 8 LVNs and 1 RN on 3 shifts revealed they understood the policies and procedures for admissions/readmissions, medication reconciliation, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation, and abuse/neglect. Reviews of the records of 20 other diabetic residents revealed no additional concerns.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 of 21 residents reviewed for medications. (Resident #134) The facility failed to review and correctly transcribe Resident #134's medication list to the MAR following readmission from the hospital for [DIAGNOSES REDACTED] on 08/05/19. The facility administered Humalog insulin 9 units per sliding scale for a blood sugar of 272 on 08/05/19. The facility administered Actos and [MEDICATION NAME]/[MEDICATION NAME] on 08/06/19. These medications, which all lower blood sugar, had been changed/discontinued when Resident #134 was discharged from the hospital on [DATE]. Resident #134 developed severe [DIAGNOSES REDACTED] with [MEDICAL CONDITION] activity requiring re-hospitalization in ICU. An Immediate Jeopardy was identified on 08/10/19. It was determined to be past non-compliance immediate jeopardy from 08/05/19 to 08/08/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. These failures could place residents at risk of not receiving the correct medications, assessments, interventions, not having their medical needs met, and hospitalization , and death. Findings included: Review of Resident #134's undated Face Sheet indicated he was [AGE] years old and was most recently admitted to the facility on [DATE]. He was originally admitted on [DATE] and was hospitalized from [DATE] - 08/05/19. [DIAGNOSES REDACTED]. Review of Resident #134's MDS assessment dated [DATE] indicated he was usually able to make himself understood and understand others. He scored 11 on the BIMS, indicating he had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, locomotion on unit, dressing, hygiene and bathing. He utilized a wheelchair. Review of Resident #134's care plan 07/02/19, included the problem of diabetes. The goal was for no complications. Approaches included FSBS checked daily, medications as ordered, and observe for s/s of hypo/[MEDICAL CONDITION]. Review of the hospital Patient Discharge Summary Report dated 08/05/19 at 3:08 PM indicated Resident #134 had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The discharge medication orders included the following, in part: New Medications to Start Taking: Humalog 100 units/ml - Take sq before meals and at bedtime .sliding scale .for blood sugar from 260 to 299, give 4 units (Insulin that lowers blood sugar) Medications to Stop Taking: Actos 45 mg orally daily (lowers blood sugar) [MEDICATION NAME] 5 mg orally daily (lowers blood sugar) Review of the facility MAR beginning 08/05/19 for Resident #134 included the following, in part: Humalog 9 units given on 08/05/19 at 8:00 PM for blood sugar of 272 (incorrect dosage) Actos 45 mg given on 08/06/19 at 8:00 AM (had been discontinued) [MEDICATION NAME]/[MEDICATION NAME] 5-500 mg given on 08/06/19 at 8:00 AM (combination of two drugs that lowers blood sugar) (had been discontinued) Review of nurses notes included the following: 08/06/19 2pm - 10pm Skilled services cont. Contact isolation precautions for [MEDICAL CONDITION]. Accu check - 60 at 8pm. Health shake and sandwich given. Recheck @ 9:30 pm accucheck 75. Health shake and Dr.Pepper given. Recheck @ 10:30 85. Dr. Pepper given. (unsigned by LVN I) 08/06/19 10pm - 6am (No times documented) Remains SNF for [MEDICAL CONDITION]. Accucheck has been going down to 37. Called Dr. _. Got order for [MEDICATION NAME] 1 mg IM. Gave and went to 94 at this time. Will continue to monitor. (Signed by LVN D) Received oral [MEDICATION NAME] from pharmacy. (Initialed by LVN D) There was no documentation of continued monitoring of the resident's blood glucose level by LVN D. There was no documentation of the resident's reported [MEDICAL CONDITION] activity (which may occur in relation to [DIAGNOSES REDACTED]), no documentation of assessment of vital signs, neurologic status, level of consciousness, or details of the [MEDICAL CONDITION] activity as specified in the facility's policy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. 08/07/19 5:30 AM Resident (#134) is lethargic - Large BM tarry dark. He is able to open eyes on request. Respirations 20 labored. Bathed, incontinent care with PPE - isolation for [MEDICAL CONDITION]. Crash cart @ door if needed. 911 per staff nurse. RN stayed with (Resident #134) awaiting EMS for transport. EMS with PPE, report per staff nurse. Full Code status - face sheet and orders sent with EMS. (signed by RN E) Review of the Provider Investigation Report dated 08/07/19 included the following; Report Details: Resident (#134) arrived back from hospital on 08/0519 during the 2pm - 10pm shift. Admitting nurse (LVN C) failed to check physician's orders [REDACTED]. ADON (B) printed MARS from H&P that listed home medications (not current discharge orders). Due to this oversight, medications were left on the MAR and given by AM (6-2 shift) nurse. These included two anti-hyper glycemic medications. On 08/06/19, 2pm - 10pm nurse charted hypoglycemic episodes with resident. Nurse treated with oral intake and remonitored blood glucose. Resident's blood sugar at 2230 (10:30 PM) was documented as 85 and oral intake was given and report provided to 10pm - 6pm nurse. The 10pm - 6pm nurse charted blood sugar down to 37 (time undocumented) and Dr. called. At that time, order received for [MEDICATION NAME] 1mg IM. Med administered as ordered. 10pm - 6pm nurse notified ADON (B) at approximately 0515 (5:15 AM) that resident was hypoglycemic and had two [MEDICAL CONDITION]. ADON (B) arrived to the facility shortly thereafter and met RN (E) who had already arrived and assessed resident and was in process of arranging transportation to ER. Resident was transported via ambulance to hospital and is presently in ICU. In an interview with the DON on 08/08/19 at 4:30 PM she said ADON B put in orders for Resident #134's readmission on 08/05/19 based on the hospital H&P (which listed home medications). The DON said that on 08/05/19 the 2p - 10p nurse (LVN C) got the hospital discharge packet when Resident #134 arrived back from the hospital, but did not review the discharge orders. She said that Actos and Glypizide/[MEDICATION NAME] were given the morning of 08/06/19, but should not have been given as they were discontinued on the discharge orders. She said Resident #134 was basically getting all the same medications as he was before he went to the hospital. The DON said the nurses have been inserviced on admissions/re-admissions, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation and abuse/neglect. In an interview with ADON B on 08/09/19 at 11:40 AM she said when she was notified that Resident t#134 was returning from the hospital on [DATE] she printed new MARs following the home medication list. She said she told the 2pm - 10pm nurse (LVN C) to be sure to compare the MARs with orders in the hospital packet when Resident #134 returns to the facility. ADON B said Resident #134 returned to the facility around 3:30 PM and had the hospital discharge packet with him. She said that what was in the packet was not transcribed to the MARs. She said a bunch of meds were highlighted in red to stop. ADON B said they have changed the procedure for when a resident is readmitted to the facility. She said they are not printing MARs based on home medications anymore. In an interview with LVN C on 08/09/19 at 12:05 PM she said the norm was for an ADON to put in the orders for new or readmitted residents. She said ADON B did that when Resident #134 was coming back from the hospital. She said Resident #134 came back with a packet from the hospital. LVN C said, I did not check the orders, and that's on me. She said that on Monday (08/05/19) they told us (charge nurses) we would be doing our own admission orders [REDACTED]. LVN C said she has been employed at the facility for two months. She said since ADON B did the MARs the day Resident #134 (08/05/12) was returning, she did not think charge nurses were doing their own admissions yet. In an interview with the DON on 08/09/19 at 5:00 PM she said that LVN D told her that CNA G reported that Resident #134 was acting weird and she (LVN D) checked his blood sugar. The DON said that LVN D's story changed between interviews about what times the [MEDICAL CONDITION] occurred, and LVN D did not document any of these events. The DON said that Resident #134's physician said he received a call at approximately 2:00 AM regarding the [DIAGNOSES REDACTED], but he wasn't told anything about [MEDICAL CONDITION]. The DON said that LVN D called ADON F on 08/06/19 at approximately 5:15 AM regarding Resident #134's low blood sugar and [MEDICAL CONDITION]. RN [NAME] arrived as usual at 5:30 AM (before ADON F) and assessed the resident and immediately arranged for him to be transported to the ER by EMS. The DON said her expectation is for nurses to completely document all symptoms and care given. She said LVN D was suspended 08/07/19, but she resigned immediately. ADON B and LVN C were both given written warnings on 08/08/19. In an interview with CNA G on 08/10/19 at 11:20 AM she said she had just gotten back from break at approximately 2am and there were two nurses in Resident #134's room. They told me he had just had a [MEDICAL CONDITION] and they had given him a shot. CNA G said she passed by his room around 4am and he was shaking and I hollered for the nurses. After he stopped having the [MEDICAL CONDITION] they gave him some sugar stuff. He had a large, loose bowel movement that was real dark. He was gurgling and I didn't want to put his head down because I was afraid he would choke. He was sitting up at about a 45° angle. Me and LVN D were trying to clean him up but he was sitting up and gurgling. RN [NAME] came in and helped me clean him up and an ambulance came and took him to the hospital. In a telephone interview with LVN D on 08/10/19 at 11:40 AM she said she came on at 9:45 PM (08/06/19) for her 10p-6am shift. She said she got report and the nurse (LVN I) that had (Resident #134) said 'I have a low blood sugar' and went to his room. Medications were delivered from the pharmacy. LVN I said she gave Resident #134 a health shake .she said she was going to take care of him while she was there doing charting. She rechecked his blood sugar and it was up to 80. She (LVN I) was there until 12:00 or 12:30 AM. LVN D said she gave some prn meds to other residents and Resident #134 was sleeping. LVN D said, I had a funny feeling, it was a little before 2:00 AM, and checked Resident #134's blood sugar and it was 27! He was still alert and talking! I called the doctor and he ordered [MEDICATION NAME]. It looked like he was having a [MEDICAL CONDITION] and I gave it ([MEDICATION NAME] injection) and he came out of it. I looked at his chart and saw he had a history of [REDACTED].#134's blood sugar about an hour later and it was 94. She said he went to sleep and looked normal. LVN D said she went back to the nurses desk and did a little bit of charting and gave more prn medications. LVN D said she looked in on Resident #134 frequently and he looked normal. Around 4:30 AM CNA G was doing rounds and hollered for me. I went to his room and he had another [MEDICAL CONDITION]. His blood sugar was in the low 30's. I tried to give him oral glucose but he couldn't swallow. He said he felt bloated and he had a history of [REDACTED]. I still had to do early morning meds, blood sugars, etc. I stayed until around 7:30 AM. My back was hurting so bad! When I got halfway home I started thinking, Did I chart?, did I chart? I thought surely I did, I always do. In a telephone interview with LVN I on 08/10/19 at 12:55 PM she said she stayed late (on 08/06/19) after a double shift. She said that around 8:00 PM Resident #134's blood sugar was 60. She said this was her first time to care for him. She said he told her he felt bad. She said she got him a health shake and a 1/2 sandwich. She said she rechecked his blood sugar and it was still low so she gave him another health shake and a DR. Pepper. She said he told her her he felt better, but his blood sugar was still on the low side. She said when she gave report to the oncoming 10pm - 6am shift she told them everything she had given him to raise his blood sugar. In an interview with the DON on 08/09/19 at 4:15 PM she said that she has only been with the facility since 08/05/19 and has not yet had the time/opportunity to review all of the clinical systems. She said that since this incident occurred with Resident #134 they are not generating MARs without current orders any longer. But, she said, even if a MAR was done prematurely, the charge nurse should have reviewed and compared the hospital discharge orders with the MAR and made any/all changes to reflect the current orders. Review of facility policy, Reconciliation of Medications on admitted d (MONTH) (YEAR), included the following, in part: General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications .for the purpose of preventing unintended changes or omissions at transition points of care. Steps in Procedure: 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 5. Review the list carefully to determine if there are discrepancies/conflicts. For example; a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; 6. If there is a discrepancy or conflict in medications, dose, route, or frequency, determine the most appropriate action to resolve the discrepancy. For example: b. Contact the physician from the referring facility; d. Contact the resident's primary physician in the community; g. Contact the admitting and/or Attending Physician. It was determined these failures placed Resident #134 in an Immediate Jeopardy situation from 08/05/19 through 08/07/19. The facility took the following actions to correct the non-compliance on 08/08/19: - Suspended LVN (D) responsible for care of this resident pending investigation with intent to terminate after investigation. During interview the LVN (D) resigned effective immediately. Refer employee file to Legal counsel and CNO for licensure referral of LVN (D). - Inservices were conducted on the following policies: 1. admission orders [REDACTED] 2. Medication Errors 3. Abuse and Neglect Prevention 4. Change of condition 5. Notification of MD on change 6. [MEDICAL CONDITION] activity 7. Documentation on accuracy 8. Documentation on dating/timing entry 9. Assessment after episode of Low Blood Sugar readings 10. Hypoglycemic Policy and Procedure - Reviewed past 90 days admission orders [REDACTED] - Generated Medication Error Reports - Reviewed all Medication errors past 90 days - Reviewed past 90 days of glucometer readings on all diabetic residents - Assessed all residents for change of condition - Reviewed resident with [MEDICAL CONDITION] medication or history of [MEDICAL CONDITION] - Reviewed lab on all diabetic residents - Reviewed glucometer machine calibration - Competency check on admitting a resident on license staff - Out of Cycle QAPI - Monitor: Competencies on licensed nurse on admissions. DON/designee will review each admission within 24 hours of admission to ensure accuracy. 24 hour report daily review for significant change Complete rounds alternating every 2 hours Review glucometer readings daily before noon. Interviews from 08/08/19 - 08/15/19 with 8 LVNs and 1 RN on 3 shifts revealed they understood the policies and procedures for admissions/readmissions, medication reconciliation, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation, and abuse/neglect. Reviews of the records of 20 other diabetic residents revealed no additional concerns.

Based on interview and record review, the facility failed to provide treatment and care based on the comprehensive assessment, in accordance with professional standards for 1 of 20 residents (Resident #134) reviewed for quality of care. a) The facility failed to review and correctly transcribe Resident #134's medication orders to the MAR following readmission from the hospital for [DIAGNOSES REDACTED] on 08/05/19. The facility administered Humalog insulin 9 units, instead of 4 units on 08/05/19 at 8:00 PM, and Actos 45 mg, and [MEDICATION NAME]/[MEDICATION NAME] 5-500 mg on 08/06/19 at 8:00 AM, which had been discontinued. (These medications all lower blood sugar.) Resident #134 developed severe [DIAGNOSES REDACTED] and [MEDICAL CONDITION] activity requiring re-hospitalization in ICU. b) The facility failed to closely monitor the resident's condition including blood sugar levels during the night shift on 08/07/19 and failed to communicate to the physician when Resident #134 experienced [MEDICAL CONDITION] activity with low blood sugar levels. An Immediate Jeopardy was identified on 08/10/19. It was determined to be past non-compliance immediate jeopardy from 08/05/19 to 08/08/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. These failures could place residents at risk of not receiving the correct medications, assessments, interventions, not having their medical needs met, and hospitalization , and death. Findings included: Review of Resident #134's undated Face Sheet indicated he was [AGE] years old and was most recently admitted to the facility on [DATE]. He was originally admitted on [DATE] and was hospitalized from [DATE] - 08/05 19. [DIAGNOSES REDACTED]. Review of Resident #134's MDS assessment dated [DATE] indicated he was usually able to make himself understood and understand others. He scored 11 on the BIMS, indicating he had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, locomotion on unit, dressing, hygiene and bathing. He utilized a wheelchair. Review of Resident #134's care plan dated 07/02/19, included the problem of diabetes. The goal was for no complications. Approaches included FSBS checked daily, medications as ordered, and observe for s/s of hypo/[MEDICAL CONDITION]. Review of the hospital Patient Discharge Summary Report dated 08/05/19 at 3:08 PM indicated Resident #134 had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The discharge medication orders included the following: New Medications to Start Taking: Humalog 100 units/ml - Take sq before meals and at bedtime .sliding scale .for blood sugar from 260 to 299, give 4 units (Insulin that lowers blood sugar) Oral [MEDICATION NAME] 125mg/2.5 ml 1 syringe - Take orally 125 mg four times a day (antibiotic to treat [MEDICAL CONDITION] infection) Medications to Stop Taking: Actos 45 mg orally daily (lowers blood sugar) [MEDICATION NAME] 5 mg orally daily (lowers blood sugar) Review of the facility MAR beginning 08/05/19 for Resident #134 included the following: **Humalog 9 units given on 08/05/19 at 8:00 PM for blood sugar of 272 (incorrect dose administered) **[MEDICATION NAME] was not given. Per nurse's note dated 08/06/19 on 10p - 6a shift oral [MEDICATION NAME] was received from pharmacy **Actos 45 mg given on 08/06/19 at 8:00 AM (had been discontinued) **[MEDICATION NAME]/[MEDICATION NAME] 5-500 mg given on 08/06/19 at 8:00 AM (combination of two drugs that lowers blood sugar) (had been discontinued) Review of nurses notes included the following: 08/06/19 2pm-10pm Skilled services cont. Contact isolation precautions for [MEDICAL CONDITION]. Accu check - 60 at 8pm. Health shake and sandwich given. Recheck @ 9:30 pm accucheck 75. Health shake and Dr.Pepper given. Recheck @ 10:30 85. Dr. Pepper given. (unsigned by LVN I) 08/06/19 10pm-6am (No times documented) Remains SNF for [MEDICAL CONDITION]. Accucheck has been going down to 37 (blood glucose). Called Dr. _. Got order for [MEDICATION NAME] 1 mg IM. Gave and went to 94 (blood glucose) at this time. Will continue to monitor. (Signed by LVN D) Received oral [MEDICATION NAME] from pharmacy. (Initialed by LVN D) There was no documentation of continued monitoring of the resident's blood glucose level by LVN D. There was no documentation of the resident's reported [MEDICAL CONDITION] activity (which may occur in relation to [DIAGNOSES REDACTED]), no documentation of assessment of vital signs, neurologic status, level of consciousness, or details of the [MEDICAL CONDITION] activity as specified in the facility's policy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. 08/07/19 5:30 AM Resident (#134) is lethargic - Large BM tarry dark. He is able to open eyes on request. Respirations 20 labored. Bathed, incontinent care with PPE - isolation for [MEDICAL CONDITION]. Crash cart @ door if needed. 911 per staff nurse. RN stayed with (Resident #134) awaiting EMS for transport. EMS with PPE, report per staff nurse. Full Code status - face sheet and orders sent with EMS. (signed by RN E) Review of the Provider Investigation Report dated 08/07/19 included the following; Report Details: Resident (#134) arrived back from hospital on [DATE] during the 2pm-10pm shift. Admitting nurse (LVN C) failed to check physician's orders [REDACTED]. ADON (B) printed MARs from H&P that listed home medications (not current discharge orders). Due to this oversight, medications were left on the MAR and given by AM (6-2 shift) nurse (on 08/06/19). These included two anti-hyper glycemic medications. On 08/06/19, 2-10 nurse charted hypoglycemic episodes with resident. Nurse treated with oral intake and remonitored blood glucose. Resident's blood sugar at 2230 (10:30 PM) was documented as 85 and oral intake was given and report provided to 10pm-6am nurse. The 10pm-6am nurse charted blood sugar down to 37 (time undocumented) and Dr. called. At that time, order received for [MEDICATION NAME] 1mg IM. Med administered as ordered. 10pm-6am nurse notified ADON (B) at approximately 0515 (5:15 AM) that resident was hypoglycemic and had two [MEDICAL CONDITION]. ADON (B) arrived to the facility shortly thereafter and met RN (E) who had already arrived and assessed resident and was in process of arranging transportation to ER. Resident was transported via ambulance to hospital and is presently in ICU. In an interview with the DON on 08/08/19 at 4:30 PM she said ADON B put in orders for Resident #134's readmission on 08/05/19 based on the hospital H&P (which listed nursing home medications). The DON said that on 08/05/19 the 2pm-10pm nurse (LVN C) got the hospital discharge packet when Resident #134 arrived back from the hospital, but did not review the discharge orders. She said that Actos and Glypizide/[MEDICATION NAME] were given the morning of 08/06/19, but should not have been given as they were discontinued on the discharge orders. She said Resident #134 was basically getting all the same medications as he was before he went to the hospital. The DON said the nurses have been inserviced on admissions/re-admissions, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation and abuse/neglect. In an interview with ADON B on 08/09/19 at 11:40 AM she said when she was notified that Resident t#134 was returning from the hospital on [DATE] she printed new MARs following the nursing home medication list. She said she told the 2pm-10pm nurse (LVN C) to be sure to compare the MARs with orders in the hospital packet when Resident #134 returns to the facility. ADON B said Resident #134 returned to the facility around 3:30 PM and had the hospital discharge packet with him. She said that what was in the packet was not transcribed to the MARs. She said a bunch of meds were highlighted in red to stop. ADON B said they have changed the procedure for when a resident is readmitted to the facility. She said they are not printing MARs based on home medications anymore. In an interview with LVN C on 08/09/19 at 12:05 PM she said the norm was for an ADON to put in the orders for new or readmitted residents. She said ADON B did that when Resident #134 was coming back from the hospital. She said Resident #134 came back with a packet from the hospital. LVN C said, I did not check the orders, and that's on me. She said that on Monday (08/05/19) they told us (charge nurses) we would be doing our own admission orders [REDACTED]. LVN C said she has been employed at the facility for two months. She said since ADON B did the MARs the day Resident #134 (08/05/12) was returning, she did not think charge nurses were doing their own admissions yet. In an interview with the DON on 08/09/19 at 5:00 PM she said that LVN D told her that CNA G reported that Resident #134 was acting weird and she (LVN D) checked his blood sugar. The DON said that LVN D's story changed between interviews about what times the [MEDICAL CONDITION] occurred, and LVN D did not document any of these events. The DON said that Resident #134's physician said he received a call at approximately 2:00 AM regarding the [DIAGNOSES REDACTED], but he wasn't told anything about [MEDICAL CONDITION]. The DON said that LVN D called ADON F on 08/06/19 at approximately 5:15 AM regarding Resident #134's low blood sugar and [MEDICAL CONDITION]. RN [NAME] arrived as usual at 5:30 AM (before ADON F) and assessed the resident and immediately arranged for him to be transported to the ER by EMS. The DON said her expectation is for nurses to completely document all symptoms and care given. She said LVN D was suspended 08/07/19, but she resigned immediately. ADON B and LVN C were both given written warnings on 08/08/19. In an interview with CNA G on 08/10/19 at 11:20 AM she said she had just gotten back from break at approximately 2am and there were two nurses in Resident #134's room. They told me he had just had a [MEDICAL CONDITION] and they had given him a shot. CNA G said she passed by his room around 4am and he was shaking and I hollered for the nurses. After he stopped having the [MEDICAL CONDITION] they gave him some sugar stuff. He had a large, loose bowel movement that was real dark. He was gurgling and I didn't want to put his head down because I was afraid he would choke. He was sitting up at about a 45° angle. Me and LVN D were trying to clean him up but he was sitting up and gurgling. RN [NAME] came in and helped me clean him up and an ambulance came and took him to the hospital. In a telephone interview with LVN D on 08/10/19 at 11:40 AM she said she came on at 9:45 PM (08/06/19) for her 10p-6am shift. She said she got report and the nurse (LVN I) that had (Resident #134) said 'I have a low blood sugar' and went to his room. Medications were delivered from the pharmacy. LVN I said she gave Resident #134 a health shake .she said she was going to take care of him while she was there doing charting. She rechecked his blood sugar and it was up to 80. She (LVN I) was there until 12:00 or 12:30 AM. LVN D said she gave some prn meds to other residents and Resident #134 was sleeping. LVN D said, I had a funny feeling, it was a little before 2:00 AM, and checked Resident #134's blood sugar and it was 27! He was still alert and talking! I called the doctor and he ordered [MEDICATION NAME]. It looked like he was having a [MEDICAL CONDITION] and I gave it ([MEDICATION NAME] injection) and he came out of it. I looked at his chart and saw he had a history of [REDACTED].#134's blood sugar about an hour later and it was 94. She said he went to sleep and looked normal. LVN D said she went back to the nurses desk and did a little bit of charting and gave more prn medications. LVN D said she looked in on Resident #134 frequently and he looked normal. Around 4:30 AM CNA G was doing rounds and hollered for me. I went to his room and he had another [MEDICAL CONDITION]. His blood sugar was in the low 30's. I tried to give him oral glucose but he couldn't swallow. He said he felt bloated and he had a history of [REDACTED]. I still had to do early morning meds, blood sugars, etc. I stayed until around 7:30 AM. My back was hurting so bad! When I got halfway home I started thinking, Did I chart?, did I chart? I thought surely I did, I always do. In a telephone interview with LVN I on 08/10/19 at 12:55 PM she said she stayed late (on 08/06/19) after a double shift. She said that around 8:00 PM Resident #134's blood sugar was 60. She said this was her first time to care for him. She said he told her he felt bad. She said she got him a health shake and a 1/2 sandwich. She said she rechecked his blood sugar and it was still low so she gave him another health shake and a DR. Pepper. She said he told her her he felt better, but his blood sugar was still on the low side. She said when she gave report to the oncoming 10pm - 6am shift she told them everything she had given him to raise his blood sugar. In an interview with the DON on 08/09/19 at 4:15 PM she said that she has only been with the facility since 08/05/19 and has not yet had the time/opportunity to review all of the clinical systems. She said that since this incident occurred with Resident #134 they are not generating MARs without current orders any longer. But, she said, even if a MAR was done prematurely, the charge nurse should have reviewed and compared the hospital discharge orders with the MAR and made any/all changes to reflect the current orders. Review of facility policy, Reconciliation of Medications on admitted d (MONTH) (YEAR), included the following, in part: General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications .for the purpose of preventing unintended changes or omissions at transition points of care. Steps in Procedure: 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 5. Review the list carefully to determine if there are discrepancies/conflicts. For example; a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; 6. If there is a discrepancy or conflict in medications, dose, route, or frequency, determine the most appropriate action to resolve the discrepancy. For example: b. Contact the physician from the referring facility; d. Contact the resident's primary physician in the community; g. Contact the admitting and/or Attending Physician. Review of facility policy, Nursing Care of the Resident with Diabetes Mellitus dated (MONTH) 2019, included the following, in part: Glucose Monitoring 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as 80-130 mg/dL before meals and <180 mg/dL after meals. 6. Approximate reference ranges for [DIAGNOSES REDACTED] are: a. Mild [DIAGNOSES REDACTED] 55-70 mg/dL; b. Moderate [DIAGNOSES REDACTED] 40-55 mg/dL; and c. Severe [DIAGNOSES REDACTED] <40 mg/dL. Management of [DIAGNOSES REDACTED] 3. For symptomatic (lethargic, drowsy) but responsive (conscious) residents with [DIAGNOSES REDACTED] (<70 mg/dL .) a. If he/she is able to swallow: (1) Immediately give the resident an oral form of rapidly absorbed glucose (4 oz juice or 5-6 ounces of soda); (2) Recheck blood glucose in 15 minutes; and (3) Repeat juice if indicated recheck blood glucose in 15 minutes. b. If he/she is unable to swallow: (1) Immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol; (2) Recheck blood glucose in 15 minutes; and (3) Repeat protocol if indicated and recheck blood glucose in 15 minutes. Review of facility policy, [MEDICAL CONDITION] and [MEDICAL CONDITION] - Clinical Protocol dated (MONTH) 2012, included the following, in part: Assessment and Recognition 1. b. Acute [MEDICAL CONDITION] may occur in relation to a metabolic disturbance (for example, [DIAGNOSES REDACTED] .) 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Neurologic assessment c. Change in level of consciousness; d. Any [MEDICAL CONDITION] activity in detail (location, duration, severity, recurrence, etc.); Review of facility policy, Charting and Documentation dated (MONTH) (YEAR), included the following, in part: All services provided to the resident, progress towart the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective .complete and accurate. It was determined these failures placed Resident #134 in an Immediate Jeopardy situation from 08/05/19 through 08/07/19. The facility took the following actions to correct the non-compliance on 08/08/19: - Suspended LVN (D) responsible for care of this resident pending investigation with intent to terminate after investigation. During interview the LVN (D) resigned effective immediately. Refer employee file to Legal counsel and CNO for licensure referral of LVN (D). - Inservices were conducted on the following policies: 1. admission orders [REDACTED] 2. Medication Errors 3. Abuse and Neglect Prevention 4. Change of condition 5. Notification of MD on change 6. [MEDICAL CONDITION] activity 7. Documentation on accuracy 8. Documentation on dating/timing entry 9. Assessment after episode of Low Blood Sugar readings 10. Hypoglycemic Policy and Procedure - Reviewed past 90 days admission orders [REDACTED] - Generated Medication Error Reports - Reviewed all Medication errors past 90 days - Reviewed past 90 days of glucometer readings on all diabetic residents - Assessed all residents for change of condition - Reviewed resident with [MEDICAL CONDITION] medication or history of [MEDICAL CONDITION] - Reviewed lab on all diabetic residents - Reviewed glucometer machine calibration - Competency check on admitting a resident on license staff - Out of Cycle QAPI - Monitor: Competencies on licensed nurse on admissions. DON/designee will review each admission within 24 hours of admission to ensure accuracy. 24 hour report daily review for significant change Complete rounds alternating every 2 hours Review glucometer readings daily before noon. Interviews from 08/08/19 - 08/15/19 with 8 LVNs and 1 RN on 3 shifts revealed they understood the policies and procedures for admissions/readmissions, medication reconciliation, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation, and abuse/neglect. Review of the records for 20 other diabetic residents revealed no additional concerns.

Based on interview and record review, the facility failed to provide treatment and care based on the comprehensive assessment, in accordance with professional standards for 1 of 20 residents (Resident #134) reviewed for quality of care. a) The facility failed to review and correctly transcribe Resident #134's medication orders to the MAR following readmission from the hospital for [DIAGNOSES REDACTED] on 08/05/19. The facility administered Humalog insulin 9 units, instead of 4 units on 08/05/19 at 8:00 PM, and Actos 45 mg, and [MEDICATION NAME]/[MEDICATION NAME] 5-500 mg on 08/06/19 at 8:00 AM, which had been discontinued. (These medications all lower blood sugar.) Resident #134 developed severe [DIAGNOSES REDACTED] and [MEDICAL CONDITION] activity requiring re-hospitalization in ICU. b) The facility failed to closely monitor the resident's condition including blood sugar levels during the night shift on 08/07/19 and failed to communicate to the physician when Resident #134 experienced [MEDICAL CONDITION] activity with low blood sugar levels. An Immediate Jeopardy was identified on 08/10/19. It was determined to be past non-compliance immediate jeopardy from 08/05/19 to 08/08/19 due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. These failures could place residents at risk of not receiving the correct medications, assessments, interventions, not having their medical needs met, and hospitalization , and death. Findings included: Review of Resident #134's undated Face Sheet indicated he was [AGE] years old and was most recently admitted to the facility on [DATE]. He was originally admitted on [DATE] and was hospitalized from [DATE] - 08/05 19. [DIAGNOSES REDACTED]. Review of Resident #134's MDS assessment dated [DATE] indicated he was usually able to make himself understood and understand others. He scored 11 on the BIMS, indicating he had moderately impaired cognition. He required extensive assistance of one person for bed mobility, transfers, locomotion on unit, dressing, hygiene and bathing. He utilized a wheelchair. Review of Resident #134's care plan dated 07/02/19, included the problem of diabetes. The goal was for no complications. Approaches included FSBS checked daily, medications as ordered, and observe for s/s of hypo/[MEDICAL CONDITION]. Review of the hospital Patient Discharge Summary Report dated 08/05/19 at 3:08 PM indicated Resident #134 had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. The discharge medication orders included the following: New Medications to Start Taking: Humalog 100 units/ml - Take sq before meals and at bedtime .sliding scale .for blood sugar from 260 to 299, give 4 units (Insulin that lowers blood sugar) Oral [MEDICATION NAME] 125mg/2.5 ml 1 syringe - Take orally 125 mg four times a day (antibiotic to treat [MEDICAL CONDITION] infection) Medications to Stop Taking: Actos 45 mg orally daily (lowers blood sugar) [MEDICATION NAME] 5 mg orally daily (lowers blood sugar) Review of the facility MAR beginning 08/05/19 for Resident #134 included the following: **Humalog 9 units given on 08/05/19 at 8:00 PM for blood sugar of 272 (incorrect dose administered) **[MEDICATION NAME] was not given. Per nurse's note dated 08/06/19 on 10p - 6a shift oral [MEDICATION NAME] was received from pharmacy **Actos 45 mg given on 08/06/19 at 8:00 AM (had been discontinued) **[MEDICATION NAME]/[MEDICATION NAME] 5-500 mg given on 08/06/19 at 8:00 AM (combination of two drugs that lowers blood sugar) (had been discontinued) Review of nurses notes included the following: 08/06/19 2pm-10pm Skilled services cont. Contact isolation precautions for [MEDICAL CONDITION]. Accu check - 60 at 8pm. Health shake and sandwich given. Recheck @ 9:30 pm accucheck 75. Health shake and Dr.Pepper given. Recheck @ 10:30 85. Dr. Pepper given. (unsigned by LVN I) 08/06/19 10pm-6am (No times documented) Remains SNF for [MEDICAL CONDITION]. Accucheck has been going down to 37 (blood glucose). Called Dr. _. Got order for [MEDICATION NAME] 1 mg IM. Gave and went to 94 (blood glucose) at this time. Will continue to monitor. (Signed by LVN D) Received oral [MEDICATION NAME] from pharmacy. (Initialed by LVN D) There was no documentation of continued monitoring of the resident's blood glucose level by LVN D. There was no documentation of the resident's reported [MEDICAL CONDITION] activity (which may occur in relation to [DIAGNOSES REDACTED]), no documentation of assessment of vital signs, neurologic status, level of consciousness, or details of the [MEDICAL CONDITION] activity as specified in the facility's policy, [MEDICAL CONDITION] and [MEDICAL CONDITION]. 08/07/19 5:30 AM Resident (#134) is lethargic - Large BM tarry dark. He is able to open eyes on request. Respirations 20 labored. Bathed, incontinent care with PPE - isolation for [MEDICAL CONDITION]. Crash cart @ door if needed. 911 per staff nurse. RN stayed with (Resident #134) awaiting EMS for transport. EMS with PPE, report per staff nurse. Full Code status - face sheet and orders sent with EMS. (signed by RN E) Review of the Provider Investigation Report dated 08/07/19 included the following; Report Details: Resident (#134) arrived back from hospital on [DATE] during the 2pm-10pm shift. Admitting nurse (LVN C) failed to check physician's orders [REDACTED]. ADON (B) printed MARs from H&P that listed home medications (not current discharge orders). Due to this oversight, medications were left on the MAR and given by AM (6-2 shift) nurse (on 08/06/19). These included two anti-hyper glycemic medications. On 08/06/19, 2-10 nurse charted hypoglycemic episodes with resident. Nurse treated with oral intake and remonitored blood glucose. Resident's blood sugar at 2230 (10:30 PM) was documented as 85 and oral intake was given and report provided to 10pm-6am nurse. The 10pm-6am nurse charted blood sugar down to 37 (time undocumented) and Dr. called. At that time, order received for [MEDICATION NAME] 1mg IM. Med administered as ordered. 10pm-6am nurse notified ADON (B) at approximately 0515 (5:15 AM) that resident was hypoglycemic and had two [MEDICAL CONDITION]. ADON (B) arrived to the facility shortly thereafter and met RN (E) who had already arrived and assessed resident and was in process of arranging transportation to ER. Resident was transported via ambulance to hospital and is presently in ICU. In an interview with the DON on 08/08/19 at 4:30 PM she said ADON B put in orders for Resident #134's readmission on 08/05/19 based on the hospital H&P (which listed nursing home medications). The DON said that on 08/05/19 the 2pm-10pm nurse (LVN C) got the hospital discharge packet when Resident #134 arrived back from the hospital, but did not review the discharge orders. She said that Actos and Glypizide/[MEDICATION NAME] were given the morning of 08/06/19, but should not have been given as they were discontinued on the discharge orders. She said Resident #134 was basically getting all the same medications as he was before he went to the hospital. The DON said the nurses have been inserviced on admissions/re-admissions, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation and abuse/neglect. In an interview with ADON B on 08/09/19 at 11:40 AM she said when she was notified that Resident t#134 was returning from the hospital on [DATE] she printed new MARs following the nursing home medication list. She said she told the 2pm-10pm nurse (LVN C) to be sure to compare the MARs with orders in the hospital packet when Resident #134 returns to the facility. ADON B said Resident #134 returned to the facility around 3:30 PM and had the hospital discharge packet with him. She said that what was in the packet was not transcribed to the MARs. She said a bunch of meds were highlighted in red to stop. ADON B said they have changed the procedure for when a resident is readmitted to the facility. She said they are not printing MARs based on home medications anymore. In an interview with LVN C on 08/09/19 at 12:05 PM she said the norm was for an ADON to put in the orders for new or readmitted residents. She said ADON B did that when Resident #134 was coming back from the hospital. She said Resident #134 came back with a packet from the hospital. LVN C said, I did not check the orders, and that's on me. She said that on Monday (08/05/19) they told us (charge nurses) we would be doing our own admission orders [REDACTED]. LVN C said she has been employed at the facility for two months. She said since ADON B did the MARs the day Resident #134 (08/05/12) was returning, she did not think charge nurses were doing their own admissions yet. In an interview with the DON on 08/09/19 at 5:00 PM she said that LVN D told her that CNA G reported that Resident #134 was acting weird and she (LVN D) checked his blood sugar. The DON said that LVN D's story changed between interviews about what times the [MEDICAL CONDITION] occurred, and LVN D did not document any of these events. The DON said that Resident #134's physician said he received a call at approximately 2:00 AM regarding the [DIAGNOSES REDACTED], but he wasn't told anything about [MEDICAL CONDITION]. The DON said that LVN D called ADON F on 08/06/19 at approximately 5:15 AM regarding Resident #134's low blood sugar and [MEDICAL CONDITION]. RN [NAME] arrived as usual at 5:30 AM (before ADON F) and assessed the resident and immediately arranged for him to be transported to the ER by EMS. The DON said her expectation is for nurses to completely document all symptoms and care given. She said LVN D was suspended 08/07/19, but she resigned immediately. ADON B and LVN C were both given written warnings on 08/08/19. In an interview with CNA G on 08/10/19 at 11:20 AM she said she had just gotten back from break at approximately 2am and there were two nurses in Resident #134's room. They told me he had just had a [MEDICAL CONDITION] and they had given him a shot. CNA G said she passed by his room around 4am and he was shaking and I hollered for the nurses. After he stopped having the [MEDICAL CONDITION] they gave him some sugar stuff. He had a large, loose bowel movement that was real dark. He was gurgling and I didn't want to put his head down because I was afraid he would choke. He was sitting up at about a 45° angle. Me and LVN D were trying to clean him up but he was sitting up and gurgling. RN [NAME] came in and helped me clean him up and an ambulance came and took him to the hospital. In a telephone interview with LVN D on 08/10/19 at 11:40 AM she said she came on at 9:45 PM (08/06/19) for her 10p-6am shift. She said she got report and the nurse (LVN I) that had (Resident #134) said 'I have a low blood sugar' and went to his room. Medications were delivered from the pharmacy. LVN I said she gave Resident #134 a health shake .she said she was going to take care of him while she was there doing charting. She rechecked his blood sugar and it was up to 80. She (LVN I) was there until 12:00 or 12:30 AM. LVN D said she gave some prn meds to other residents and Resident #134 was sleeping. LVN D said, I had a funny feeling, it was a little before 2:00 AM, and checked Resident #134's blood sugar and it was 27! He was still alert and talking! I called the doctor and he ordered [MEDICATION NAME]. It looked like he was having a [MEDICAL CONDITION] and I gave it ([MEDICATION NAME] injection) and he came out of it. I looked at his chart and saw he had a history of [REDACTED].#134's blood sugar about an hour later and it was 94. She said he went to sleep and looked normal. LVN D said she went back to the nurses desk and did a little bit of charting and gave more prn medications. LVN D said she looked in on Resident #134 frequently and he looked normal. Around 4:30 AM CNA G was doing rounds and hollered for me. I went to his room and he had another [MEDICAL CONDITION]. His blood sugar was in the low 30's. I tried to give him oral glucose but he couldn't swallow. He said he felt bloated and he had a history of [REDACTED]. I still had to do early morning meds, blood sugars, etc. I stayed until around 7:30 AM. My back was hurting so bad! When I got halfway home I started thinking, Did I chart?, did I chart? I thought surely I did, I always do. In a telephone interview with LVN I on 08/10/19 at 12:55 PM she said she stayed late (on 08/06/19) after a double shift. She said that around 8:00 PM Resident #134's blood sugar was 60. She said this was her first time to care for him. She said he told her he felt bad. She said she got him a health shake and a 1/2 sandwich. She said she rechecked his blood sugar and it was still low so she gave him another health shake and a DR. Pepper. She said he told her her he felt better, but his blood sugar was still on the low side. She said when she gave report to the oncoming 10pm - 6am shift she told them everything she had given him to raise his blood sugar. In an interview with the DON on 08/09/19 at 4:15 PM she said that she has only been with the facility since 08/05/19 and has not yet had the time/opportunity to review all of the clinical systems. She said that since this incident occurred with Resident #134 they are not generating MARs without current orders any longer. But, she said, even if a MAR was done prematurely, the charge nurse should have reviewed and compared the hospital discharge orders with the MAR and made any/all changes to reflect the current orders. Review of facility policy, Reconciliation of Medications on admitted d (MONTH) (YEAR), included the following, in part: General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications .for the purpose of preventing unintended changes or omissions at transition points of care. Steps in Procedure: 3. Using an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). 5. Review the list carefully to determine if there are discrepancies/conflicts. For example; a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; 6. If there is a discrepancy or conflict in medications, dose, route, or frequency, determine the most appropriate action to resolve the discrepancy. For example: b. Contact the physician from the referring facility; d. Contact the resident's primary physician in the community; g. Contact the admitting and/or Attending Physician. Review of facility policy, Nursing Care of the Resident with Diabetes Mellitus dated (MONTH) 2019, included the following, in part: Glucose Monitoring 5. Finger sticks (capillary blood samples) measure current blood glucose levels. b. Normal ranges are defined as 80-130 mg/dL before meals and <180 mg/dL after meals. 6. Approximate reference ranges for [DIAGNOSES REDACTED] are: a. Mild [DIAGNOSES REDACTED] 55-70 mg/dL; b. Moderate [DIAGNOSES REDACTED] 40-55 mg/dL; and c. Severe [DIAGNOSES REDACTED] <40 mg/dL. Management of [DIAGNOSES REDACTED] 3. For symptomatic (lethargic, drowsy) but responsive (conscious) residents with [DIAGNOSES REDACTED] (<70 mg/dL .) a. If he/she is able to swallow: (1) Immediately give the resident an oral form of rapidly absorbed glucose (4 oz juice or 5-6 ounces of soda); (2) Recheck blood glucose in 15 minutes; and (3) Repeat juice if indicated recheck blood glucose in 15 minutes. b. If he/she is unable to swallow: (1) Immediately administer oral glucose paste to the [MEDICATION NAME] mucosa, intramuscular [MEDICATION NAME], or IV 50% [MEDICATION NAME], per facility protocol; (2) Recheck blood glucose in 15 minutes; and (3) Repeat protocol if indicated and recheck blood glucose in 15 minutes. Review of facility policy, [MEDICAL CONDITION] and [MEDICAL CONDITION] - Clinical Protocol dated (MONTH) 2012, included the following, in part: Assessment and Recognition 1. b. Acute [MEDICAL CONDITION] may occur in relation to a metabolic disturbance (for example, [DIAGNOSES REDACTED] .) 2. In addition, the nurse shall assess and document/report the following: a. Vital signs; b. Neurologic assessment c. Change in level of consciousness; d. Any [MEDICAL CONDITION] activity in detail (location, duration, severity, recurrence, etc.); Review of facility policy, Charting and Documentation dated (MONTH) (YEAR), included the following, in part: All services provided to the resident, progress towart the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 3. Documentation in the medical record will be objective .complete and accurate. It was determined these failures placed Resident #134 in an Immediate Jeopardy situation from 08/05/19 through 08/07/19. The facility took the following actions to correct the non-compliance on 08/08/19: - Suspended LVN (D) responsible for care of this resident pending investigation with intent to terminate after investigation. During interview the LVN (D) resigned effective immediately. Refer employee file to Legal counsel and CNO for licensure referral of LVN (D). - Inservices were conducted on the following policies: 1. admission orders [REDACTED] 2. Medication Errors 3. Abuse and Neglect Prevention 4. Change of condition 5. Notification of MD on change 6. [MEDICAL CONDITION] activity 7. Documentation on accuracy 8. Documentation on dating/timing entry 9. Assessment after episode of Low Blood Sugar readings 10. Hypoglycemic Policy and Procedure - Reviewed past 90 days admission orders [REDACTED] - Generated Medication Error Reports - Reviewed all Medication errors past 90 days - Reviewed past 90 days of glucometer readings on all diabetic residents - Assessed all residents for change of condition - Reviewed resident with [MEDICAL CONDITION] medication or history of [MEDICAL CONDITION] - Reviewed lab on all diabetic residents - Reviewed glucometer machine calibration - Competency check on admitting a resident on license staff - Out of Cycle QAPI - Monitor: Competencies on licensed nurse on admissions. DON/designee will review each admission within 24 hours of admission to ensure accuracy. 24 hour report daily review for significant change Complete rounds alternating every 2 hours Review glucometer readings daily before noon. Interviews from 08/08/19 - 08/15/19 with 8 LVNs and 1 RN on 3 shifts revealed they understood the policies and procedures for admissions/readmissions, medication reconciliation, change of condition, [MEDICAL CONDITION], hypo/[MEDICAL CONDITION], medication errors, documentation, and abuse/neglect. Review of the records for 20 other diabetic residents revealed no additional concerns.

Based on interview and record review, the facility failed to ensure that Resident #1 received treatment and care in accordance with professional standards of practice for one (Resident #1) of three residents reviewed quality of care. The facility did not initiate CPR for Resident #1 when he was found unresponsive, with no respirations and no pulse. Resident #1 was a full code. Resident #1 was pronounced dead in the facility by RN A at 8:17 AM on [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure affected one resident who died on [DATE] and could place 49 residents who were documented as requesting full code status at risk of not being provided resuscitation, which could lead to death. Findings include: Review of Resident #1's undated Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] indicated he had moderate cognitive impairment. He was occasionally incontinent of urine and frequently incontinent of bowel. He required limited assistance of one person for ADLs. Review of Resident #1's Physician order [REDACTED].>Review of Resident #1's Baseline Care Plan dated [DATE] indicated his goal was to discharge to the community. Review of a nurse's note dated [DATE] at 10:59 A.M., by RN A, included the following: Skilled nursing svcs (services), DX: acute kidney failure, diabetes, [MEDICAL CONDITION]. @ 06:15 went to Room B7 to check blood sugar level. The blood sugar was 157 and 6 units Humalog were given to abdomen. Resident was conversant and remained lying down during entire procedure. I left the room and continued on with my blood sugar checks. At 8:15 the aides were summoning me to B7 because Resident appeared to have passed. I assessed with [REDACTED]. I determined deceased at 8:17. I notified resident physician and family at 8:30 and notified staff of the deceased . Review of nurse's note dated [DATE] at 15:10 (3:10 PM), by RN A, included the following: Addendum to [DATE]; 10:59 entry. When I was assessing resident (#1) for signs of life I noted that the resident was unresponsive with cold fingers. His face was very blue. Eyes were fixated with no response to light. I listened with stethoscope to all lung and heart regions with no response. I checked for pulses in the carotid arteries as well as brachial pulses. No pulses and no respiration. Exterior distal extremities were cold to touch and very pale. I noted cyanosis in the abdominal region. Resident was lying on the left side with face turned to left. There were no emissions of bodily fluids from mouth or bowels. No odor was present. The left side was darkened by blood pooling. Review of the Provider Investigation Report dated [DATE] included the following Investigation Summary: The Administrator conducted the investigation through review of the Texas Board of Nursing statements/statutes, medical records and staff interviews. At 0615 on [DATE] (RN A) entered (Resident #1's) room to conduct a blood sugar check and administer insulin prior to his meal. (Resident #1) was awake and responsive to (RN A's) conversation. Between 0715 and 0730, (CNA B) took (Resident #1) his breakfast tray and appeared to be sleeping. (Resident #1 did not respond to (CNA B's) good morning. At between 0800 - 0815, (CNA B) went back to pick up the tray and (Resident #1) had not touched his food. (CNA B) attempted to arouse (Resident #1) and got no response. At that point, (CNA B) felt for a pulse and did not feel one. She caught another CNA in the hallway and had them go get (RN A). At 0815 (RN A) came into the room and attempted to arouse (Resident #1). He was still unresponsive so (RN A) performed a sternum rub and (Resident #1) was still unresponsive. (RN A) then assessed (Resident #1) for pulse, respirations and eye dilitations (sp). None were present. (RN A) noted (Resident #1's) face was blue and extremities were cold to the touch. (RN A) pronounced his death at 0817 and notified the attending physician and family around 0830. The Administrator finds this unconfirmed for neglect due to the RN [MEDICATION NAME] within his scope of practice according to the TBON. In an interview on [DATE] at 9:40 AM with the DON, she said the corporation added the BON statement on the RN Role in Withholding CPR . after the incident. (the previous Medical Director) signed it on [DATE]. We can follow the BON, we just added it to the policy to make it clear . In an interview with RN A on [DATE] at 10:10 AM he said he checked Resident #1's blood sugar at 6:10 AM, with a result of 157. He gave the resident 6 units of Humalog insulin (5 units ordered 3 times daily and 1 unit per sliding scale for blood sugar of 150 - 175). RN A said Resident #1 kind of came awake while he was checking his blood sugar and administering insulin. Afterwards, RN A said he went to the next hall to continue his rounds with other residents. RN A said that approximately 8:15 AM CNA B came to get him to come to Resident #1's room. He said the resident's face was blue, there was pooling in his abdomen, he was laying on his left side and the left side of his abdomen was kind of purplish. He said his eyes were glassy and his fingers were cold. He had no pulse or respirations. He said there was evidence of cyanosis, his face was real blue. RN A was unable to describe Resident #1's extremities looked like. He said, I didn't take his clothes off. RN A said he wrote the addendum nurse's note after he talked to the facility administrator and was told he needed more documentation, nothing specific, just more complete documentation. In an interview with the facility administrator he said they had a conference call with the RNC after Resident #1 death. He said the RNC had questions that were not in RN A's original nurse's note. He said he had RN A do the addendum to include the information he told us on the conference call. In a telephone interview with CNA B on [DATE] at 10:30 AM she said the day Resident #1 died was her second day of orientation. She said that she and the other CNAs were passing out breakfast trays on the halls. She said she was told that Resident #1 would eat when he wakes up, and to just leave his tray for him. She said when she came back after breakfast, she told him she was going to take his tray, and he didn't respond. She said he was lying on his back and she noticed his hands were cold. She checked for a pulse and saw he wasn't breathing. She said she didn't notice any skin discoloration, he looked the same to her. She said CNA D was picking up trays across the hall and she called her to Resident #1's room. She walked in and asked if he was okay, then went to get a nurse. LVN C came to the room and told CNA B to go get RN A. In a telephone interview with LVN C on [DATE] at 10:43 AM she said One of the girls down the hall said they needed help. RN A was down another hall. I called out to him and we went to Resident #1's room. He was unresponsive. RN A shook his arm. He wasn't breathing. He was on his back with a pillow under his head. His tray was there, and it looked like he had eaten and gone back to sleep. The cover was off the tray with food eaten. LVN C said she had never seen Resident #1 before as she works other halls. LVN C could not describe the appearance of Resident #1's face. In a telephone interview with CNA D on [DATE] at 11:15 AM she works part time. On the day Resident #1 died she said she worked 8:00 AM - 2:00 PM. She said they (the CNA's) were picking up breakfast trays. Resident #1's room was on the right side of the hall and she was picking up trays on the left side of the hall. CNA B came out of his room and told me to get a nurse. I got (LVN C) from the rotunda. She came and checked Resident #1 and said to go get RN A. He came and checked (the resident). Me and (CNA B) left with his tray. She said nothing on his breakfast tray was touched. She said he would usually sit in the recliner for his meals. When I checked his pulse, he was cold. I turned off the air conditioner. He was down in the bed. He looked like he was asleep with lots of blankets and the AC on cold. That's how he liked it. He was uncovered to the chest and his left arm was out. He was on his back. His skin on his arm was kind of purple red. His face was flushed, his cheeks purplish red. His mouth was open, and his eyes were closed with tears puddled in the corners. RN A was in a lot of shock. We (the CNAs) left the room and LVN C was behind us I think. She said that neither of the nurses told them to call 911. In an interview with RN A on [DATE] at 11:57 AM he said he knew that Resident #1 was a full code when he was found unresponsive. He said he decided not to do CPR because it had been too long. He said Resident #1 had a 4-inch diameter area of pooling on his left abdomen. He said he did not turn the resident to further assess for lividity. In a telephone interview with RN A on [DATE] at 3:44 PM he said he did not initiate CPR for Resident #1 because too much time had passed, he hadn't touched his breakfast. He said he did not know specifically what the facility policy was at the time regarding CPR. He said there was an in-service the following day or so regarding what to do when a resident is found unresponsive: Call 911 and get the firemen; start CPR; let the paramedics make the call. He said he thought the facility had held mock codes in the past, but he had not attended. He said, All of us were supposed to have CPR certification. Review of licensed nursing staff personnel files revealed 14 out of 20 nurses, including the DON, did not have current CPR certifications at the time of Resident #1's death. RN A's CPR certification expired (MONTH) (YEAR). LVN C's CPR certification was current, expiring (MONTH) 2019. In an interview with RN A on [DATE] at 11:10 AM, (with the DON in attendance at RN A's request) in Resident #1's previous room, RN A demonstrated how the resident was lying on the bed and described the events of the morning of [DATE]: The bed was against the wall with the right side of the bed next to the window AC unit. RN A said that Resident #1 was usually groggy in the mornings. He said a CNA delivered his breakfast at approximately 7:30 AM. He said that he was on C hall at approximately 8:15 AM when CNA B came to get him to go to Resident #1's room. The resident was lying on his left side. His face was very blue. RN A said he went to the nurses' desk to get his stethoscope. When he returned he did a sternal rub on Resident #1 without response. He checked the resident's eyes with a penlight and there was no pupil reaction. He said the felt the resident's fingers and they were cold. He said he was covered from waist down with blankets. He had a shirt on. He said there was an approximately 4-inch circumference discoloration on his left abdomen. He said that after his assessment of the resident he returned to the nurses' station and called the resident's doctor and his family regarding his death. He then told the Interim DON and the ADON. The Administrator, DON and RNC were notified of the Immediate Jeopardy situation on [DATE] at 3:55 PM. In a telephone interview on [DATE] at 11:10 AM with the facility Medical Director who was also Resident #1's primary physician, he said he did not remember exactly what RN A had said when he called him and reported Resident #1's death at the facility, as he did not have immediate access to his records. He was notified of the Immediate Jeopardy situation. He said that for a resident who was a full code he would expect the nursing staff to start CPR and call 911. He said he was not aware until now of the circumstances of Resident#1's death. Review of the facility's Code Status System, revised [DATE], included the following, in part: Green alerts (located in the front of the clinical record) indicate the resident's desire to have CPR and every attempt to provide all heroic measures must be recognized. Review of www.bon.texas.gov/practice_wposition_statements_content.asp#15.20 accessed [DATE], include the following, in part: approved by the Board of Nursing (MONTH) 24, 2002, and last revised ,[DATE], included the following, in part: 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility The Texas Board of Nursing (BON) has approved this position statement, only applicable to long term care settings, in an effort to provide guidance to registered nurse in long-term care facilities and to clarify issues of [MEDICATION NAME] end-of-life care . Assessment of death in which CPR would be a futile and inappropriate intervention requires that all seven of the following signs be present and that the arrest is unwitnessed: Presumptive Signs of Death 1. The resident is unresponsive; 2. The resident has no respirations; 3. The resident has no pulse; 4. Resident's pupils are fixed and dilated; 5. The resident's body temperature indicates hypothermia: skin is cold relative to the resident's baseline skin temperature; 6. The resident has generalized cyanosis; and Conclusive Sign of Death 7. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). RN Role in Withholding CPR With an Unwitnessed Arrest Pronouncement of Death There may be a time when initiating CPR is not [MEDICATION NAME] or is futile. The Texas Board of Nursing has provided the following position statement for an unwitnessed arrest AND pronouncing death: Unwitnessed Arrest In the case of an unwitnessed resident arrest without DNR orders, determination of the appropriateness of CPR initiation should be undertaken by the registered nurse through a resident assessment, and interventions appropriate to the findings initiated. Assessment of death in which CPR would be a futile and inappropriate intervention requires that all seven of the following signs be present and that the arrest is unwitnessed. Presumptive Signs of Death 8. The resident is unresponsive, 9. The resident has no respirations, 10. The resident has no pulse, a. Resident's pupils are fixed and dilated. 11. The resident's body temperature indicates hypothermia: skin is cold relative to the resident's baseline skin temperature' 12. The resident has generalized cyanosis, and Conclusive Sign of Death 13. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). Documentation After assessment of the resident is completed and appropriate interventions taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. The rules of the BON establish legal documentation standards (BON Standards of Nursing Practice, 22 TAC § Rule 217.1 (1)(D)). Examples of important documentation elements include: Description of discovery of the resident Any treatment of [REDACTED]. The findings of each of the assessment elements outlined in the standards All individuals notified of the resident's status (e.g., [DATE], the health care provider, the administrator of the facility, family, coroner, etc. Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED].> The results of any communications Presence or absence of witnesses Documentation should be adequate to give a clear picture of the situation and all the actions that were taken or not taken on behalf of the resident. Even if the nurse's decision not to initiate CPR was appropriate, failure to document can result in an action against a nurse's license by the BON. Furthermore, lack of documentation places the nurse at a disadvantage should the nurse be required to explain the circumstances of the resident's death. Registered nurses should be aware that actions documented at the time of death provide a much more credible and accurate clinical description. Documentation that is absent, incomplete or inaccurate reveals gaps in care, requiring the nurse to prove actions not appropriately documented were actually taken . RN Role in Pronouncement of Death Texas law provides for RN pronouncement of death (Health & Safety Code §§ 671.001 - .002). The law requires that for a nurse to pronounce death, the facility must have a written policy which is jointly developed and approved by the medical staff or medical consultant and the nursing staff, specifying under what circumstances a RN can make a pronouncement of death. It is important that nurses understand that the assessment that death has occurred and that CPR is not an appropriate intervention are not the equivalent to the pronouncement of death, Texas statutory law governs who can pronounce death, and only someone legally authorized to pronounce death may do so. If the RN does not have the authority to pronounce death, upon assessment of death the RN must notify a person legally authorized to pronounce death. Qualifier to Position The BON evaluates failure to initiate CPR cases based on the premise that in the absence of a physician's DNR order it is generally outside the standard of nursing practice not to initiate CPR. Consequently, RNs deciding not to initiate CPR when not all seven signs of death are present, must assure themselves that not initiating CPR complies with their respective standards of practice. Depending on the circumstances, a nurse's failure to initiate CPR when not all seven signs are present may constitute failure to comply with the standards of nursing care. This position statement is limited to situations when all seven signs are present and should not be construed as providing guidance on the appropriateness of not initiating CPR when not all seven signs are present. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE]. The plan included the following: 1. CPR, Assessment, Neglect a. DON/designee inserviced licensed nurses on the revised facility CPR policy, including honoring resident wishes and the RN's responsibility according to the BON scope of practice. RN involved in the event and licensed nurses were inserviced on the CPR policy in place during the event by regional nurse and ADON on the date of occurrence [DATE] through [DATE] and again on the revised CPR policy on [DATE] by the regional nurse. No licensed nurse will work prior to receiving inservices from this point forward. Inservicing to be complete by 2PM [DATE]. b. DON/designee inserviced licensed nurses on change in condition, notification and detailed documentation of assessment/evaluation findings. No licensed nurse will work prior to receiving inservices from this point forward. Inservices to be complete by 2PM [DATE]. c. CPR classes were held (MONTH) 2, (YEAR), by American Heart Association. Additional online classes were also completed. All licensed nurses have current CPR certifications. The Business Office Manager will monitor the expiration dates on a monthly basis and notify the DON on upcoming expirations. d. DON/designee provided abuse/neglect inservice to licensed facility staff on [DATE]. No licensed nurse will work prior to receiving inservices. Completed by 2PM [DATE]. e. Licensed nurses will complete a post test on inservice information to monitor effectiveness of training and staff comprehension and will be completed by [DATE]. f. New hires and Agency staff will receive the inservices prior to working their shift from this point forward. PRN staff who choose not to come in for inservices will be terminated and removed from the system. Staff who are on vacation and cannot be reached will not return to work until they receive the education. g. Admin/DON/Medical Director reviewed and revised CPR policy to include withholding CPR on [DATE] and was signed by the Medical Director on [DATE]. h. DON/designee will review code status changes during clinical start up meeting and present any identified trends to QAPI monthly for 3 months for additional analysis and recommendations. i. DON/designee conducted Mock Code Blue drills on [DATE] and [DATE] and will continue to be completed monthly on alternating shifts for three months. Next one is scheduled for [DATE]. j. Administrator will review clinical start-up checklist weekly for 3 months, ending [DATE]. Verification of the Plan of removal was conducted [DATE] and [DATE]. Four licensed nurses were interviewed on [DATE] and [DATE]. All four verbalized the steps to follow for an unresponsive full code resident: Yell for help, direct someone to call 911, direct someone to get crash cart and call the code; in the meantime, prepare to do CPR, do not leave the resident, and do not stop CPR until EMS takes over or doctor orders to stop. Review of the Advance Directives and Code Status Report dated [DATE] listed 49 resident as Full Code.

Based on interview, and record review, the facility failed to have evidence that all allegations of neglect were thoroughly investigated and preventative interventions were implemented to prevent further neglect from occurring for 1 of 3 residents reviewed for neglect. (Resident #1). The facility failed to: a) initiate CPR for Resident #1 when he was found unresponsive, with no respirations and no pulse. Resident #1 was a full code. Resident #1 was pronounced dead in the facility by RN A on [DATE] at 8:17 AM. b) ensure all licensed nursing staff were inserviced on resident neglect, code status, performing CPR, documentation, and c) ensure all licensed nursing staff had current CPR certification. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a level of actual harm with a scope of isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure affected one resident who died on [DATE] and could place 49 residents who were documented as requesting full code status at risk of not being provided resuscitation, which could lead to death. Findings include: Review of Resident #1's undated Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] indicated he had moderate cognitive impairment. He was occasionally incontinent of urine and frequently incontinent of bowel. He required limited assistance of one person for ADLs. Review of Resident #1's Physician order [REDACTED].>Review of Resident #1's Baseline Care Plan dated [DATE] indicated his goal was to discharge to the community. Review of a nurse's note dated [DATE] at 10:59 A.M., by RN A, included the following: Skilled nursing svcs (services), DX: acute kidney failure, diabetes, [MEDICAL CONDITION]. @ 06:15 went to Room B7 to check blood sugar level. The blood sugar was 157 and 6 units Humalog were given to abdomen. Resident was conversant and remained lying down during entire procedure. I left the room and continued on with my blood sugar checks. At 8:15 the aides were summoning me to B7 because Resident appeared to have passed. I assessed with [REDACTED]. I determined deceased at 8:17. I notified resident physician and family at 8:30 and notified staff of the deceased . Review of nurse's note dated [DATE] at 15:10 (3:10 PM), by RN A, included the following: Addendum to [DATE]; 10:59 AM entry. When I was assessing resident (#1) for signs of life I noted that the resident was unresponsive with cold fingers. His face was very blue. Eyes were fixated with no response to light. I listened with stethoscope to all lung and heart regions with no response. I checked for pulses in the carotid arteries as well as brachial pulses. No pulses and no respiration. Exterior distal extremities were cold to touch and very pale. I noted cyanosis in the abdominal region. Resident was lying on the left side with face turned to left. There were no emissions of bodily fluids from mouth or bowels. No odor was present. The left side was darkened by blood pooling. Review of the Provider Investigation Report dated [DATE] included the following Investigation Summary: The Administrator conducted the investigation through review of the Texas Board of Nursing statements/statutes, medical records and staff interviews. At 0615 on [DATE] (RN A) entered (Resident #1's) room to conduct a blood sugar check and administer insulin prior to his meal. (Resident #1) was awake and responsive to (RN A's) conversation. Between 0715 and 0730, (CNA B) took (Resident #1) his breakfast tray and appeared to be sleeping. (Resident #1 did not respond to (CNA B's) good morning. At between 0800 - 0815, (CNA B) went back to pick up the tray and (Resident #1) had not touched his food. (CNA B) attempted to arouse (Resident #1) and got no response. At that point, (CNA B) felt for a pulse and did not feel one. She caught another CNA in the hallway and had them go get (RN A). At 0815 (RN A) came into the room and attempted to arouse (Resident #1). He was still unresponsive so (RN A) performed a sternum rub and (Resident #1) was still unresponsive. (RN A) then assessed (Resident #1) for pulse, respirations and eye dilitations (sp). None were present. (RN A) noted (Resident #1's) face was blue and extremities were cold to the touch. (RN A) pronounced his death at 0817 and notified the attending physician and family around 0830. The Administrator finds this unconfirmed for neglect due to the RN [MEDICATION NAME] within his scope of practice according to the TBON. Review of the inservice records dated ,[DATE] and [DATE] indicated that 8 of 19 current licensed nursing staff had not received inservicing on resident neglect, code status, performing CPR, documentation. Review of licensed nursing staff personnel files revealed 14 out of 20 nurses, including the DON, did not have current CPR certifications at the time of Resident #1's death. RN A's CPR certification expired (MONTH) (YEAR). LVN C's CPR certification was current, expiring (MONTH) 2019. Further review of the personnel files revealed that all licensed nursing staff had current CPR certification at the time of this investigation, except the DON. Her certification expired (MONTH) (YEAR). In an interview on [DATE] at 9:40 AM with the DON, she said the corporation added the BON statement on the RN Role in Withholding CPR . after the incident. (the previous Medical Director) signed it on [DATE]. We can follow the BON, we just added it to the policy to make it clear. Regarding CPR certification, she said she just hasn't had time to do it yet, but will do so soon. Regarding the licensed nurses inservices, she said she thinks there is another sign-in page somewhere, but they cannot find it. She said she thought that all licensed nurses had received the inservice training. In an interview with RN A on [DATE] at 10:10 AM he said he checked Resident #1's blood sugar at 6:10 AM, with a result of 157. He gave the resident 6 units of Humalog insulin (5 units ordered 3 times daily and 1 unit per sliding scale for blood sugar of 150 - 175). RN A said Resident #1 kind of came awake while he was checking his blood sugar and administering insulin. Afterwards, RN A said he went to the next hall to continue his rounds with other residents. RN A said that approximately 8:15 AM CNA B came to get him to come to Resident #1's room. He said the resident's face was blue, there was pooling in his abdomen, he was laying on his left side and the left side of his abdomen was kind of purplish. He said his eyes were glassy and his fingers were cold. He had no pulse or respirations. He said there was evidence of cyanosis, his face was real blue. RN A was unable to describe Resident #1's extremities looked like. He said, I didn't take his clothes off. RN A said he wrote the addendum nurse's note after he talked to the facility administrator and was told he needed more documentation, nothing specific, just more complete documentation. In an interview with the facility administrator he said they had a conference call with the RNC after Resident #1 death. He said the RNC had questions that were not in RN A's original nurse's note. He said he had RN A do the addendum to include the information he told us on the conference call. In a telephone interview with CNA B on [DATE] at 10:30 AM she said the day Resident #1 died was her second day of orientation. She said that she and the other CNAs were passing out breakfast trays on the halls. She said she was told that Resident #1 would eat when he wakes up, and to just leave his tray for him. She said when she came back after breakfast, she told him she was going to take his tray, and he didn't respond. She said he was lying on his back and she noticed his hands were cold. She checked for a pulse and saw he wasn't breathing. She said she didn't notice any skin discoloration, he looked the same to her. She said CNA D was picking up trays across the hall and she called her to Resident #1's room. She walked in and asked if he was okay, then went to get a nurse. LVN C came to the room and told CNA B to go get RN A. In a telephone interview with LVN C on [DATE] at 10:43 AM she said One of the girls down the hall said they needed help. RN A was down another hall. I called out to him and we went to Resident #1's room. He was unresponsive. RN A shook his arm. He wasn't breathing. He was on his back with a pillow under his head. His tray was there, and it looked like he had eaten and gone back to sleep. The cover was off the tray with food eaten. LVN C said she had never seen Resident #1 before as she works other halls. LVN C could not describe the appearance of Resident #1's face. In a telephone interview with CNA D on [DATE] at 11:15 AM she works part time. On the day Resident #1 died she said she worked 8:00 AM - 2:00 PM. She said they (the CNA's) were picking up breakfast trays. Resident #1's room was on the right side of the hall and she was picking up trays on the left side of the hall. CNA B came out of his room and told me to get a nurse. I got (LVN C) from the rotunda. She came and checked Resident #1 and said to go get RN A. He came and checked (the resident). Me and (CNA B) left with his tray. She said nothing on his breakfast tray was touched. She said he would usually sit in the recliner for his meals. When I checked his pulse, he was cold. I turned off the air conditioner. He was down in the bed. He looked like he was asleep with lots of blankets and the AC on cold. That's how he liked it. He was uncovered to the chest and his left arm was out. He was on his back. His skin on his arm was kind of purple red. His face was flushed, his cheeks purplish red. His mouth was open, and his eyes were closed with tears puddled in the corners. RN A was in a lot of shock. We (the CNAs) left the room and LVN C was behind us I think. She said that neither of the nurses told them to call 911. In an interview with RN A on [DATE] at 11:57 AM he said he knew that Resident #1 was a full code when he was found unresponsive. He said he decided not to do CPR because it had been too long. He said Resident #1 had a 4-inch diameter area of pooling on his left abdomen. He said he did not turn the resident to further assess for lividity. In a telephone interview with RN A on [DATE] at 3:44 PM he said he did not initiate CPR for Resident #1 because too much time had passed, he hadn't touched his breakfast. He said he did not know specifically what the facility policy was at the time regarding CPR. He said there was an in-service the following day or so regarding what to do when a resident is found unresponsive: Call 911 and get the firemen; start CPR; let the paramedics make the call. He said he thought the facility had held mock codes in the past, but he had not attended. He said, All of us were supposed to have CPR certification. In an interview with RN A on [DATE] at 11:10 AM, (with the DON in attendance at RN A's request) in Resident #1's previous room, RN A demonstrated how the resident was lying on the bed and described the events of the morning of [DATE]: The bed was against the wall with the right side of the bed next to the window AC unit. RN A said that Resident #1 was usually groggy in the mornings. He said a CNA delivered his breakfast at approximately 7:30 AM. He said that he was on C hall at approximately 8:15 AM when CNA B came to get him to go to Resident #1's room. The resident was lying on his left side. His face was very blue. RN A said he went to the nurses' desk to get his stethoscope. When he returned he did a sternal rub on Resident #1 without response. He checked the resident's eyes with a penlight and there was no pupil reaction. He said the felt the resident's fingers and they were cold. He said he was covered from waist down with blankets. He had a shirt on. He said there was an approximately 4-inch circumference discoloration on his left abdomen. He said that after his assessment of the resident he returned to the nurses' station and called the resident's doctor and his family regarding his death. He then told the Interim DON and the ADON. The Administrator, DON and RNC were notified of the Immediate Jeopardy situation on [DATE] at 3:55 PM. In a telephone interview on [DATE] at 11:10 AM with the facility Medical Director who was also Resident #1's primary physician, he said he did not remember exactly what RN A had said when he called him and reported Resident #1's death at the facility, as he did not have immediate access to his records. He was notified of the Immediate Jeopardy situation. He said that for a resident who was a full code he would expect the nursing staff to start CPR and call 911. He said he was not aware, until now, of the circumstances of Resident#1's death. Review of the facility's Code Status System, revised [DATE], included the following, in part: Green alerts (located in the front of the clinical record) indicate the resident's desire to have CPR and every attempt to provide all heroic measures must be recognized. Review of www.bon.texas.gov/practice_wposition_statements_content.asp#15.20 accessed [DATE], include the following, in part: approved by the Board of Nursing (MONTH) 24, 2002, and last revised ,[DATE], included the following, in part: 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility The Texas Board of Nursing (BON) has approved this position statement, only applicable to long term care settings, in an effort to provide guidance to registered nurse in long-term care facilities and to clarify issues of [MEDICATION NAME] end-of-life care . Assessment of death in which CPR would be a futile and inappropriate intervention requires that all seven of the following signs be present and that the arrest is unwitnessed: Presumptive Signs of Death 1. The resident is unresponsive; 2. The resident has no respirations; 3. The resident has no pulse; 4. Resident's pupils are fixed and dilated; 5. The resident's body temperature indicates hypothermia: skin is cold relative to the resident's baseline skin temperature; 6. The resident has generalized cyanosis; and Conclusive Sign of Death 7. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). RN Role in Withholding CPR With an Unwitnessed Arrest Pronouncement of Death There may be a time when initiating CPR is not [MEDICATION NAME] or is futile. The Texas Board of Nursing has provided the following position statement for an unwitnessed arrest AND pronouncing death: Unwitnessed Arrest In the case of an unwitnessed resident arrest without DNR orders, determination of the appropriateness of CPR initiation should be undertaken by the registered nurse through a resident assessment, and interventions appropriate to the findings initiated. Assessment of death in which CPR would be a futile and inappropriate intervention requires that all seven of the following signs be present and that the arrest is unwitnessed. Presumptive Signs of Death 8. The resident is unresponsive, 9. The resident has no respirations, 10. The resident has no pulse, a. Resident's pupils are fixed and dilated. 11. The resident's body temperature indicates hypothermia: skin is cold relative to the resident's baseline skin temperature' 12. The resident has generalized cyanosis, and Conclusive Sign of Death 13. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). Documentation After assessment of the resident is completed and appropriate interventions taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. The rules of the BON establish legal documentation standards (BON Standards of Nursing Practice, 22 TAC § Rule 217.1 (1)(D)). Examples of important documentation elements include: Description of discovery of the resident Any treatment of [REDACTED]. The findings of each of the assessment elements outlined in the standards All individuals notified of the resident's status (e.g., [DATE], the health care provider, the administrator of the facility, family, coroner, etc. Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED].> The results of any communications Presence or absence of witnesses Documentation should be adequate to give a clear picture of the situation and all the actions that were taken or not taken on behalf of the resident. Even if the nurse's decision not to initiate CPR was appropriate, failure to document can result in an action against a nurse's license by the BON. Furthermore, lack of documentation places the nurse at a disadvantage should the nurse be required to explain the circumstances of the resident's death. Registered nurses should be aware that actions documented at the time of death provide a much more credible and accurate clinical description. Documentation that is absent, incomplete or inaccurate reveals gaps in care, requiring the nurse to prove actions not appropriately documented were actually taken . RN Role in Pronouncement of Death Texas law provides for RN pronouncement of death (Health & Safety Code §§ 671.001 - .002). The law requires that for a nurse to pronounce death, the facility must have a written policy which is jointly developed and approved by the medical staff or medical consultant and the nursing staff, specifying under what circumstances a RN can make a pronouncement of death. It is important that nurses understand that the assessment that death has occurred and that CPR is not an appropriate intervention are not the equivalent to the pronouncement of death, Texas statutory law governs who can pronounce death, and only someone legally authorized to pronounce death may do so. If the RN does not have the authority to pronounce death, upon assessment of death the RN must notify a person legally authorized to pronounce death. Qualifier to Position The BON evaluates failure to initiate CPR cases based on the premise that in the absence of a physician's DNR order it is generally outside the standard of nursing practice not to initiate CPR. Consequently, RNs deciding not to initiate CPR when not all seven signs of death are present, must assure themselves that not initiating CPR complies with their respective standards of practice. Depending on the circumstances, a nurse's failure to initiate CPR when not all seven signs are present may constitute failure to comply with the standards of nursing care. This position statement is limited to situations when all seven signs are present and should not be construed as providing guidance on the appropriateness of not initiating CPR when not all seven signs are present. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE]. The plan included the following: 1. CPR, Assessment, Neglect a. DON/designee inserviced licensed nurses on the revised facility CPR policy, including honoring resident wishes and the RN's responsibility according to the BON scope of practice. RN involved in the event and licensed nurses were inserviced on the CPR policy in place during the event by regional nurse and ADON on the date of occurrence [DATE] through [DATE] and again on the revised CPR policy on [DATE] by the regional nurse. No licensed nurse will work prior to receiving inservices from this point forward. Inservicing to be complete by 2PM [DATE]. b. DON/designee inserviced licensed nurses on change in condition, notification and detailed documentation of assessment/evaluation findings. No licensed nurse will work prior to receiving inservices from this point forward. Inservices to be complete by 2PM [DATE]. c. CPR classes were held (MONTH) 2, (YEAR), by American Heart Association. Additional online classes were also completed. All licensed nurses have current CPR certifications. The Business Office Manager will monitor the expiration dates on a monthly basis and notify the DON on upcoming expirations. d. DON/designee provided abuse/neglect inservice to licensed facility staff on [DATE]. No licensed nurse will work prior to receiving inservices. Completed by 2PM [DATE]. e. Licensed nurses will complete a post test on inservice information to monitor effectiveness of training and staff comprehension and will be completed by [DATE]. f. New hires and Agency staff will receive the inservices prior to working their shift from this point forward. PRN staff who choose not to come in for inservices will be terminated and removed from the system. Staff who are on vacation and cannot be reached will not return to work until they receive the education. g. Admin/DON/Medical Director reviewed and revised CPR policy to include withholding CPR on [DATE] and was signed by the Medical Director on [DATE]. h. DON/designee will review code status changes during clinical start up meeting and present any identified trends to QAPI monthly for 3 months for additional analysis and recommendations. i. DON/designee conducted Mock Code Blue drills on [DATE] and [DATE] and will continue to be completed monthly on alternating shifts for three months. Next one is scheduled for [DATE]. j. Administrator will review clinical start-up checklist weekly for 3 months, ending [DATE]. Verification of the Plan of removal was conducted [DATE] and [DATE]. Four licensed nurses were interviewed on [DATE] and [DATE]. All four verbalized the steps to follow for an unresponsive full code resident: Yell for help, direct someone to call 911, direct someone to get crash cart and call the code; in the meantime, prepare to do CPR, do not leave the resident, and do not stop CPR until EMS takes over or doctor orders to stop. Review of the Advance Directives and Code Status Report dated [DATE] listed 49 resident as Full Code.

Based on interview and record review, the facility failed to ensure each resident was free from neglect for 1 of 3 residents reviewed for neglect (Resident #1). The facility did not initiate CPR for Resident #1 when he was found unresponsive, with no respirations and no pulse. Resident #1 was a full code. Resident #1 was pronounced dead in the facility by RN A on [DATE] at 8:17 AM. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a level of actual harm with a scope identified as isolated due to the facility's need to complete training of all staff and monitor the plan of removal. This failure affected one resident who died on [DATE] and could place 49 residents who were documented as requesting full code status at risk of not being provided resuscitation, which could lead to death. Findings include: Review of Resident #1's undated Face Sheet indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's MDS assessment dated [DATE] indicated he had moderate cognitive impairment. He was occasionally incontinent of urine and frequently incontinent of bowel. He required limited assistance of one person for ADLs. Review of Resident #1's Physician order [REDACTED].>Review of Resident #1's Baseline Care Plan dated [DATE] indicated his goal was to discharge to the community. Review of a nurse's note dated [DATE] at 10:59 A.M., by RN A, included the following: Skilled nursing svcs (services), DX: acute kidney failure, diabetes, [MEDICAL CONDITION]. @ 06:15 went to Room B7 to check blood sugar level. The blood sugar was 157 and 6 units Humalog were given to abdomen. Resident was conversant and remained lying down during entire procedure. I left the room and continued on with my blood sugar checks. At 8:15 the aides were summoning me to B7 because Resident appeared to have passed. I assessed with [REDACTED]. I determined deceased at 8:17. I notified resident physician and family at 8:30 and notified staff of the deceased . Review of nurse's note dated [DATE] at 15:10 (3:10 PM), by RN A, included the following: Addendum to [DATE]; 10:59 AM entry. When I was assessing resident (#1) for signs of life I noted that the resident was unresponsive with cold fingers. His face was very blue. Eyes were fixated with no response to light. I listened with stethoscope to all lung and heart regions with no response. I checked for pulses in the carotid arteries as well as brachial pulses. No pulses and no respiration. Exterior distal extremities were cold to touch and very pale. I noted cyanosis in the abdominal region. Resident was lying on the left side with face turned to left. There were no emissions of bodily fluids from mouth or bowels. No odor was present. The left side was darkened by blood pooling. Review of the Provider Investigation Report dated [DATE] included the following Investigation Summary: The Administrator conducted the investigation through review of the Texas Board of Nursing statements/statutes, medical records and staff interviews. At 0615 on [DATE] (RN A) entered (Resident #1's) room to conduct a blood sugar check and administer insulin prior to his meal. (Resident #1) was awake and responsive to (RN A's) conversation. Between 0715 and 0730, (CNA B) took (Resident #1) his breakfast tray and appeared to be sleeping. (Resident #1 did not respond to (CNA B's) good morning. At between 0800 - 0815, (CNA B) went back to pick up the tray and (Resident #1) had not touched his food. (CNA B) attempted to arouse (Resident #1) and got no response. At that point, (CNA B) felt for a pulse and did not feel one. She caught another CNA in the hallway and had them go get (RN A). At 0815 (RN A) came into the room and attempted to arouse (Resident #1). He was still unresponsive so (RN A) performed a sternum rub and (Resident #1) was still unresponsive. (RN A) then assessed (Resident #1) for pulse, respirations and eye dilitations (sp). None were present. (RN A) noted (Resident #1's) face was blue and extremities were cold to the touch. (RN A) pronounced his death at 0817 and notified the attending physician and family around 0830. The Administrator finds this unconfirmed for neglect due to the RN [MEDICATION NAME] within his scope of practice according to the TBON. In an interview on [DATE] at 9:40 AM with the DON, she said the corporation added the BON statement on the RN Role in Withholding CPR . after the incident. (the previous Medical Director) signed it on [DATE]. We can follow the BON, we just added it to the policy to make it clear . In an interview with RN A on [DATE] at 10:10 AM he said he checked Resident #1's blood sugar at 6:10 AM, with a result of 157. He gave the resident 6 units of Humalog insulin (5 units ordered 3 times daily and 1 unit per sliding scale for blood sugar of 150 - 175). RN A said Resident #1 kind of came awake while he was checking his blood sugar and administering insulin. Afterwards, RN A said he went to the next hall to continue his rounds with other residents. RN A said that approximately 8:15 AM CNA B came to get him to come to Resident #1's room. He said the resident's face was blue, there was pooling in his abdomen, he was laying on his left side and the left side of his abdomen was kind of purplish. He said his eyes were glassy and his fingers were cold. He had no pulse or respirations. He said there was evidence of cyanosis, his face was real blue. RN A was unable to describe Resident #1's extremities looked like. He said, I didn't take his clothes off. RN A said he wrote the addendum nurse's note after he talked to the facility administrator and was told he needed more documentation, nothing specific, just more complete documentation. In an interview with the facility administrator he said they had a conference call with the RNC after Resident #1 death. He said the RNC had questions that were not in RN A's original nurse's note. He said he had RN A do the addendum to include the information he told us on the conference call. In a telephone interview with CNA B on [DATE] at 10:30 AM she said the day Resident #1 died was her second day of orientation. She said that she and the other CNAs were passing out breakfast trays on the halls. She said she was told that Resident #1 would eat when he wakes up, and to just leave his tray for him. She said when she came back after breakfast, she told him she was going to take his tray, and he didn't respond. She said he was lying on his back and she noticed his hands were cold. She checked for a pulse and saw he wasn't breathing. She said she didn't notice any skin discoloration, he looked the same to her. She said CNA D was picking up trays across the hall and she called her to Resident #1's room. She walked in and asked if he was okay, then went to get a nurse. LVN C came to the room and told CNA B to go get RN A. In a telephone interview with LVN C on [DATE] at 10:43 AM she said One of the girls down the hall said they needed help. RN A was down another hall. I called out to him and we went to Resident #1's room. He was unresponsive. RN A shook his arm. He wasn't breathing. He was on his back with a pillow under his head. His tray was there, and it looked like he had eaten and gone back to sleep. The cover was off the tray with food eaten. LVN C said she had never seen Resident #1 before as she works other halls. LVN C could not describe the appearance of Resident #1's face. In a telephone interview with CNA D on [DATE] at 11:15 AM she works part time. On the day Resident #1 died she said she worked 8:00 AM - 2:00 PM. She said they (the CNA's) were picking up breakfast trays. Resident #1's room was on the right side of the hall and she was picking up trays on the left side of the hall. CNA B came out of his room and told me to get a nurse. I got (LVN C) from the rotunda. She came and checked Resident #1 and said to go get RN A. He came and checked (the resident). Me and (CNA B) left with his tray. She said nothing on his breakfast tray was touched. She said he would usually sit in the recliner for his meals. When I checked his pulse, he was cold. I turned off the air conditioner. He was down in the bed. He looked like he was asleep with lots of blankets and the AC on cold. That's how he liked it. He was uncovered to the chest and his left arm was out. He was on his back. His skin on his arm was kind of purple red. His face was flushed, his cheeks purplish red. His mouth was open, and his eyes were closed with tears puddled in the corners. RN A was in a lot of shock. We (the CNAs) left the room and LVN C was behind us I think. She said that neither of the nurses told them to call 911. In an interview with RN A on [DATE] at 11:57 AM he said he knew that Resident #1 was a full code when he was found unresponsive. He said he decided not to do CPR because it had been too long. He said Resident #1 had a 4-inch diameter area of pooling on his left abdomen. He said he did not turn the resident to further assess for lividity. In a telephone interview with RN A on [DATE] at 3:44 PM he said he did not initiate CPR for Resident #1 because too much time had passed, he hadn't touched his breakfast. He said he did not know specifically what the facility policy was at the time regarding CPR. He said there was an in-service the following day or so regarding what to do when a resident is found unresponsive: Call 911 and get the firemen; start CPR; let the paramedics make the call. He said he thought the facility had held mock codes in the past, but he had not attended. He said, All of us were supposed to have CPR certification. Review of licensed nursing staff personnel files revealed 14 out of 20 nurses, including the DON, did not have current CPR certifications at the time of Resident #1's death. RN A's CPR certification expired (MONTH) (YEAR). LVN C's CPR certification was current, expiring (MONTH) 2019. In an interview with RN A on [DATE] at 11:10 AM, (with the DON in attendance at RN A's request) in Resident #1's previous room, RN A demonstrated how the resident was lying on the bed and described the events of the morning of [DATE]: The bed was against the wall with the right side of the bed next to the window AC unit. RN A said that Resident #1 was usually groggy in the mornings. He said a CNA delivered his breakfast at approximately 7:30 AM. He said that he was on C hall at approximately 8:15 AM when CNA B came to get him to go to Resident #1's room. The resident was lying on his left side. His face was very blue. RN A said he went to the nurses' desk to get his stethoscope. When he returned he did a sternal rub on Resident #1 without response. He checked the resident's eyes with a penlight and there was no pupil reaction. He said the felt the resident's fingers and they were cold. He said he was covered from waist down with blankets. He had a shirt on. He said there was an approximately 4-inch circumference discoloration on his left abdomen. He said that after his assessment of the resident he returned to the nurses' station and called the resident's doctor and his family regarding his death. He then told the Interim DON and the ADON. The Administrator, DON and RNC were notified of the Immediate Jeopardy situation on [DATE] at 3:55 PM. In a telephone interview on [DATE] at 11:10 AM with the facility Medical Director who was also Resident #1's primary physician, he said he did not remember exactly what RN A had said when he called him and reported Resident #1's death at the facility, as he did not have immediate access to his records. He was notified of the Immediate Jeopardy situation. He said that for a resident who was a full code he would expect the nursing staff to start CPR and call 911. He said he was not aware until now of the circumstances of Resident#1's death. Review of the facility's Code Status System, revised [DATE], included the following, in part: Green alerts (located in the front of the clinical record) indicate the resident's desire to have CPR and every attempt to provide all heroic measures must be recognized. Review of www.bon.texas.gov/practice_wposition_statements_content.asp#15.20 accessed [DATE], include the following, in part: approved by the Board of Nursing (MONTH) 24, 2002, and last revised ,[DATE], included the following, in part: 15.20 Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long Term Care Facility The Texas Board of Nursing (BON) has approved this position statement, only applicable to long term care settings, in an effort to provide guidance to registered nurse in long-term care facilities and to clarify issues of [MEDICATION NAME] end-of-life care . Assessment of death in which CPR would be a futile and inappropriate intervention requires that all seven of the following signs be present and that the arrest is unwitnessed: Presumptive Signs of Death 1. The resident is unresponsive; 2. The resident has no respirations; 3. The resident has no pulse; 4. Resident's pupils are fixed and dilated; 5. The resident's body temperature indicates hypothermia: skin is cold relative to the resident's baseline skin temperature; 6. The resident has generalized cyanosis; and Conclusive Sign of Death 7. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). RN Role in Withholding CPR With an Unwitnessed Arrest Pronouncement of Death There may be a time when initiating CPR is not [MEDICATION NAME] or is futile. The Texas Board of Nursing has provided the following position statement for an unwitnessed arrest AND pronouncing death: Unwitnessed Arrest In the case of an unwitnessed resident arrest without DNR orders, determination of the appropriateness of CPR initiation should be undertaken by the registered nurse through a resident assessment, and interventions appropriate to the findings initiated. Assessment of death in which CPR would be a futile and inappropriate intervention requires that all seven of the following signs be present and that the arrest is unwitnessed. Presumptive Signs of Death 8. The resident is unresponsive, 9. The resident has no respirations, 10. The resident has no pulse, a. Resident's pupils are fixed and dilated. 11. The resident's body temperature indicates hypothermia: skin is cold relative to the resident's baseline skin temperature' 12. The resident has generalized cyanosis, and Conclusive Sign of Death 13. There is presence of livor mortis (venous pooling of blood in dependent body parts causing purple discoloration of the skin). Documentation After assessment of the resident is completed and appropriate interventions taken, documentation of the circumstances and the assessment of the resident in the resident record are a requirement. The rules of the BON establish legal documentation standards (BON Standards of Nursing Practice, 22 TAC § Rule 217.1 (1)(D)). Examples of important documentation elements include: Description of discovery of the resident Any treatment of [REDACTED]. The findings of each of the assessment elements outlined in the standards All individuals notified of the resident's status (e.g., [DATE], the health care provider, the administrator of the facility, family, coroner, etc. Any directions that were provided to staff or others during the assessment and/or treatment of [REDACTED].> The results of any communications Presence or absence of witnesses Documentation should be adequate to give a clear picture of the situation and all the actions that were taken or not taken on behalf of the resident. Even if the nurse's decision not to initiate CPR was appropriate, failure to document can result in an action against a nurse's license by the BON. Furthermore, lack of documentation places the nurse at a disadvantage should the nurse be required to explain the circumstances of the resident's death. Registered nurses should be aware that actions documented at the time of death provide a much more credible and accurate clinical description. Documentation that is absent, incomplete or inaccurate reveals gaps in care, requiring the nurse to prove actions not appropriately documented were actually taken . RN Role in Pronouncement of Death Texas law provides for RN pronouncement of death (Health & Safety Code §§ 671.001 - .002). The law requires that for a nurse to pronounce death, the facility must have a written policy which is jointly developed and approved by the medical staff or medical consultant and the nursing staff, specifying under what circumstances a RN can make a pronouncement of death. It is important that nurses understand that the assessment that death has occurred and that CPR is not an appropriate intervention are not the equivalent to the pronouncement of death, Texas statutory law governs who can pronounce death, and only someone legally authorized to pronounce death may do so. If the RN does not have the authority to pronounce death, upon assessment of death the RN must notify a person legally authorized to pronounce death. Qualifier to Position The BON evaluates failure to initiate CPR cases based on the premise that in the absence of a physician's DNR order it is generally outside the standard of nursing practice not to initiate CPR. Consequently, RNs deciding not to initiate CPR when not all seven signs of death are present, must assure themselves that not initiating CPR complies with their respective standards of practice. Depending on the circumstances, a nurse's failure to initiate CPR when not all seven signs are present may constitute failure to comply with the standards of nursing care. This position statement is limited to situations when all seven signs are present and should not be construed as providing guidance on the appropriateness of not initiating CPR when not all seven signs are present. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE]. The plan included the following: 1. CPR, Assessment, Neglect a. DON/designee inserviced licensed nurses on the revised facility CPR policy, including honoring resident wishes and the RN's responsibility according to the BON scope of practice. RN involved in the event and licensed nurses were inserviced on the CPR policy in place during the event by regional nurse and ADON on the date of occurrence [DATE] through [DATE] and again on the revised CPR policy on [DATE] by the regional nurse. No licensed nurse will work prior to receiving inservices from this point forward. Inservicing to be complete by 2PM [DATE]. b. DON/designee inserviced licensed nurses on change in condition, notification and detailed documentation of assessment/evaluation findings. No licensed nurse will work prior to receiving inservices from this point forward. Inservices to be complete by 2PM [DATE]. c. CPR classes were held (MONTH) 2, (YEAR), by American Heart Association. Additional online classes were also completed. All licensed nurses have current CPR certifications. The Business Office Manager will monitor the expiration dates on a monthly basis and notify the DON on upcoming expirations. d. DON/designee provided abuse/neglect inservice to licensed facility staff on [DATE]. No licensed nurse will work prior to receiving inservices. Completed by 2PM [DATE]. e. Licensed nurses will complete a post test on inservice information to monitor effectiveness of training and staff comprehension and will be completed by [DATE]. f. New hires and Agency staff will receive the inservices prior to working their shift from this point forward. PRN staff who choose not to come in for inservices will be terminated and removed from the system. Staff who are on vacation and cannot be reached will not return to work until they receive the education. g. Admin/DON/Medical Director reviewed and revised CPR policy to include withholding CPR on [DATE] and was signed by the Medical Director on [DATE]. h. DON/designee will review code status changes during clinical start up meeting and present any identified trends to QAPI monthly for 3 months for additional analysis and recommendations. i. DON/designee conducted Mock Code Blue drills on [DATE] and [DATE] and will continue to be completed monthly on alternating shifts for three months. Next one is scheduled for [DATE]. j. Administrator will review clinical start-up checklist weekly for 3 months, ending [DATE]. Verification of the Plan of removal was conducted [DATE] and [DATE]. Four licensed nurses were interviewed on [DATE] and [DATE]. All four verbalized the steps to follow for an unresponsive full code resident: Yell for help, direct someone to call 911, direct someone to get crash cart and call the code; in the meantime, prepare to do CPR, do not leave the resident, and do not stop CPR until EMS takes over or doctor orders to stop. Review of the Advance Directives and Code Status Report dated [DATE] listed 49 resident as Full Code.

Based on observations, interviews and record review the facility failed to ensure 2 of 6 residents reviewed for accident hazards and smoking safety received adequate supervision to prevent accidents: (Resident # 1 and 23 ) The facility failed to: 1). ensure supervision of Resident #1 for safe smoking. Resident # 1 had a previous history of first and second degree burns to his face and nose (04/27/14) due to smoking unsupervised while wearing his oxygen. On 06/03/14 staff failed again to supervise the resident by not removing his oxygen tank and cannula prior to him smoking. The oxygen ignited his cigarette and Resident # 1 again suffered first and second degree burns to his face, nose, nares and behind his left ear. 2). to ensure that staff followed the facility smoking policy which stated Only Licensed Nursing Staff could remove, turn off and replace oxgyen on residents prior to and after smoke breaks. The facility was allowing residents who smoke and use oxygen to turn off and remove their own oxygen unsupervised prior to the resident exiting the building to smoke. (Resident # 1 and 23 ) 3). to ensure nursing administrative staff were supervising Certified Nurse Aides and licensed staff who were assigned to supervise the smoke breaks to insure residents were smoking safely. On 06/05/14 an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 06/05/14 the facility remained out of compliance at actual harm at a pattern due to the facility' s need to evaluate and monitor their corrective action system. These failures affected Resident #1 who received 1st and 2nd degree burns to his nose, nares and behind his left ear and could have affected the 7 other residents (which include Residents # 23 ) who were smokers and on the patio at the time of the incident, placing them at risk of burns and injuries. Findings include: Resident # 1 Review of Resident # 1 ' s admission sheet indicated he had been admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The resident was [AGE] years old. Review of Resident # 1 ' s most current Minimum Data Set ((MDS) dated [DATE] indicated the resident's score was a 1 out of a possible 15 on the (BIMS) Brief Interview for Mental Status indicating he had severe cognitive impairment. The MDS also indicated Resident # 1 suffered from signs and symptoms of Delirium, displaying inattention, disorganized thinking and altered level of consciousness that was continuously present and did not fluctuate. According to the MDS Resident # 1 required only supervision on all of his activities of daily living, except bathing the Resident was totally dependent and required the assistance of one staff member. Resident # 1 used a wheelchair for mobility and was on oxygen therapy due to shortness of breath. Resident # 1 ' s care plan dated 04/30/14 indicated he was a smoker. Goals were that the resident will be safe and free of injury as a result of smoking for the next 90 days. Approaches were: Explain smoking policy as frequently as needed, keep smoking materials in a safe and secure place and provide them per smoking schedule, assign someone to go with the resident when he smokes so that if something should happen there will be someone there to assist. Inform the resident of inability to sign self out to leave facility grounds to smoke unless supervised. Report observations of unsupervised smoking to charge nurse or other administrative staff, report observations of resident having smoking materials other than times of supervised smoking. Provide a protective apron so that resident does not burn himself. Explain to the resident the dangers of wearing oxygen while smoking as needed and do not allow the resident to wear oxygen when smoking. Review of Resident # 1's smoking evaluation dated 05/01/14 indicated the resident was cognitively impaired with poor decision making skills with intermittent confusion and the resident had pertinent [DIAGNOSES REDACTED]. According to the assessment the resident used a wheelchair for mobility and also had a hearing impairment. The resident had expressed a desire to smoke and had a history of [REDACTED]. According to the evaluation the resident's BIMS (Brief Interview Mental Status) score was 1 out of a possible 15 indicating severe cognitive disability. The resident required a smoking apron on when smoking and the resident was able to extinguish his own cigarette. The evaluation indicated Resident # 1 wore oxygen and that all oxygen equipment must be removed during smoke breaks, which included the nasal cannulas and the oxygen canister/tank. According to the evaluation Resident # 1 had signed the facility smoking agreement. Review of an incident report dated 04/27/14 and timed at 7:50 p.m. indicated Resident # 1 had a previous injury from smoking unsupervised with his oxygen on. According to the incident report Resident # 1 had been outside of the facility on the west end of the building sitting in his wheelchair, another resident saw Resident # 1 sitting in his wheelchair, glanced away and then looked back at the resident in time to see him with a lighter, which he lit and flames shot up in from of his face. The other resident pushed Resident # 1 back into the building and yelled for help. Two CNA's brought the resident to the charge nurse. The resident's face was black from smoke and his mustache was singed off, along with a 3 inch area to the residents right temple. The resident complained of a lot of pain. A wet was cloth was applied to the resident's face and a small area of skin began to roll off the resident's nose. EMS was called and the resident was transported to the emergency room . ( A previous Immediate Jeopardy was called on this incident. See CMS 2567 dated 05/01/14) Review of a hospital emergency room Nurse Report dated 04/27/14 at 8:17 p.m. indicated Resident # 1 had first and second Degree Burns to the left ear, left base of the skull, right temporal area, nose and mouth. Review of a facility's investigation report dated 06/03/14 at 1:28 p.m. indicated the facility's RVP and RRC (administrative nurses) were summoned to the smoking area (patio) by dietary aide (A). The dietary aide said there was a fight out on the patio. However, when they got out on the patio they were told by CNA A who had been supervising the smokers that Resident # 1 had his oxygen on and that she (CNA A) was not aware he had it on and the oxygen caught fire. According to the report when the RVP and RRC arrived on the patio there was no fire. Resident # 1 was on his knees on the patio floor, he had fallen from his wheelchair when he attempted to get up. Another resident had reportedly stomped the fire out on the oxygen tubing. Resident # 1 was assessed by the RRC and found to have black discoloration around his nose. His nose was swollen and bleeding; there was also a burned area on the left posterior of his ear and scalp. There appeared to be a blister on the forth finger of his left hand. 911 was called and Resident # 1 was sent to the emergency room . Review of a nurse ' s note dated 06/03/14 at 1:30 p.m. indicated Resident # 1 was outside in the smoking area on his knees. The resident was assisted up to wheelchair and wheeled to nurse ' s station and assessed the resident for injuries from fire. Resident # 1 had a black burned area noted to his nose and on his face, his nose tip was bleeding 0.5 centimeters (cm), nose was swollen, redness was noted to his face from oxygen tubing line. Resident #1 complained of pain behind left ear, black, raised fluid filled area approximately 0.8 cm noted. Redness was noted to scalp area behind his ear approximately 3 cm x 2 cm. Resident also had fluid filled area to fore finger on the left hand approximately 0.8 cm. Resident stated he was in pain, on a scale of 1 to 10 resident said his pain was at a 10. Respirations were even and unlabored. EMS arrived during the assessment. Review of Resident # 1's emergency room visit on 06/03/14 at 1:40 p.m. indicated the resident had a small 2nd degree burn to left ear and 3rd degree burn to intranasal and upper lip. Intranasal is black and charred. Resident # 1 was transferred to the Burn Center in another city. Review of the final report from Burn Center dated 06/04/14 indicated Resident # 1 had 2nd degree burn to the face. The resident was discharged to come back to the nursing facility with orders for burn care for second-degree burns. During an interview with the RVP and Director of Nurses (DON) on 06/04/14 at 1:30 p.m. they stated there was a burned area on the concrete floor out on the smoking patio where Resident # 1 had been sitting in his wheelchair. The RVP said this was where the 02 (oxygen) tubing was on fire and had been stomped out by one of the residents. During this interview an observation was made of the smoking apron and the 02 tubing the Resident #1 was wearing at the time of the incident. There were three burned areas on the apron and the nasal cannula portion of the 02 tubing that fit in the resident ' s nose was burned in half. According to the RVP CNA " A " was supervising the residents while they smoked. The CNA did not notice that Resident # 1 came out on the patio with his oxygen on. The CNA had already lit Resident # 1 ' s cigarette and had her back to him getting other resident ' s cigarettes when she heard the resident scream out, she turned to see a flash of fire. Another resident rushed over and stomped out the fire on Resident # 1's oxygen tubing. There was also a Certified Medication Aide (CMA) out on the patio during the incident passing medications and he turned off Resident # 1' s oxygen. During an interview with Certified Medication Aide ( CMA " R ") on 06/04/14 at 1:45 p.m. he said he had been out on the patio on 06/03/14 between 1 p.m. and 1:30 p.m. CMA " R " said when he came out on the patio he glanced at Resident # 1 but did not notice he had on his 02 (oxygen). The CMA said Resident # 1 sits hunched over. He said he was giving another resident her medication and had his back to Resident # 1. CMA " R " said he heard the resident scream out and turned and realized there was a fire. He said he ran to the resident, who had turned over his wheelchair and was on his knees on the ground and turned off the resident ' s oxygen. CMA " R " said he saw that the resident's face was black and burned and he smelled the odor of burnt hair. He said a nurse came outside and started helping the resident. CMA " R " said he did not know how many residents there were on the patio at the time. but there were quite a few. During an interview with CNA " A " on 06/05/14 at 9:50 a.m. she said it was her turn to do the smoke break on 06/03/14 at 1 p.m. CNA " A " said she announced the smoke break over the intercom system in the facility. She said she stood at the door to the patio and handed out the smoking aprons to the residents. She said there had been about 15 smokers outside at the time of the incident. CNA " A " said about half the smokers went back inside during and after the incident. She said the residents have 15 minutes to smoke 2 cigarettes. She said she gave each resident a cigarette and then lit them after all the residents had one. She said Licensed Vocational Nurse (LVN " B " ) came outside during the smoke break to see if a resident who was still inside the facility had any cigarettes left in the box because he wanted to come out side to smoke. She said she and the LVN looked through the box then the LVN went inside the facility. CNA " A " said Resident # 1 was on the last part of his first cigarette and was asking for his second cigarette. CNA " A " said she turned to look into the smoking box when she heard Resident # 1 cry out " Oh[***]" she said she turned and saw his face was on fire and she ran to the fire extinguisher, by that time the Certified Medication Aide (CMA " R " ) that was on the patio ran over to help Resident # 1. The other residents were pounding on the door and trying to leave the patio area. CNA " A " confirmed she had been trained on the smoking policy. She said she had not noticed that Resident # 1 still had his oxygen on when he came out to smoke. She said usually Resident # 1 and another resident who smokes take off their own oxygen tubing and turn their own oxygen off too. She said we just take the tanks off the wheelchairs and put them up in the dining room while the residents are outside. CNA " A " said for a while after the last oxygen/fire incident involving Resident #1 (04/27/14) the nurses would make sure the resident did not have their oxygen on and that it had been turned off. But lately the nurses are not automatically at the door to turn off the oxygen, we have to call them to help us and the residents are turning their own oxygen off too. During an interview and observation with Resident # 1 on 06/05/14 at 11:05 a.m. he said " I forgot to take my oxygen off. " According to Resident # 1 he was late to the smoke break and everyone was already out on the patio. He said staff opened the door for him and let him out. He said he wheeled himself onto the patio and then the staff lit the cigarette for me. He said he was taking the last drag off of his first cigarette when it exploded. Resident # 1 said he dropped down on the ground and was trying to put it out. He said it " hurt real bad " . Observation of Resident # 1 at this time revealed under his nose and up into his nares was burned and scabbed over. There was a burned and scabbed over area approximately and an inch and half long that was behind his left ear. Resident # 1 said his fingers were not burned. However there appeared to be a healed blister on the middle finger, left hand. During an interview with LVN " B " on 06/05/14 at 12:00 p.m. she said she was in the dining room when the smoke break was announced. She said she took the oxygen off of a Resident ( not Resident # 1) and followed him out onto the patio. She said there were a lot of residents going out to smoke. LVN " B " said when she was out on the patio she did not notice Resident # 1 had his oxygen on. She said she asked CNA " A " if a certain resident had any cigarettes because he wanted to come out and smoke. She said after they looked in the box she went inside to finish charting. LVN " B " said when she heard all the commotion she rushed back out to the patio and saw Resident # 1 on his knees. Staff were assisting him back into his wheelchair. LVN " B " said usually the CNA' s do the smoking breaks and will call them (charge nurses) if needed to turn off the resident' s oxygen. During an interview with CNA "P" on 06/05/14 at 3:00 p.m. she said Resident # 1 had been doing so well lately with his smoking. She said Resident # 1 had been leaving his wheelchair by the air conditioner on the patio and turning off his own oxygen off prior to sitting down at the table to smoke. Resident # 23 Review of Resident # 23 admission record indicated he was admitted to the facility on [DATE] with a readmission date of [DATE]. Admitting [DIAGNOSES REDACTED]. He was [AGE] years old. Review of the resident's MDS dated [DATE] indicated the resident had a BIMS of 8 on a scale of 0 to 15, indicating moderate cognitive impairment. The resident required limited assistance on one staff for transfers and extensive assistance of one staff for dressing, toileting and hygiene. Resident # 23 required the assistance of staff to ambulate and used an electric wheelchair for mobility. The resident utilized oxygen continuously for his pulmonary disease. Review of the resident's care plan dated 03/25/14 indicated he was a smoker and was at risk for injury due to his oxygen use. The care plan did not address the removal of the oxygen prior to smoking. The approach was listed as: monitoring when smoking and use of a smoking apron. Review of Resident # 23's smoking evaluation dated 05/08/14 indicated he had cognitive deficit with schizophrenia, used a wheelchair and had a BIMS of 8. Evaluation indicated the resident required oxygen and it was to be removed prior to smoke breaks. The resident also required a smoking apron. During an interview with Resident # 23 on 06/05/14 at 10:30 a.m. he said he was not on the smoking patio when the incident on 06/03/14 occurred. He said he always parks his wheelchair inside by the patio door, gets up and turns off his oxygen himself before he goes outside to smoke. Review of the facility (revised) smoking policy dated 04/16/14 indicated in part: Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas is posted with signs that read NO smoking or with the international symbol for on Smoking. All oxygen equipment must be removed from the resident's person during smoke breaks. This includes the removal of oxygen masks or nasal cannulas and oxygen canisters/tanks of any type. Review of an inservice dated 04/28/14 ( after the previous incident on 04/27/14) given by the previous Director of Nurses on the facility smoking policy indicated "in Part" # 3. Oxygen tanks are to be turned off and left inside the building by the door. Review of the signature page for the inservice indicated CNA "V" and CNA "A" had signed and acknowledge they had attending this inservice and received the training. Review of an inservice record dated 04/29/14 ( after previous incident on 04/27/14) indicated the Regional Nurse Consultant (RNC) provided an inservice to staff covering the facility smoking policy, adaptive smoking equipment, supervised smoking and no resident sign out for smoking. Review of the sign in page indicated CNA "A" signed and acknowledged she had been trained regarding removal of residents' 02 equipment prior to the supervised smoke breaks. Review of an inservice training report dated 04/30/14 (after previous incident on 04/27/14) indicated the RNC provided an inservice to staff covering "smoking/oxygen/CNA role" indicated a list of oxygen users and all apron users that would be kept in the smoking box and must be utilized without fail. Also contained in this inservice was a notification to staff that would be placed in the smoke box, that said "Attention all Staff: only licensed nursing personnel are allowed to turn off or otherwise adjust any form of oxygen delivered equipment. CNA's are not ever allowed to adjust settings on oxygen bottles prior to residents smoking. The notification listed the residents with oxygen that smoke . The notification said "These residents use oxygen and are smokers. Their oxygen has to be turned off and left beside the door before they can go out to smoke. If they refuse, they can not smoke. Oxygen is combustible and there for dangerous around any fire. Review of the sign in page indicated CNA "A", CNA "V", CMA "R" and LVN "B" all signed and acknowledged that they attended the inservice and reveived the training. The RVP was notified of the Immediate Jeopardy situation on 06/04/14 at 12:30 p.m. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on 06/05/14. The plan included the following: To prevent reoccurrence and ensure all other residents safety, the smoking procedure was revised to limit no more than 7 residents at a time to smoke supervised. The current staff on shift on 06/03/14 were inserviced by the DON immediately and then returned at 10 p.m. to do the 10-6 am shift. No one that has not received the training on supervising the smokers will be allowed to supervise the smokers. This will be monitored by Check Point Charlie Nurse 4 times a day. The smoking residents were educated on new immediate procedures to ensure all safety measures are in place and signed acknowledgment of revised schedule and limited smokers at the time by the marketing director. DON will monitor the 3pm smoke break on 06/03/14. RVP will monitor the 6:30 pm smoke break on 06/03/14 to ensure resident safety. DON revised smoking schedule to include a specific time for only oxygen users to smoke supervised to implement "Check Point Charlie" for this group. No oxygen user resident is allowed outside in the smoking area unless approved thru "Check Point Charlie" no staff member will allow resident out in smoking area until approved. "Check Point Charlie" consists of Licensed Nurse is the "Charlie", the nurse will validate that the person supervising has been trained on supervised smoking by utilizing the list of names on the sheet in front of the "Check Point Charlie" book located in a three ring binder in the dining room, in a 3 ring binder on the inside of the door. This validation will take place inside the building in the dining room. If the person is not on the list then this person will not be allowed to supervise smoke break by nurse. The Licensed Nurse will validate that the oxygen is removed off of the wheelchair or chair. The Licensed Nurse will turn the oxygen off of the resident. The Licensed Nurse will validate that the resident does not have the masks and/ or cannula on. The licensed nurse will validate that there are no more than 7 residents at a time out in smoke break. The licensed nurse will "approve" smoking break to be initiated and all residents are safe to smoke and sign the form for documentation validation. This form will be dated and timed by the Licensed Nurse. An in-service about the "Check Point Charlie" procedure was conducted on 06/04/14 by the DON to consists of licensed nurses held accountable to be at check point Charlie at the designated time. The validation was initiated immediately after incident and procedure named on 06/04/14. The training will continue to include all staff on the payroll until that is complete, only those trained on the list in the check point Charlie list will be allowed to approve the check point Charlie checklist and only those on the list will be able to supervise the smokers. Out of cycle QA was conducted by the DON, RVP and Marketing person and RRC nurse on 06/0314. Monitoring by facility: How- Nursing Dept. Manager will monitor "Check Point Charlie" system to ensure that the above system is effective by visualization of 2 Check Point Charlie smoking breaks on a daily basis alternating the times, the weekend RN manager will do this on the weekends on 2 Check Point Charlie checks. Nurse Managers will monitor that the licensed Nurse are validating safety by using the book, turning off the oxygen, showing up at scheduled time for smoke break, validating the person supervising is trained and approving the smokers safety. Evidence of the monitoring will be documented on the Check Point Charlie work sheet. (06/05/14 and ongoing) Out of cycle QA (Quality Assurance) conducted by the DON, RVP and Medical Director, on 06/04/14, summary of finding for the monitoring was reviewed. Out of cycle QA scheduled for Monday 06/09/14 to discuss effect of monitoring. Validation of the Plan of Removal by DADs surveyors was conducted on 06/05 and 06/06/14. Review of facility ( revised) smoking policy dated 06/03/14 indicated all smoking residents with a score of 13 or below on the BIMS must wear smoking apron. No more than 7 smoking residents will be allowed at each smoke break. A separate smoke break will be assigned for residents who require oxygen. 02 tanks will be turned off by nurse and will be removed by CNA and placed in 02 holders in dining room. Once the residents are at designated smoking area CNA will pass out cigarettes, once every resident has their cigarette CNA will light them. Observation of the Check Point Charlie system on two smoke breaks on 06/05 and 06/06/14 that involved residents who use oxygen and two smoke breaks on residents who do not require oxygen indicated staff correctly followed the facility system. Licensed staff, dietary staff, medical records staff, certified medication aides and certified nursing aides on all three shifts were interviewed concerning the new smoking policy and how "Check Point Charlie" worked. All staff interviewed were able to verbalize how the system worked. Interview with resident's concerning the new smoking policy indicated all residents interviewed understood the policy. Documentation of monitoring by administrative staff was reviewed and found to be in place and appropriately completed and signed off on. The Immediate Jeopardy was removed prior to exit on 06/06/14, effective 06/05/14. However the facility remained out of compliance at Actual Harm at a Pattern due to the facility's need to monitor their plan for continued effectiveness to protect the safety of smoking residents. According to a list provided by the Director of Nurses on 06/04/14 there were 18 residents who lived in the facility that smoked and three of those residents required oxygen.

Based on observations, interviews and record review the facility failed to implement policies and procedures that prohibit neglect for two (Resident # 1 and 23) of 6 residents reviewed for neglect. The facility failed to: 1). ensure of Resident #1 was safe from fire/injury while smoking. Resident # 1 had a previous history of first and second [MEDICAL CONDITION] his face and nose (04/27/14) due to smoking unsupervised while wearing his oxygen. On 06/03/14 staff failed again to supervise the resident by not removing his oxygen tank and cannula prior to him smoking. The oxygen ignited his cigarette and Resident # 1 again suffered first and second [MEDICAL CONDITION] his face, nose, nares and behind his left ear. 2). to ensure that staff followed the facility smoking policy which stated Only Licensed Nursing Staff could remove, turn off and replace oxygen on residents prior to and after smoke breaks. The facility was allowing residents who smoke and use oxygen to turn off and remove their own oxygen unsupervised prior to the resident exiting the building to smoke. (Resident # 1 and 23 ) 3). to ensure nursing administrative staff were supervising Certified Nurse Aides and licensed staff who were assigned to supervise the smoke breaks to insure residents were smoking safely. On 06/05/14 an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 06/05/14 the facility remained out of compliance at actual harm at a pattern due to the facility' s need to evaluate and monitor their corrective action system. These failures affected Resident #1 who received 1st and 2nd [MEDICAL CONDITION] his nose, nares and behind his left ear and could have affected the 7 other residents (which include Residents # 23 ) who were smokers and on the patio at the time of the incident, placing them at risk [MEDICAL CONDITION] injuries. Findings include: Resident # 1 Review of Resident # 1 ' s admission sheet indicated he had been admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The resident was [AGE] years old. Review of Resident # 1 ' s most current Minimum Data Set ((MDS) dated [DATE] indicated the resident's score was a 1 out of a possible 15 on the (BIMS) Brief Interview for Mental Status indicating he had severe cognitive impairment. The MDS also indicated Resident # 1 suffered from signs and symptoms of [MEDICAL CONDITION], displaying inattention, disorganized thinking and altered level of consciousness that was continuously present and did not fluctuate. According to the MDS Resident # 1 required only supervision on all of his activities of daily living, except bathing the Resident was totally dependent and required the assistance of one staff member. Resident # 1 used a wheelchair for mobility and was on oxygen therapy due to shortness of breath. Resident # 1 ' s care plan dated 04/30/14 indicated he was a smoker. Goals were that the resident will be safe and free of injury as a result of smoking for the next 90 days. Approaches were: Explain smoking policy as frequently as needed, keep smoking materials in a safe and secure place and provide them per smoking schedule, assign someone to go with the resident when he smokes so that if something should happen there will be someone there to assist. Inform the resident of inability to sign self out to leave facility grounds to smoke unless supervised. Report observations of unsupervised smoking to charge nurse or other administrative staff, report observations of resident having smoking materials other than times of supervised smoking. Provide a protective apron so that resident does not burn himself. Explain to the resident the dangers of wearing oxygen while smoking as needed and do not allow the resident to wear oxygen when smoking. Review of Resident # 1's smoking evaluation dated 05/01/14 indicated the resident was cognitively impaired with poor decision making skills with intermittent confusion and the resident had pertinent [DIAGNOSES REDACTED]. According to the assessment the resident used a wheelchair for mobility and also had a hearing impairment. The resident had expressed a desire to smoke and had a history of [REDACTED]. According to the evaluation the resident's BIMS (Brief Interview Mental Status) score was 1 out of a possible 15 indicating severe cognitive disability. The resident required a smoking apron on when smoking and the resident was able to extinguish his own cigarette. The evaluation indicated Resident # 1 wore oxygen and that all oxygen equipment must be removed during smoke breaks, which included the nasal cannulas and the oxygen canister/tank. According to the evaluation Resident # 1 had signed the facility smoking agreement. Review of an incident report dated 04/27/14 and timed at 7:50 p.m. indicated Resident # 1 had a previous injury from smoking unsupervised with his oxygen on. According to the incident report Resident # 1 had been outside of the facility on the west end of the building sitting in his wheelchair, another resident saw Resident # 1 sitting in his wheelchair, glanced away and then looked back at the resident in time to see him with a lighter, which he lit and flames shot up in from of his face. The other resident pushed Resident # 1 back into the building and yelled for help. Two CNA's brought the resident to the charge nurse. The resident's face was black from smoke and his mustache was singed off, along with a 3 inch area to the residents right temple. The resident complained of a lot of pain. A wet was cloth was applied to the resident's face and a small area of skin began to roll off the resident's nose. EMS was called and the resident was transported to the emergency room . ( A previous Immediate Jeopardy was called on this incident. See CMS 2567 dated 05/01/14) Review of a hospital emergency room Nurse Report dated 04/27/14 at 8:17 p.m. indicated Resident # 1 had first and second [MEDICAL CONDITION] the left ear, left base of the skull, right temporal area, nose and mouth. Review of a facility's investigation report dated 06/03/14 at 1:28 p.m. indicated the facility's RVP and RRC (administrative nurses) were summoned to the smoking area (patio) by dietary aide (A). The dietary aide said there was a fight out on the patio. However, when they got out on the patio they were told by CNA A who had been supervising the smokers that Resident # 1 had his oxygen on and that she (CNA A) was not aware he had it on and the oxygen caught fire. According to the report when the RVP and RRC arrived on the patio there was no fire. Resident # 1 was on his knees on the patio floor, he had fallen from his wheelchair when he attempted to get up. Another resident had reportedly stomped the fire out on the oxygen tubing. Resident # 1 was assessed by the RRC and found to have black discoloration around his nose. His nose was swollen and bleeding; there was also a burned area on the left posterior of his ear and scalp. There appeared to be a blister on the forth finger of his left hand. 911 was called and Resident # 1 was sent to the emergency room . Review of a nurse ' s note dated 06/03/14 at 1:30 p.m. indicated Resident # 1 was outside in the smoking area on his knees. The resident was assisted up to wheelchair and wheeled to nurse ' s station and assessed the resident for injuries from fire. Resident # 1 had a black burned area noted to his nose and on his face, his nose tip was bleeding 0.5 centimeters (cm), nose was swollen, redness was noted to his face from oxygen tubing line. Resident #1 complained of pain behind left ear, black, raised fluid filled area approximately 0.8 cm noted. Redness was noted to scalp area behind his ear approximately 3 cm x 2 cm. Resident also had fluid filled area to fore- finger on the left hand approximately 0.8 cm. Resident stated he was in pain, on a scale of 1 to 10 resident said his pain was at a 10. Respirations were even and unlabored. EMS arrived during the assessment. Review of Resident # 1's emergency room visit on 06/03/14 at 1:40 p.m. indicated the resident had a small 2nd degree burn to left ear and 3rd degree burn to intranasal and upper lip. Intranasal is black and charred. Resident # 1 was transferred to a burn center in another city. Review of the final report from Burn Center dated 06/04/14 indicated Resident # 1 had 2nd degree burn to the face. The resident was discharged to come back to the nursing facility with orders for burn care for second-degree burns. During an interview with the RVP and Director of Nurses (DON) on 06/04/14 at 1:30 p.m. they stated there was a burned area on the concrete floor out on the smoking patio where Resident # 1 had been sitting in his wheelchair. The RVP said this was where the 02 (oxygen) tubing was on fire and had been stomped out by one of the residents. During this interview an observation was made of the smoking apron and the 02 tubing the Resident #1 was wearing at the time of the incident. There were three burned areas on the apron and the nasal cannula portion of the 02 tubing that fit in the resident ' s nose was burned in half. According to the RVP CNA " A " was supervising the residents while they smoked. The CNA did not notice that Resident # 1 came out on the patio with his oxygen on. The CNA had already lit Resident # 1 ' s cigarette and had her back to him getting other resident ' s cigarettes when she heard the resident scream out, she turned to see a flash of fire. Another resident rushed over and stomped out the fire on Resident # 1's oxygen tubing. There was also a Certified Medication Aide (CMA) out on the patio during the incident passing medications and he turned off Resident # 1' s oxygen. During an interview with Certified Medication Aide ( CMA " R ") on 06/04/14 at 1:45 p.m. he said he had been out on the patio on 06/03/14 between 1 p.m. and 1:30 p.m. CMA " R " said when he came out on the patio he glanced at Resident # 1 but did not notice he had on his 02 (oxygen). The CMA said Resident # 1 sits hunched over. He said he was giving another resident her medication and had his back to Resident # 1. CMA " R " said he heard the resident scream out and turned and realized there was a fire. He said he ran to the resident, who had turned over his wheelchair and was on his knees on the ground and turned off the resident ' s oxygen. CMA " R " said he saw that the resident's face was black and burned and he smelled the odor of burnt hair. He said a nurse came outside and started helping the resident. CMA " R " said he did not know how many residents there were on the patio at the time. but there were quite a few. During an interview with CNA " A " on 06/05/14 at 9:50 a.m. she said it was her turn to do the smoke break on 06/03/14 at 1 p.m. CNA " A " said she announced the smoke break over the intercom system in the facility. She said she stood at the door to the patio and handed out the smoking aprons to the residents. She said there had been about 15 smokers outside at the time of the incident. CNA " A " said about half the smokers went back inside during and after the incident. She said the residents have 15 minutes to smoke 2 cigarettes. She said she gave each resident a cigarette and then lit them after all the residents had one. She said Licensed Vocational Nurse (LVN " B " ) came outside during the smoke break to see if a resident who was still inside the facility had any cigarettes left in the box because he wanted to come out side to smoke. She said she and the LVN looked through the box then the LVN went inside the facility. CNA " A " said Resident # 1 was on the last part of his first cigarette and was asking for his second cigarette. CNA " A " said she turned to look into the smoking box when she heard Resident # 1 cry out " Oh[***]" she said she turned and saw his face was on fire and she ran to the fire extinguisher, by that time the Certified Medication Aide (CMA " R " ) that was on the patio ran over to help Resident # 1. The other residents were pounding on the door and trying to leave the patio area. CNA " A " confirmed she had been trained on the smoking policy. She said she had not noticed that Resident # 1 still had his oxygen on when he came out to smoke. She said usually Resident # 1 and another resident who smokes take off their own oxygen tubing and turn their own oxygen off too. She said we just take the tanks off the wheelchairs and put them up in the dining room while the residents are outside. CNA " A " said for a while after the last oxygen/fire incident involving Resident #1 (04/27/14) the nurses would make sure the resident did not have their oxygen on and that it had been turned off. But lately the nurses are not automatically at the door to turn off the oxygen, we have to call them to help us and the residents are turning their own oxygen off too. During an interview and observation with Resident # 1 on 06/05/14 at 11:05 a.m. he said " I forgot to take my oxygen off. " According to Resident # 1 he was late to the smoke break and everyone was already out on the patio. He said staff opened the door for him and let him out. He said he wheeled himself onto the patio and then the staff lit the cigarette for me. He said he was taking the last drag off of his first cigarette when it exploded. Resident # 1 said he dropped down on the ground and was trying to put it out. He said it " hurt real bad " . Observation of Resident # 1 at this time revealed under his nose and up into his nares was burned and scabbed over. There was a burned and scabbed over area approximately and an inch and half long that was behind his left ear. Resident # 1 said his fingers were not burned. However there appeared to be a healed blister on the middle finger, left hand. During an interview with LVN " B " on 06/05/14 at 12:00 p.m. she said she was in the dining room when the smoke break was announced. She said she took the oxygen off of a Resident ( not Resident # 1) and followed him out onto the patio. She said there were a lot of residents going out to smoke. LVN " B " said when she was out on the patio she did not notice Resident # 1 had his oxygen on. She said she asked CNA " A " if a certain resident had any cigarettes because he wanted to come out and smoke. She said after they looked in the box she went inside to finish charting. LVN " B " said when she heard all the commotion she rushed back out to the patio and saw Resident # 1 on his knees. Staff were assisting him back into his wheelchair. LVN " B " said usually the CNA' s do the smoking breaks and will call them (charge nurses) if needed to turn off the resident' s oxygen. During an interview with CNA "P" on 06/05/14 at 3:00 p.m. she said Resident # 1 had been doing so well lately with his smoking. She said Resident # 1 had been leaving his wheelchair by the air conditioner on the patio and turning off his own oxygen off prior to sitting down at the table to smoke. Resident # 23 Review of Resident # 23 admission record indicated he was admitted to the facility on [DATE] with a readmission date of [DATE]. Admitting [DIAGNOSES REDACTED]. He was [AGE] years old. Review of the resident's MDS dated [DATE] indicated the resident had a BIMS of 8 on a scale of 0 to 15, indicating moderate cognitive impairment. The resident required limited assistance on one staff for transfers and extensive assistance of one staff for dressing, toileting and hygiene. Resident # 23 required the assistance of staff to ambulate and used an electric wheelchair for mobility. The resident utilized oxygen continuously for his [MEDICAL CONDITION] disease. Review of the resident's care plan dated 03/25/14 indicated he was a smoker and was at risk for injury due to his oxygen use. The care plan did not address the removal of the oxygen prior to smoking. The approach was listed as: monitoring when smoking and use of a smoking apron. Review of Resident # 23's smoking evaluation dated 05/08/14 indicated he had cognitive deficit with [MEDICAL CONDITION], used a wheelchair and had a BIMS of 8. Evaluation indicated the resident required oxygen and it was to be removed prior to smoke breaks. The resident also required a smoking apron. During an interview with Resident # 23 on 06/05/14 at 10:30 a.m. he said he was not on the smoking patio when the incident on 06/03/14 occurred. He said he always parks his wheelchair inside by the patio door, gets up and turns off his oxygen himself before he goes outside to smoke. Review of the facility (revised) smoking policy dated 04/16/14 indicated in part: Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas is posted with signs that read NO smoking or with the international symbol for on Smoking. All oxygen equipment must be removed from the resident's person during smoke breaks. This includes the removal of oxygen masks or nasal cannulas and oxygen canisters/tanks of any type. Review of an inservice dated 04/28/14 ( after the previous incident on 04/27/14) given by the previous Director of Nurses on the facility smoking policy indicated "in Part" # 3. Oxygen tanks are to be turned off and left inside the building by the door. Review of the signature page for the inservice indicated CNA "V" and CNA "A" had signed and acknowledge they had attending this inservice and received the training. Review of an inservice record dated 04/29/14 ( after previous incident on 04/27/14) indicated the Regional Nurse Consultant (RNC) provided an inservice to staff covering the facility smoking policy, adaptive smoking equipment, supervised smoking and no resident sign out for smoking. Review of the sign in page indicated CNA "A" signed and acknowledged she had been trained regarding removal of residents' 02 equipment prior to the supervised smoke breaks. Review of an inservice training report dated 04/30/14 (after previous incident on 04/27/14) indicated the RNC provided an inservice to staff covering "smoking/oxygen/CNA role" indicated a list of oxygen users and all apron users that would be kept in the smoking box and must be utilized without fail. Also contained in this inservice was a notification to staff that would be placed in the smoke box, that said "Attention all Staff: only licensed nursing personnel are allowed to turn off or otherwise adjust any form of oxygen delivered equipment. CNA's are not ever allowed to adjust settings on oxygen bottles prior to residents smoking. The notification listed the residents with oxygen that smoke . The notification said "These residents use oxygen and are smokers. Their oxygen has to be turned off and left beside the door before they can go out to smoke. If they refuse, they can not smoke. Oxygen is combustible and there for dangerous around any fire. Review of the sign in page indicated CNA "A", CNA "V", CMA "R" and LVN "B" all signed and acknowledged that they attended the inservice and received the training. Review of the facility Abuse and Neglect Policy and Procedure dated 11/11/11 indicated the following; Policy Statement: Our facility implements an effective system for the prevention of abuse and neglect. The facility initiates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. The facility ensures timely, thorough and objective investigations of all allegations of abuse and neglect are reported and analyzed and appropriate corrective actions occur. Interpretation and Implementation: Identify, assess, care plan and monitor residents with needs and behaviors which might lead to conflict or neglect. Identify characteristics of physical environment that may make abuse and/or neglect more likely to occur. Supervision will be provided for residents with known special needs: Impaired individuals with known elopement risk, supervised smoking will be provided for all residents of a facility and individuals with repeated occurrences such as falls which place the individual at risk of harm. Investigation: The Administrator or DON will conduct investigations. The medical record should be reviewed to determine the residents past history, condition and its relevance to the alleged incident. The facility shall make reasonable efforts to determine the cause of the alleged incident, take corrective action consistent with the investigation findings and to eliminate and ongoing dangers to the resident. Appropriate steps shall be taken to prevent recurrence of the incident. The definition of Neglect is provided: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The RVP was notified of the Immediate Jeopardy situation on 06/04/14 at 12:30 p.m. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on 06/05/14. The plan included the following: To prevent reoccurrence and ensure all other residents safety, the smoking procedure was revised to limit no more than 7 residents at a time to smoke supervised. The current staff on shift on 06/03/14 were inserviced by the DON immediately and then returned at 10 p.m. to do the 10-6 am shift. No one that has not received the training on supervising the smokers will be allowed to supervise the smokers. This will be monitored by Check Point Charlie Nurse 4 times a day. The smoking residents were educated on new immediate procedures to ensure all safety measures are in place and signed acknowledgment of revised schedule and limited smokers at the time by the marketing director. DON will monitor the PM smoke break on 06/03/14. RVP will monitor the 6:30 PM smoke break on 06/03/14 to ensure resident safety. DON revised smoking schedule to include a specific time for only oxygen users to smoke supervised to implement "Check Point Charlie" for this group. No oxygen user resident is allowed outside in the smoking area unless approved thru "Check Point Charlie" no staff member will allow resident out in smoking area until approved. "Check Point Charlie" consists of Licensed Nurse is the "Charlie", the nurse will validate that the person supervising has been trained on supervised smoking by utilizing the list of names on the sheet in front of the "Check Point Charlie" book located in a three ring binder in the dining room, in a 3 ring binder on the inside of the door. This validation will take place inside the building in the dining room. If the person is not on the list then this person will not be allowed to supervise smoke break by nurse. The Licensed Nurse will validate that the oxygen is removed off of the wheelchair or chair. The Licensed Nurse will turn the oxygen off of the resident. The Licensed Nurse will validate that the resident does not have the masks and/ or cannula on. The licensed nurse will validate that there are no more than 7 residents at a time out in smoke break. The licensed nurse will "approve" smoking break to be initiated and all residents are safe to smoke and sign the form for documentation validation. This form will be dated and timed by the Licensed Nurse. An in-service about the "Check Point Charlie" procedure was conducted on 06/04/14 by the DON to consists of licensed nurses held accountable to be at check point Charlie at the designated time. The validation was initiated immediately after incident and procedure named on 06/04/14. The training will continue to include all staff on the payroll until that is complete, only those trained on the list in the check point Charlie list will be allowed to approve the check point Charlie checklist and only those on the list will be able to supervise the smokers. Out of cycle QA was conducted by the DON, RVP and Marketing person and RRC nurse on 06/0314. Monitoring by facility: How- Nursing Dept. Manager will monitor "Check Point Charlie" system to ensure that the above system is effective by visualization of 2 Check Point Charlie smoking breaks on a daily basis alternating the times, the weekend RN manager will do this on the weekends on 2 Check Point Charlie checks. Nurse Managers will monitor that the licensed Nurse are validating safety by using the book, turning off the oxygen, showing up at scheduled time for smoke break, validating the person supervising is trained and approving the smokers safety. Evidence of the monitoring will be documented on the Check Point Charlie work sheet. (06/05/14 and will be ongoing) Out of cycle QA (Quality Assurance) conducted by the DON, RVP and Medical Director, on 06/04/14, summary of finding for the monitoring was reviewed. Out of cycle QA scheduled for Monday 06/09/14 to discuss effect of monitoring. Validation of the Plan of Removal by DADs surveyors was conducted on 06/05 and 06/06/14. Review of facility smoking policy dated 06/03/14 indicated all smoking residents with a score of 13 or below on the BIMS must wear smoking apron. No more than 7 smoking residents will be allowed at each smoke break. A separate smoke break will be assigned for residents who require oxygen. 02 tanks will be turned off by nurse and will be removed by CNA and placed in 02 holders in dining room. Once the residents are at designated smoking area CNA will pass out cigarettes, once every resident has their cigarette CNA will light them. Observation of the Check Point Charlie system on two smoke breaks on 06/05 and 06/06/14 that involved residents who use oxygen and two smoke breaks on residents who do not require oxygen indicated staff correctly followed the facility system. Licensed staff, dietary staff, medical records staff, certified medication aides and certified nursing aides on all three shifts were interviewed concerning the new smoking policy and how "Check Point Charlie" worked. All staff interviewed were able to verbalize how the system worked. Interview with resident's concerning the new smoking policy indicated all residents interviewed understood the policy. Documentation of monitoring by administrative staff was reviewed and found to be in place and appropriately completed and signed off on. The Immediate Jeopardy was removed on 06/05/14 prior to exit on 06/06/14. However the facility remained out of compliance at Actual Harm at a Pattern due to the facility's need to monitor their plan for continued effectiveness to protect the safety of smoking residents. According to a list provided by the Director of Nurses on 06/04/14 there were 18 residents who lived in the facility that smoked and three of those residents required oxygen.

Based on observations, interviews and record review the facility failed to develop and implement their policy and procedure that prohibits neglect for 2 of 6 residents reviewed for neglect related to fire safety while smoking. (Resident # 1 and 23 ) The facility failed to: 1). ensure Resident #1 was safe while smoking to prevent injury from fire. Resident # 1 had a previous history of first and second [MEDICAL CONDITION] his face and nose (04/27/14) due to smoking unsupervised while wearing his oxygen. On 06/03/14 staff failed again to supervise the resident by not removing his oxygen tank and cannula prior to him smoking. The oxygen ignited his cigarette and Resident # 1 again suffered first and second [MEDICAL CONDITION] his face, nose, nares and behind his left ear. 2). to ensure that staff followed the facility smoking policy which stated Only Licensed Nursing Staff could remove, turn off and replace oxygen on residents prior to and after smoke breaks. The facility was allowing residents who smoke and use oxygen to turn off and remove their own oxygen unsupervised prior to the resident exiting the building to smoke. (Resident # 1 and 23 ) 3). to ensure nursing administrative staff were supervising Certified Nurse Aides and licensed staff who were assigned to supervise the smoke breaks to insure residents were smoking safely. On 06/05/14 an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on 06/05/14 the facility remained out of compliance at actual harm at a pattern due to the facility' s need to evaluate and monitor their corrective action system. These failures affected Resident #1 who received 1st and 2nd [MEDICAL CONDITION] his nose, nares and behind his left ear and could have affected the 7 other residents (which include Residents # 23 ) who were smokers and on the patio at the time of the incident, placing them at risk [MEDICAL CONDITION] injuries. Findings include: Review of the facility Abuse and Neglect Policy and Procedure dated 11/11/11 indicated the following; Policy Statement: Our facility implements an effective system for the prevention of abuse and neglect. The facility initiates a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect. The facility ensures timely, thorough and objective investigations of all allegations of abuse and neglect are reported and analyzed and appropriate corrective actions occur. Interpretation and Implementation: Identify, assess, care plan and monitor residents with needs and behaviors which might lead to conflict or neglect. Identify characteristics of physical environment that may make abuse and/or neglect more likely to occur. Supervision will be provided for residents with known special needs: Impaired individuals with known elopement risk, supervised smoking will be provided for all residents of a facility and individuals with repeated occurrences such as falls which place the individual at risk of harm. Investigation: The Administrator or DON will conduct investigations. The medical record should be reviewed to determine the residents past history, condition and its relevance to the alleged incident. The facility shall make reasonable efforts to determine the cause of the alleged incident, take corrective action consistent with the investigation findings and to eliminate and ongoing dangers to the resident. Appropriate steps shall be taken to prevent recurrence of the incident. The definition of Neglect is provided: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident # 1 Review of Resident # 1 ' s admission sheet indicated he had been admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. The resident was [AGE] years old. Review of Resident # 1 ' s most current Minimum Data Set ((MDS) dated [DATE] indicated the resident's score was a 1 out of a possible 15 on the (BIMS) Brief Interview for Mental Status indicating he had severe cognitive impairment. The MDS also indicated Resident # 1 suffered from signs and symptoms of [MEDICAL CONDITION], displaying inattention, disorganized thinking and altered level of consciousness that was continuously present and did not fluctuate. According to the MDS Resident # 1 required only supervision on all of his activities of daily living, except bathing the Resident was totally dependent and required the assistance of one staff member. Resident # 1 used a wheelchair for mobility and was on oxygen therapy due to shortness of breath. Resident # 1 ' s care plan dated 04/30/14 indicated he was a smoker. Goals were that the resident will be safe and free of injury as a result of smoking for the next 90 days. Approaches were: Explain smoking policy as frequently as needed, keep smoking materials in a safe and secure place and provide them per smoking schedule, assign someone to go with the resident when he smokes so that if something should happen there will be someone there to assist. Inform the resident of inability to sign self out to leave facility grounds to smoke unless supervised. Report observations of unsupervised smoking to charge nurse or other administrative staff, report observations of resident having smoking materials other than times of supervised smoking. Provide a protective apron so that resident does not burn himself. Explain to the resident the dangers of wearing oxygen while smoking as needed and do not allow the resident to wear oxygen when smoking. Review of Resident # 1's smoking evaluation dated 05/01/14 indicated the resident was cognitively impaired with poor decision making skills with intermittent confusion and the resident had pertinent [DIAGNOSES REDACTED]. According to the assessment the resident used a wheelchair for mobility and also had a hearing impairment. The resident had expressed a desire to smoke and had a history of [REDACTED]. According to the evaluation the resident's BIMS (Brief Interview Mental Status) score was 1 out of a possible 15 indicating severe cognitive disability. The resident required a smoking apron on when smoking and the resident was able to extinguish his own cigarette. The evaluation indicated Resident # 1 wore oxygen and that all oxygen equipment must be removed during smoke breaks, which included the nasal cannulas and the oxygen canister/tank. According to the evaluation Resident # 1 had signed the facility smoking agreement. Review of an incident report dated 04/27/14 and timed at 7:50 p.m. indicated Resident # 1 had a previous injury from smoking unsupervised with his oxygen on. According to the incident report Resident # 1 had been outside of the facility on the west end of the building sitting in his wheelchair, another resident saw Resident # 1 sitting in his wheelchair, glanced away and then looked back at the resident in time to see him with a lighter, which he lit and flames shot up in from of his face. The other resident pushed Resident # 1 back into the building and yelled for help. Two CNA's brought the resident to the charge nurse. The resident's face was black from smoke and his mustache was singed off, along with a 3 inch area to the residents right temple. The resident complained of a lot of pain. A wet was cloth was applied to the resident's face and a small area of skin began to roll off the resident's nose. EMS was called and the resident was transported to the emergency room . ( A previous Immediate Jeopardy was called on this incident. See CMS 2567 dated 05/01/14) Review of a hospital emergency room Nurse Report dated 04/27/14 at 8:17 p.m. indicated Resident # 1 had first and second [MEDICAL CONDITION] the left ear, left base of the skull, right temporal area, nose and mouth. Review of a facility's investigation report dated 06/03/14 at 1:28 p.m. indicated the facility's RVP and RRC (administrative nurses) were summoned to the smoking area (patio) by dietary aide (A). The dietary aide said there was a fight out on the patio. However, when they got out on the patio they were told by CNA A who had been supervising the smokers that Resident # 1 had his oxygen on and that she (CNA A) was not aware he had it on and the oxygen caught fire. According to the report when the RVP and RRC arrived on the patio there was no fire. Resident # 1 was on his knees on the patio floor, he had fallen from his wheelchair when he attempted to get up. Another resident had reportedly stomped the fire out on the oxygen tubing. Resident # 1 was assessed by the RRC and found to have black discoloration around his nose. His nose was swollen and bleeding; there was also a burned area on the left posterior of his ear and scalp. There appeared to be a blister on the forth finger of his left hand. 911 was called and Resident # 1 was sent to the emergency room . Review of a nurse ' s note dated 06/03/14 at 1:30 p.m. indicated Resident # 1 was outside in the smoking area on his knees. The resident was assisted up to wheelchair and wheeled to nurse ' s station and assessed the resident for injuries from fire. Resident # 1 had a black burned area noted to his nose and on his face, his nose tip was bleeding 0.5 centimeters (cm), nose was swollen, redness was noted to his face from oxygen tubing line. Resident #1 complained of pain behind left ear, black, raised fluid filled area approximately 0.8 cm noted. Redness was noted to scalp area behind his ear approximately 3 cm x 2 cm. Resident also had fluid filled area to fore finger on the left hand approximately 0.8 cm. Resident stated he was in pain, on a scale of 1 to 10 resident said his pain was at a 10. Respirations were even and unlabored. EMS arrived during the assessment. Review of Resident # 1's emergency room visit on 06/03/14 at 1:40 p.m. indicated the resident had a small 2nd degree burn to left ear and 3rd degree burn to intranasal and upper lip. Intranasal is black and charred. Resident # 1 was transferred to a Burn Center in another city. Review of the final report from Burn Center dated 06/04/14 indicated Resident # 1 had 2nd degree burn to the face. The resident was discharged to come back to the nursing facility with orders for burn care for second-degree burns. During an interview with the RVP and Director of Nurses (DON) on 06/04/14 at 1:30 p.m. they stated there was a burned area on the concrete floor out on the smoking patio where Resident # 1 had been sitting in his wheelchair. The RVP said this was where the 02 (oxygen) tubing was on fire and had been stomped out by one of the residents. During this interview an observation was made of the smoking apron and the 02 tubing the Resident #1 was wearing at the time of the incident. There were three burned areas on the apron and the nasal cannula portion of the 02 tubing that fit in the resident ' s nose was burned in half. According to the RVP CNA " A " was supervising the residents while they smoked. The CNA did not notice that Resident # 1 came out on the patio with his oxygen on. The CNA had already lit Resident # 1 ' s cigarette and had her back to him getting other resident ' s cigarettes when she heard the resident scream out, she turned to see a flash of fire. Another resident rushed over and stomped out the fire on Resident # 1's oxygen tubing. There was also a Certified Medication Aide (CMA) out on the patio during the incident passing medications and he turned off Resident # 1' s oxygen. During an interview with Certified Medication Aide ( CMA " R ") on 06/04/14 at 1:45 p.m. he said he had been out on the patio on 06/03/14 between 1 p.m. and 1:30 p.m. CMA " R " said when he came out on the patio he glanced at Resident # 1 but did not notice he had on his 02 (oxygen). The CMA said Resident # 1 sits hunched over. He said he was giving another resident her medication and had his back to Resident # 1. CMA " R " said he heard the resident scream out and turned and realized there was a fire. He said he ran to the resident, who had turned over his wheelchair and was on his knees on the ground and turned off the resident ' s oxygen. CMA " R " said he saw that the resident's face was black and burned and he smelled the odor of burnt hair. He said a nurse came outside and started helping the resident. CMA " R " said he did not know how many residents there were on the patio at the time. but there were quite a few. During an interview with CNA " A " on 06/05/14 at 9:50 a.m. she said it was her turn to do the smoke break on 06/03/14 at 1 p.m. CNA " A " said she announced the smoke break over the intercom system in the facility. She said she stood at the door to the patio and handed out the smoking aprons to the residents. She said there had been about 15 smokers outside at the time of the incident. CNA " A " said about half the smokers went back inside during and after the incident. She said the residents have 15 minutes to smoke 2 cigarettes. She said she gave each resident a cigarette and then lit them after all the residents had one. She said Licensed Vocational Nurse (LVN " B " ) came outside during the smoke break to see if a resident who was still inside the facility had any cigarettes left in the box because he wanted to come out side to smoke. She said she and the LVN looked through the box then the LVN went inside the facility. CNA " A " said Resident # 1 was on the last part of his first cigarette and was asking for his second cigarette. CNA " A " said she turned to look into the smoking box when she heard Resident # 1 cry out " Oh[***]" she said she turned and saw his face was on fire and she ran to the fire extinguisher, by that time the Certified Medication Aide (CMA " R " ) that was on the patio ran over to help Resident # 1. The other residents were pounding on the door and trying to leave the patio area. CNA " A " confirmed she had been trained on the smoking policy. She said she had not noticed that Resident # 1 still had his oxygen on when he came out to smoke. She said usually Resident # 1 and another resident who smokes take off their own oxygen tubing and turn their own oxygen off too. She said we just take the tanks off the wheelchairs and put them up in the dining room while the residents are outside. CNA " A " said for a while after the last oxygen/fire incident involving Resident #1 (04/27/14) the nurses would make sure the resident did not have their oxygen on and that it had been turned off. But lately the nurses are not automatically at the door to turn off the oxygen, we have to call them to help us and the residents are turning their own oxygen off too. During an interview and observation with Resident # 1 on 06/05/14 at 11:05 a.m. he said " I forgot to take my oxygen off. " According to Resident # 1 he was late to the smoke break and everyone was already out on the patio. He said staff opened the door for him and let him out. He said he wheeled himself onto the patio and then the staff lit the cigarette for me. He said he was taking the last drag off of his first cigarette when it exploded. Resident # 1 said he dropped down on the ground and was trying to put it out. He said it " hurt real bad " . Observation of Resident # 1 at this time revealed under his nose and up into his nares was burned and scabbed over. There was a burned and scabbed over area approximately and an inch and half long that was behind his left ear. Resident # 1 said his fingers were not burned. However there appeared to be a healed blister on the middle finger, left hand. During an interview with LVN " B " on 06/05/14 at 12:00 p.m. she said she was in the dining room when the smoke break was announced. She said she took the oxygen off of a Resident ( not Resident # 1) and followed him out onto the patio. She said there were a lot of residents going out to smoke. LVN " B " said when she was out on the patio she did not notice Resident # 1 had his oxygen on. She said she asked CNA " A " if a certain resident had any cigarettes because he wanted to come out and smoke. She said after they looked in the box she went inside to finish charting. LVN " B " said when she heard all the commotion she rushed back out to the patio and saw Resident # 1 on his knees. Staff were assisting him back into his wheelchair. LVN " B " said usually the CNA' s do the smoking breaks and will call them (charge nurses) if needed to turn off the resident' s oxygen. During an interview with CNA "P" on 06/05/14 at 3:00 p.m. she said Resident # 1 had been doing so well lately with his smoking. She said Resident # 1 had been leaving his wheelchair by the air conditioner on the patio and turning off his own oxygen off prior to sitting down at the table to smoke. Resident # 23 Review of Resident # 23 admission record indicated he was admitted to the facility on [DATE] with a readmission date of [DATE]. Admitting [DIAGNOSES REDACTED]. He was [AGE] years old. Review of the resident's MDS dated [DATE] indicated the resident had a BIMS of 8 on a scale of 0 to 15, indicating moderate cognitive impairment. The resident required limited assistance on one staff for transfers and extensive assistance of one staff for dressing, toileting and hygiene. Resident # 23 required the assistance of staff to ambulate and used an electric wheelchair for mobility. The resident utilized oxygen continuously for his [MEDICAL CONDITION] disease. Review of the resident's care plan dated 03/25/14 indicated he was a smoker and was at risk for injury due to his oxygen use. The care plan did not address the removal of the oxygen prior to smoking. The approach was listed as: monitoring when smoking and use of a smoking apron. Review of Resident # 23's smoking evaluation dated 05/08/14 indicated he had cognitive deficit with [MEDICAL CONDITION], used a wheelchair and had a BIMS of 8. Evaluation indicated the resident required oxygen and it was to be removed prior to smoke breaks. The resident also required a smoking apron. During an interview with Resident # 23 on 06/05/14 at 10:30 a.m. he said he was not on the smoking patio when the incident on 06/03/14 occurred. He said he always parks his wheelchair inside by the patio door, gets up and turns off his oxygen himself before he goes outside to smoke. Review of the facility (revised) smoking policy dated 04/16/14 indicated in part: Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas is posted with signs that read NO smoking or with the international symbol for on Smoking. All oxygen equipment must be removed from the resident's person during smoke breaks. This includes the removal of oxygen masks or nasal cannulas and oxygen canisters/tanks of any type. Review of an inservice dated 04/28/14 ( after the previous incident on 04/27/14) given by the previous Director of Nurses on the facility smoking policy indicated "in Part" # 3. Oxygen tanks are to be turned off and left inside the building by the door. Review of the signature page for the inservice indicated CNA "V" and CNA "A" had signed and acknowledge they had attending this inservice and received the training. Review of an inservice record dated 04/29/14 ( after previous incident on 04/27/14) indicated the Regional Nurse Consultant (RNC) provided an inservice to staff covering the facility smoking policy, adaptive smoking equipment, supervised smoking and no resident sign out for smoking. Review of the sign in page indicated CNA "A" signed and acknowledged she had been trained regarding removal of residents' 02 equipment prior to the supervised smoke breaks. Review of an inservice training report dated 04/30/14 (after previous incident on 04/27/14) indicated the RNC provided an inservice to staff covering "smoking/oxygen/CNA role" indicated a list of oxygen users and all apron users that would be kept in the smoking box and must be utilized without fail. Also contained in this inservice was a notification to staff that would be placed in the smoke box, that said "Attention all Staff: only licensed nursing personnel are allowed to turn off or otherwise adjust any form of oxygen delivered equipment. CNA's are not ever allowed to adjust settings on oxygen bottles prior to residents smoking. The notification listed the residents with oxygen that smoke . The notification said "These residents use oxygen and are smokers. Their oxygen has to be turned off and left beside the door before they can go out to smoke. If they refuse, they can not smoke. Oxygen is combustible and there for dangerous around any fire. Review of the sign in page indicated CNA "A", CNA "V", CMA "R" and LVN "B" all signed and acknowledged that they attended the inservice and received the training. The RVP was notified of the Immediate Jeopardy situation on 06/06/14 at 12:30 p.m. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on 06/05/14. The plan included the following: To prevent reoccurrence and ensure all other residents safety, the smoking procedure was revised to limit no more than 7 residents at a time to smoke supervised. The current staff on shift on 06/03/14 were inserviced by the DON immediately and then returned at 10 p.m. to do the 10-6 am shift. No one that has not received the training on supervising the smokers will be allowed to supervise the smokers. This will be monitored by Check Point Charlie Nurse 4 times a day. The smoking residents were educated on new immediate procedures to ensure all safety measures are in place and signed acknowledgment of revised schedule and limited smokers at the time by the marketing director. DON will monitor the PM smoke break on 06/03/14. RVP will monitor the 6:30 PM smoke break on 06/03/14 to ensure resident safety. DON revised smoking schedule to include a specific time for only oxygen users to smoke supervised to implement "Check Point Charlie" for this group. No oxygen user resident is allowed outside in the smoking area unless approved thru "Check Point Charlie" no staff member will allow resident out in smoking area until approved. "Check Point Charlie" consists of Licensed Nurse is the "Charlie", the nurse will validate that the person supervising has been trained on supervised smoking by utilizing the list of names on the sheet in front of the "Check Point Charlie" book located in a three ring binder in the dining room, in a 3 ring binder on the inside of the door. This validation will take place inside the building in the dining room. If the person is not on the list then this person will not be allowed to supervise smoke break by nurse. The Licensed Nurse will validate that the oxygen is removed off of the wheelchair or chair. The Licensed Nurse will turn the oxygen off of the resident. The Licensed Nurse will validate that the resident does not have the masks and/ or cannula on. The licensed nurse will validate that there are no more than 7 residents at a time out in smoke break. The licensed nurse will "approve" smoking break to be initiated and all residents are safe to smoke and sign the form for documentation validation. This form will be dated and timed by the Licensed Nurse. An in-service about the "Check Point Charlie" procedure was conducted on 06/04/14 by the DON to consists of licensed nurses held accountable to be at check point Charlie at the designated time. The validation was initiated immediately after incident and procedure named on 06/04/14. The training will continue to include all staff on the payroll until that is complete, only those trained on the list in the check point Charlie list will be allowed to approve the check point Charlie checklist and only those on the list will be able to supervise the smokers. Out of cycle QA was conducted by the DON, RVP and Marketing person and RRC nurse on 06/0314. Monitoring by facility: How- Nursing Dept. Manager will monitor "Check Point Charlie" system to ensure that the above system is effective by visualization of 2 Check Point Charlie smoking breaks on a daily basis alternating the times, the weekend RN manager will do this on the weekends on 2 Check Point Charlie checks. Nurse Managers will monitor that the licensed Nurse are validating safety by using the book, turning off the oxygen, showing up at scheduled time for smoke break, validating the person supervising is trained and approving the smokers safety. Evidence of the monitoring will be documented on the Check Point Charlie work sheet. (06/05/14 and ongoing) Out of cycle QA (Quality Assurance) conducted by the DON, RVP and Medical Director, on 06/04/14, summary of finding for the monitoring was reviewed. Out of cycle QA scheduled for Monday 06/09/14 to discuss effect of monitoring. Validation of the Plan of Removal by DADs surveyors was conducted on 06/05 and 06/06/14. Review of facility smoking policy dated 06/03/14 indicated all smoking residents with a score of 13 or below on the BIMS must wear smoking apron. No more than 7 smoking residents will be allowed at each smoke break. A separate smoke break will be assigned for residents who require oxygen. 02 tanks will be turned off by nurse and will be removed by CNA and placed in 02 holders in dining room. Once the residents are at designated smoking area CNA will pass out cigarettes, once every resident has their cigarette CNA will light them. Observation of the Check Point Charlie system on two smoke breaks on 06/05 and 06/06/14 that involved residents who use oxygen and two smoke breaks on residents who do not require oxygen indicated staff correctly followed the facility system. Licensed staff, dietary staff, medical records staff, certified medication aides and certified nursing aides on all three shifts were interviewed concerning the new smoking policy and how "Check Point Charlie" worked. All staff interviewed were able to verbalize how the system worked. Interview with resident's concerning the new smoking policy indicated all residents interviewed understood the policy. Documentation of monitoring by administrative staff was reviewed and found to be in place and appropriately completed and signed off on. The Immediate Jeopardy was removed on 06/05/14 prior to exit on 06/06/14. However the facility remained out of compliance at Actual Harm at a Pattern due to the facility's need to monitor their plan for continued effectiveness to protect the safety of smoking residents. According to a list provided by the Director of Nurses on 06/04/14 there were 18 residents who lived in the facility that smoked and three of those residents required oxygen.

Based on observation, interview and record review, the facility failed to implement policies and procedures that prohibited neglect for ten (Resident #1,#11, #12, #13,#15, #16, #17, #18, #19 and #20) of ten residents reviewed reviewed for Neglect. The facility failed to: 1) ensure Resident #1's physician ordered wanderguard was implemented as ordered following an incident on 3/27/14 2) ensure residents who smoked, only did so in the designated smoking area during designated smoking times per the facility Smoking Policy. 2) ensure residents including Resident #1 and Resident #12, did not have access to smoking paraphenalia in the facility pre the facility Smoking Policy. 3) ensure residents had been assessed and safety measures had been implemented on the residents Care Plan to reflect each individual resident's smoking safety needs. 4) ensure appropriate monitoring per the facility Smoking Policy and Sign In/Out policy, was in place regarding Resident #1, who was oxygen dependent, signing In/Out to smoke outside of the facility unsupervised and [MEDICAL CONDITION] from smoking with oxygen on. An Immediate Jeopardy (IJ) was identified on 4/29/14. While the IJ was removed on 5/01/14, the facility remained out of compliance at a level of Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of corrective systems. These failures affected Resident #1 who received 1st and 2nd [MEDICAL CONDITION] his face and could have affected any of the facility's 23 residents who were identified to smoke cigarettes by placing the residents at risk of burns, potential fires and death. The findings included: Resident #1 Review of Resident #1's Admission Record the [AGE] year old male was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1's consolidated Physician order [REDACTED]. Review of Resident #1's quarterly Minimum (MDS) data set [DATE] indicated the resident had been identified with a BIMS score of 1 of a possible 15, indicating the resident had severe cognitive impairment. The resident was identified as requiring only supervision for all activities of daily living. Review of an Incident and Accident report dated 3/27/14 at 9:20 p.m. indicated the following: A local police officer arrived at the building pushing Resident #1 in his wheelchair. The officer reported to the nurse that they had received a call that someone had fallen across the street from the nursing home. When the officer went to the park, he noticed Resident #1 lying on the ground next to his wheelchair. The officer assisted the resident back into his wheelchair and back to the facility. Resident #1 was assessed by the nurse and had no injuries. The resident ' s physician and responsible party were notified. The resident stated he would not leave the facility grounds again. While investigating the incident it was determined the resident had signed himself out of the facility. No documentation of the Conclusions and Interventions of the incident by the Supervisor/Department Director of Nursing/ Designee Follow-up was found. Review of the Police Departments Call for Service Report dated 3/27/14 at 9:07 p.m. indicated the following: Subject was found sitting under a tree in the park across the street from the nursing facility. The subject was outside smoking a cigarette and as he was making his way back to the facility he fell out of his wheelchair. The subject advised he was not injured and refused medical attention and that he often falls from his wheelchair. The subject was escorted back to the facility and the staff was notified of his fall. Review of a Release of Responsibility for Absence Sign In/Out sheet indicated the resident had signed himself out of the facility on 3/27/14 at 8:30 p.m. Review of Resident #1's Nursing Notes dated 3/27/14 at 9:30 p.m. indicated the following; A police officer brought the resident into the building. The officer stated that a passerby had called and reported a person on the ground. The resident stated he had slid out of his wheelchair. He denied any pain and/or injuries. Hospice Nurse to notify physician. Resident ' s responsible party was notified. Review of an Incident Report Log dated March 2014 indicated on 3/27/14; Resident #1 had been outside of the facility and was found on the ground. Contributing factors were listed as: Resident reported he had slipped out of his wheelchair. Interventions to Prevent Reoccurrences: Will place a wanderguard on the resident per IDT. Review of Resident #1 ' s Physician order [REDACTED]. Signed by the DON. Review of Resident #1's MAR indicated [REDACTED]. Review of Resident #1's Care Plan with a review dated of 4/02/14 indicated the following: --Problem: Resident to smoke supervised while in the facility. Resident can also Sign Out on pass and leave the facility with his cigarettes. Goals: Resident will be safe while smoking over the next 90 days. Resident will be free of injury as a result of smoking over the next 90 days. Approaches: Resident needs the nurse to; monitor ability to smoke safely every three months, keep smoking materials in a safe and secure place and provide them to resident per smoking schedule, Provide a protective apron while smoking so the resident does not burn himself, Assign someone to go with resident to smoke so that if something should happen there is assistance there to help the resident. (There was no documentation located in Resident #1's comprehensive Care Plan regarding the implementation of a wanderguard for the resident's safety.) Review of Resident #1's Nursing Notes dated 4/26/14 on the 2:00 p.m. to 10:00 p.m. shift indicated the following entry: Resident out front smoking multiple times in between scheduled smoke breaks. Signed by LVN P Review of an Incident and Accident Report dated 4/27/14 at 7:50 p.m. indicated the following; Resident #1 had been outside of the facility on the west end of the building sitting in his wheelchair. Another resident (Resident #11) saw Resident #1 sitting in his wheelchair, glanced away and then looked back at the resident in time to see him with a lighter, which he lit and flames shoot up in front of his face. Resident #11 pushed Resident #1 back into the building and yelled for help. CNA J and CNA K brought Resident #1 to the charge nurse. The resident ' s face was covered in black smoke; his mustache was singed off, along with a 3 inch area to the resident ' s right temple. Resident had complaints of " A lot of Pain " . A wet washcloth was applied to the resident ' s face and a small area of skin began to roll off the resident ' s nose. EMS was called. Resident #1 ' s vital signs were documented as: Blood Pressure of 217/114, heart rate of 89, and Oxygen saturation of 97%. Conclusions and Interventions of the incident by the Supervisor/Department Director of Nursing/ Designee Follow-up indicated the following: Interventions in Place to Prevent Incident was left blank. Interventions Needed to Prevent Recurrence was: Place wanderguard on the resident. Review smoking policy with the resident. Issue the resident a discharge letter. Signed by the DON and Administrator. Review of a Release of Responsibility for Absence Sign In/Out sheet indicated the resident had signed himself out of the facility on 4/27/14 at 7:40 p.m. Review of Resident #1's Nursing Notes dated 4/27/14 at 7:50 p.m. indicated two CNA's came pushing the resident down the hall towards the nurse, stating another resident had brought him in from outside of the facility stating that he had burned himself with a lighter while his oxygen was on. Quickly assessed the resident. The resident was noted to have blackened soot covering his face, parts of his mustache was singed. Attempted to remove soot with a damp washcloth and the skin began to roll off the resident ' s nose. The resident was noted to have a 3 inch diameter singed area to the right side of his head at the temple area. Resident vital signs assessed and found to have: Blood Pressure of 217/114, heart rate of 89, respirations of 22. The resident denies shortness of breath. EMS notified. At 8:00 p.m. the resident was transferred to the emergency room via EMS. Physician notified. Responsible party notified. At 8:10 p.m. spoke with Resident #11. She said she was outside on the sidewalk in front of the building when she noticed Resident #1 sitting on the sidewalk near the west end of the building. She said she asked Resident #1 what he was doing; however the resident had ignored her. She said she glanced away and when she looked back at him he was lighting a lighter close to his face and flames shot up in front of him. She said she ran to the resident, the flames were out at that time, and she rushed the resident into the facility where she turned him over to the CNA's. Review of a hospital emergency room Nurse Report indicated the following; the patient arrived to the emergency roiagnom on [DATE] at approximately 8:17 p.m. Diagnoses: [REDACTED]. Triage Assessment: Pain: complaints of pain in the resident ' s nose and mouth. Pain is currently 10 out of 10 on a 1-10 pain scale. General: appears uncomfortable, smells of singed hair. Respiratory: Airway is patent respiratory effort is unlabored. [MEDICAL CONDITION] his nose, lips, facial hair around the mouth and nose, singed hair in nasal passages. Injury Description:[MEDICAL CONDITION] to left ear, left base of the skull, right temporal area, nose and mouth. The patient has First and Second Degree burns. Outcome: at 11:12 p.m. the facility was contacted regarding the patients release back to the facility. Instructions given for after care and follow up with wound care. Review of a hospital emergency room Physician Report indicated the following; the patient arrived to the emergency roiagnom on [DATE] at approximately 8:17 p.m. The patient is a [AGE] year old male who presents to the emergency department via EMS with complaints of facial burns. The patient presents with [MEDICAL CONDITION] a result from lighting a cigarette with his oxygen on. Burn type and severity: 1st [MEDICAL CONDITION] 0.7% total body surface area with 1st [MEDICAL CONDITION] the face. 2nd [MEDICAL CONDITION] 0.3% total body surface with 2nd [MEDICAL CONDITION] the face. Associated signs and symptoms: The patient possibly suffered an inhalation injury from smoke. Review of Resident #1 ' s Physician order [REDACTED]. Signed by the DON. Review of Resident #1 ' s MAR indicated [REDACTED]. Review of the resident ' s entire clinical record indicated the resident did not have a smoking assessment to determine if he was safe to smoke and no care plan was located regarding the residents wanderguard device. Review of Resident #1 ' s care plan dated 4/28/14 indicated a problem Resident is a smoker and at risk for injury related to oxygen use. Goal was the resident will smoke in designated areas without occurrence of injury for 90 days. Approaches were as follows: 1) Perform smoking assessment according to the facility policy 2) Explain/show were designated smoking areas are and smoking times 3) Monitor When needed to assure residents safety 4) Keep all smoking material at nurses station 5) Use smoking vest when appropriate. Review of the facility Investigation/Corrective Actions Report dated 4/28/14-4/29/14 indicated the following; " On 4/27/14 at approximately 7:50 p.m., Resident #1 was smoking unsupervised on the northwest side of the facility. Documentation (Sign out Book) reveals that the resident had signed himself out of the facility at 7:40 p.m. prior to going outside and the incident ensuing. When Resident #1 attempted to light his cigarette, the oxygen flow from his nasal cannula ignited. The resident [MEDICAL CONDITION] his face, (primarily to his nose) and singed his facial hair. Another resident witnessed the ignition incident and alerted staff of the situation. Resident #1 was brought back into the facility and assessed by the LVN charge nurse. Local EMS was notified and staff monitored the resident until their arrival. Resident #1 was treated at the local emergency room and returned to the facility with instructions for follow-up at the local wound care center. " " On the evening of the incident, the LVN charge nurse completed the appropriate paperwork, notified the physician, notified the sister, notified the Hospice provider and notified the DON. It was found with investigation, that the DON failed to notify RNC and RVP per cooperate policy (notification required with any incidents in which resident requires treatment ordered by the physician or ER evaluation). The Administrator reports that he was not notified the evening of the incident. " " Investigation reveals a history of the resident attempting (some successful) of smoking unsupervised at non-scheduled smoking times. " " The Administrator was informed of the burn incident on the morning of 4/28/14 and subsequently notified the RNC, RVP and VP of clinical operations. A Roam Alert device (wanderguard) was initiated to aide in the prevention of any similar reoccurrence. Resident #1 initially stated he had obtained the cigarette from his sister and then stated he had hid a cigarette in his pocket during smoke break. Interviewing with staff on 4/28/14 revealed inconsistency in relation to following policy. " " In conclusion; a lack of sufficient staff training, resident supervision, and adherence to policy culminated in the incident with Resident #1 being harmed. Corrective and preventative measures were begun on the morning of 4/28/14 and are on-going to ensure resident safety and substantial compliance. " Signed by the RNC During an observation/interview on 4/29/14 at 10:30 a.m. Resident #1 was observed sitting on his bed in his room. The resident had red/white/and black patches to his nose, lips and cheeks. The resident ' s mustache hair was singed and missing in areas and the resident had large raised blistered areas to his lips. The resident ' s nose and nares had blisters which were bleeding in areas. Resident #1 said he was in severe pain. Resident #1 was observed to have a wanderguard in place on his right wrist. Resident #1 said he had been outside in the pasture smoking and had forgotten to take his oxygen off. He said he had hid a cigarette and lighter from smoke break and had signed himself out to go smoke. He said when he lit the lighter, there was a flash of fire and the nasal cannula tubing had melted to his face. He said he yanked the tubing off and began stomping it in order to stop the fire from going up through the tubing and blowing up the tank. He said while heading back into the facility, Resident #11 had found him. He said Resident #11 ran to help him back into the facility. He said a CNA took him to the nurse. He said he had been transferred to the emergency room via ambulance and treated for [REDACTED]. He said he was very upset about being discharged from the facility, that he really loved living there. During an interview with the Regional RNC on 04/29/14 at 4:20 p.m. he said the facility did not do smoking assessments. The RNC was shown care plans for residents that smoke that indicated one of the approaches was that the facility was going to do smoking assessments on the residents that smoked. After reviewing the care plans the RNC said that the intervention of smoking assessments was a mistake and should have been omitted from the care plans. The RNC said after the facility developed their smoking policy it required all smokers to be supervised, so there was not a need for each resident to have a smoking assessment. The Regional RNC could not explain how care plans were developed for smokers without a smoking assessment. The RNC confirmed the issue with the assessments and care plans were conflicting. Review of a care plan for Resident #1 dated 04/30/14 indicated a problem that the resident was a smoker. Goal was to be safe and free from injury while smoking cigarettes over the next 90 days. Approaches were as follows: (1) Explain smoking policy as frequently as needed; keep smoking materials in a safe and secure place. (2) Provide them to the resident as per smoking schedule. (3) Assign someone to go with resident when he smokes in case something should happen someone will be there, (4) inform the resident he is unable to sign out to go smoke unless someone is supervising him, (5) Report observations of unsupervised smoking to charge nurse or other administrative staff, (6) Report observations of resident having smoking materials in possession at times other than during supervised smoking On 05/01/14 the Corporate RNC gave the surveyors a smoking evaluation on Resident #1 dated 05/01/14. According to the smoking evaluation Resident #1 was moderately cognitively impaired with intermittent confusion, cognitive deficit or disoriented at time with a BIMS of 11. According to the evaluation the resident did require a protective apron. Resident #11 Admission Face sheet indicated Resident #11 was admitted on [DATE] from psychiatric facility and was [AGE] years old female with the following Diagnoses: [REDACTED]. Annual MDS dated [DATE] indicated Resident #11 had a BIMS score of 10 out of a possible 15, which indicated the resident, had moderate cognitive impairment with disorganized thinking. The resident required supervision with bathing but was independent in all other areas of Activities of Daily Living. The resident was continent of bowel and bladder. Review of Resident #11's entire clinical record indicated no smoking evaluation had been conducted to determine if the resident was safe to smoke. Review of Resident #11's Nurse ' s notes dated 12/6/13, 01/20/14, 03/05/14 and 03/21/14 indicated the resident was a smoker and took scheduled smoke breaks. Review of Resident #11's Care Plan dated 02/28/14 indicated there was no care plan addressing the resident ' s safety while smoking until 04/28/14 (after the incident with Resident #1). On 04/28/14 the facility developed a care plan for Resident #11 that indicated the resident was a smoker and was at risk for injury. The goal was the resident would smoke in designated areas without occurrence of injury over the next 90 days. Approaches were: (1) The resident will have a smoking assessment according to facility policy. (note: facility ' s current smoking policy dated 11/12/12 does not require the facility to do smoking evaluations) (2) Explain/show where designated smoking areas are and smoking times- repeat PRN (3) Monitor PRN when smoking to assure residents safety. (4) Keep all smoking material at nurses' station (5) Uses smoking vest- when appropriate Review of another smoking care plan dated 04/30/14 indicated other approaches had been added: Which included: (1) " Assign someone to go with me with I smoke so that if something should happen I have someone there to assist and help me. " (2) Inform the resident of unable to sign out to leave the facility grounds to smoke unless supervised. (3) Report observations of unsupervised smoking to charge nurse or other administrative staff. Resident #12 According to the resident ' s admission sheet he was admitted on [DATE] from a psychiatric facility. Resident #12 was [AGE] years old at the time of this investigation. Admission diagnose were as follows: [MEDICAL CONDITIONS], Diabetes Mellitus, uncontrolled, [MEDICAL CONDITIONS], anxiety, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], asthma and reflux disease. Review of Resident #12 ' s current MDS dated [DATE] indicated the resident had a BIMS score of 12 out of a possible 15 indicating he had moderate cognitive impairment. Resident #12 also had [MEDICAL CONDITION] with inattentiveness and disorganized thing that was continuous throughout the day and did not fluctuate. The resident ' s mood indicated he was depressed with feelings of hopelessness, little interested or pleasure in doing things, had little energy, trouble falling or staying asleep, overeating, and felt bad about himself. According to the MDS Resident #12 needed supervision for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use and personal hygiene. The resident was totally dependent on staff for bathing. Resident #12 was not steady, only able to balance with staff assistance while moving from seated to standing, walking, turning around, moving on and off the toilet and surface to surface transfers. The resident also had impaired range of motion on both sides of his upper and lower extremities and used an electric wheelchair for mobility. Resident #12 was continent of bladder and bowel. Review of Resident #12 ' s care plan dated 11/12/12 indicated the resident was a supervised smoker while in the facility. According to the care plan the resident could also sign himself out on pass and he could take his cigarettes with him. The care plan goal was the resident would be free of injury as a result of smoking over the next 90 days. Approaches were as follows: (1) Monitor my ability to smoke safely every three months. (2) Keep my smoking materials in a safe and secure place. Provide them to me as per smoking schedule. (3) Provide a protective apron while I am smoking so that I don't not burn myself. (4) Assign someone to go with me when I smoke so that if something should happen I have someone there to assist and help me. (5) If I sign out on pass and take my cigarettes with me, while on pass I am responsible for my own cigarettes. I have been advised of the facility smoking policy and understand the policy. I have been advised of the city ordinances on smoking. This care plan was updated on 12/5/12 and 02/08/13. According to monthly summaries dated June and October 2013 Resident #12 was a heavy smoker. (Note: there were not any monthly summaries after October 2013 for this resident.) During an interview with the administrator on 04/29/14 at 10:10 a.m. he said on 04/28/14 during a room search for smoking materials, Resident #12 was found with cigarettes in his room. Review of a care plan dated 04/28/14 indicated Resident #12 was a smoker and was at risk for injury. The care plan goal was will smoke in designated areas without occurrence of injury over the next 90 days. Approaches were as follows: (1) Perform smoking assessment according to facility policy, (2) explain/show where designated smoking areas are and smoking times-repeat PRN, (3) monitor PRN (as needed) when smoking to assure resident ' s safety, (4) Keep all smoking material at nurses station, use smoking vest when appropriate. Review of another care plan dated 04/30/14 indicated Resident #12 was a smoker. The care plan goal was to keep resident safe while smoking for the next 90 days. Approaches were as follows: (1) Explain smoking policy as frequently as needed, keep smoking materials in a safe and secure place. (2) Provide the to the resident as per smoking schedule. (3) Assign someone to go with resident when he smoked in case something should happen someone will be there, inform the resident he is unable to sign out to go smoke unless someone is supervising him, (4) Report observations of unsupervised smoking to charge nurse or other administrative staff, (5) Report observations of resident having smoking materials in possession at times other than during supervised smoking. Review of Resident #12 entire clinical revealed that the resident had not had a smoking evaluation to determine if he was safe to smoke. On 05/01/14 the Corporate RNC gave the surveyors a smoking evaluation dated 05/01/14 on Resident #12. According to the smoking evaluation Resident #12 was cognitively impaired and required the use of an apron when smoking. Resident #13 According to Resident #13 admission sheet he was admitted from an acute care hospital on [DATE]. The admitting [DIAGNOSES REDACTED]. The resident was 67 at the time of this investigation. According to Resident #13 ' s hospital history and physical he was 02 dependent, had a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Review of the resident ' s latest MDS dated [DATE] indicated the resident had a BIMS of 13 out of a possible 15 indicating he was cognitively intact. However he did have [MEDICAL CONDITION] with inattentiveness that fluctuated throughout the day and continuous disorganized thinking. According to the MDS Resident #13 ' s mood indicated that he had little interest or pleasure in doing things, was depressed, had little energy and problems with sleeping. Resident #13 ' s functional status indicated he required supervision with bed mobility, transfers, locomotion on and off the unit, and eating. Resident #13 required extensive assistance with two staff for dressing, extensive assistance with one staff for personal hygiene and limited assistance of two staff with toilet use. Resident #13 was occasionally incontinent of bowel and bladder. According to the resident ' s MDS he was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, and moving on and off the toilet and surface to surface transfers. Review of a nurses' note dated 03/06/14 at 9:25 a.m. indicated a nurse had called Resident #13 ' s doctor and told him that the resident had been caught multiple times smoking with his 02 on despite several warnings. During an interview with LVN F on 05/01/14 at 3:30 p.m. she said after reading the nurses ' notes on Resident #13 dated 03/06/14 it appeared the resident was caught multiple times with his 02 on and smoking. She said she did not have any direct knowledge of any incidents. LVN F said the nurse that wrote the note does not work at the facility anymore. During an interview on 05/01/14 at 3:35 p.m. the note dated 03/06/14 was shown to the Regional VP and the Regional RN Consultant. They confirmed and acknowledged that an incident report should have been written on any incident that involved a resident smoking inside the facility with 02 on. They stated these are some of the problems they are facing in the facility and they are trying to work on them. Review of an incident report dated 03/09/14 indicated Resident #13 was found by another resident at about 11:00 a.m. smoking in the B Hall common bathroom/shower room. The nurse attempted to remove the cigarette from the resident and he became very angry and was cursing and hitting out at the nurse. Review of a nurses ' note dated 03/09/14 at 11:05 a.m. indicated the resident was found smoking in the B Hall bathroom/shower. Resident was put on Q 15 minute checks and the administration, family and doctor were notified. During an interview with LVN I on 05/01/14 at 11:15 a.m. she said Resident #13 went into the B Hall shower room. She said she got up to check on the resident and found him smoking in the shower room. LVN I said she took the cigarette and lighter away from the resident and he got very upset. The Resident told the nurse he got the cigarette and lighter when he went out on pass with his brother. Review of a Nurses Notes dated 03/10/14 at 2:24 p.m. indicated Resident #13 was going into B Hall bathroom/shower. Staff noted he was in the bathroom a long time. When the staff checked on him he was noted to be smoking in the bathroom. Cigarettes were taken away from him. Review of the incident log indicated there was no entry in the log concerning Resident #13 for 03/10/14 that reported the resident was caught smoking again. There were no notations in the Nurses Notess that the incident was reported. Review of the resident ' s care plan dated 03/12/14 indicated there was no care plan for safe smoking until 04/28/14 despite the fact the resident had been caught smoking in the facility on at least 3 occasions. Review of a care plan dated 04/28/14 indicated the resident was a smoker and was at risk for injury, related to oxygen use, [MEDICAL CONDITION], dementia and Parkinson disease. The approaches were the same as the other residents who smoked in the facility. Approaches were as follows: (1) The resident will have a smoking assessment according to facility policy. (Note: facility ' s current smoking policy dated 11/12/12 does not require the facility to do smoking evaluations) (2) Explain/show where designated smoking areas are and smoking times- repeat PRN (3) Monitor PRN when smoking to assure residents safety. (4) Keep all smoking material at nurses ' station (5) Uses smoking vest- when appropriate Review of Resident #13 ' s entire clinical record indicated the facility had not done a smoking evaluation on the resident to ensure he was safe to smoke Review of another care plan for Resident #13 dated 04/30/14 indicated Resident #13 was a smoker. The care plan goal was to keep resident safe and free from injury while smoking for the next 90 days. Approaches were as follows: (1) Explain smoking policy as frequently as needed, (2) Keep smoking materials in a safe and secure place. Provide them to the resident as per smoking schedule. (3) Assign someone to go with resident when he smokes in case something should happen someone will be there, (4) inform the resident he is unable to sign out to go smoke unless someone is supervising him, (5) Report observations of unsupervised smoking to charge nurse or other administrative staff, report observations of resident having smoking materials in possession at times other than during supervised smoking. On 05/01/14 the Corporate RNC gave the surveyors a smoking evaluation on Resident #13 dated 05/01/14. According to the smoking evaluation Resident #13 was cognitively impaired and required the use of an apron when smoking. Resident #15 Review of Resident #15 admission sheet indicated she was [AGE] years old at the time of this investigation. Resident #15 was admitted to the facility on [DATE] from an acute care hospital. Her admission [DIAGNOSES REDACTED]. The resident also had a [MEDICAL CONDITION] and nephrostomy tube. Review of the resident ' s most current MDS dated [DATE] indicated Resident #15 had a BIMS score of 9 out of a possible 15 indicating she was moderately cognitively impaired and had disorganized thinking. The resident ' s mood indicated she had little interest or pleasure in doing things, she felt down and depressed and had trouble falling asleep and staying asleep. Resident #15 had little energy and had trouble concentrating on things such as a newspaper or watching TV. Resident #15 was assessed to have problems with her behaviors, such as screaming, cussing and threatening to others on a daily basis. Resident #15 ' s required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. She required only supervision with locomotion on and off the unit and used an electric wheelchair. Review of Resident #15's care plan dated 11/12/12 and updated on 02/26/14 indicated that the resident was a smoker and smoked supervised in the facility, but also signed herself out to go on pass and could take her cigarettes with

Based on interviews, and record review, it was determined the facility failed to ensure they followed their policy and procedure regarding investigations of Incidents/Accidents for one (Resident #2) of 10 residents reviewed for safety devices. The facility failed to: 1) ensure LVN D completed an Incident/Accident report on [DATE] when Resident #2 had a unwitnessed fall 2) ensure the Adminsitrator and/or DON performed an Internal investigation to rule out abuse/neglect 3) ensure LVN D documented a complete Nursing assessment following the residents unwitnessed fall on [DATE] in Resident #2 ' s Nursing Notes 4) ensure a Neurological Assessment Flow Sheet was initiated and maintained for 72 hours following Resident #2 ' s unwitnessed fall. 5) ensure Resident #2 ' s physician and responsible party were notified of the incident. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of no Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of corrective systems. Theses failures could affect any of the 13 residents identified with safety devices and place them at risk of experiencing a change in condition, unidentified injuries and possible decline in health status. The findings included: Review of Resident #2's Admission Record the [AGE] year old male was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's consolidated Physician order [REDACTED]. --Order dated [DATE] for the resident to have a bed alarm per the IDT (Interdisciplinary Team). --Order dated [DATE] for the resident to have a chair alarm per the IDT --Order dated [DATE] for the resident to have a seat belt alarm per the IDT Review of Resident #2's annual Minimum (MDS) data set [DATE] indicated the following the resident had been identified with a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15; indicating severe cognitive impairment. Resident #2 was identified with inattention and disorganized thinking. Resident #2 required extensive assistance of one to two staff with activities of daily living. Resident #2 was identified with functional range of motion limitations on both upper and lower extremities. Resident #2 was identified with one fall with no injuries. Review of Resident #2's comprehensive Care Plan updated [DATE] indicated the following: --Problem: Resident has a history of falling related to being noncompliant with not transferring himself. Goals: Resident will remain free from injury Approaches: Equip resident with device that monitors rising. Seat belt alarm and bed alarm. Give resident verbal reminders not to ambulate/transfer without assistance. Keep call light in reach. Keep personal items within reach. -- Problem: The resident has multiple problems that affect his ability to think clearly. He is supposed to use a bed alarm at night to alert staff that he is rising without the assistance and endangering himself. Goal: Resident will be safe and not have a major accident over the next 90 days. Approaches: Anticipate when resident needs something. Ensure that the resident has his bed alarm on and that it is checked every two hours during the night. (No documentation was found in the Resident ' s clinical record regarding the Resident's alarm being checked every two hours) Review of Resident #2's quarterly Minimum (MDS) data set [DATE] indicated the resident had been identified with one fall with no injuries since admission. Review of Resident #2's Medication Administration Record [REDACTED]. There was no documentation of monitoring the Resident ' s alarms on the 2:00 p.m. to 10:00 p.m. shifts or the 10:00 p.m. to 6:00 a.m. shifts. Review of an Incident and Accident Report Dated [DATE] at 4:00 p.m. indicated Resident #2 was found on the floor in his room. The resident reported to the nurse he was [MEDICATION NAME] putting himself to bed due to the resident feeling as if he was going home the next week. The resident received a skin tear to his left arm and abrasions to his right knee. Physician and family notified. Signed by the DON and Administrator. Review of Resident #2's Nursing Notes dated [DATE] at 4:00 p.m. indicated the resident had been found on the floor by a CNA. Resident #2 was assisted to bed. Unwitnessed fall, neurological checks started. Resident stated he had plans to go home the next week and was [MEDICATION NAME] putting himself to bed. When asked why his alarm did not sound, the resident stated he had turned his alarm off. Resident was assessed and found to have a skin tear to his left lower arm and an abrasion to his right knee. Review of Resident #2's Nursing Notes dated [DATE] indicated the resident was out on pass with his wife. On [DATE] the resident was admitted to the hospital. Review of Resident #2's hospital History and Physical dated [DATE] indicated the resident had been admitted to the hospital with [REDACTED]. Review of Resident #2's hospital Discharge Summary dated [DATE] indicated the following; Resident #2's discharge [DIAGNOSES REDACTED]. Resident #2's functional status was listed as: impaired mobility. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Nursing Notes dated [DATE] at 4:00 p.m. Resident #2 had arrived at the facility via facility van. The resident was noted to have multiple bruises and skin tears " all over " , a dressing to the right side of his neck and a 3 small open areas to the residents buttocks which measured 2 cm and smaller. Review of Resident #2's Fall Risk assessment dated [DATE] indicated the resident had been identified with a total score of 24. (Instructions indicated: If the total score is more than 10 or greater, the resident should be considered HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the residents care plan) During an interview on [DATE] at 5:15 a.m. LVN A said she had been off on [DATE] and [DATE]; however she had been informed the resident had a fall during the early morning hours of [DATE]. She said the incident had been documented on the 24 hour report. She said she was not aware of any new interventions which had been implemented due to the fall. She said she had been informed the resident had been out on pass with his wife and had fallen at home, was then transferred to the hospital via EMS, and had fallen at the hospital following his admission. She said the resident had been admitted back to the facility on [DATE]. She said the resident had been found non- responsive at 3:15 a.m. on [DATE], CPR had been initiated, and she had received report from the hospital at 4:30 a.m. that the resident had expired. She said the resident had severe tremors and spastic muscle movements and had recently experienced several episodes in which his O2 saturation had been assessed to be in the 70% range due to the resident knocking his oxygen off. She said she was aware of the resident being a fall risk, and the resident was to have a bed alarm, chair alarm and seat belt alarm. She said there had been occasions in which the resident had turned his alarm off and required redirection from the staff. During an interview on [DATE] at 5:25 a.m. LVN B said she had been on duty on the 10:00 p.m. to 6:00 a.m. shift on [DATE] to [DATE]. She said she was aware of Resident #2 experiencing a fall in the early morning hours of [DATE]; however she had not been the charge nurse for the Resident ' s hall. She said LVN D had been the Resident ' s charge nurse. She said to her knowledge the resident had suffered no major injuries related to the fall and had not required medical treatment at the hospital. She said information about the incident should be documented in the Incident and Accident Report and Nursing Note. During an interview on [DATE] at 5:30 a.m. CNA C said she had been on duty during the 10:00 p.m. to 6:00 a.m. shift on [DATE] to [DATE]. She said she was aware of Resident #2 experiencing a fall around 4:30 a.m. on [DATE]. She said LVN D had asked her to assist him and another CNA in getting the resident off of the floor and back into his bed. She said when she arrived to the Resident ' s room he was sitting on the floor with his back up against the end of the bed. She said the resident had a bed alarm, however it was not sounding when she entered the room. She said she was unaware if the resident had any injuries related to the fall, due to the resident having so many bruises and abrasion when he had been admitted back from the hospital. She said she was aware of LVN D dressing a skin tear to the Resident ' s right arm following transferring the resident back to his bed. She said the resident did not go to the hospital. She said the resident needed frequent monitoring because he had a history of [REDACTED]. She said it was her understanding that the fall was unwitnessed and was unsure of the resident had hit his head or not. During an interview on [DATE] at 6:15 a.m. The Administrator said Resident #2 ' s wife had spoken to him on [DATE] and had requested to see a copy of the Incident and Accident Report related to the residents fall on [DATE]. He said he had not been aware of the resident having a fall on [DATE]. He said Resident #2 ' s wife said the resident had fallen at home while out on pass and she had to contact EMS for assistance with the resident. He said Resident #2 ' s wife had informed him that Resident #2 had also fallen following his admission into the hospital. He said he had not received an incident and accident report related to the fall and would have to attempt to locate one. During an interview on [DATE] at 8:30 a.m. The Director of Nursing (DON) said she had not received an incident and accident report regarding Resident #2 ' s fall on [DATE]. She said the incident had not been reported to her. She said it was her expectation if an incident or accident occurred with a resident that the nurse fill out an incident and accident report, document the situation in the nursing notes and contact the family and physician. She said Resident #2 had been identified to deactivate his alarm in order to transfer himself without staff assistance. She said the resident had been redirected on multiple occasions to call for assistance. During an interview on [DATE] at 10:10 a.m. The Administrator said he had been unable to locate an incident and accident report regarding Resident #2 ' s fall on [DATE]. He said due to not having an incident and accident report, he was not aware of the incident and had not performed and investigation of the incident. He said while looking through the Resident ' s clinical record, he found that the incident had not been documented in the nursing notes; therefore he could not guarantee the Resident ' s family and physician had been notified of the incident. During an interview on [DATE] at 11:30 a.m. Resident #2 ' s roommate said he was aware of Resident #2 ' s fall on [DATE]. He said the privacy curtain had been closed halfway and he did not see the resident fall; however he heard the resident groaning on the floor. He said he did not hear the Resident ' s bed alarm sound when the resident fell . He said he immediately used his call light to attempt to get staff to help his roommate. He said the staff responded within 5 minutes of him using his call light. During an interview on [DATE] at 6:00 a.m. LVN D said he had been the charge nurse on duty on [DATE] at 4:30 a.m. when Resident #2 had been found on the floor. He said he had been passing medication down the hallway from the Resident ' s room, when CNA E had alerted him that Resident #2 was on the floor. He said the residents alarm was not sounding. He said Resident #2 was alert; however he did not ask the resident why he was on the floor. LVN D said he assessed the resident and did not find any new areas of injuries; however he said the resident was covered with bruises in different stages of healing all over his body. He said he had attempted to contact Resident #2 ' s physician and had left a message on medical exchange. He said he had tried to contact the Resident ' s wife with no answer and the Resident ' s son's number was not a good number. He said he could not remember if he left a message for the wife. LVN D said he had not done a nursing note due to running late. He said he had done an Incident and Accident report and placed it in the DON's box. He said he was unsure what had happened to it after that. LVN D said he did not specifically remember doing an alarm check on Resident #2 on [DATE]; however he said he always checked the Resident ' s alarms when he came on shift. He said if he checked Resident #2 ' s alarm he would have initialed the area for alarm monitoring on the MAR. During an interview on [DATE] at 6:15 p.m. LVN I said She had worked [DATE] from 6:00 a.m. - 2:00 p.m. and had received report from LVN D. She said LVN D had informed her that Resident #2 had " tried to fall out of the bed " . She said she had not been told the resident had actually fallen out of the bed. She said she had written on the 24 Hour Report that the resident had fallen due to " always " being told that is a resident almost fell and something stopped them it should still be considered a fall. She said she was not aware of any further assessments on Resident #2 and she had not received any information in report that neurological checks had been initiated. LVN I said she had observed bruising in different stages of healing on the Resident ' s arms, legs and a fading bruise on the residents forehead. She said she had been informed that Resident #2 had fallen at home while out on pass and at the hospital and she assumed the bruising was from the falls. She said she had heard the residents alarm sounding on several occasions on [DATE] due to the Resident ' s spastic movements. She said she was aware the resident was at an increased risk for falls and ensured the residents alarms were in place at all times. During an interview on [DATE] at 6:40 a.m. LVN F said she had spoken to Resident #2 ' s physician who had instructed her he had not been notified of Resident #2 ' s fall on [DATE]. She said Resident #2 ' s physician said he had received no messages and/or texts regarding the fall. During an interview on [DATE] at 7:30 a.m. The Director of Nursing (DON) said she had been unable to locate and incident and accident report regarding Resident #2 ' s fall on [DATE]. She said she was not aware of the incident until [DATE], when the 6:00 a.m. to 2:00 p.m. nurse had brought it to her attention from the 24 Hour Report. She said she was unaware if the resident ' s family and/or physician had been notified of the fall. She said she was not aware of the resident's care plan not being updated to reflect revisions implemented following the residents falls and/or Fall Risk Assessment scores. She said she had instructed the nurses who perform the resident care planning, that each new physician order [REDACTED]. She said however, the nurses needed further education in assessment and care planning. She said during chart audits on [DATE], the Regional Nurse Consultant (RNC) had made her aware that there were problems with some of the Resident ' s Medication Administration Records (MAR) in that some of the Resident ' s orders for monitoring wander guards and alarms had been dropped off. She said she was aware that several of the residents who had alarms only had areas on the MAR indicated [REDACTED]. She said she was in the process of getting the Resident ' s MAR ' s updated in the computer system to reflect the designated areas for the 2:00 p.m. to 10:00 p.m. shifts and the 10:00 p.m. to 6:00 a.m. shifts to initial. She said she had not had the nurses edit the MAR's immediately upon becoming aware of the problem due to trying to get the MAR's fixed in the computer. She said she was not aware of any other documentation which would be available to show monitoring of the residents alarms, unless the nurses documented their observations in the nursing notes. During an interview on [DATE] at 7:41 a.m. CNA E said she had been on duty during the 10:00 p.m. to 6:00 a.m. shift on [DATE] to [DATE]. She said she was the first person to find Resident #2 on the floor in his room. She said the Resident ' s alarm was attached; however it was not sounding. She was unsure of why the alarm was not sounding; however said the batteries might have died . She said when she entered the room the resident was lying face down on the floor. She said he was moaning and groaning and she instructed the resident not to move that she was getting the nurse. She said she had immediately alerted LVN D of the resident being on the floor. She said LVN D had assessed the resident and she, CNA C and LVN D had lifted the resident off the floor and placed him in his bed. Review of Resident #2's Nursing Notes dated [DATE] on 10:00 p.m. - 6:00 a.m. shift indicated the resident was resting in bed with oxygen at 3 liters via nasal cannula. Respirations were even and unlabored. The resident had no complaints of pain. Call light was in reach. (Resident #2 had a fall during the shift; however no documentation was located in the Resident's clinical record) Review of the facility 24 Hour Report/ Change of Condition Report dated [DATE] indicated the following: The Resident's vital signs were documented on the section designated for night shift report. The area designated for day shift report indicated a notation of " fell on night shift. Looks horrible. " Review of Resident #2's Nursing Notes dated [DATE] at 10:10 a.m. indicated the following: Resident #2's respirations were even and unlabored. The resident experienced shortness of breath with exertion. The resident continued on oxygen at 3 liters via nasal cannula and had received nebulizer treatments as ordered. The head of the Resident's bed was elevated to facilitate easier breathing. The resident was noted to be making a growling like sound. The resident was able to answer questions when spoken to; however went to sleep easily. Review of Resident #2's Nursing Notes dated [DATE] at 12:45 p.m. indicated the following: The Resident's son was at the facility and spoke to the nurse " at length " regarding the Resident's condition. The resident was noted to be " very lethargic " but able to open his eyes when spoken to and answer yes/no questions. Review of Resident #2's Nursing Notes dated [DATE] at 8:00 p.m., indicated the following: Resident #2 was in bed with the head of the bed elevated. Resident #2 had been found to have removed his oxygen and O2 saturation was assessed at 72%. Explained to resident the importance of leaving his oxygen in place. Placed oxygen back on resident and O2 saturation assessed at 94%. Medications crushed and mixed with jelly, the resident had difficulty swallowing. Attempted to administer 4:00 p.m. and 8:00 p.m. medications with yogurt but resident was very lethargic. Resident's wife attempted to administer medications but resident wouldn't stay awake. Resident did not take all of medication mixture. Multiple bruises throughout. Review of Resident #2's Nursing Notes dated [DATE] at 1:40 a.m. indicated the resident continued to have bruising to " most of his body " . Review of Resident #2's Nursing Notes dated [DATE] at 3:00 a.m. indicated the resident had O2 saturation of 73% on 2 (?) Liters of oxygen per nasal cannula. Repositioned resident with head of bed elevated to 45%. Oxygen switched to mask at 5 Liters and nebulizer treatment administered. Oxygen saturation up to 93%. Review of Resident #2's Nursing Notes dated [DATE] at 3:15 a.m. indicated the nurse was alerted by the CNA that she thought the resident had " passed away " . CPR was initiated and 911 called. While CPR was in progress, the Resident ' s skin was warm and dry. No response from resident. EMS arrived at 3:30 a.m. CPR taken over by EMS. Several attempts made by phone to contact the Resident's spouse and son. At 4:30 a.m. Notified by hospital that resident had expired and the hospital was unable to contact the family. During an interview on [DATE] at 9:00 a.m. LVN F said the Resident's with alarms were monitored throughout the day by the Meal Managers as an extra approach to ensure the Resident ' s alarms were in place. She said she would locate the list used by the Meal Manager for breakfast that morning. Upon searching, LVNF said she had located a blank copy of the Meal Manager's List. Review of the Meal Manager's List on [DATE] indicated 11 residents who had been identified with seat belts/alarms. Upon further review with LVN F, 2 of the residents had been discharged and 2 of the residents were deceased . ( The list had not been updated to reflect accurate information on resident's identifed with alarms) Review of a list of Resident's with alarms received from the Assistant Director of Nursing (ADON) on [DATE] at 9:15 a.m. indicated 17 residents who had been identified with seat belts/alarms. Upon further review with LVN F, 1 of the Resident's was deceased , and 4 residents had no orders for alarms located in the residents clinical records. Review of an updated list of Resident's with alarms received from LVN G on [DATE] at 9:30 a.m. indicated 12 Resident's with seat belts/alarms. During an interview on [DATE] at 9:40 a.m. The Maintenance Director said he had been the designated Meal Manager for breakfast on [DATE] and had forgotten to do the Meal Manager alarm check that morning. During an interview on [DATE] at 11:45 a.m. The DON said she had identified multiple problems with the nursing staff's documentation. She said she had several meetings with the staff about accurate documentation of Resident ' s conditions, incidents, accidents etc.; She said she expected the Resident's Care Plans to be updated with each physician order [REDACTED]. During an interview on [DATE] at 12:15 p.m. The Regional Nurse Consultant (RNC) said he did not remember specifically discussing resident's alarms not being documented as monitored with the DON on [DATE]; however he had informed her that the resident's with wander guards were not being documented as being monitored by the staff for 2:00 p.m. - 10:00 p.m. shifts and 10:00 p.m. - 6:00 a.m. shifts. He said it was his expectation that all monitoring of resident safety devices be documented on each shift. He said if the DON had identified the resident alarms were not being monitored on each shift, it was his expectation that the situation be immediately fixed. He said he felt the MAR indicated [REDACTED]. During a telephone interview on [DATE] at 12:58 p.m. Resident #2's Physician said he had not been notified of the resident's fall on [DATE]. He said he had not received any messages on the office phone, by fax or on his personal cell phone regarding the incident. He said if a message had been left with the medical exchange, the medical exchange would have forwarded the information. He said he was unsure if he would have made any changes to the residents care; however felt he should have been informed of the incident and given the opportunity to determine if changes should have been made to the residents care at the time. On [DATE] at 10:20 a.m. an IJ was identified and the Administrator and DON were informed. During an interview on [DATE] at 10:20 a.m., The Administrator was informed of the identified Immediate Jeopardy. The Administrator said he had not been aware that the resident ' s seat belts/alarms had not been being monitored on the evening and night shifts. He said he felt the failure to appropriately monitor the residents for safety concerns was unacceptable and the problem should have been fixed immediately when identified. He said he was aware the nurses needed further education regarding their documentation of nursing notes and incident and accident reports. He said he was not aware the resident's care plans were not being updated with changes in the resident's care needs. He said the facility had not identified concerns with monitoring resident seat belts/alarms in the facility's Quality Assurance Meetings. During an interview and record review on [DATE] at 2:15 p.m. The RNC said he had updated all of the resident's MAR's in the computer system to reflect accurate monitoring of alarms and safety devices on all three shifts. He said the updates would be reflected on the [DATE] MAR's; however all the [DATE] MAR indicated [REDACTED]. The facility's Plan of Removal of Immediate Jeopardy was accepted on [DATE] at 9:05 a.m. and included: -- Residents with alarms and safety devices were reassessed for Fall Risk and their Care Plans were reviewed and revised for completeness and accuracy. --Alarms and safety devices will be checked each shift by a nurse for placement and functioning then documented in the MAR. This will be checked by the DON on a daily basis to ensure the MAR indicated [REDACTED]. -- The Maintenance Supervisor was inserviced and will be checking the alarms and personal devices on a weekly basis. This will be documented on the Battery Visualization Sheet. --A review of all Incident and Accident Reports with falls from [DATE] through the present was done on [DATE] to identify residents with a pattern for falls. Residents identified with a pattern of falls will be reassessed and their care plans revised. --An inservice was done on [DATE] with staff on reporting Incidents and Accidents to the charge nurse. Nurses were inserviced on completing Incident and Accident Reports. This included doing a thorough investigation of event leading up to the incident, the residents condition after the incident, documenting is an alarm or safety device was in place and if the alarm or safety device was functioning properly. All facility staff has been inserviced on these new procedures. On [DATE] from 10:15 a.m. through 3:18 p.m. the surveyor verified the staff had been inserviced on the new procedures. CNA's and Nurses from all three shifts were interviewed and found to have knowledge of the inservice information. View of the facility Policy and Procedure Accidents and Incidents revised [DATE] indicated the following; An Accident/Incident Report must be completed immediately upon facility staff awareness of the incident involving a resident or visitor. Each Accident/Incident Report form must be reviewed at the Administrator ' s Daily stand up meeting until all sections of the report are completed. A complete Nursing Assessment is performed at the time of the accident/incident. Resident findings are documented every shift for 72 hours. The assessment is documented in the Nurse ' s Notes and the Resident Care Plan is updated. An Accident/Incident Investigation is completed in addition to the Accident /Incident Report form when staff discovers and n-witnessed accident/incident or falls. The Director of Nursing Services completes the Conclusion and Intervention form when the investigation is completed. The DON or Designee will interview witnesses, using the approved witness statement form and have them sign that the information is reflective of their statement. The DON will maintain a monthly Accident/Incident log which is updated daily. The Administrator will complete the Individual tracking/trending of Resident incidents and have the log available for Daily Stand Up Meeting. The IDT reviews the incident and the care plan is updated. A Neurological Assessment flow sheet must be immediately initiated and maintained for at least 72 hours following each accident/incident involving injury to the head or unwitnessed fall. A complete Accident/Incident Investigation must be completed for each occurrence of actual or suspected Resident abuse. The Administrator serves as the Abuse Prevention Coordinator. In the absence of the Administrator, the DON or Designee will fulfill the duties. According to a list received on [DATE] from the DON, the facility had identified 12 residents who required seat belt alarms/ chair alarms/ bed alarms due to being identified as increased fall risk.

Based on observation, record review and interviews, the facility failed to ensure 11 of 21 residents (Residents #1, #2, #11, #12, #13, #15, #16, #17, #18, #19 and #20) reviewed for accident hazards and smoking safety received adequate supervision to prevent accidents: The facility failed to: A: 1) ensure Resident #1 was kept safe from fire and burns while smoking with his oxygen on. 2) ensure residents (#1, #12, #13, #15, #16 and #18) who smoked, only did so in the designated smoking area during designated smoking times. 3) ensure residents ( #1, #12, #13, #15,#16 and #18)did not have access to smoking paraphernalia in the facility 4) ensure residents (#1, #11, #12, #13, #15, #16, #17, #18, #19 and #20) had been assessed and safety measures had been implemented in the residents Care Plan to reflect each individual resident's smoking safety needs. 5) ensure appropriate monitoring was in place regarding residents ( #1, #12,#13, #15, #16 and #18) leaving the building unsupervised and using the Sign In/Out system to smoke outside of the facility. An Immediate Jeopardy (IJ) was identified on 4/29/14. While the IJ was removed on 5/01/14, the facility remained out of compliance at a level of Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of corrective systems. These failures could have affected any of the facility's 23 residents who were identified to smoke cigarettes and placed them at risk of burn injuries and/or death. B: 1) ensure Resident #2's safety devices were monitored each shift for placement and functionality. 2) ensure Resident #2 had updates and revisions implemented to his comprehensive Care Plans to ensure the resident's safety needs were met. An Immediate Jeopardy (IJ) was identified on 4/24/14. While the IJ was removed on 4/25/14, the facility remained out of compliance at a level of no Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of corrective systems. This failure could place any of the 12 resident's identified as requiring seat belts/alarms for safety from falls. Findings included (for Part A): Review of the Facility Policy and Procedure Re: Smoking dated 4/16/14 indicated the following; Policy: Our facility provides our residents and our employees with a smoke free environment. While we recognize the need of many of our residents and employees, we must also respect the rights of those residents and employees who choose to smoke. Policy Interpretation and Implementation: Areas where smoking is permitted will be posted with a " Designated Smoking Area " sign. Smoking will be prohibited in public areas or where groups of people frequently gather. Certain smoking restrictions apply to our residents and visitors. The facility will supervise all resident smoking for the safety of all resident and employees. Residents will not be permitted to smoke in any area that is not designated as a smoking area. Supervised smoking times are scheduled and limited to 15 minute increments per smoking session. All resident smoking paraphernalia must be checked in with the nurse, secured at the Nurse ' s station and provided to the resident at specified smoking times. Supervision of smoking will be shared by all departments. Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area is posted with a No Smoking or international symbol for No Smoking. All Oxygen must be removed from the resident ' s person during smoke breaks. This includes removal of oxygen masks or nasal cannulas and oxygen canisters/tanks of any type. It is the responsibility of all personnel to report smoking violations. Violations should be reported to the employee ' s supervisor as soon as practical. The various supervisors are responsible for enforcing the rules. Resident ' s that fail to abide by the facility smoking rules may be given a notice of intent to transfer. Review of the facility Policy and Procedure; Signing Out a Resident revised December 2003 indicated the following: Each resident leaving the premises (excluding transfers/discharges) must sign out. A sign out register is located at the nurses station. Registers must indicate the resident ' s expected time of return. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents must sign in upon returning to the facility. Inquiries concerning the signing out of residents should be referred to the Director of Nursing services or to the Adminsitrator. Resident #1 Review of Resident #1 ' s Admission Record the [AGE] year old male was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1 ' s consolidated Physician Orders indicated the resident had the following order dated 7/24/13: Oxygen at 2 liters via nasal cannula, continuously. Review of Resident #1 ' s quarterly Minimum (MDS) data set [DATE] indicated the resident had been identified with a BIMS score of 1, indicating the resident had severe cognitive impairment. The resident was identified as requiring only supervision for all activities of daily living. Review of an Incident and Accident report dated 3/27/14 at 9:20 p.m. indicated the following: A local police officer arrived at the building pushing Resident #1 in his wheelchair. The officer reported to the nurse that they had received a call that someone had fallen across the street from the nursing home. When the officer went to the park, he noticed Resident #1 lying on the ground next to his wheelchair. The officer assisted the resident back into his wheelchair and back to the facility. Resident #1 was assessed by the nurse and had no injuries. The resident ' s physician and responsible party were notified. The resident stated he would not leave the facility grounds again. While investigating the incident it was determined the resident had signed himself out of the facility. No documentation of the Conclusions and Interventions of the incident by the Supervisor/Department Director of Nursing/ Designee Follow-up was found. Review of the Police Departments Call for Service Report dated 3/27/14 at 9:07 p.m. indicated the following: Subject was found sitting under a tree in the park across the street from the nursing facility. The subject was outside smoking a cigarette and as he was making his way back to the facility he fell out of his wheelchair. The subject advised he was not injured and refused medical attention and that he often falls from his wheelchair. The subject was escorted back to the facility and the staff was notified of his fall. Review of a Release of Responsibility for Absence Sign In/Out sheet indicated the resident had signed himself out of the facility on 3/27/14 at 8:30 p.m. Review of Resident #1 ' s Nursing Notes dated 3/27/14 at 9:30 p.m. indicated the following; A police officer brought the resident into the building. The officer stated that a passerby had called and reported a person on the ground. The resident stated he had slid out of his wheelchair. He denied any pain and/or injuries. Hospice Nurse to notify physician. Resident ' s responsible party was notified. Review of an Incident Report Log dated March 2014 indicated on 3/27/14; Resident #1 had been outside of the facility and was found on the ground. Contributing factors were listed as: Resident reported he had slipped out of his wheelchair. Interventions to Prevent Reoccurrences: Will place a wanderguard on the resident per IDT. Review of Resident #1 ' s Physician Orders dated 3/27/14 with no documented time indicated the following order: Place wanderguard on resident. Signed by the DON. Review of Resident #1 ' s MAR dated March 2014 indicated no documentation of monitoring the resident ' s wanderguard for safety. Review of Resident #1 ' s Care Plan with a review dated of 4/02/14 indicated the following: --Problem: Resident to smoke supervised while in the facility. Resident can also Sign Out on pass and leave the facility with his cigarettes. Goals: Resident will be safe while smoking over the next 90 days. Resident will be free of injury as a result of smoking over the next 90 days. Approaches: Resident needs the nurse to; monitor ability to smoke safely every three months, keep smoking materials in a safe and secure place and provide them to resident per smoking schedule, Provide a protective apron while smoking so the resident does not burn himself, Assign someone to go with resident to smoke so that if something should happen there is assistance there to help the resident. (There was no documentation located in Resident #1 ' s comprehensive Care Plan regarding the implementation of a wanderguard for the resident ' s safety.) Review of Resident #1 ' s Nursing Notes dated 4/26/14 on the 2:00 p.m. to 10:00 p.m. shift indicated the following entry: Resident out front smoking multiple times in between scheduled smoke breaks. Signed by LVN P Review of an Incident and Accident Report dated 4/27/14 at 7:50 p.m. indicated the following; Resident #1 had been outside of the facility on the west end of the building sitting in his wheelchair. Another resident (Resident #11) saw Resident #1 sitting in his wheelchair, glanced away and then looked back at the resident in time to see him with a lighter, which he lit and flames shoot up in front of his face. Resident #11 pushed Resident #1 back into the building and yelled for help. CNA J and CNA K brought Resident #1 to the charge nurse. The resident ' s face was covered in black smoke; his mustache was singed off, along with a 3 inch area to the resident ' s right temple. Resident had complaints of " A lot of Pain " . A wet washcloth was applied to the resident ' s face and a small area of skin began to roll off the resident ' s nose. EMS was called. Resident #1 ' s vital signs were documented as: Blood Pressure of 217/114, heart rate of 89, and Oxygen saturation of 97%. Conclusions and Interventions of the incident by the Supervisor/Department Director of Nursing/ Designee Follow-up indicated the following: Interventions in Place to Prevent Incident was left blank. Interventions Needed to Prevent Recurrence was: Place wanderguard on the resident. Review smoking policy with the resident. Issue the resident a discharge letter. Signed by the DON and Administrator. Review of a Release of Responsibility for Absence Sign In/Out sheet indicated the resident had signed himself out of the facility on 4/27/14 at 7:40 p.m. Review of Resident #1 ' s Nursing Notes dated 4/27/14 at 7:50 p.m. indicated two CNA ' s came pushing the resident down the hall towards the nurse, stating another resident had brought him in from outside of the facility stating that he had burned himself with a lighter while his oxygen was on. Quickly assessed the resident. The resident was noted to have blackened soot covering his face, parts of his mustache was singed. Attempted to remove soot with a damp washcloth and the skin began to roll off the resident ' s nose. The resident was noted to have a 3 inch diameter singed area to the right side of his head at the temple area. Resident vital signs assessed and found to have: Blood Pressure of 217/114, heart rate of 89, respirations of 22. The resident denies shortness of breath. EMS notified. At 8:00 p.m. the resident was transferred to the emergency room via EMS. Physician notified. Responsible party notified. At 8:10 p.m. spoke with Resident #11. She said she was outside on the sidewalk in front of the building when she noticed Resident #1 sitting on the sidewalk near the west end of the building. She said she asked Resident #1 what he was doing; however the resident had ignored her. She said she glanced away and when she looked back at him he was lighting a lighter close to his face and flames shot up in front of him. She said she ran to the resident, the flames were out at that time, and she rushed the resident into the facility where she turned him over to the CNA ' s. Review of a hospital emergency room Nurse Report indicated the following; the patient arrived to the emergency roiagnom on [DATE] at approximately 8:17 p.m. Diagnoses: [REDACTED]. Triage Assessment: Pain: complaints of pain in the resident ' s nose and mouth. Pain is currently 10 out of 10 on a 1-10 pain scale. General: appears uncomfortable, smells of singed hair. Respiratory: Airway is patent respiratory effort is unlabored. Have burns to his nose, lips, facial hair around the mouth and nose, singed hair in nasal passages. Injury Description: Burns sustained to left ear, left base of the skull, right temporal area, nose and mouth. The patient has First and Second Degree burns. Outcome: at 11:12 p.m. the facility was contacted regarding the patients release back to the facility. Instructions given for after care and follow up with wound care. Review of a hospital emergency room Physician Report indicated the following; the patient arrived to the emergency roiagnom on [DATE] at approximately 8:17 p.m. The patient is a [AGE] year old male who presents to the emergency department via EMS with complaints of facial burns. The patient presents with facial burns as a result from lighting a cigarette with his oxygen on. Burn type and severity: 1st degree burns approximately 0.7% total body surface area with 1st degree burns to the face. 2nd degree burns approximately 0.3% total body surface with 2nd degree burns to the face. Associated signs and symptoms: The patient possibly suffered an inhalation injury from smoke. Review of Resident #1 ' s Physician Orders dated 4/27/14 at 7:15 a.m. indicated the following order: Wanderguard per IDT. Signed by the DON. Review of Resident #1 ' s MAR dated April 2014 indicated monitoring the resident ' s wanderguard for safety began on 4/28/14 and was initialed on day, evening and night shift. Review of the resident ' s entire clinical record indicated the resident did not have a smoking assessment to determine if he was safe to smoke and no care plan was located regarding the residents wanderguard device. Review of Resident #1 ' s care plan dated 4/28/14 indicated a problem Resident is a smoker and at risk for injury related to oxygen use. Goal was the resident will smoke in designated areas without occurrence of injury for 90 days. Approaches were as follows: 1) Perform smoking assessment according to the facility policy 2) Explain/show were designated smoking areas are and smoking times 3) Monitor When needed to assure residents safety 4) Keep all smoking material at nurses station 5) Use smoking vest when appropriate. Review of the facility Investigation/Corrective Actions Report dated 4/28/14-4/29/14 indicated the following; " On 4/27/14 at approximately 7:50 p.m., Resident #1 was smoking unsupervised on the northwest side of the facility. Documentation (Sign out Book) reveals that the resident had signed himself out of the facility at 7:40 p.m. prior to going outside and the incident ensuing. When Resident #1 attempted to light his cigarette, the oxygen flow from his nasal cannula ignited. The resident received burns to his face, (primarily to his nose) and singed his facial hair. Another resident witnessed the ignition incident and alerted staff of the situation. Resident #1 was brought back into the facility and assessed by the LVN charge nurse. Local EMS was notified and staff monitored the resident until their arrival. Resident #1 was treated at the local emergency room and returned to the facility with instructions for follow-up at the local wound care center. " " On the evening of the incident, the LVN charge nurse completed the appropriate paperwork, notified the physician, notified the sister, notified the Hospice provider and notified the DON. It was found with investigation, that the DON failed to notify RNC and RVP per cooperate policy (notification required with any incidents in which resident requires treatment ordered by the physician or ER evaluation). The Administrator reports that he was not notified the evening of the incident. " " Investigation reveals a history of the resident attempting (some successful) of smoking unsupervised at non-scheduled smoking times. " " The Administrator was informed of the burn incident on the morning of 4/28/14 and subsequently notified the RNC, RVP and VP of clinical operations. A Roam Alert device (wanderguard) was initiated to aide in the prevention of any similar reoccurrence. Resident #1 initially stated he had obtained the cigarette from his sister and then stated he had hid a cigarette in his pocket during smoke break. Interviewing with staff on 4/28/14 revealed inconsistency in relation to following policy. " " In conclusion; a lack of sufficient staff training, resident supervision, and adherence to policy culminated in the incident with Resident #1 being harmed. Corrective and preventative measures were begun on the morning of 4/28/14 and are on-going to ensure resident safety and substantial compliance. " Signed by the RNC During an observation/interview on 4/29/14 at 10:30 a.m. Resident #1 was observed sitting on his bed in his room. The resident had red/white/and black patches to his nose, lips and cheeks. The resident ' s mustache hair was singed and missing in areas and the resident had large raised blistered areas to his lips. The resident ' s nose and nares had blisters which were bleeding in areas. Resident #1 said he was in severe pain. Resident #1 was observed to have a wanderguard in place on his right wrist. Resident #1 said he had been outside in the pasture smoking and had forgotten to take his oxygen off. He said he had hid a cigarette and lighter from smoke break and had signed himself out to go smoke. He said when he lit the lighter, there was a flash of fire and the nasal cannula tubing had melted to his face. He said he yanked the tubing off and began stomping it in order to stop the fire from going up through the tubing and blowing up the tank. He said while heading back into the facility, Resident #11 had found him. He said Resident #11 ran to help him back into the facility. He said a CNA took him to the nurse. He said he had been transferred to the emergency room via ambulance and treated for [REDACTED]. He said he was very upset about being discharged from the facility, that he really loved living there. During an interview with the Regional RNC on 04/29/14 at 4:20 p.m. he said the facility did not do smoking assessments. The RNC was shown care plans for residents that smoke that indicated one of the approaches was that the facility was going to do smoking assessments on the residents that smoked. After reviewing the care plans the RNC said that the intervention of smoking assessments was a mistake and should have been omitted from the care plans. The RNC said after the facility developed their smoking policy it required all smokers to be supervised, so there was not a need for each resident to have a smoking assessment. The Regional RNC could not explain how care plans were developed for smokers without a smoking assessment. The RNC confirmed the issue with the assessments and care plans were conflicting. Review of a care plan for Resident #1 dated 04/30/14 indicated a problem that the resident was a smoker. Goal was to be safe and free from injury while smoking cigarettes over the next 90 days. Approaches were as follows: (1) Explain smoking policy as frequently as needed; keep smoking materials in a safe and secure place. (2) Provide them to the resident as per smoking schedule. (3) Assign someone to go with resident when he smokes in case something should happen someone will be there, (4) inform the resident he is unable to sign out to go smoke unless someone is supervising him, (5) Report observations of unsupervised smoking to charge nurse or other administrative staff, (6) Report observations of resident having smoking materials in possession at times other than during supervised smoking On 05/01/14 the Corporate RNC gave the surveyors a smoking evaluation on Resident #1 dated 05/01/14. According to the smoking evaluation Resident #1 was moderately cognitively impaired with intermittent confusion, cognitive deficit or disoriented at time with a BIMS of 11. According to the evaluation the resident did require a protective apron. Resident #11 Admission Face sheet indicated Resident #11 was admitted on [DATE] from psychiatric facility and was [AGE] years old female with the following Diagnoses: [REDACTED]. Annual MDS dated [DATE] indicated Resident #11 had a BIMS score of 10 out of a possible 15, which indicated the resident, had moderate cognitive impairment with disorganized thinking. The resident required supervision with bathing but was independent in all other areas of Activities of Daily Living. The resident was continent of bowel and bladder. Review of Resident #11's entire clinical record indicated no smoking evaluation had been conducted to determine if the resident was safe to smoke. Review of Resident #11's Nurse ' s notes dated 12/6/13, 01/20/14, 03/05/14 and 03/21/14 indicated the resident was a smoker and took scheduled smoke breaks. Review of Resident #11's Care Plan dated 02/28/14 indicated there was no care plan addressing the resident ' s safety while smoking until 04/28/14 (after the incident with Resident #1). On 04/28/14 the facility developed a care plan for Resident #11 that indicated the resident was a smoker and was at risk for injury. The goal was the resident would smoke in designated areas without occurrence of injury over the next 90 days. Approaches were: (1) The resident will have a smoking assessment according to facility policy. (note: facility ' s current smoking policy dated 11/12/12 does not require the facility to do smoking evaluations) (2) Explain/show where designated smoking areas are and smoking times- repeat PRN (3) Monitor PRN when smoking to assure residents safety. (4) Keep all smoking material at nurses' station (5) Uses smoking vest- when appropriate Review of another smoking care plan dated 04/30/14 indicated other approaches had been added: Which included: (1) " Assign someone to go with me with I smoke so that if something should happen I have someone there to assist and help me. " (2) Inform the resident of unable to sign out to leave the facility grounds to smoke unless supervised. (3) Report observations of unsupervised smoking to charge nurse or other administrative staff. Resident #12 According to the resident ' s admission sheet he was admitted on [DATE] from a psychiatric facility. Resident #12 was [AGE] years old at the time of this investigation. Admission diagnose were as follows: Renal disease, Bipolar, Diabetes Mellitus, uncontrolled, hypothyroid, morbid obesity, schizophrenia, anxiety, depressive disorder, hypertension, congestive heart failure, asthma and reflux disease. Review of Resident #12 ' s current MDS dated [DATE] indicated the resident had a BIMS score of 12 out of a possible 15 indicating he had moderate cognitive impairment. Resident #12 also had Delirium with inattentiveness and disorganized thing that was continuous throughout the day and did not fluctuate. The resident ' s mood indicated he was depressed with feelings of hopelessness, little interested or pleasure in doing things, had little energy, trouble falling or staying asleep, overeating, and felt bad about himself. According to the MDS Resident #12 needed supervision for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use and personal hygiene. The resident was totally dependent on staff for bathing. Resident #12 was not steady, only able to balance with staff assistance while moving from seated to standing, walking, turning around, moving on and off the toilet and surface to surface transfers. The resident also had impaired range of motion on both sides of his upper and lower extremities and used an electric wheelchair for mobility. Resident #12 was continent of bladder and bowel. Review of Resident #12 ' s care plan dated 11/12/12 indicated the resident was a supervised smoker while in the facility. According to the care plan the resident could also sign himself out on pass and he could take his cigarettes with him. The care plan goal was the resident would be free of injury as a result of smoking over the next 90 days. Approaches were as follows: (1) Monitor my ability to smoke safely every three months. (2) Keep my smoking materials in a safe and secure place. Provide them to me as per smoking schedule. (3) Provide a protective apron while I am smoking so that I don ' t not burn myself. (4) Assign someone to go with me when I smoke so that if something should happen I have someone there to assist and help me. (5) If I sign out on pass and take my cigarettes with me, while on pass I am responsible for my own cigarettes. I have been advised of the facility smoking policy and understand the policy. I have been advised of the city ordinances on smoking. This care plan was updated on 12/5/12 and 02/08/13. According to monthly summaries dated June and October 2013 Resident #12 was a heavy smoker. (Note: there were not any monthly summaries after October 2013 for this resident.) During an interview with the administrator on 04/29/14 at 10:10 a.m. he said on 04/28/14 during a room search for smoking materials, Resident #12 was found with cigarettes in his room. Review of a care plan dated 04/28/14 indicated Resident #12 was a smoker and was at risk for injury. The care plan goal was will smoke in designated areas without occurrence of injury over the next 90 days. Approaches were as follows: (1) Perform smoking assessment according to facility policy, (2) explain/show where designated smoking areas are and smoking times-repeat PRN, (3) monitor PRN (as needed) when smoking to assure resident ' s safety, (4) Keep all smoking material at nurses station, use smoking vest when appropriate. Review of another care plan dated 04/30/14 indicated Resident #12 was a smoker. The care plan goal was to keep resident safe while smoking for the next 90 days. Approaches were as follows: (1) Explain smoking policy as frequently as needed, keep smoking materials in a safe and secure place. (2) Provide the to the resident as per smoking schedule. (3) Assign someone to go with resident when he smoked in case something should happen someone will be there, inform the resident he is unable to sign out to go smoke unless someone is supervising him, (4) Report observations of unsupervised smoking to charge nurse or other administrative staff, (5) Report observations of resident having smoking materials in possession at times other than during supervised smoking. Review of Resident #12 entire clinical revealed that the resident had not had a smoking evaluation to determine if he was safe to smoke. On 05/01/14 the Corporate RNC gave the surveyors a smoking evaluation dated 05/01/14 on Resident #12. According to the smoking evaluation Resident #12 was cognitively impaired and required the use of an apron when smoking. Resident #13 According to Resident #13 admission sheet he was admitted from an acute care hospital on [DATE]. The admitting [DIAGNOSES REDACTED]. The resident was 67 at the time of this investigation. According to Resident #13 ' s hospital history and physical he was 02 dependent, had a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Review of the resident ' s latest MDS dated [DATE] indicated the resident had a BIMS of 13 out of a possible 15 indicating he was cognitively intact. However he did have Delirium with inattentiveness that fluctuated throughout the day and continuous disorganized thinking. According to the MDS Resident #13 ' s mood indicated that he had little interest or pleasure in doing things, was depressed, had little energy and problems with sleeping. Resident #13 ' s functional status indicated he required supervision with bed mobility, transfers, locomotion on and off the unit, and eating. Resident #13 required extensive assistance with two staff for dressing, extensive assistance with one staff for personal hygiene and limited assistance of two staff with toilet use. Resident #13 was occasionally incontinent of bowel and bladder. According to the resident ' s MDS he was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, and moving on and off the toilet and surface to surface transfers. Review of a nurses' note dated 03/06/14 at 9:25 a.m. indicated a nurse had called Resident #13 ' s doctor and told him that the resident had been caught multiple times smoking with his 02 on despite several warnings. During an interview with LVN F on 05/01/14 at 3:30 p.m. she said after reading the nurses ' notes on Resident #13 dated 03/06/14 it appeared the resident was caught multiple times with his 02 on and smoking. She said she did not have any direct knowledge of any incidents. LVN F said the nurse that wrote the note does not work at the facility anymore. During an interview on 05/01/14 at 3:35 p.m. the note dated 03/06/14 was shown to the Regional VP and the Regional RN Consultant. They confirmed and acknowledged that an incident report should have been written on any incident that involved a resident smoking inside the facility with 02 on. They stated these are some of the problems they are facing in the facility and they are trying to work on them. Review of an incident report dated 03/09/14 indicated Resident #13 was found by another resident at about 11:00 a.m. smoking in the B Hall common bathroom/shower room. The nurse attempted to remove the cigarette from the resident and he became very angry and was cursing and hitting out at the nurse. Review of a nurses ' note dated 03/09/14 at 11:05 a.m. indicated the resident was found smoking in the B Hall bathroom/shower. Resident was put on Q 15 minute checks and the administration, family and doctor were notified. During an interview with LVN I on 05/01/14 at 11:15 a.m. she said Resident #13 went into the B Hall shower room. She said she got up to check on the resident and found him smoking in the shower room. LVN I said she took the cigarette and lighter away from the resident and he got very upset. The Resident told the nurse he got the cigarette and lighter when he went out on pass with his brother. Review of a Nurses Notes dated 03/10/14 at 2:24 p.m. indicated Resident #13 was going into B Hall bathroom/shower. Staff noted he was in the bathroom a long time. When the staff checked on him he was noted to be smoking in the bathroom. Cigarettes were taken away from him. Review of the incident log indicated there was no entry in the log concerning Resident #13 for 03/10/14 that reported the resident was caught smoking again. There were no notations in the Nurses Notess that the incident was reported. Review of the resident ' s care plan dated 03/12/14 indicated there was no care plan for safe smoking until 04/28/14 despite the fact the resident had been caught smoking in the facility on at least 3 occasions. Review of a care plan dated 04/28/14 indicated the resident was a smoker and was at risk for injury, related to oxygen use, COPD, dementia and Parkinson disease. The approaches were the same as the other residents who smoked in the facility. Approaches were as follows: (1) The resident will have a smoking assessment according to facility policy. (Note: facility ' s current smoking policy dated 11/12/12 does not require the facility to do smoking evaluations) (

Based on observation, interview and record review, the Administrator and the Director of Nurses (DON) failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being for 11 of 21 residents (Residents #1, #2, #11, #12, #13, #15, #16, #17, #18, #19 and #20) reviewed for accident hazards and smoking safety received adequate supervision to prevent accidents: A: The Administrator failed to: 1) Implement the facility's Abuse and Neglect Prevention Policies and Procedures 2) Implement the facility ' s Smoking Policy and Procedure to ensure residents were not smoking in undesignated smoking areas and residents did not have access to smoking paraphernalia when unsupervised by facility staff. 3) Implement the facility ' s Sign In/Out Policies and Procedures 4) Supervise the DON to ensure she was doing a thorough job of ensuring staff complied with their job responsibilities and systems were implemented for monitoring of Residents with identified as smoker ' s. The DON failed to supervise nursing staff to ensure: 1) All nurses were trained and following the facility's policy/procedure ' s related to; Smoking Policy/Procedure, Sign In/Out Policy/Procedure. 2) Facility staff reported all incidents in which residents were smoking in undesignated smoking areas. 3) Facility Staff reported all incidents in which residents were identified with smoking paraphernalia. 4) Residents (#1, #2, #11, #12, #13, #15, #16, #17, #18, #19 and #20) had been assessed and safety measures had been implemented to reflect each individual resident ' s smoking safety needs. 5) Nursing Staff and CNA ' s were aware of which residents (#1, #12 and #13) required smoking safety aprons. 6) Nursing staff were properly monitoring and documenting residents signing In/Out of the building. 7) Appropriate documentation and Incident/Accident Reports were completed following residents being observed smoking in no-designated smoking areas near the building. An Immediate Jeopardy (IJ) was identified on 4/29/14. While the IJ was removed on 5/01/14, the facility remained out of compliance at a level of Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of corrective systems. These failures could have affected any of the facility's 23 residents who were identified to smoke cigarettes and placed them at risk of burn injuries and/or death. B: The Administrator failed to: 1) Implement the facility's Abuse and Neglect Prevention Policies and Procedures 2) Implemented the facility's Incident and Accident Investigation Policies and Procedures 3) Supervise the DON to ensure she was doing a thorough job of ensuring staff complied with their job responsibilities and systems were implemented for monitoring of Residents with alarms. The DON failed to ensure: 1) Resident #1 ' s physician ordered wanderguard was implemented, care planned, documented and monitored following a 3/27/14 incident. The DON failed to supervise nursing staff to ensure: 1) Nursing staff were made aware of resident safety devices being unintentionally omitted from the residents MAR indicated [REDACTED]. 2) Resident #2, #5, #6, #7, #9 and #10 had their safety devices monitored each shift by a licensed nurse for placement and functionality. 3) Resident #2, #5, #6, #7, #9 and #10 had updates and revisions implemented to their comprehensive Care Plans regarding their safety alarms. 4) Nursing staff were properly implementing, monitoring and documenting residents with safety devices on all three shifts. 5) LVN D filled out an Incident & Accident Report following Resident #2's unwitnessed fall on 4/20/14. 6) LVN D notified the physician and responsible party following Resident #2's unwitnessed fall on 4/20/14 7) LVN D performed a complete assessment on Resident #2 and documented the incident in the Nursing Notes on 4/20/14. An Immediate Jeopardy (IJ) was identified on 4/24/14. While the IJ was removed on 4/25/14, the facility remained out of compliance at a level of no Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of corrective systems. This failure could place any of the 12 resident's identified as requiring seat belts/alarms for safety from falls. Findings included (for Part A): Review of the Facility Policy and Procedure Re: Smoking dated 4/16/14 indicated the following; Policy: Our facility provides our residents and our employees with a smoke free environment. While we recognize the need of many of our residents and employees, we must also respect the rights of those residents and employees who choose to smoke. Policy Interpretation and Implementation: Areas where smoking is permitted will be posted with a " Designated Smoking Area " sign. Smoking will be prohibited in public areas or where groups of people frequently gather. Certain smoking restrictions apply to our residents and visitors. The facility will supervise all resident smoking for the safety of all resident and employees. Residents will not be permitted to smoke in any area that is not designated as a smoking area. Supervised smoking times are scheduled and limited to 15 minute increments per smoking session. All resident smoking paraphernalia must be checked in with the nurse, secured at the Nurse ' s station and provided to the resident at specified smoking times. Supervision of smoking will be shared by all departments. Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area is posted with a No Smoking or international symbol for No Smoking. All Oxygen must be removed from the resident ' s person during smoke breaks. This includes removal of oxygen masks or nasal cannulas and oxygen canisters/tanks of any type. It is the responsibility of all personnel to report smoking violations. Violations should be reported to the employee ' s supervisor as soon as practical. The various supervisors are responsible for enforcing the rules. Resident ' s that fail to abide by the facility smoking rules may be given a notice of intent to transfer. Review of the facility Policy and Procedure; Signing Out a Resident revised December 2003 indicated the following: Each resident leaving the premises (excluding transfers/discharges) must sign out. A sign out register is located at the nurses station. Registers must indicate the resident ' s expected time of return. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. Residents must sign in upon returning to the facility. Inquiries concerning the signing out of residents should be referred to the Director of Nursing services or to the Adminsitrator. Resident #1 Review of Resident #1 ' s Admission Record the [AGE] year old male was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #1 ' s consolidated Physician Orders indicated the resident had the following order dated 7/24/13: Oxygen at 2 liters via nasal cannula, continuously. Review of Resident #1 ' s quarterly Minimum (MDS) data set [DATE] indicated the resident had been identified with a BIMS score of 1, indicating the resident had severe cognitive impairment. The resident was identified as requiring only supervision for all activities of daily living. Review of an Incident and Accident report dated 3/27/14 at 9:20 p.m. indicated the following: A local police officer arrived at the building pushing Resident #1 in his wheelchair. The officer reported to the nurse that they had received a call that someone had fallen across the street from the nursing home. When the officer went to the park, he noticed Resident #1 lying on the ground next to his wheelchair. The officer assisted the resident back into his wheelchair and back to the facility. Resident #1 was assessed by the nurse and had no injuries. The resident ' s physician and responsible party were notified. The resident stated he would not leave the facility grounds again. While investigating the incident it was determined the resident had signed himself out of the facility. No documentation of the Conclusions and Interventions of the incident by the Supervisor/Department Director of Nursing/ Designee Follow-up was found. Review of the Police Departments Call for Service Report dated 3/27/14 at 9:07 p.m. indicated the following: Subject was found sitting under a tree in the park across the street from the nursing facility. The subject was outside smoking a cigarette and as he was making his way back to the facility he fell out of his wheelchair. The subject advised he was not injured and refused medical attention and that he often falls from his wheelchair. The subject was escorted back to the facility and the staff was notified of his fall. Review of a Release of Responsibility for Absence Sign In/Out sheet indicated the resident had signed himself out of the facility on 3/27/14 at 8:30 p.m. Review of Resident #1 ' s Nursing Notes dated 3/27/14 at 9:30 p.m. indicated the following; A police officer brought the resident into the building. The officer stated that a passerby had called and reported a person on the ground. The resident stated he had slid out of his wheelchair. He denied any pain and/or injuries. Hospice Nurse to notify physician. Resident ' s responsible party was notified. Review of an Incident Report Log dated March 2014 indicated on 3/27/14; Resident #1 had been outside of the facility and was found on the ground. Contributing factors were listed as: Resident reported he had slipped out of his wheelchair. Interventions to Prevent Reoccurrences: Will place a wanderguard on the resident per IDT. Review of Resident #1 ' s Physician Orders dated 3/27/14 with no documented time indicated the following order: Place wanderguard on resident. Signed by the DON. Review of Resident #1 ' s MAR indicated [REDACTED]. Review of Resident #1 ' s Care Plan with a review dated of 4/02/14 indicated the following: --Problem: Resident to smoke supervised while in the facility. Resident can also Sign Out on pass and leave the facility with his cigarettes. Goals: Resident will be safe while smoking over the next 90 days. Resident will be free of injury as a result of smoking over the next 90 days. Approaches: Resident needs the nurse to; monitor ability to smoke safely every three months, keep smoking materials in a safe and secure place and provide them to resident per smoking schedule, Provide a protective apron while smoking so the resident does not burn himself, Assign someone to go with resident to smoke so that if something should happen there is assistance there to help the resident. (There was no documentation located in Resident #1 ' s comprehensive Care Plan regarding the implementation of a wanderguard for the resident ' s safety.) Review of Resident #1 ' s Nursing Notes dated 4/26/14 on the 2:00 p.m. to 10:00 p.m. shift indicated the following entry: Resident out front smoking multiple times in between scheduled smoke breaks. Signed by LVN P Review of an Incident and Accident Report dated 4/27/14 at 7:50 p.m. indicated the following; Resident #1 had been outside of the facility on the west end of the building sitting in his wheelchair. Another resident (Resident #11) saw Resident #1 sitting in his wheelchair, glanced away and then looked back at the resident in time to see him with a lighter, which he lit and flames shoot up in front of his face. Resident #11 pushed Resident #1 back into the building and yelled for help. CNA J and CNA K brought Resident #1 to the charge nurse. The resident ' s face was covered in black smoke; his mustache was singed off, along with a 3 inch area to the resident ' s right temple. Resident had complaints of " A lot of Pain " . A wet washcloth was applied to the resident ' s face and a small area of skin began to roll off the resident ' s nose. EMS was called. Resident #1 ' s vital signs were documented as: Blood Pressure of 217/114, heart rate of 89, and Oxygen saturation of 97%. Conclusions and Interventions of the incident by the Supervisor/Department Director of Nursing/ Designee Follow-up indicated the following: Interventions in Place to Prevent Incident was left blank. Interventions Needed to Prevent Recurrence was: Place wanderguard on the resident. Review smoking policy with the resident. Issue the resident a discharge letter. Signed by the DON and Administrator. Review of a Release of Responsibility for Absence Sign In/Out sheet indicated the resident had signed himself out of the facility on 4/27/14 at 7:40 p.m. Review of Resident #1 ' s Nursing Notes dated 4/27/14 at 7:50 p.m. indicated two CNA ' s came pushing the resident down the hall towards the nurse, stating another resident had brought him in from outside of the facility stating that he had burned himself with a lighter while his oxygen was on. Quickly assessed the resident. The resident was noted to have blackened soot covering his face, parts of his mustache was singed. Attempted to remove soot with a damp washcloth and the skin began to roll off the resident ' s nose. The resident was noted to have a 3 inch diameter singed area to the right side of his head at the temple area. Resident vital signs assessed and found to have: Blood Pressure of 217/114, heart rate of 89, respirations of 22. The resident denies shortness of breath. EMS notified. At 8:00 p.m. the resident was transferred to the emergency room via EMS. Physician notified. Responsible party notified. At 8:10 p.m. spoke with Resident #11. She said she was outside on the sidewalk in front of the building when she noticed Resident #1 sitting on the sidewalk near the west end of the building. She said she asked Resident #1 what he was doing; however the resident had ignored her. She said she glanced away and when she looked back at him he was lighting a lighter close to his face and flames shot up in front of him. She said she ran to the resident, the flames were out at that time, and she rushed the resident into the facility where she turned him over to the CNA ' s. Review of a hospital emergency room Nurse Report indicated the following; the patient arrived to the emergency roiagnom on [DATE] at approximately 8:17 p.m. Diagnoses: [REDACTED]. Triage Assessment: Pain: complaints of pain in the resident ' s nose and mouth. Pain is currently 10 out of 10 on a 1-10 pain scale. General: appears uncomfortable, smells of singed hair. Respiratory: Airway is patent respiratory effort is unlabored. [MEDICAL CONDITION] his nose, lips, facial hair around the mouth and nose, singed hair in nasal passages. Injury Description:[MEDICAL CONDITION] to left ear, left base of the skull, right temporal area, nose and mouth. The patient has First and Second Degree burns. Outcome: at 11:12 p.m. the facility was contacted regarding the patients release back to the facility. Instructions given for after care and follow up with wound care. Review of a hospital emergency room Physician Report indicated the following; the patient arrived to the emergency roiagnom on [DATE] at approximately 8:17 p.m. The patient is a [AGE] year old male who presents to the emergency department via EMS with complaints of facial burns. The patient presents with [MEDICAL CONDITION] a result from lighting a cigarette with his oxygen on. Burn type and severity: 1st [MEDICAL CONDITION] 0.7% total body surface area with 1st [MEDICAL CONDITION] the face. 2nd [MEDICAL CONDITION] 0.3% total body surface with 2nd [MEDICAL CONDITION] the face. Associated signs and symptoms: The patient possibly suffered an inhalation injury from smoke. Review of Resident #1 ' s Physician Orders dated 4/27/14 at 7:15 a.m. indicated the following order: Wanderguard per IDT. Signed by the DON. Review of Resident #1 ' s MAR indicated [REDACTED]. Review of the resident ' s entire clinical record indicated the resident did not have a smoking assessment to determine if he was safe to smoke and no care plan was located regarding the residents wanderguard device. Review of Resident #1 ' s care plan dated 4/28/14 indicated a problem Resident is a smoker and at risk for injury related to oxygen use. Goal was the resident will smoke in designated areas without occurrence of injury for 90 days. Approaches were as follows: 1) Perform smoking assessment according to the facility policy 2) Explain/show were designated smoking areas are and smoking times 3) Monitor When needed to assure residents safety 4) Keep all smoking material at nurses station 5) Use smoking vest when appropriate. Review of the facility Investigation/Corrective Actions Report dated 4/28/14-4/29/14 indicated the following; " On 4/27/14 at approximately 7:50 p.m., Resident #1 was smoking unsupervised on the northwest side of the facility. Documentation (Sign out Book) reveals that the resident had signed himself out of the facility at 7:40 p.m. prior to going outside and the incident ensuing. When Resident #1 attempted to light his cigarette, the oxygen flow from his nasal cannula ignited. The resident [MEDICAL CONDITION] his face, (primarily to his nose) and singed his facial hair. Another resident witnessed the ignition incident and alerted staff of the situation. Resident #1 was brought back into the facility and assessed by the LVN charge nurse. Local EMS was notified and staff monitored the resident until their arrival. Resident #1 was treated at the local emergency room and returned to the facility with instructions for follow-up at the local wound care center. " " On the evening of the incident, the LVN charge nurse completed the appropriate paperwork, notified the physician, notified the sister, notified the Hospice provider and notified the DON. It was found with investigation, that the DON failed to notify RNC and RVP per cooperate policy (notification required with any incidents in which resident requires treatment ordered by the physician or ER evaluation). The Administrator reports that he was not notified the evening of the incident. " " Investigation reveals a history of the resident attempting (some successful) of smoking unsupervised at non-scheduled smoking times. " " The Administrator was informed of the burn incident on the morning of 4/28/14 and subsequently notified the RNC, RVP and VP of clinical operations. A Roam Alert device (wanderguard) was initiated to aide in the prevention of any similar reoccurrence. Resident #1 initially stated he had obtained the cigarette from his sister and then stated he had hid a cigarette in his pocket during smoke break. Interviewing with staff on 4/28/14 revealed inconsistency in relation to following policy. " " In conclusion; a lack of sufficient staff training, resident supervision, and adherence to policy culminated in the incident with Resident #1 being harmed. Corrective and preventative measures were begun on the morning of 4/28/14 and are on-going to ensure resident safety and substantial compliance. " Signed by the RNC During an observation/interview on 4/29/14 at 10:30 a.m. Resident #1 was observed sitting on his bed in his room. The resident had red/white/and black patches to his nose, lips and cheeks. The resident ' s mustache hair was singed and missing in areas and the resident had large raised blistered areas to his lips. The resident ' s nose and nares had blisters which were bleeding in areas. Resident #1 said he was in severe pain. Resident #1 was observed to have a wanderguard in place on his right wrist. Resident #1 said he had been outside in the pasture smoking and had forgotten to take his oxygen off. He said he had hid a cigarette and lighter from smoke break and had signed himself out to go smoke. He said when he lit the lighter, there was a flash of fire and the nasal cannula tubing had melted to his face. He said he yanked the tubing off and began stomping it in order to stop the fire from going up through the tubing and blowing up the tank. He said while heading back into the facility, Resident #11 had found him. He said Resident #11 ran to help him back into the facility. He said a CNA took him to the nurse. He said he had been transferred to the emergency room via ambulance and treated for [REDACTED]. He said he was very upset about being discharged from the facility, that he really loved living there. During an interview with the Regional RNC on 04/29/14 at 4:20 p.m. he said the facility did not do smoking assessments. The RNC was shown care plans for residents that smoke that indicated one of the approaches was that the facility was going to do smoking assessments on the residents that smoked. After reviewing the care plans the RNC said that the intervention of smoking assessments was a mistake and should have been omitted from the care plans. The RNC said after the facility developed their smoking policy it required all smokers to be supervised, so there was not a need for each resident to have a smoking assessment. The Regional RNC could not explain how care plans were developed for smokers without a smoking assessment. The RNC confirmed the issue with the assessments and care plans were conflicting. Review of a care plan for Resident #1 dated 04/30/14 indicated a problem that the resident was a smoker. Goal was to be safe and free from injury while smoking cigarettes over the next 90 days. Approaches were as follows: (1) Explain smoking policy as frequently as needed; keep smoking materials in a safe and secure place. (2) Provide them to the resident as per smoking schedule. (3) Assign someone to go with resident when he smokes in case something should happen someone will be there, (4) inform the resident he is unable to sign out to go smoke unless someone is supervising him, (5) Report observations of unsupervised smoking to charge nurse or other administrative staff, (6) Report observations of resident having smoking materials in possession at times other than during supervised smoking On 05/01/14 the Corporate RNC gave the surveyors a smoking evaluation on Resident #1 dated 05/01/14. According to the smoking evaluation Resident #1 was moderately cognitively impaired with intermittent confusion, cognitive deficit or disoriented at time with a BIMS of 11. According to the evaluation the resident did require a protective apron. Resident #11 Admission Face sheet indicated Resident #11 was admitted on [DATE] from psychiatric facility and was [AGE] years old female with the following Diagnoses: [REDACTED]. Annual MDS dated [DATE] indicated Resident #11 had a BIMS score of 10 out of a possible 15, which indicated the resident, had moderate cognitive impairment with disorganized thinking. The resident required supervision with bathing but was independent in all other areas of Activities of Daily Living. The resident was continent of bowel and bladder. Review of Resident #11's entire clinical record indicated no smoking evaluation had been conducted to determine if the resident was safe to smoke. Review of Resident #11's Nurse ' s notes dated 12/6/13, 01/20/14, 03/05/14 and 03/21/14 indicated the resident was a smoker and took scheduled smoke breaks. Review of Resident #11's Care Plan dated 02/28/14 indicated there was no care plan addressing the resident ' s safety while smoking until 04/28/14 (after the incident with Resident #1). On 04/28/14 the facility developed a care plan for Resident #11 that indicated the resident was a smoker and was at risk for injury. The goal was the resident would smoke in designated areas without occurrence of injury over the next 90 days. Approaches were: (1) The resident will have a smoking assessment according to facility policy. (note: facility ' s current smoking policy dated 11/12/12 does not require the facility to do smoking evaluations) (2) Explain/show where designated smoking areas are and smoking times- repeat PRN (3) Monitor PRN when smoking to assure residents safety. (4) Keep all smoking material at nurses' station (5) Uses smoking vest- when appropriate Review of another smoking care plan dated 04/30/14 indicated other approaches had been added: Which included: (1) " Assign someone to go with me with I smoke so that if something should happen I have someone there to assist and help me. " (2) Inform the resident of unable to sign out to leave the facility grounds to smoke unless supervised. (3) Report observations of unsupervised smoking to charge nurse or other administrative staff. Resident #12 According to the resident ' s admission sheet he was admitted on [DATE] from a psychiatric facility. Resident #12 was [AGE] years old at the time of this investigation. Admission diagnose were as follows: [MEDICAL CONDITIONS], Diabetes Mellitus, uncontrolled, [MEDICAL CONDITIONS], anxiety, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], asthma and reflux disease. Review of Resident #12 ' s current MDS dated [DATE] indicated the resident had a BIMS score of 12 out of a possible 15 indicating he had moderate cognitive impairment. Resident #12 also had [MEDICAL CONDITION] with inattentiveness and disorganized thing that was continuous throughout the day and did not fluctuate. The resident ' s mood indicated he was depressed with feelings of hopelessness, little interested or pleasure in doing things, had little energy, trouble falling or staying asleep, overeating, and felt bad about himself. According to the MDS Resident #12 needed supervision for bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use and personal hygiene. The resident was totally dependent on staff for bathing. Resident #12 was not steady, only able to balance with staff assistance while moving from seated to standing, walking, turning around, moving on and off the toilet and surface to surface transfers. The resident also had impaired range of motion on both sides of his upper and lower extremities and used an electric wheelchair for mobility. Resident #12 was continent of bladder and bowel. Review of Resident #12 ' s care plan dated 11/12/12 indicated the resident was a supervised smoker while in the facility. According to the care plan the resident could also sign himself out on pass and he could take his cigarettes with him. The care plan goal was the resident would be free of injury as a result of smoking over the next 90 days. Approaches were as follows: (1) Monitor my ability to smoke safely every three months. (2) Keep my smoking materials in a safe and secure place. Provide them to me as per smoking schedule. (3) Provide a protective apron while I am smoking so that I don ' t not burn myself. (4) Assign someone to go with me when I smoke so that if something should happen I have someone there to assist and help me. (5) If I sign out on pass and take my cigarettes with me, while on pass I am responsible for my own cigarettes. I have been advised of the facility smoking policy and understand the policy. I have been advised of the city ordinances on smoking. This care plan was updated on 12/5/12 and 02/08/13. According to monthly summaries dated June and October 2013 Resident #12 was a heavy smoker. (Note: there were not any monthly summaries after October 2013 for this resident.) During an interview with the administrator on 04/29/14 at 10:10 a.m. he said on 04/28/14 during a room search for smoking materials, Resident #12 was found with cigarettes in his room. Review of a care plan dated 04/28/14 indicated Resident #12 was a smoker and was at risk for injury. The care plan goal was will smoke in designated areas without occurrence of injury over the next 90 days. Approaches were as follows: (1) Perform smoking assessment according to facility policy, (2) explain/show where designated smoking areas are and smoking times-repeat PRN, (3) monitor PRN (as needed) when smoking to assure resident ' s safety, (4) Keep all smoking material at nurses station, use smoking vest when appropriate. Review of another care plan dated 04/30/14 indicated Resident #12 was a smoker. The care plan goal was to keep resident safe while smoking for the next 90 days. Approaches were as follows: (1) Explain smoking policy as frequently as needed, keep smoking materials in a safe and secure place. (2) Provide the to the resident as per smoking schedule. (3) Assign someone to go with resident when he smoked in case something should happen someone will be there, inform the resident he is unable to sign out to go smoke unless someone is supervising him, (4) Report observations of unsupervised smoking to charge nurse or other administrative staff, (5) Report observations of resident having smoking materials in possession at times other than during supervised smoking. Review of Resident #12 entire clinical revealed that the resident had not had a smoking evaluation to determine if he was safe to smoke. On 05/01/14 the Corporate RNC gave the surveyors a smoking evaluation dated 05/01/14 on Resident #12. According to the smoking evaluation Resident #12 was cognitively impaired and required the use of an apron when smoking. Resident #13 According to Resident #13 admission sheet he was admitted from an acute care hospital on [DATE]. The admitting [DIAGNOSES REDACTED]. The resident was 67 at the time of this investigation. According to Resident #13 ' s hospital history and physical he was 02 dependent, had a [DIAGNOSES REDACTED]. The resident also had a history of [REDACTED]. Review of the resident ' s latest MDS dated [DATE] indicated the resident had a BIMS of 13 out of a possible 15 indicating he was cognitively intact. However he did have [MEDICAL CONDITION] with inattentiveness that fluctuated throughout the day and continuous disorganized thinking. According to the MDS Resident #13 ' s mood indicated that he had little interest or pleasure in doing things, was depressed, had little energy and problems with sleeping. Resident #13 ' s functional status indicated he required supervision with bed mobility, transfers, locomotion on and off the unit, and eating. Resident #13 required extensive assistance with two staff for dressing, extensive assistance with one staff for personal hygiene and limited assistance of two staff with toilet use. Resident #13 was occasionally incontinent of bowel and bladder. According to the resident ' s MDS he was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, and moving on and off the toilet and surface to surface transfers. Review of a nurses' note dated 03/06/14 at 9:25 a.m. indicated a nurse had called Resident #13 ' s doctor and told him that the resident had been caught multiple times smoking with his 02 on despite several warnings. During an interview with LVN F on 05/01/14 at 3:30 p.m. she said after reading the nurses ' notes on Resident #13 dated 03/06/14 it appeared the resident was caught multiple times with his 02 on and smoking. She said she did not have any direct knowledge of any incidents. LVN F said the nurse that wrote the note does not work at the facility anymore. During an interview on 05/01/14 at 3:35 p.m. the note dated 03/06/14 was shown to the Regional VP and the Regional RN Consultant. They confirmed and acknowledged that an incident report should have been written on any incident that involved a resident smoking inside the facility with 02 on

Based on interview and record review the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents regarding Accidents and Incidents for one (Resident #2) of 10 residents reviewed for safety devices. The facility failed to: 1) ensure LVN D completed an Incident/Accident report on [DATE] when Resident #2 had a unwitnessed fall 2) ensure the Adminsitrator and/or DON performed an Internal investigation to rule out abuse/neglect 3) ensure LVN D documented a complete Nursing assessment following the residents unwitnessed fall on [DATE] in Resident #2 ' s Nursing Notes 4) ensure a Neurological Assessment Flow Sheet was initiated and maintained for 72 hours following Resident #2 ' s unwitnessed fall. 5) ensure Resident #2 ' s physician and responsible party were notified of the incident. An Immediate Jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a level of no Actual Harm at a pattern due to the facility's need to evaluate the effectiveness of corrective systems. Theses failures could affect any of the 13 residents identified with safety devices and place them at risk of experiencing a change in condition, unidentified injuries and possible decline in health status. The findings included: View of the facility Policy and Procedure Accidents and Incidents revised [DATE] indicated the following; An Accident/Incident Report must be completed immediately upon facility staff awareness of the incident involving a resident or visitor. Each Accident/Incident Report form must be reviewed at the Administrator ' s Daily stand up meeting until all sections of the report are completed. A complete Nursing Assessment is performed at the time of the accident/incident. Resident findings are documented every shift for 72 hours. The assessment is documented in the Nurse ' s Notes and the Resident Care Plan is updated. An Accident/Incident Investigation is completed in addition to the Accident /Incident Report form when staff discovers and n-witnessed accident/incident or falls. The Director of Nursing Services completes the Conclusion and Intervention form when the investigation is completed. The DON or Designee will interview witnesses, using the approved witness statement form and have them sign that the information is reflective of their statement. The DON will maintain a monthly Accident/Incident log which is updated daily. The Administrator will complete the Individual tracking/trending of Resident incidents and have the log available for Daily Stand Up Meeting. The IDT reviews the incident and the care plan is updated. A Neurological Assessment flow sheet must be immediately initiated and maintained for at least 72 hours following each accident/incident involving injury to the head or unwitnessed fall. A complete Accident/Incident Investigation must be completed for each occurrence of actual or suspected Resident abuse. The Administrator serves as the Abuse Prevention Coordinator. In the absence of the Administrator, the DON or Designee will fulfill the duties. Review of Resident #2's Admission Record the [AGE] year old male was admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #2's consolidated Physician order [REDACTED]. --Order dated [DATE] for the resident to have a bed alarm per the IDT (Interdisciplinary Team). --Order dated [DATE] for the resident to have a chair alarm per the IDT --Order dated [DATE] for the resident to have a seat belt alarm per the IDT Review of Resident #2's annual Minimum (MDS) data set [DATE] indicated the following the resident had been identified with a BIMS (Brief Interview for Mental Status) score of 6 out of a possible score of 15; indicating severe cognitive impairment. Resident #2 was identified with inattention and disorganized thinking. Resident #2 required extensive assistance of one to two staff with activities of daily living. Resident #2 was identified with functional range of motion limitations on both upper and lower extremities. Resident #2 was identified with one fall with no injuries. Review of Resident #2's comprehensive Care Plan updated [DATE] indicated the following: --Problem: Resident has a history of falling related to being noncompliant with not transferring himself. Goals: Resident will remain free from injury Approaches: Equip resident with device that monitors rising. Seat belt alarm and bed alarm. Give resident verbal reminders not to ambulate/transfer without assistance. Keep call light in reach. Keep personal items within reach. -- Problem: The resident has multiple problems that affect his ability to think clearly. He is supposed to use a bed alarm at night to alert staff that he is rising without the assistance and endangering himself. Goal: Resident will be safe and not have a major accident over the next 90 days. Approaches: Anticipate when resident needs something. Ensure that the resident has his bed alarm on and that it is checked every two hours during the night. (No documentation was found in the Resident ' s clinical record regarding the Resident's alarm being checked every two hours) Review of Resident #2's quarterly Minimum (MDS) data set [DATE] indicated the resident had been identified with one fall with no injuries since admission. Review of Resident #2's Medication Administration Record [REDACTED]. There was no documentation of monitoring the Resident ' s alarms on the 2:00 p.m. to 10:00 p.m. shifts or the 10:00 p.m. to 6:00 a.m. shifts. Review of an Incident and Accident Report Dated [DATE] at 4:00 p.m. indicated Resident #2 was found on the floor in his room. The resident reported to the nurse he was [MEDICATION NAME] putting himself to bed due to the resident feeling as if he was going home the next week. The resident received a skin tear to his left arm and abrasions to his right knee. Physician and family notified. Signed by the DON and Administrator. Review of Resident #2's Nursing Notes dated [DATE] at 4:00 p.m. indicated the resident had been found on the floor by a CNA. Resident #2 was assisted to bed. Unwitnessed fall, neurological checks started. Resident stated he had plans to go home the next week and was [MEDICATION NAME] putting himself to bed. When asked why his alarm did not sound, the resident stated he had turned his alarm off. Resident was assessed and found to have a skin tear to his left lower arm and an abrasion to his right knee. Review of Resident #2's Nursing Notes dated [DATE] indicated the resident was out on pass with his wife. On [DATE] the resident was admitted to the hospital. Review of Resident #2's hospital History and Physical dated [DATE] indicated the resident had been admitted to the hospital with [REDACTED]. Review of Resident #2's hospital Discharge Summary dated [DATE] indicated the following; Resident #2's discharge [DIAGNOSES REDACTED]. Resident #2's functional status was listed as: impaired mobility. Review of Resident #2's Physician order [REDACTED]. Review of Resident #2's Nursing Notes dated [DATE] at 4:00 p.m. Resident #2 had arrived at the facility via facility van. The resident was noted to have multiple bruises and skin tears " all over " , a dressing to the right side of his neck and a 3 small open areas to the residents buttocks which measured 2 cm and smaller. Review of Resident #2's Fall Risk assessment dated [DATE] indicated the resident had been identified with a total score of 24. (Instructions indicated: If the total score is more than 10 or greater, the resident should be considered HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the residents care plan) During an interview on [DATE] at 5:15 a.m. LVN A said she had been off on [DATE] and [DATE]; however she had been informed the resident had a fall during the early morning hours of [DATE]. She said the incident had been documented on the 24 hour report. She said she was not aware of any new interventions which had been implemented due to the fall. She said she had been informed the resident had been out on pass with his wife and had fallen at home, was then transferred to the hospital via EMS, and had fallen at the hospital following his admission. She said the resident had been admitted back to the facility on [DATE]. She said the resident had been found non- responsive at 3:15 a.m. on [DATE], CPR had been initiated, and she had received report from the hospital at 4:30 a.m. that the resident had expired. She said the resident had severe tremors and spastic muscle movements and had recently experienced several episodes in which his O2 saturation had been assessed to be in the 70% range due to the resident knocking his oxygen off. She said she was aware of the resident being a fall risk, and the resident was to have a bed alarm, chair alarm and seat belt alarm. She said there had been occasions in which the resident had turned his alarm off and required redirection from the staff. During an interview on [DATE] at 5:25 a.m. LVN B said she had been on duty on the 10:00 p.m. to 6:00 a.m. shift on [DATE] to [DATE]. She said she was aware of Resident #2 experiencing a fall in the early morning hours of [DATE]; however she had not been the charge nurse for the Resident ' s hall. She said LVN D had been the Resident ' s charge nurse. She said to her knowledge the resident had suffered no major injuries related to the fall and had not required medical treatment at the hospital. She said information about the incident should be documented in the Incident and Accident Report and Nursing Note. During an interview on [DATE] at 5:30 a.m. CNA C said she had been on duty during the 10:00 p.m. to 6:00 a.m. shift on [DATE] to [DATE]. She said she was aware of Resident #2 experiencing a fall around 4:30 a.m. on [DATE]. She said LVN D had asked her to assist him and another CNA in getting the resident off of the floor and back into his bed. She said when she arrived to the Resident ' s room he was sitting on the floor with his back up against the end of the bed. She said the resident had a bed alarm, however it was not sounding when she entered the room. She said she was unaware if the resident had any injuries related to the fall, due to the resident having so many bruises and abrasion when he had been admitted back from the hospital. She said she was aware of LVN D dressing a skin tear to the Resident ' s right arm following transferring the resident back to his bed. She said the resident did not go to the hospital. She said the resident needed frequent monitoring because he had a history of [REDACTED]. She said it was her understanding that the fall was unwitnessed and was unsure of the resident had hit his head or not. During an interview on [DATE] at 6:15 a.m. The Administrator said Resident #2 ' s wife had spoken to him on [DATE] and had requested to see a copy of the Incident and Accident Report related to the residents fall on [DATE]. He said he had not been aware of the resident having a fall on [DATE]. He said Resident #2 ' s wife said the resident had fallen at home while out on pass and she had to contact EMS for assistance with the resident. He said Resident #2 ' s wife had informed him that Resident #2 had also fallen following his admission into the hospital. He said he had not received an incident and accident report related to the fall and would have to attempt to locate one. During an interview on [DATE] at 8:30 a.m. The Director of Nursing (DON) said she had not received an incident and accident report regarding Resident #2 ' s fall on [DATE]. She said the incident had not been reported to her. She said it was her expectation if an incident or accident occurred with a resident that the nurse fill out an incident and accident report, document the situation in the nursing notes and contact the family and physician. She said Resident #2 had been identified to deactivate his alarm in order to transfer himself without staff assistance. She said the resident had been redirected on multiple occasions to call for assistance. During an interview on [DATE] at 10:10 a.m. The Administrator said he had been unable to locate an incident and accident report regarding Resident #2 ' s fall on [DATE]. He said due to not having an incident and accident report, he was not aware of the incident and had not performed and investigation of the incident. He said while looking through the Resident ' s clinical record, he found that the incident had not been documented in the nursing notes; therefore he could not guarantee the Resident ' s family and physician had been notified of the incident. During an interview on [DATE] at 11:30 a.m. Resident #2 ' s roommate said he was aware of Resident #2 ' s fall on [DATE]. He said the privacy curtain had been closed halfway and he did not see the resident fall; however he heard the resident groaning on the floor. He said he did not hear the Resident ' s bed alarm sound when the resident fell . He said he immediately used his call light to attempt to get staff to help his roommate. He said the staff responded within 5 minutes of him using his call light. During an interview on [DATE] at 6:00 a.m. LVN D said he had been the charge nurse on duty on [DATE] at 4:30 a.m. when Resident #2 had been found on the floor. He said he had been passing medication down the hallway from the Resident ' s room, when CNA E had alerted him that Resident #2 was on the floor. He said the residents alarm was not sounding. He said Resident #2 was alert; however he did not ask the resident why he was on the floor. LVN D said he assessed the resident and did not find any new areas of injuries; however he said the resident was covered with bruises in different stages of healing all over his body. He said he had attempted to contact Resident #2 ' s physician and had left a message on medical exchange. He said he had tried to contact the Resident ' s wife with no answer and the Resident ' s son's number was not a good number. He said he could not remember if he left a message for the wife. LVN D said he had not done a nursing note due to running late. He said he had done an Incident and Accident report and placed it in the DON's box. He said he was unsure what had happened to it after that. LVN D said he did not specifically remember doing an alarm check on Resident #2 on [DATE]; however he said he always checked the Resident ' s alarms when he came on shift. He said if he checked Resident #2 ' s alarm he would have initialed the area for alarm monitoring on the MAR. During an interview on [DATE] at 6:15 p.m. LVN I said She had worked [DATE] from 6:00 a.m. - 2:00 p.m. and had received report from LVN D. She said LVN D had informed her that Resident #2 had " tried to fall out of the bed " . She said she had not been told the resident had actually fallen out of the bed. She said she had written on the 24 Hour Report that the resident had fallen due to " always " being told that is a resident almost fell and something stopped them it should still be considered a fall. She said she was not aware of any further assessments on Resident #2 and she had not received any information in report that neurological checks had been initiated. LVN I said she had observed bruising in different stages of healing on the Resident ' s arms, legs and a fading bruise on the residents forehead. She said she had been informed that Resident #2 had fallen at home while out on pass and at the hospital and she assumed the bruising was from the falls. She said she had heard the residents alarm sounding on several occasions on [DATE] due to the Resident ' s spastic movements. She said she was aware the resident was at an increased risk for falls and ensured the residents alarms were in place at all times. During an interview on [DATE] at 6:40 a.m. LVN F said she had spoken to Resident #2 ' s physician who had instructed her he had not been notified of Resident #2 ' s fall on [DATE]. She said Resident #2 ' s physician said he had received no messages and/or texts regarding the fall. During an interview on [DATE] at 7:30 a.m. The Director of Nursing (DON) said she had been unable to locate and incident and accident report regarding Resident #2 ' s fall on [DATE]. She said she was not aware of the incident until [DATE], when the 6:00 a.m. to 2:00 p.m. nurse had brought it to her attention from the 24 Hour Report. She said she was unaware if the resident ' s family and/or physician had been notified of the fall. She said she was not aware of the resident's care plan not being updated to reflect revisions implemented following the residents falls and/or Fall Risk Assessment scores. She said she had instructed the nurses who perform the resident care planning, that each new physician order [REDACTED]. She said however, the nurses needed further education in assessment and care planning. She said during chart audits on [DATE], the Regional Nurse Consultant (RNC) had made her aware that there were problems with some of the Resident ' s Medication Administration Records (MAR) in that some of the Resident ' s orders for monitoring wander guards and alarms had been dropped off. She said she was aware that several of the residents who had alarms only had areas on the MAR indicated [REDACTED]. She said she was in the process of getting the Resident ' s MAR ' s updated in the computer system to reflect the designated areas for the 2:00 p.m. to 10:00 p.m. shifts and the 10:00 p.m. to 6:00 a.m. shifts to initial. She said she had not had the nurses edit the MAR's immediately upon becoming aware of the problem due to trying to get the MAR's fixed in the computer. She said she was not aware of any other documentation which would be available to show monitoring of the residents alarms, unless the nurses documented their observations in the nursing notes. During an interview on [DATE] at 7:41 a.m. CNA E said she had been on duty during the 10:00 p.m. to 6:00 a.m. shift on [DATE] to [DATE]. She said she was the first person to find Resident #2 on the floor in his room. She said the Resident ' s alarm was attached; however it was not sounding. She was unsure of why the alarm was not sounding; however said the batteries might have died . She said when she entered the room the resident was lying face down on the floor. She said he was moaning and groaning and she instructed the resident not to move that she was getting the nurse. She said she had immediately alerted LVN D of the resident being on the floor. She said LVN D had assessed the resident and she, CNA C and LVN D had lifted the resident off the floor and placed him in his bed. Review of Resident #2's Nursing Notes dated [DATE] on 10:00 p.m. - 6:00 a.m. shift indicated the resident was resting in bed with oxygen at 3 liters via nasal cannula. Respirations were even and unlabored. The resident had no complaints of pain. Call light was in reach. (Resident #2 had a fall during the shift; however no documentation was located in the Resident's clinical record) Review of the facility 24 Hour Report/ Change of Condition Report dated [DATE] indicated the following: The Resident's vital signs were documented on the section designated for night shift report. The area designated for day shift report indicated a notation of " fell on night shift. Looks horrible. " Review of Resident #2's Nursing Notes dated [DATE] at 10:10 a.m. indicated the following: Resident #2's respirations were even and unlabored. The resident experienced shortness of breath with exertion. The resident continued on oxygen at 3 liters via nasal cannula and had received nebulizer treatments as ordered. The head of the Resident's bed was elevated to facilitate easier breathing. The resident was noted to be making a growling like sound. The resident was able to answer questions when spoken to; however went to sleep easily. Review of Resident #2's Nursing Notes dated [DATE] at 12:45 p.m. indicated the following: The Resident's son was at the facility and spoke to the nurse " at length " regarding the Resident's condition. The resident was noted to be " very lethargic " but able to open his eyes when spoken to and answer yes/no questions. Review of Resident #2's Nursing Notes dated [DATE] at 8:00 p.m., indicated the following: Resident #2 was in bed with the head of the bed elevated. Resident #2 had been found to have removed his oxygen and O2 saturation was assessed at 72%. Explained to resident the importance of leaving his oxygen in place. Placed oxygen back on resident and O2 saturation assessed at 94%. Medications crushed and mixed with jelly, the resident had difficulty swallowing. Attempted to administer 4:00 p.m. and 8:00 p.m. medications with yogurt but resident was very lethargic. Resident's wife attempted to administer medications but resident wouldn't stay awake. Resident did not take all of medication mixture. Multiple bruises throughout. Review of Resident #2's Nursing Notes dated [DATE] at 1:40 a.m. indicated the resident continued to have bruising to " most of his body " . Review of Resident #2's Nursing Notes dated [DATE] at 3:00 a.m. indicated the resident had O2 saturation of 73% on 2 (?) Liters of oxygen per nasal cannula. Repositioned resident with head of bed elevated to 45%. Oxygen switched to mask at 5 Liters and nebulizer treatment administered. Oxygen saturation up to 93%. Review of Resident #2's Nursing Notes dated [DATE] at 3:15 a.m. indicated the nurse was alerted by the CNA that she thought the resident had " passed away " . CPR was initiated and 911 called. While CPR was in progress, the Resident ' s skin was warm and dry. No response from resident. EMS arrived at 3:30 a.m. CPR taken over by EMS. Several attempts made by phone to contact the Resident's spouse and son. At 4:30 a.m. Notified by hospital that resident had expired and the hospital was unable to contact the family. During an interview on [DATE] at 9:00 a.m. LVN F said the Resident's with alarms were monitored throughout the day by the Meal Managers as an extra approach to ensure the Resident ' s alarms were in place. She said she would locate the list used by the Meal Manager for breakfast that morning. Upon searching, LVNF said she had located a blank copy of the Meal Manager's List. Review of the Meal Manager's List on [DATE] indicated 11 residents who had been identified with seat belts/alarms. Upon further review with LVN F, 2 of the residents had been discharged and 2 of the residents were deceased . ( The list had not been updated to reflect accurate information on resident's identifed with alarms) Review of a list of Resident's with alarms received from the Assistant Director of Nursing (ADON) on [DATE] at 9:15 a.m. indicated 17 residents who had been identified with seat belts/alarms. Upon further review with LVN F, 1 of the Resident's was deceased , and 4 residents had no orders for alarms located in the residents clinical records. Review of an updated list of Resident's with alarms received from LVN G on [DATE] at 9:30 a.m. indicated 12 Resident's with seat belts/alarms. During an interview on [DATE] at 9:40 a.m. The Maintenance Director said he had been the designated Meal Manager for breakfast on [DATE] and had forgotten to do the Meal Manager alarm check that morning. During an interview on [DATE] at 11:45 a.m. The DON said she had identified multiple problems with the nursing staff's documentation. She said she had several meetings with the staff about accurate documentation of Resident ' s conditions, incidents, accidents etc.; She said she expected the Resident's Care Plans to be updated with each physician order [REDACTED]. During an interview on [DATE] at 12:15 p.m. The Regional Nurse Consultant (RNC) said he did not remember specifically discussing resident's alarms not being documented as monitored with the DON on [DATE]; however he had informed her that the resident's with wander guards were not being documented as being monitored by the staff for 2:00 p.m. - 10:00 p.m. shifts and 10:00 p.m. - 6:00 a.m. shifts. He said it was his expectation that all monitoring of resident safety devices be documented on each shift. He said if the DON had identified the resident alarms were not being monitored on each shift, it was his expectation that the situation be immediately fixed. He said he felt the MAR indicated [REDACTED]. During a telephone interview on [DATE] at 12:58 p.m. Resident #2's Physician said he had not been notified of the resident's fall on [DATE]. He said he had not received any messages on the office phone, by fax or on his personal cell phone regarding the incident. He said if a message had been left with the medical exchange, the medical exchange would have forwarded the information. He said he was unsure if he would have made any changes to the residents care; however felt he should have been informed of the incident and given the opportunity to determine if changes should have been made to the residents care at the time. On [DATE] at 10:20 a.m. an IJ was identified and the Administrator and DON were informed. During an interview on [DATE] at 10:20 a.m., The Administrator was informed of the identified Immediate Jeopardy. The Administrator said he had not been aware that the resident ' s seat belts/alarms had not been being monitored on the evening and night shifts. He said he felt the failure to appropriately monitor the residents for safety concerns was unacceptable and the problem should have been fixed immediately when identified. He said he was aware the nurses needed further education regarding their documentation of nursing notes and incident and accident reports. He said he was not aware the resident's care plans were not being updated with changes in the resident's care needs. He said the facility had not identified concerns with monitoring resident seat belts/alarms in the facility's Quality Assurance Meetings. During an interview and record review on [DATE] at 2:15 p.m. The RNC said he had updated all of the resident's MAR's in the computer system to reflect accurate monitoring of alarms and safety devices on all three shifts. He said the updates would be reflected on the [DATE] MAR's; however all the [DATE] MAR indicated [REDACTED]. The facility's Plan of Removal of Immediate Jeopardy was accepted on [DATE] at 9:05 a.m. and included: -- Residents with alarms and safety devices were reassessed for Fall Risk and their Care Plans were reviewed and revised for completeness and accuracy. --Alarms and safety devices will be checked each shift by a nurse for placement and functioning then documented in the MAR. This will be checked by the DON on a daily basis to ensure the MAR indicated [REDACTED]. -- The Maintenance Supervisor was inserviced and will be checking the alarms and personal devices on a weekly basis. This will be documented on the Battery Visualization Sheet. --A review of all Incident and Accident Reports with falls from [DATE] through the present was done on [DATE] to identify residents with a pattern for falls. Residents identified with a pattern of falls will be reassessed and their care plans revised. --An inservice was done on [DATE] with staff on reporting Incidents and Accidents to the charge nurse. Nurses were inserviced on completing Incident and Accident Reports. This included doing a thorough investigation of event leading up to the incident, the residents condition after the incident, documenting is an alarm or safety device was in place and if the alarm or safety device was functioning properly. All facility staff has been inserviced on these new procedures. On [DATE] from 10:15 a.m. through 3:18 p.m. the surveyor verified the staff had been inserviced on the new procedures. CNA's and Nurses from all three shifts were interviewed and found to have knowledge of the inservice information. According to a list received on [DATE] from the DON, the facility had identified 12 residents who required seat belt alarms/ chair alarms/ bed alarms due to being identified as increased fall risk.

Based on interview and record review the facility failed to ensure that one of five residents (Resident #3), reviewed for supervision, received adequate supervision to prevent elopement from the facility. The facility failed to ensure adequate supervision to prevent Resident #3 from eloping from the facility and hitchhiking on multiple occassions. Resident #3 had severe cognitive deficits related to a stroke. An Immediate Jeopardy situation was identified on 03/12/14. The Immediate Jeopardy was removed on 03/13/14. The facility remained out of compliance at no actual harm at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This failure affected Resident #3 and could affect 21 other residents with impaired cognitive skills by placing them at risk of adverse weather conditions, dehydration and/or other medical conditions, falls, drowning, being struck by a motor vehicle, acts of violence/exploitation, and death. Findings included: Review of Resident #3's Resident Admission Record, dated 03/21/13, in his closed clinical record indicated he was [AGE] years old and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The primary payer was listed as private insurance. The form indicated he was not responsible for himself. His son who resided in Arizona was listed as the emergency contact, responsible party, and primary financial contact. There were no documents for financial or medical POA. Review of an Elopement Risk assessment dated [DATE] indicated that Resident #3 verbally expressed his desire to go home. A personal safety alarm (wanderguard), frequent monitoring, and utilization of a check in/out log were initiated. Review of an Elopement Risk assessment dated [DATE] indicated that Resident #3 verbally expressed his desire to go home. The personal safety alarm ("roam alert") was discontinued. No reason was documented for discontinuing the wanderguard. Use of frequent monitoring, and utilization of a check in/out log was continued. Review of an Elopement Risk assessment dated [DATE] indicated that Resident #3 verbally expressed his desire to go home. Use of frequent monitoring, and utilization of a check in/out log was continued. No Elopement Risk Assessments were found after 07/03/13. Frequent monitoring and utilization of a check in/out log were not included in the resident's care plan. Review of Resident #3's quarterly MDS assessment dated [DATE] indicated he was usually able to make himself understood to understand others. His BIMS score was 4. (0 - 7 indicates severe cognitive impairment.) He had continous disorganized thinking and inattention. The assessment listed verbal behavioral symptoms directed to others. It did not list any wandering behavior. He required supervision for transfers and ambulation. He normally used a walker for ambulation. Review of the Care Plans updated 11/11/13 for Resident #3 did not include any care plan addressing cognitive impairment or wandering/elopement. In an interview with the MDS Coordinator B on 03/04/14 at 11:45 a.m. she said someone else had done Resident #3's initial care plan. She acknowledged that there was no care plan addressing elopement. She said she should have made one when she updated his care plans. Review of Resident #3's nurses' notes indicated that on 12/24/13 at 9:00 p.m. he went out on pass with a friend to see Christmas lights. When they returned to the facility the resident refused to get out of the vehicle. Staff attempted to talk him into going into the facility and he refused. The friend decided to take him out on pass overnight. He remained out on pass 12/25/13 and returned to the facility on [DATE] at 5:15 p.m. Documentation in the nurses' notes on 12/30/13 at 3:30 p.m. indicated Resident #3 was observed across the street from the facility without any assistive devices, attempting to get a ride. Staff attempted to get the resident to come back to the facility over a 30 minute time span. The resident was combative with the staff and refused to come back to the facility. According to the staff Resident #3 recieved a ride in an unidentified vehicle. At 5:00 p.m. a call was recieved from a bank downtown reporting that the resident was at the bank. (The bank was 0.6 miles from the facility.) The facility maintenance coordinator picked the resident up and brought him back to the facility. It was documented that the resident's son was aware that the resident was back at the facility, and to continue to closely monitor. There was no documentation that the physician had been notified. There was no update of the resident's care plan. In an interview with LVN D on 03/12/14 regarding the elopement of Resident #3 on 12/30/13 she said he got a ride in a blue pick-up. She said no one got the license number. She said that after notifing the administrator, DON, and the resident's son they waited to hear from someone as to the resident's whereabouts. She said that about an hour later the facility received a call from a bank reporting the resident was there. She said the physician was not notified and an incident report was not written because "it was such a normal occurance." She said he would leave his walker behind when he got rides. The next nurses' note entry dated 01/08/14 at 2:15 p.m. indicated that an off-duty facility staff member called and reported that Resident #3 was downtown hitchhiking. (No specific location was documented.) The staff member offered the resident a ride back to the facility. At 2:30 p.m. the resident had arrived at the facility and no agitation was noted. Resident #3 stated, "I was going to come back later." There was no documentation that the physician had been notified. There was no update of the resident's care plan. In a telephone interview with LVN E on 03/12/14 at 12:20 p.m. she said she worked the 6am - 2pm shift of 01/08/14. She was assigned to Resident #3's hall. She said Resident #3 was allowed to go out after signing himself out. She said she did not know when the resident left the facility that day. She said she worked a double shift that day and switched halls for the 2pm to 10pm shift. She said after she started the second shift she heard the ADON and LVN D "dealing with him being out." There was no documentation in the nurses' notes on the 6am - 2pm shift on 01/08/14. Resident #3 was found by an off-duty staff member at 2:15 p.m., hitchhiking downtown. Review of the nurses' notes dated 02/18/14 at 8:50 a.m. indicated the writer was notifed by staff that Resident #3 was across the street attempting to hitchhike. Multiple staff members talked to the resident and after about 30 minutes he consented to go back to the facility and take a shower. Resident #3 was very adamant that he wanted a face-to-face appointment with his physician. An appointment was made for the following day at 10:40 a.m. On 02/18/14 at 11:30 a.m. the resident was again across the street and was adamant that he was leaving. The resident's physician and son were notified that he had left the facility. It was explained to the son that since the resident was his own responsible party the facility could not force him to stay. At 12:45 p.m. a car dealership called and reported that Resident #3 was there attempting to buy a truck. (The dealership was located 5.5 miles from the facility.) The facility transportation aide picked up the resident at the dealership. In an interview with LVN A on 03/04/14 at 10:10 a.m. she said that Resident #3 was across the street on the morning of 02/18/14. She said several staff members tried to persuade him to go back to the facility. After a while he did come back. He took a shower then left again. Someone, "a visitor maybe, or a passerby", came in and told someone (staff) they saw Resident #3 get into a blue pick-up. A few minutes later the car dealership called and reported he was there. The facility van driver went and picked him up. She said he would not get out of the van when they arrived at the facility, so the van driver let him ride along while she took other residents to appointments. When they returned to the facility, he got out of the van and came inside. She said she did not fill out an incident report. She said the administrator told her to just thoroughly document the incident in the nurses' notes. LVN A also said that Resident #3 used to have a wanderguard. She said each time they put one on him he would have it off within 1 - 2 days. He finally refused to have another one put on. She said there weren't any other plans put in place to monitor his wandering after the wanderguard was discontinued. She said he would go through phases of wanting to go home. She said his friend would take him out on pass, then he wouldn't get out of the car when she brought him back to the facility. In an interview with the facility van driver, on 03/12/14 at 10:30 a.m., she said she picked up Resident #3 at a car dealership on 02/18/14. She said when they arived at the faciltiy he did not want to get out of the van. She said she let him ride along while she took another resident to an appointment. She said that resident had family accompaning him, so she did not have to get out of the van. She said Resident #3 was not left alone in the van. She said he enjoyed the ride and upon return to the facility, he went inside without any protest or resistance. On 02/19/14 at 12:30 p.m. nurses' notes indicated that Resident #3 returned from his physician appointment with an order for [REDACTED]. The order read "Pt (patient) is cleared to be discharged home." The resident's son was notified and the son did not want him to be discharged . It was explained to the son that since the resident was his own responsible party and had not been deemed incompetent, they could not force him to stay at the facility. At 3:45 p.m. the resident was discharged and left the facility to go home via the facility van. In an interview with the marketing/admissions coordinator on 03/03/14 at 4:30 p.m. she said that Resident #3's physician called her after he saw the resident in his office on 02/19/14. She said he instructed her to set up home health and make a referral to APS for Resident #3. She said the resident initally refused home health, but then agreed to allow the home health nurse to meet with him at home to explain what type of services they could provide to him. She said that an APS case worker visited her today (03/03/14) and told her the resident was receiving home health services. The case worker also said that APS would conduct a competency evaluation the following day. In an interview with the DON on 03/04/14 at 11:40 a.m. she said Resident #3's wanderguard was discontinued before she was hired at the facility. She acknowledged that there should have been a care plan to address Resident #3's elopements. She said she didn't know why there was not. In an interview with the administrator on 03/04/14 at 11:50 a.m. he said that since Resident #3 was his own responsible party, they could not make him stay at the facility. He said he had talked to the resident about signing out whenever he was going to leave so they would know where he was. He said he would sometimes sign himself out as requested, but not every time. The administrator checked the residents' sign out book and Resident #3 had not signed himself out on 02/18/14. Review of Resident #3's Release of Responsibility for Leave of Absence log it showed he was signed out on four occasions: 11/03/13, 11/07/13, 11/30/13, and 12/11/13. He was only signed back in on two occassions: 11/03/13 and 12/16/13. None of the signatures was that of Resident #3. Review of the Incident/Accident log from 01/01/14 through 02/19/14 revealed no Incident Reports regarding Resident #3. In a telephone interview with Resident #3's primary care physician on 03/07/14 at 3:20 p.m. he said he was well aware of Resident #3's elopements from the facility. The facility notified him and he was in the facility almost every week. He said that staff at the facility had expressed they "felt uncomfortable about (Resident #3"s) safety and competence." He said Resident #3 could "put on his best face" and answer questions appropriately and tell you how he was able to manage for himself. He did not have delusions, hallucinations or suicidal/homicidal ideations. He said his judgment was impaired and he had poor hygiene. He said he thinks the stroke happened about 6 months ago, but didn't recall the actual date. When informed of the allegation of facility neglect, he said no, the facility was not neglectful. He said they could not keep a wander guard on him. He agreed that the facility should have provided more supervision given his elopement behavior. In an interview with the administrator on on 03/12/14 at 11:25 a.m. he acknowledged that the facility has the responsibility to ensure the safety of all residents regardless of their cognitive or functional status. Review of an Elopements policy dated 12/2006 included the following, in part: "3. Upon return of the resident to the facility, the director of nursing services or charge nurse should: a. Examine the resident for injuries; b. Contact the attending physician and report what happened; c. Contact the resident's legal representative...; d. Document the investigation of the incident; e. Make appropriate notations in the resident's medical record. 4. Should an employee discover that a resident is missing from the facilility, he/she should: a. Determine if the resident is out on an authorized pass. IF NOT; b. Make a thorough search of the building(s) and premises. IF NOT LOCATED; c. Notify the administrator and the director of nursing services; d. Notify the resident's legal representative; e. Notify the attending physician; f. Notify law enforcement officials; g. If necessary, notify volunteer agencies...; h. Provide search teams with resident identification information; and i. Make an extensive search of the surrounding area. Review of a policy dated 12/2003, Signing Residents Out, including the following, in part: 1. Each resident leaving the premises (excluding transfers/discharges) must be signed out. 2. A sign-out register is located at each nurses' station. Registers must indicate the resident's expected time of return. 6. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out, should notify their supervisor at once. 9. Residents must be signed in upon return to the facility. ..." The administrator was notified on 03/12/14 at 2:25 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 03/13/14 at 10:50 a.m. and included: * Elopement assessments on all current residents, and on admission, readmission, quarterly, and significant change; * Interventions put in place, and on the care plan, for individuals identified as an elopement risk; * Referral to ombudsman for guardianship for those residents identified as an elopement risk and without responsible parties; * In-servicing of staff on policy and procedure for elopement and residents signing out. These policies will be included in orientation for new employees; * Current residents received a copy of the sign out policy; * New admissions will receive a copy of the sign out policy; * Any time a resident elopes or leaves without signing out in incident report will be completed and the administrator/designee will be notified; * All roam alerts in use were checked on 03/12/13 and will be checked daily; * If a roam alert does not work it will be replaced at that time. The surveyor confirmed the Plan of Removal had been implemented sufficiently to remove the IJ by: * Review of Elopement Risk Assessments done on every resident on 03/12/14; * Review of Care Plans updated on 03/12/14 for 21 residents with roam alerts (wander guards); * Review of the sign-in sheet for the in-service, Elopement/Resident sign-out dated 03/12/14, indicated all current staff had been inserviced. * Interviews with 1 LVN, 2 CNAs, and one housekeeper on the 6am - 2pm shift; 1 LVN and 1 CNA on the 2pm - 10pm shift, and 1 RN and 1 CNA on the 10pm - 6am shift. All were knowledgeable of the facility's policies and procedures for elopement and residents signing out when leaving the premises. On 03/13/14 at 2:35 p.m. the administrator was informed the IJ was removed; however, the facility remained out of compliance at no actual harm at a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Review of the Elopment Risk Assessments and the updated Plans of Care, all dated 03/12/14, indicated there were 21 residents with dementia who could potentially wander.

Based on interview, observation, and record review the facility failed to ensure the resident's environment remained as free of accident hazards as possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 11 residents (# 1 and 2) who required two staff for care and transfers. The facility failed to: 1) Shower resident #1 in a safe manner to prevent an accident resulting in actual harm. Resident #1 had a seizure disorder and had a [DIAGNOSES REDACTED]. The resident also had periods of agitation in which he would throw himself forward and he would sometimes try to bite staff. Resident #1 fell when he was being showered on a regular shower chair by one staff without any safety devices to keep him from falling during showers. 2) Ensure staff followed Resident #3's doctor's order to transfer the resident using a mechanical lift. 3) Ensure staff followed Resident #3's Care Plan to transfer the resident using a mechanical lift by two staff. One staff attempted to transfer the resident alone without using a mechanical lift and the resident fell to the floor. The failure to ensure Resident #1's safety in the shower resulted in actual harm to the resident when he fell to the floor face first on 11/16/12. The fall resulted in significant facial injury with fractures to the resident's sinus and right eye socket as well as a head injury and cerebral contusion. The resident also lost multiple front teeth. This failure could have affected any of the other 3 residents who had seizure disorders and who were completely dependent on staff for all activities of daily living, including showers. The failure to follow Resident #3's physician orders [REDACTED]. Findings include: Resident #1 Review of an annual Minimum Data Set ((MDS) dated [DATE] revealed [AGE] year-old male Resident #1 had short term and long term memory problems and was severely impaired in cognitive skills for daily decision making. Resident #1 was totally dependent on two or more staff for transfers, dressing, and bathing. The Resident was totally dependent on one staff for eating and personal hygiene and was not ambulatory. Resident #1 was incontinent of both bowel and bladder. [DIAGNOSES REDACTED]. Review of Resident #1's medical record revealed the following comprehensive care plans: --10/16/12 Resident #1 was at risk for falls. According to the plan of care Resident #1 had a reclining wheelchair with cervical support, a seatbelt, and a torso support strap. --10/16/12 Resident #1 was at risk for injury due to a history of seizures. Approaches for care included monitoring for warning signs prior to seizures, giving medications as ordered, assuring direct care staff were aware of the Resident's seizure history and protected the Resident from harm when a seizure occurred. --10/12/12 Resident #1 had the potential for injury from tremors and involuntary muscle movements related to his [DIAGNOSES REDACTED]. Approaches for care included monitoring activities of daily living and monitoring the Resident's environment for possible special chair needs if involuntary muscle movements placed the Resident at risk for injury. --10/16/12 Resident #1 had inappropriate behaviors related to episodes of agitation. --10/16/12 The Resident's care plan included a plan related to the Resident's inability to think clearly. Approaches included wearing a Velcro safety belt for safety. --10/16/12 Resident #1 required a mechanical lift to transfer between his bed and his chair. There was no care plan for showers despite the resident having seizures and involuntary muscle movements that placed him at risk for falls and injuries. Review of an incident/accident report dated 11/16/12 at 11:05 a.m. revealed Resident #1 was sitting in a shower chair in the shower. CNA A was holding on to the Resident to keep him from falling. CNA A slipped and fell and Resident #1 fell out of the shower chair to the floor face first. The Resident was transferred to the emergency room via ambulance on 11/16/12. In an interview on 11/19/12 at 9:10 a.m. the Administrator and Director of Nurses (DON) said Resident #1 was being showered by CNA A on 11/16/12. The CNA had Resident #1 leaning forward in a regular shower chair. (note: there was no seatbelt or torso support strap on the wheelchair). CNA A had one hand across the front part of Resident #1's chest, partially supporting his weight, and was washing the Resident's back. The CNA's feet slipped and both the CNA and Resident #1 fell to the floor. Resident #1 was transferred to the emergency room and admitted to the hospital for facial and head trauma. The Resident was still an inpatient in the hospital at the time of the interview. In an interview on 11/19/12 at 10:00 a.m. CNA A said just prior to lunch time on 11/16/12 she was showering Resident #1 in a regular shower chair. The CNA leaned Resident #1 forward and held the Resident with her left arm across the front part of his chest and was washing the Resident's back. The CNA slipped on the soapy wet floor and fell forward. Resident #1 fell forward out of the shower chair and his face struck the floor before any other part of his body struck the floor. According to CNA A, she ended up on the floor with the Resident on both her knees. CNA A said CNA B was in the shower room in another stall giving a shower to another resident. CNA B went to get a nurse. LVN C arrived first and LVN D arrived immediately after LVN C. An ambulance was summoned and the Resident was taken to the hospital. According to CNA A only she and CNA B actually witnessed the incident. In an interview on 11/19/12 at 10:10 a.m. CNA B said she was in the shower room in the other stall but had left the stall and walked over to the shelf to get a towel. She had her back to Resident #1 and CNA A but she heard the CNA say, "Oh", and turned in time to see both the CNA and the Resident fall forward. CNA A had one hand on the Resident's chest and one hand on his back. Resident #1 fell face first out of the shower chair onto the floor. CNA A fell forward onto the floor too. CNA B said she did not have time to reach the Resident in time to prevent the fall. In an interview on 11/19/12 at 10:50 a.m. LVN D said a CNA called to her on 11/16/12 and told her Resident #1 had fallen in the shower. The LVN said she went immediately to the shower and saw Resident #1 lying on his right side with his right arm underneath him. The Resident was bleeding from the mouth. LVN D stayed with the Resident while LVN C, who had entered the shower, went and called the Resident's doctor and emergency medical services. In an interview on 11/19/12 at 12:00 noon CNA A said she had worked at the facility since August 2012 as a shower aide and had showered Resident #1 many times in a regular shower chair. The CNA said Resident #1 was a two person transfer but she always showered him alone once he was transferred into the shower chair. CNA A said she was not aware Resident #1 had a seizure disorder. The CNA said Resident #1 would sometimes try to bite staff when he became agitated. In an observation on 12/04/12 at 9:30 a.m. Resident #1 was lying in bed supine with the head of his bed up. Resident #1 was awake. When spoken to Resident #1 opened his mouth, smiled, and laughed, but did not make eye contact. There appeared to be at least two missing teeth in the front portion of Resident #1's mouth. The Resident's mother was present and asked Resident #1 to open his mouth wide to show some broken teeth on the side. The Resident opened his mouth but it was not possible to see the Resident's teeth due to involuntary movement on the Resident's part. According to the Resident's mother at that time several teeth had been broken on the right side of the Resident's mouth. In an interview on 12/04/12 at 2:00 p.m. LVN C said she responded to a call from a CNA for help on 11/16/12. When she entered the shower room she saw Resident #1 lying on the floor of the shower bleeding from his mouth. LVN C said she tried to keep him on his side and tried to keep him from aspirating. LVN C said at least two teeth were missing in the front part of Resident #1's mouth. In an interview on 12/05/12 at 10:00 a.m., LVN D said Resident #1 had clusters of seizure activity. During these times, the Resident would have episodes of very frequent seizures, approximately every 10 to 20 minutes, and this could continue to occur for one to two days. When this occurred the Resident would be sent to the hospital. The Resident's family told the facility this has occurred approximately once a year for most of his life. LVN D said during the Resident's seizures, his whole body would jerk. Otherwise, in addition to these clusters of seizures, the Resident would have an isolated seizure approximately every six months. Review of Resident #1's Fall Risk Assessments in May 2012, July 2012, and October 2012 revealed a total score of 10 to 11. A score of 10 or over indicates the Resident is at higher risk for falls. A Fall Risk Assessment was conducted on 11/19/12 and 11/26/12, the Resident's total score was 16. In an interview on 12/05/12 at 08:20 a.m., the DON said Resident #1 is now being showered in a reclining shower chair. According to the DON, the reclining shower chair also has a footrest that can be elevated. In an observation on 12/05/12 at 10:30 a.m., a reclining shower chair was observed in E Hall outside the shower. In an interview at that time, CNA A said the facility has had the reclining shower chair for some time now and had been using it for another resident and had recently starting using it with Resident #1. CNA A said using the reclining chair with Resident #1 was so much better. In an interview at 10:35 a.m., LVN E said the facility had the reclining chair prior to Resident #1's fall. In an observation on 12/05/12 at 12:10 p.m. Resident #1 was sitting in a high-back, reclining wheelchair with a head support. The Resident was wearing a restraint, which fit around his waist and over his chest. Resident #1 was transferred to bed using a mechanical lift by CNA G and CNA F. In an interview on 12/05/12 at 1:50 p.m., CNA F said she had showered Resident #1 several times in the past. CNA F said Resident #1 moves and jerks around a lot and will throw himself forward. The CNA said when she showered him, she held him "real tight" and demonstrated with one arm around the Resident, holding him to her body. The CNA said that was the only way to keep him from falling. Review of Resident #1's consolidated physician's orders [REDACTED]. The Resident's transfers would be by mechanical lift. Review of a hospital history and physical dated 11/16/12 revealed Resident #1 was admitted to the hospital via the emergency room following a fall in which the Resident landed on his face. The Resident was noted to have significant facial injury with sinus fracture, dental loss, head injury, and possible cerebral contusion. There was a right frontal sinus injury with probable hemorrhage. The Resident was started on antibiotics for a resulting sinusitis. Review of a discharge summary dated 11/19/12 revealed the Resident also had a right orbital (eye socket) fracture and multiple front teeth were lost. Resident #3: Review of Resident #3's annual MDS dated [DATE] revealed Resident #3 had short-term memory problems. Resident #3 was totally dependent on two or more staff for transfers and required extensive assistance from at least one staff for dressing, personal hygiene, and bathing. The Resident was frequently incontinent of bowel and had an in-dwelling urinary catheter. [DIAGNOSES REDACTED]. Review of Resident #3's Comprehensive Plan of Care revealed a Care Plan dated 09/25/12 due to the Resident requiring a mechanical lift for all transfers. According to approaches for care, two staff would transfer the Resident using a mechanical lift. A Care Plan dated 09/25/12 revealed Resident #3 was at risk for falls and another care plan dated 09/25/12 revealed Resident #3 had multiple problems that affected his ability to think clearly and the Resident needed a bed alarm and chair alarm to ensure his safety. Review of Consolidated Physician order [REDACTED]. In an interview on 11/19/12 at 11:35 a.m., the DON said Resident #3 was a functional quadriplegic and staff used a Hoyer lift for all transfers. The DON said Resident #3 sometimes thought he could stand but his knees would give out without warning. The DON said staff could not transfer the resident without a mechanical lift because he was such a big man (69 inches tall and 345 pounds) and if his knees gave out, there would be no way to keep him from falling to the floor. Review of an incident/accident report dated 10/25/12 at 11:50 a.m. revealed Resident #3 was transferring to bed from the shower chair and his knees buckled. The Resident fell to the floor. Resident #3 reopened some scabs to his left lower extremity but sustained no other injury. Review of an interview worksheet attached to the incident/accident report by CNA H revealed on 10/25/12, the Resident was transferring from a shower chair to bed and his knees buckled and CNA H lowered the Resident to the floor. Review of a conclusion and interventions of incident report sheet attached to the incident/accident report revealed the Resident was referred to Restorative for safety training. CNAs were in-serviced on using the mechanical lift and following the care plans. According to interventions listed, facility CNAs will follow CNA care plan and will not "follow what the Resident says." CNAs will also transfer mechanical lift patients by the mechanical lift only. In an interview on 11/19/12 at 11:50 a.m., CNA B said when Resident #3 fell on [DATE], she had just finished showering him. CNA H came to get the Resident from the shower and CNA B and CNA H both took the Resident to his room. CNA H asked CNA B to go get a clean hospital gown. CNA B left the room and when she returned in a "couple of minutes", Resident #3 was on the floor. Resident #3 told CNA B that he slipped. CNA B said CNA H did not tell her anything. CNA B said she did not know what happened. She only knew that Resident #3 was on the floor when she came back with the gown. In an interview on 12/05/12 at 10:45 a.m., CNA H said she had worked at the facility since July 2012. On 10/25/12, Resident #3 returned to his room after a shower. Resident #3 wanted to go to bed immediately, so CNA H said she attempted to transfer the Resident from the shower chair to the bed without help. The Resident's foot slipped and he fell to the floor. CNA H said she knew the Resident was a two-person transfer with a mechanical lift but the Resident was demanding to go to bed immediately, so she attempted to transfer him. In an observation on 12/05/12 at 1:40 p.m., Resident #3 was transferred from his electric wheelchair to bed by CNA F and CNA I using a mechanical lift. In an interview on 12/05/12 at 1:45 PM, Resident #3 said staff were real good and tried hard to keep him from falling. Resident #3 said he did not like it when they used the mechanical lift because he had undergone back surgery in the past and the mechanical lift hurt his back. Resident #3 said he can bear weight on his legs but his legs will give out on him without warning. Resident #3 said he remembered falling in October. The Resident said the reason he fell was because he did not lock his knee and one leg gave out on him and he went to the floor. The Resident said he could not remember if one CNA was helping him or if there were two staff in the room helping him and he could not remember who was helping him that day. In an interview on 12/5/12 at 2:05 p.m. the DON said there were 3 residents in the facility who had a seizure disorder and were totally dependent on staff for all activities of daily living. The DON said there were 11 residents in the facility who were transferred using a mechanical lift.