Every finding on record at Avir at Meadow Creek

Based on observation, interview, 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 2 (Residents #7 and #13) of 4 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was on the doorways of Resident #7 and Resident #13. This failure could place residents at risk of not receiving appropriate respiratory care.The findings were: 1. Record review of Resident #13's admission record dated 06/02/2026 revealed was an [AGE] year-old male with an admission date to the facility of 06/02/2026. admission record revealed Resident #13 had diagnoses that included unspecified bacterial pneumonia (a lung infection where the alveoli become inflamed and fill with fluid or pus and unspecified hypertension (used to describe high blood pressure). Record review of Resident #13's MDS assessment dated [DATE] revealed Resident #13 had a BIMS score of 14 indicating the resident was cognitively intact. MDS also noted in Section O under Special treatments, respiratory Treatments continuous Record review of Resident #13's order summary dated 06/02/2026 revealed an order of O2 at 2L/min via Nasal cannula CONTINUOUS. every shift . 2. Record review of Resident #7's admission record dated 01/18/2026 revealed a readmission date of 05/14/2026 was a [AGE] year-old female with diagnoses Interstitial Pulmonary Disease (inflammation or scarring in lungs). Record review of Resident #7's Care plan dated 05/15/2026 revealed O2 @ 2L/Min via Nasal cannula to maintain O2 saturation greater than 90 percent. Record review of Resident #7's order summary dated 01/08/2026 revealed the following orders: O2 at 2L/Min via Nasal cannula to maintain O2 sats greater than 90 percent two times a day check every shift. Observation on the following dates and times revealed there was no oxygen in use sign on Resident #13's door:-06/08/2026 at 06:35 a.m-06/09/2026 at 07:10 a.m. ,-06/10/2026 at 3:40 p.m., ,-06/10/2026 at 4:40 p.m., , -06/08/2026 at 7:15 a.m., ,-06/09/2026 at 10:56 a.m.,, and-06/10/2026 at 10:45 a.m., . During an interview on 06/09/2026 at 3:10 p.m., Resident #13 stated she wears her oxygen continuously for shortness of breath and takes breathing treatments During an interview with LVN CC on 06/10/2026 at 11:00 a.m., she stated the nurses are designated to direct care staff to set up oxygen in rooms when ordered. the magnetic sign should be put on the door when the oxygen is brought in the room. LVN CC stated the risk of not having an oxygen sign outside the door could be an increased chance for fire. During an interview with the DON on 06/10/2026 at 3:40 p.m., she stated that nurses are responsible for setting up oxygen in rooms and to post a sign outside the door of any rooms that have oxygen. She did state that without a sign outside the door there could be a potential for increased hazards if people did not know that oxygen was in the room. Record review of the undated facility policy titled Oxygen Administration revised October 2010 indicated in part Place an Oxygen in Use- sign outside the door and close the door.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to: Ensure the multi-juice dispenser spigot (a faucet) was cleaned. This failure could place residents at risk of foodborne illnesses.Findings included: Observation and interview on 06/08/2026 at 6:22 AM, conducted initial rounds of the kitchen. The multi-juice dispensing spigots caps were removed and on the inner part of the spigot there was a gooey slimy residue and crusted deposits around the tips of both spigots. DA A said that it was the evening crew's responsibility to cleanse the juice spigots every day. The DA said she had not noticed the spigots were dirty. Interview on 06/09/2026 at 4:48 PM, the DM said that the multi-juice machine spigots were supposed to be cleaned on a daily basis. The DM said that they kept a daily cleaning schedule and provided a copy of it. The DM said that he normally checked the juice machine spigots on a daily basis when he arrived at the facility. The DM was told what the spigots looked like with the build-up of gooey slimy residue and crusted deposits around the tips of both spigots. The DM said that a possible negative outcome was if juice was served with those juice dispenser spigots there was a possibility of spreading bacteria and making the residents ill. Interview on 06/10/2026 at 4:24 PM, the Administrator was made aware of the observation of the multi-juice machine spigot having the gooey slimy residue and crusted deposits around the tips of both spigots. The Administrator said the kitchen staff was responsible for keeping those items clean. The Administrator said that if the spigots were used like that to fill cups with juice then that could possibly cause some kind of infection to the residents. Record review of the kitchen cleaning schedule for June 2026 and titled Nutrition and food service policies and procedures manual and dated 2018 revealed in part; Juice machine, When cleansed - once a day, position responsible was blank. The days of Monday 06/08/26 through 06/09/2026 revealed that there were initials that the spigots had been cleaned. Record review of the facility policy titled Sanitization and dated November 2022 revealed in part: The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris and protected from rodents and insects. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. When cleaning fixed equipment (e.g., mixers, slicers, and other equipment that cannot readily be immersed in water) the removable parts are: Washed and sanitized and non-removable parts cleaned with detergent and hot water, rinsed, air dried and sprayed with a sanitizing solution.

Based on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #38) of 7 residents reviewed for advance directives. The facility failed to ensure Resident #38's advance directive was clearly identified and documented in the resident's electronic medical record. The failure could place residents at risk of not having their end-of-life wishes honored and having incomplete records.Findings included: Record review of Resident #38's face sheet dated 6/11/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Mild Intermittent Asthma (occasional flare ups of difficulty breathing), anxiety disorder (mental health condition that causes intense, persistent and excessive fear or worry), (life-threatening medical condition that occurs when damaged muscle tissue breaks down rapidly). Record review of Resident #38's admission MDS dated [DATE] revealed a BIMS of 14 that indicated cognition was intact. Record review of Resident #38's electronic medical record on 6/9/29 at 2:14 p.m. revealed no advance directive information in Code Status section. Record review of Resident #38's Order Summary Report as of 6/9/26 revealed no physician's order for Code Status. Record review of Resident #38's base line care plan as of 6/9/26 revealed Advanced Directive/Code Status section was not completed. Record review of Resident #38's Social Work Assessment with date of 6/3/2026 revealed code status was full code. During interview on 6/9/26 at 1:35 p.m., the DON said Resident #38 was a full code. The DON said the advance directive section on the electronic medical record should be updated on admission and should go in the care plan within 24 hours of admission. The DON said the order for advanced directives generated information in the electronic medical record. The DON said the social worker updated the resident's care plan for information regarding advance directives. The DON said the nurses were instructed that residents who did not have a DNR were automatically a full code. The DON said the admitting charge nurse was responsible for generating the advance directive order as part of the resident's admission orders. The DON said if advance directives were not updated then it could cause miscommunication of their wishes and might not be handled per the residents' wishes. During an interview on 6/9/2026 at 2:00 p.m., Resident #38 stated the facility did speak to her about code status and gave her an option to be full code or Do Not Resuscitate. Resident #38 stated she chose to be a full code. During interview on 6/10/25 at 8:50 a.m., the Social Worker said the residents were always full code unless they had a DNR. The Social Worker said the charge nurse put in the order for residents who were full code. The Social Worker said she entered information into the residents' care plan if they were full code or DNR. The Social Worker stated she did not complete the baseline care plan and Resident #38's comprehensive care plan was not complete yet due to her admitting recently. The social worker said she completed the paperwork if a resident wished to be a DNR but would notify the nurse to obtain the order. The Social Worker stated Resident #38 desired to be a full code. During interview on 6/10/26 at 8:54 a.m., RN F said the admitting nurse can update advance directive orders if changed. RN F said there is a notebook at the nurses' station that contains residents DNR's and Medical Records reviews it weekly. RN F said she was trained all the time regarding advanced directives and training was part of admission training. RN F stated failure to enter code status could lead to resident wishes not being met at the end of life. During interview on 6/10/26 at 9:06 a.m., Medical Records said the admitting nurse would put the order for advance directives on admission. Medical Records said all residents were a full code unless they came to the facility with a DNR or until the social worker saw the resident and they wanted to be a DNR. Medical Records stated she audits code statuses weekly if they are DNR's but would not audit the resident's that were full code. During interview on 6/11/26 at 9:43 a.m., the Administrator said they should have orders for advanced directives and nursing puts the information for advanced directives on the care plans. The Administrator said the effect on residents if there were no orders or information entered into the care plan for advanced directives then there would be lack of communication with the nursing staff. Record review of facility's policy Advance Directives revised November 2024 revealed The admitting charge nurse will obtain an order for code status.

Based on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information from 6/2/2026 through 6/10/2026. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.The findings included: During an observation on 06/08/2026 at 5:50 a.m., the daily staffing posting read 6/01/2026. During an observation on 6/8/2026 at 11:30 a.m., the daily staffing post showed a date of 06/01/2026. During an observation on 6/09/2026 at 10:15 a.m., daily staffing sheet at front bulletin board was last updated on 06/01/2026. During an observation 06/10/2026 at 9:10 a.m., daily staffing posted showed 06/01/2026. During a record review on 6/10/2026 at 9:10 a.m., all staffing sheets pulled for review, staffing the only sheet available was 6/01/2026. During an interview on 6/10/2026 2:05 p.m., the ADON stated the staffing sheet is updated every morning by her or the DON, but the DON had been out of facility. She stated they did have a policy and knows that they are reviewing that process in quality Assurance. The ADON stated the purpose of the daily staffing sheets was so that family and residents were aware of how many staff were available. She stated she did not update the staffing sheets because she had not had a chance. During an interview on 6/10/2026 at 3:00 p.m., the DON stated that it has been her responsibility and her staff. When asked if there were any other staffing sheets for the last month the DON stated that now they were all in the frame posted at the front and no other sheets were completed. The DON stated the expectation was that it should be posted daily as required. The DON stated the risk of not updating the daily staffing could be residents and families not being aware of the staff available. During an interview on 06/10/2026, at 3:30 p.m., the Administrator said that the expectation was that daily staffing was posted daily. She said recently in Quality Assurance meeting she was now tasked with ensuring it was complete. She said the Daily Staffing Sheet should be updated to show everyone (visitors or family) how many staff are available each shift. Record review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, August 2022, indicated, Our facility will post on a daily basis for each shift Nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.

Based on interview and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 resident (Resident # 1) reviewed for transfers.The facility failed to ensure LVN C utilized a gait belt to transfer Resident #1 while toileting which resulted in a right dislocated shoulder. This failure could place residents at risk for falls, injury and a diminished quality of life.The findings include:Record review of Resident #1's face sheet dated 5/28/2026 revealed a [AGE] year-old female, admitted on [DATE] with diagnoses which included: pneumonia (an infection that inflames the air sacs in the lungs), age related osteoporosis without current pathological fracture (natural, progressive loss of bone mass and density with age, however no broken bones have broken from the disease yet).Record review of Resident #1's admission MDS assessment dated [DATE] revealed a BIMs score of 6 which indicated the resident was cognitively impaired. The assessment indicated Resident #1 required maximum assistance with transfers.Record review of Resident #1's Care Plan for ADL self-care initiated on 4/24/2026 revealed the resident required the maximum assistance by staff for transfers.Record review of Resident #1's progress notes dated 4/23/2026 at 4:28 p.m. written by LVN C revealed, Upon attempting to stand up resident cried out in pain, resident became dead weight so staff had to clean her the best they could and then set her in wheelchair. During an interview on 5/28/2026 at 9:25 a.m. with Resident #1's responsible party, she stated that on 4/23/2026 at approximately 4:30pm she was present when LVN C assisted her Resident #1 off the toilet. She stated LVN C did not use a gait belt. She stated during the transfer she witnessed Resident #1 slip and LVN C grabbed her right arm to keep her from falling. She stated after LVN C grabbed Resident #1's arm she hollered out in pain. Resident #1's responsible party stated she was told a portable x-ray would be done in the facility. She stated on 4/24/2026 around 11:30am she chose to have Resident #1 sent to the emergency room because the portable x-ray had not been completed. Resident #1's responsible party stated at the emergency room they determined the right shoulder was dislocated.During an interview on 5/28/2026 at 10:00 a. m. with LVN C, he stated on 4/23/2026 at approximately 4:30 p.m. he did transfer Resident #1 off the toilet to the wheelchair and did not use a gait belt. LVN C stated he put his arms under Resident #1's arms and transferred her. LVN C stated she did not slip but did become dead weight during the transfer and he was holding all her weight. LVN C stated when Resident #1 complained of pain he administered medication and notified the MD who ordered an x-ray. He stated the x-ray was not completed prior to his shift ending. LVN C stated Resident #1 normally did not complain of pain. LVN C stated he had been educated on gait belt use by the facility upon hire and annually. LVN C stated he did not use a gait belt because he was just trying to help the resident off the toilet and thought that she would assist more with the transfer than she did.During an interview on 5/28/2026 at 11:25 a.m. CNA M stated she was present on 4/23/2026 at approximately 4:30 p.m. when LVN C transferred Resident #1 off the toilet. CNA M stated LVN C did not use a gait belt for the transfer. CNA M stated Resident #1 did give out during transfer and LVN C had to support all of Resident #1's weight but he did not see LVN C grab Resident #1's arm. CNA M stated Resident #1 did not verbalize pain prior to the transfer, but she did seem tired. CNA M stated she has been trained in using gait belts for transfers. CNA M stated gait belts were available in resident rooms. CNA M stated the risk of not using a gait belt could be falls.During an interview on 5/28/2026 at 11:45 a.m. with the DOR, she stated Resident #1 required maximum assistance for transfers which meant the helper did 75% of the work. The DOR stated staff should have been using a gait belt when transferring Resident #1 because she was maximum assist. The DOR stated the risk of not using a gait belt would be falls and injury.During an interview on 5/28/2026 at 11:58 p.m. CNA C stated gait belts were supposed to be used for transfers. She stated she had received training in using gait belts. CNA C stated if a gait belt was not used it could result in falls and injury.During an interview on 5/28/2026 at 1:23 p.m., the ADON stated she sent Resident #1 to the emergency room after talking with Resident #1's responsible party, the DON, and Administrator. The ADON stated Resident #1 did not appear to be in any pain at that time. The ADON stated she was not sure how often training on transfers with staff as completed. The ADON stated staff should have been using a gait belt for safety. The ADON stated the risk of not using a gait belt could be injury.During an interview on 5/28/2026 at 2:28 p.m., the DON stated Resident #1 did have a dislocated shoulder but was unsure if it was due to the transfer. The DON stated she was not aware of any other incidents that occurred around the same time. The DON stated Resident #1 had not complained of any pain until after the incident. The DON stated transfer training was done upon hire and annually. The DON stated upon admission the resident care profile was updated with transfer techniques for each resident. The DON stated a gait belt should be utilized for transfers for safety. The DON stated not using a gait belt for transfers could result in falls and injuries.During an interview on 5/28/2026 at 3:00 p.m. the Administrator stated a gait belts should be used for all assisted transfers that did not require a mechanical lift. The Administrator stated it was the DON and ADON's responsibility to ensure staff received education on transfers. The Administrator stated it was her expectation for staff to use gait belts for transfers. The Administrator stated they did not have a policy on gait belt use. The Administrator stated the risk of not using gait belts for transfers could be falls and injuries. During an interview on 5/29/2026 at 10:45 a.m. Resident #1 stated the young man was helping her off the toilet placed his arms under my arms. Resident #1 stated she started to fall and he grabbed her right arm and it hurt. During an interview on 5/29/2026 at 3:08pm the MD stated he did remember the incident being reported to him, but he was not sure if it was unavoidable because he was not present during the incident. The MD stated, I think the nurse should know what he needs to do and follow facility protocol.Record review of facilities policy titled Safe Lifting and Movement of Residents revised July 2017 revealed in part: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents.2. Manual lifting of residents shall be eliminated when feasible.4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices.

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 #1) reviewed for baseline care plans. The facility failed to develop the baseline care plan for Resident #1 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: Record review of Resident #1's face sheet dated 5/28/2026 revealed a [AGE] year-old female, admitted on [DATE] with diagnoses which included: pneumonia (an infection that inflames the air sacs in the lungs), age related osteoporosis without current pathological fracture (natural, progressive loss of bone mass and density with age, however no broken bones have broken from the disease yet). A record review on 5/28/2026 of Resident #1's electronic clinical records revealed the facility had not completed an initial baseline care plan within 48 hours of Resident #1's admission. During an interview on 5/28/2026 at 3:50 p.m., the Director of Nursing (DON) confirmed that a baseline care plan had not been completed within the 48-hour timeframe. The DON stated she started the baseline care plan on 4/16/2026 but did not complete and close it until 4/24/2026. She said her expectation was for the baseline care plans to be completed within the first 48 hours after admission by an RN. The 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 5/28/2026 at 4:00 p.m. 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. Requested facility policy at this time for baseline care plans. A policy was not received prior to exit.

Based on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure ulcer treatment.The facility failed to ensure Resident #1's wound care treatments were implemented according to physician orders and wound care recommendations.This failure could place residents at risk of delayed wound healing, increased risk of infection, and further skin breakdown.Findings included:During a record review of Resident #1's face sheet, dated 03/12/2026, revealed a [AGE] year-old female, admitted [DATE], with diagnoses of displaced fracture of lateral condyle of left femur, subsequent encounter for closed fracture with routine healing (follow up care after initial surgery of left hip fracture), type 2 diabetes (chronic condition where the body resists insulin or fails to produce enough, causing high blood sugar), pressure ulcer of left heel, unstageable (stage cannot be determined because the wound base is completely covered by dead or dying tissue).During a record review of Resident #1's admission MDS assessment, dated 02/17/2026, revealed BIMS score was 05 which indicated severe cognitive impairment. The MDS further revealed Section M, Skin Conditions, indicated Resident #1 had pressure ulcer upon admission/entry to the facility and was receiving pressure ulcer/injury care.During a record review of Resident #1's care plan, dated 03/11/2026, revealed a focus area indicating Resident #1 had a pressure injury to her left heel related to impaired mobility. Care planned interventions: included follow the facility's policies/protocols, monitor/document/report PRN any changes in skin status, weekly treatment documentation to include measurement width, length, depth, type of tissue and exudate(fluid that leaks out of blood vessels into nearby tissue). Care plan also revealed Resident #1 required maximum assistance to turn and reposition in bed, and maximum assistance for transfers.During a record review of Resident #1's Initial Wound Evaluation and Management Summary, dated 02/17/2026 completed by Wound NP, reflected the following Treatment Plan/Orders: Left heel pressure ulcer injury: 1.cleanse with soap and water, pat dry 2.apply betadine to base of the wound(the bottom layer of wound) 3.leave open to air 4.change daily.During a record review of Resident #1's eTAR for February 2026 revealed orders were put in the system and wound care was not provided until 02/18/26. There were no signatures on 2/21/2026, 2/25/2026, 2/26/2026 indicating wound care was completed. Record review revealed the eTAR did not indicate a wound care treatment order from 2/11/2026 through 2/17/2026.During a record review of Resident #1's Wound Evaluation and Management Summary, dated 3/3/2026, revealed an order change: Left heel pressure ulcer injury: 1. Cleanse with soap and water, pat dry 2.apply collagen hydrogel (three-dimensional structure formed by self-assembly or crosslinking of collagen fibrils which can serve as supportive matrix for tissue regeneration) 3. Secure with silicone bordered dressing 4. Change three times a week.During a record review of Resident #1's eTAR for March 2026, reviewed on 3/12/2026, revealed the order was not updated and the wound care order was still the existing one from 2/18/2026 to apply betadine and leave open to air.During a record review of Resident #1's Wound evaluation and Management Summary, dated 3/10/2026, revealed another order change: Left heel pressure ulcer: 1. Cleanse with soap and water, pat dry. 2. Apply honey hydrogel sheet dressing to base of the wound. 3. Secure with silicone bordered dressing. 4. Change 3 times per week.During a record review of Resident #1's eTAR for March 2026, reviewed on 3/12/2026, did not reflect an order change. During an observation on 3/12/2026 at 10:50 a.m., Resident #1 was lying in bed on her back. RN E entered Resident #1's room to perform treatment on her left heel. RN E explained the procedure to Resident #1 and stated the treatment order was to cleanse with soap and water, pat dry, apply betadine and leave open to air. RN E performed hand hygiene and applied gloves. RN E was observed pulling the covers back and Resident #1 had a soft heel protector on and RN E removed it. The wound had a loose bandage on it only attached on one side. There was brownish red colored drainage on the bandage. RN E discarded the bandage and performed hand hygiene and reapplied gloves. RN E then cleansed the wound, applied betadine, and left open to air with heel floating on heel protector. During an interview on 3/12/2026 at 11:10 a.m., RN E stated the DON updated the wound care orders in the computer after the Wound Nurse Practitioner visited. RN E stated she was unaware of the order changes. She stated she just followed the orders that were in the eTAR. RN E stated the Wound Nurse Practitioner would sometimes update the charge nurse if there were any negative findings. RN E stated wound care for Resident #1's pressure ulcer was normally done on night shift. RN E stated she was trained to do wound care and had competency done annually for wound care. RN E stated the risk of not following ordered wound care could be delayed healing. RN E stated Resident #1's wound had not worsened.During an interview on 3/12/2026 at 11:45 a.m., the DON stated the Wound Care Nurse Practitioner made rounds once a week, updated the Charge Nurses with findings, and emailed her (the DON) an updated report. The DON stated she was responsible for updating orders until a new ADON was hired. The DON stated the ADON was overseeing the wound program but there was no ADON currently. The DON stated she was not aware orders were not input into the system until 2/17/2026. The DON was not aware the order in the computer was not the most recent order or that it was changed. The DON stated the risk in not updating orders per NP recommendations could be delay in wound healing and infection. The DON stated, to her knowledge, the wound had not deteriorated or gotten worse. During an interview on 3/12/2026 at 3:12 p.m., the Wound Care Nurse Practitioner stated she noticed that the orders had not been updated to her most recent recommendation on 3/10/2026. The Wound Care NP stated she sent the DON an email and reported the updated wound care orders were not implemented. The Wound Care NP stated her expectations were for the facility to follow her wound care orders. She stated the risk of not following order changes could be deterioration in wound or infection. The NP stated she was not aware of any harm caused to Resident #1 by not following orders. She stated Resident #1's wound had not worsened. During an interview on 3/12/2026 at 3:30 p.m., the Corporate Regional Nurse stated it was the DON's responsibility to update the orders. She stated her expectation was the orders were updated 24-48 hours as a reasonable time frame. She stated she expected the DON to review orders and update them as needed. Corporate Regional Nurse stated training is done annually with every nurse. She stated this facility does not have a treatment nurse and charge nurses did all wound care. She stated the DON was responsible for updating the wound care orders. She stated a risk of not updating orders is delayed wound healing and infection.During an interview on 3/12/2026 at 3:45 p.m., the Administrator stated it was the DON's responsibility to update wound care physician orders because the reports were emailed to her. The Administrator stated the risk of not updating the orders could be delayed healing, infection, and deterioration. During a record review on 3/12/2026 at 4:00 p.m. of the facility's current policy, dated October 2010, titled Wound Care, revealed, Preparation1.Verify that there is a physician's order for this procedure2.Review residents care plan to assess any special needs of the resident.Steps in Procedure12.Apply treatments as indicatedDocumentationThe following information should be recorded in the residents' medical record:1.The date the wound care was given2. The initials of the individual performing wound care.6.The signature and the title of the person recording the data.Reporting2. Report other information in accordance with facility policy and professional standards of practice.

Based on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated. 2. The facility failed to ensure prepared food was discarded after 72 hours (3 days) per facility policy. 3. The facility failed to check temperatures of food items prior to serving food. 4. The facility failed to ensure food was not handled with bare hands. 5. The facility failed to ensure food items remained covered on the steam table prior to food service between breakfast and lunch. 6. The facility failed to ensure personal food items were not stored in 1 of 2 of the kitchen refrigerators. 7. The facility failed to ensure dishes were washed and rinsed at the correct temperatures, per dishwasher manufacturer's instructions. These failures could place residents who received prepared meals from the kitchen at risk for food borne illness and cross-contamination. The findings included: During the initial tour of the kitchen on 4/8/25 at 8:55 AM, the following was observed: Dry storage - a package labeled butterscotch pudding powder was opened and not sealed - a package labeled cherry gelatin powder was opened and not sealed - a package labeled citrus gelatin powder was opened and not sealed - a package labeled dry potato pearls was opened and not sealed Freezer -a drinking glass with a whitish yellow frozen liquid, covered with plastic wrap, did not have a label, identification, or date. Refrigerator #1 - a metal storage container with cooked sausage in the bottom and cooked eggs on top covered with plastic wrap - no date, For [name] was written in marker on the plastic wrap. - meat sauce dated 3/18/25 - chicken noodle soup dated 3/26/25 - tomato soup dated 3/24/25 - vegetable soup dated 3/31/25 - pimento cheese dated 3/25/25 - sliced ham dated 3/29/25 - grated cheese dated 3/28/2 - a package of grated cheese was open to air and not dated. Refrigerator #2 - crushed pineapple opened 3/24/25 - sour cream opened and not dated - cranberry sauce opened 4/2/25 - apple sauce opened 3/29/25 During an observation of the kitchen on 4/9/25 at 11:25 AM, the following observations of the dishwasher were made: - first load temperature for both washing and rinsing was 110 degrees F - second load temperature for both washing and rinsing was 112 degrees F - third load temperature for both washing and rinsing was 116 degrees F - fourth load temperature for both washing and rinsing was 120 degrees F - a sticker on the dishwasher stated manufacturer's recommended temperature for both washing and rinsing is 120 degrees F Observation of lunch items on the steam table on 4/9/25 at 11:40 AM revealed the following: - the fortified soup was not covered, temperature was not taken, the soup was dried out on top and was dried out on the sides of the container - the white gravy was not covered, temperature was not taken, the gravy was dried out on top and was dried out on the sides of the container - the chicken strips were not temped - the fries were not temped Observation of the lunch service on 4/9/25 at 1145 AM revealed the following: - [NAME] N dropped a hot mitten on the floor, picked it up, and used it to transfer a pan of enchiladas to the steam table - [NAME] N touched a baked potato with bare left hand while cutting it In an interview on 4/9/25 at 11:35 AM with Dietary Aide O she said she was not sure what the dishwasher temperatures are supposed to be. Stated she was a cook covering the shift for the regular aide. In an interview on 4/9/25 at 11:37 AM with the Dietary Manager (DM) he stated the staff should know to run the dishwasher a couple times until the water temperature reached 120. In an interview on 4/9/25 at 11:40 AM with [NAME] N she said the fortified soup and white gravy was left from breakfast because they will be used again at lunch. In an interview on 4/10/25 at 1:12 PM with the DM said his expectations for labeling opened/prepared food is - date opened/prepared, name of item if not on the package, and use by date. The DM said his expectations for the use by date was 72 hours for everything except canned soups can stay a few days longer. The DM said his expectations for open packages was to be placed in a resealable bag or container and to be sealed. The DM stated the container with eggs and sausage, labeled for [name] was probably served the day before and saved for the cook, [name]. The DM stated it should have been in the employee's refrigerator. The DM states he went through both refrigerators 4/9/25 and removed everything that was past the use by date. The DM stated he tried to do that every morning or when he had time. The DM states the white gravy had been on the steam table since breakfast and stated the soup had just been placed on the steam table. The DM states all foods should be covered and temped before serving. The DM stated the hot mitten that fell on the floor should not have been re-used. Review of facility policy Food Storage, revised 2018, revealed, in part: - To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated. - Date, label and tightly seal all refrigerated foods using clean, nonabsorbent covered containers that are approved for food storage. - Use all leftovers within 72 hours. Discard items that are over 72 hours old. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 residents (Resident #10 and #11), 2 of 2 residents who used a mechanical lift in the resident council meeting, and one unsampled resident reviewed for the mechanical lift. The facility failed to have sufficient mechanical lift slings to accommodate all residents who required the use of a sling (Resident #10, Resident #11, two residents in the resident council meeting). These failures could place residents at risk of a diminished quality of life due to an environment that is nonfunctional or uncomfortable. The findings included: Review of Resident #10's Admission Record dated 4/10/25 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis included Multiple Sclerosis (an autoimmune disease-causing numbness, weakness, and trouble walking), and osteoporosis (thinning of the bone) without fracture. Review of Resident #10's Quarterly MDS assessment dated [DATE] revealed: * a 15 of 15 on mental status exam. (indicating she was cognitively intact) *Chair to bed transfer: dependent, the assistance of two or more helpers is required for the resident to complete the activity. Review of Resident #10's Care Plan revised 10/19/22 revealed: * an ADL self-care performance deficit related to weakness associated with MS. *Interventions: Transfer: Resident #10 requires assist by (2) staff transfer. Requires mechanical lift. Interview on 4/8/25 at 3:35 p.m. Resident #10 stated she was left in bed because there were no slings occasionally. She said this made her angry because she liked to be involved in activities. Resident #10 said it was a once in a while thing and it did not happen all the time. Resident #10 said this happened once or twice a month. Interview on 4/10/25 at 11:07 p.m. Resident #10 stated every once in a while they would not get her up and it would upset her. Resident #10 said it would also upset the aides because they (the aides) would want to get Resident #10 up. Resident #10 said it would mostly happen when there were new staff who did not know her. Resident #10 said it would hurt her feelings because it would make her feel like the residents who used the lift did not matter. Resident #10 said sometimes the staff would borrow her mechanical lift sling but it was ok because the staff would bring it right back. Review of Resident #11's Admission Record revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, major depressive disorder, and generalized anxiety disorder. Review of Resident #11's Quarterly MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating she was cognitively intact. She had impaired range of motion in her upper and lower extremities and required a wheelchair for mobility. She was dependent on staff or required maximum assistance for most ADLs (except eating and oral hygiene for which she required setup assistance). Review of Resident #11's care plan revised 03/06/2025 revealed Problem: resident has an ADL self-care performance deficit related to osteoarthritis, pain, and weakness. Goal: resident will maintain current level of function through the review date. Interventions: may use mechanical lift with 2 staff assistance for transfers. In an observation and interview on 04/08/2025 at 11:28 am Resident #11 was resting quietly in her bed. She stated she required a mechanical lift for transfers and the slings are always missing. She stated she had been left in bed for 3 days recently and the staff told her it was because the facility had run out of clean slings. She stated she had missed activities in the past due to staff not getting her out of bed. Interview on 4/9/25 at 9:41 a.m. the two residents present in the Resident Council meeting who used the mechanical lift stated they lived on different wings of the facility. The Residents stated they both had been left in bed because there was no sling available. The Residents stated this did not happen often. Interview on 4/8/25 at 2:28 p.m. Resident #39 stated her only issue with the facility was they would occasionally run out of slings for the mechanical lift, and she would have to spend the day in bed. Resident #39 said the last time this happened was 4/4/25. Resident # 39 said she did not like to be in bed all day. Resident # 39 said the facility did not have a sling for her about once a month. Interview on 4/9/25 at 3:29 p.m. LVN B said the facility was getting more and more mechanical lift residents and sometimes laundry was unable to keep up with the demand for clean slings and the facility did run out occasionally. LVN B said the mechanical lift residents were very opinionated when it happened. Interview on 4/9/25 at 3:35 p.m. CNA K stated slings getting backed up in laundry did not happen often and when he got here at 2 p.m. most of the mechanical lift residents were already in bed. Interview on 4/9/25 at 3:42 p.m. LVN L said there were enough slings but occasionally the residents had to wait on laundry because the day shift started getting residents up at 6 a.m. and laundry did not start until 7 a.m. and they would have to wait. Interview on 4/10/25 at 10:09 a.m. the Social Worker said the facility did have a complaint about not having enough slings, it was discussed in the morning meeting and the facility ordered more slings. Interview on 4/10/25 at 10:16 a.m. the DON said there were 14 residents in the facility who used slings and 19 slings in the building. The DON stated the facility ordered 3 slings a month and believed it was enough to meet the needs of the residents. The DON said she did not remember hearing any complaints about there not being enough slings in the building and it had never been discussed in morning meeting. Interview on 4/10/25 at 2:33 p.m. the Housekeeping Supervisor stated she had 3 sets of linen for each resident: one for use, one for back up, and one for washing. The DCO who was present stated the expectation was there be two slings for each resident. Interview on 4/10/25 at 1:45 p.m. the Administrator stated the facility bought 3 new slings each month. Review of the complaint book revealed a resident complained on 2/26/25 that there was not a sling for a transfer with a mechanical lift for an extended period of time. The complaint was forwarded to the DON for the investigation where it was: explained to the resident that she was a mechanical lift and required two people to assist her so it may take a minute, the resident was put on a prompt toileting schedule. Review of the receipts revealed the facility ordered 3 slings on 4/2/25 and 4/10/25. No policy or list of what was considered essential equipment was provided.

Based on observation, interview, 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 one (Resident #41) of two residents reviewed for transmission-based precautions care in that: 1. CNA G failed to wear required PPE when entering Resident #41's room on 04/08/2025. 2. HSK H failed to wear required PPE when entering Resident #41's room on 04/09/2025. 3. CNA I failed to wear required PPE when entering Resident #41's room on 04/10/2025. This failure could place resident's risk for cross contamination and the spread of infection. Findings included: Review of Resident #41's Admission Record revealed she was an [AGE] year-old female originally admitted to the facility 03/14/2023 with a most recent admitted [DATE] with a diagnosis of recurrent enterocolitis due to clostridium difficile (infection of the colon caused by the bacteria clostridium difficile resulting in inflammation of the lining of the colon and diarrhea). Review of Resident #41's Annual MDS assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. She required moderate assistance with most ADLs. She was frequently incontinent of bowel and bladder. She was receiving an antibiotic. Review of Resident #41's care plan most recently revised on 03/20/2025 revealed no care plan addressing her contact isolation due to recurrent C. difficile infections. Observation on 04/08/25 at 11:31 am revealed Resident #41 was on contact isolation. The resident had a PPE station outside her room and a STOP sign on door indicating the type of isolation and required PPE to be worn when in the resident's room. Resident #41's door was open at the time of the observation. In an observation on 04/08/25 at 2:25 pm Resident #41's door remained open. In an observation and interview on 04/08/25 at 5:19 pm Resident #41's door was open, and CNA G was observed entering the room wearing no PPE to deliver the resident's meal tray. The tray was a regular tray, not disposable. CNA G left the room and did not perform hand hygiene. CNA G stated she always worked on Resident #41's hall and that when the resident was on contact isolation, she (CNA G) was supposed to wear a gown, gloves, and a mask when providing care for any resident on contact isolation. She had no explanation for why she failed to wear PPE when delivering Resident #41's meal tray. In an interview on 04/09/25 at 8:54 am Resident #41 stated she was on an antibiotic for a UTI in March 2025 and she thought that was the cause of her current C. difficile flare up. She stated she had had C. difficile infections in the past. Resident #41 stated that she understood that she would remain in jail (on contact isolation) until the flare up was done. In a telephone interview on 04/09/25 at 10:32 am with MD E, he stated that his expectation was that when a resident was placed on contact precautions/isolation, that the resident's room door remained closed at all times. He stated that any staff member entering the room of a resident on contact isolation should were a gown and gloves regardless of the activity to be performed. He stated that the PPE use was extremely important for a resident with an active C. difficile infection because of how easily it could spread. MD E stated that if the proper PPE was not worn by staff it could lead to an outbreak of C. difficile in the facility. In a telephone interview on 04/09/25 at 10:59 am with MD F, she stated that her expectation was that all staff would wear masks, gloves, and gowns when entering the room of a resident on contact isolation. She stated she believed that disposable trays and utensils should be used for all meals when a resident was on contact isolation, but she was unsure of the facility's policy regarding meal service. MD F stated that a resident on contact isolation absolutely should not have their door left open and especially not if they had an active C. difficile infection. In an interview on 04/09/25 at 12:32 pm with the DM, he stated he was notified by nursing staff when there was a contagious infection in the building. He stated that the serving process was the same for residents on contact isolation as other residents (regular dishes and plates), and currently there were not any infections in the facility that he was aware of. In an observation and interview on 04/09/25 at 2:28 pm HSK H was observed in Resident #41's room wearing no PPE. She stated that when cleaning a Resident #41's room, she only wore gloves because her sickness doesn't spread but she made sure to leave the isolation rooms to the end of her rounds to be cleaned. In an observation and interview on 4/10/25 at 9:33 am CNA I walked in and out of Resident #41's room three times without wearing PPE. She was observed leaning on the resident's bed during this time. CNA I stated she had been trained to wear a gown, gloves, and depending on what care was being provided to the resident, a mask. She stated that she was required to wash her hands before and after providing care because C. difficile was spread by spores. In an interview on 04/10/25 at 11:05 am LVN B stated that Resident #41 had recurrent C. difficile flare ups because she was colonized with the bacteria, and she was placed on contact isolation each time. She stated that staff was required to wear a gown, gloves and a mask when doing direct care and at least gloves when entering the room. She stated that staff had been in-serviced on the different types of isolation precautions. She stated that the most recent in-service was done at the end of March 2025. She stated there was no reason that staff should be going into contact isolation rooms without PPE on. She stated the management staff did refresher in-services when any resident was diagnosed with an infection requiring isolation. In an interview on 04/10/25 at 11:15 am the Housekeeping Supervisor stated that she and all of her staff (housekeeping and laundry) were contract employees, but they received and were required to participate in trainings and in-services through the facility. She stated that for a resident on contact isolation her staff wore only gloves when cleaning the resident's room. She stated that the CNAs were responsible for picking up trash and laundry from contact isolation rooms. In an interview on 04/10/25 at 12:30 pm the ADON stated her expectations for staff going in and out of a contact isolation room for any reason was to put on a gown and gloves. She stated that she expected staff to wear full PPE (gown and gloves, mask if they chose) when in the room of a resident with C. difficile for any reason not just when providing direct care. She stated that meals were taken into the room for a resident on contact isolation on regular trays, but she had always been taught/told that facilities were supposed to use disposable trays, plates, cups, and utensils, and that current facility policies did not address the issue. She stated that infection control in-services were done every month. She stated that the in-services the last three months had been focused on transmission-based precautions and C. difficile. She stated the last C. difficile in-service was done at the end of March 2025 when Resident #41 tested positive. She stated that the staff might not understand the severity of C. difficile and how contagious it was and that was why they were not wearing the appropriate PPE when entering Resident #41's room. The ADON stated that if the staff were not following contact isolation guidelines and wearing the proper PPE that the outcome could be disastrous. The ADON then clarified that by disastrous she meant that if the staff were not following proper PPE protocol for contact isolation C. difficile could spread like wildfire throughout the facility because it was so contagious and for some of the more medically fragile residents that could contracting C. difficile could be life or death. In an interview on 04/10/25 at 1:01 pm The DON stated that her expectations were that staff would refer to signs on individual resident doors that indicated the type of isolation the resident was on (contact, droplet, enhanced barrier precaution) and what PPE was required when entering the room. The DON stated they (herself and the ADON) had done in-services the past three months regarding C. difficile and the different types of isolation. She stated that she did not understand why some staff were not wearing the proper PPE in any of the resident rooms. The DON stated that a C. difficile outbreak could occur if staff were not adhering to contact isolation guidelines and wearing the proper PPE. Review of the facility infection tracking log on 04/10/2025 at 2:23 pm revealed one case of C. difficile in January 2025 and two cases in March 2025, one of which had resolved and the other being Resident #41. Review of facility in-services revealed: an all-staff in-service on 01/28/2025 titled Covid Precautions/PPE/C. diff signed by CNA G, HSK H, and CNA I. A nursing department in-service titled EBP Guidelines/PPE dated 01/28/2025 which contained the CMS guidance for placing a resident on enhanced barrier precautions versus contact isolation, and was signed by CNA G and CNA I. An in-service for nurses titled C. diff Prevention was given on 03/31/2025. Review of facility policy titled Clostridium Difficile revised October 2018 revealed, in part: Residents with diarrhea associated with C. difficile (i.e., residents who are colonized and symptomatic) are placed on Contact Precautions. Residents with diarrhea and suspected CDI (C. difficile infection) are placed on Contact Precautions while awaiting laboratory results. A facility policy for contact isolation/precautions was requested by the survey team on 04/09/2025. The Corporate Compliance RN stated on 04/09/2025 at 4:30 pm that no policy was available that related to contact isolation. Review of CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings last updated in September 2024 revealed when Contact Precautions are used (i.e., to prevent transmission of an infectious agent that is not interrupted by Standard Precautions alone and that is associated with environmental contamination), donning of both gown and gloves upon room entry is indicated to address unintentional contact with contaminated environmental surfaces.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 13 residents (Resident #20 and 41) reviewed for care plans. There was no care plan addressing Resident #20's use of a gait belt across his wheelchair. There was no care plan addressing Resident #41's isolation status. This failure could affect the resident by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The findings included: Review of Resident #20's Admission Record, dated 4/9/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fracture of thoracic vertebra with routine healing (upper back). Review of Resident #20's initial MDS Assessment, dated 3/9/25 revealed: * a mental status of 11 of 15 (indicating moderate cognitive impairment). * range of motion impairment of the upper and lower extremities on both sides and used a wheelchair. * totally dependent on staff to transfer from the wheelchair to the bed. Review of Resident #20's Care Plan, revised 3/17/25 revealed Resident #20 had an ADL self-care performance deficit related to Pneumonia (Fluid in the lungs), Congestive Heart Failure, and Chronic Obstructive Pulmonary Disorder (lung disease causing restricted air flow and breathing problems). Resident #20 requires maximum assist by staff to move between surfaces. There was no care plan addressing Resident #20's use of a gait belt across his wheelchair. Observation and interview on 4/8/25 at 11:33 a.m. revealed Resident #20 in his wheelchair with a gait belt secured across the arms. Resident #20 stated he put the gait belt across the arms and the staff knew about it and were ok with it. Resident #20 said he had because it took too many people to help him transfer, so he had that around the wheelchair to keep him from falling out. Resident #20 stated he was aware if he fell out of the wheelchair with the gait belt secured across him that the wheelchair would fall on top of him. Resident #20 said he was at the facility for rehabilitation services. Interview on 4/10/25 at 2:30 p.m. the DON stated Resident #20 was here for rehabilitation services and had been at the facility for about a month. The DON said she said if there was anything abnormal, she would expect staff to bring it to her attention. The DON stated she would consider Resident #20 tying a gait belt across his wheelchair abnormal and should have been brought to her attention. The DON said she did not think there was a risk to Resident #20 using a gait belt across his wheelchair since he could take it off himself. The DON said she could not say if there was a risk while he was asleep since she never had anything bad happen. The DON said she did not know what would happen if Resident #20 either slid out of his wheelchair with the gait belt in place or fell forward with the gait belt in place and could not speculate on what would happen. Interview on 4/10/25 at 2:39 p.m. the DCO stated it was the resident's right to tie the gait belt across the wheelchair if it made him feel safe. The DCO said she did not see how it was a risk. The DCO said it was 50-50 chance that the wheelchair could go with him, if the resident was sliding out of the wheelchair. The DCO repeated she never saw Resident #20 put the gait belt across his wheelchair. When asked what would happen if the wheelchair landed on a resident the DON responded it never happened, she did not have a care plan for it, and if Resident #20 felt comfortable with it, it was his right to have it. The DCO stated she did not see how it was an issue. Interview on 4/10/25 at 3:28 p.m. Physical Therapist(PT) M stated he knew Resident #20 put the gait belt across the wheelchair. PT M said he educated Resident #20 about taking it off. Interview on 4/10/25 at 3:33 p.m. the Administrator stated she had previously seen Resident #20 wear the belt and was aware he wore it. Review of Resident #41's Admission Record revealed she was an [AGE] year-old female originally admitted to the facility 03/14/2023 with a most recent admitted [DATE] with diagnoses including chronic respiratory failure with hypoxia (decreased levels of oxygen in the blood), Alzheimer's disease, and recurrent enterocolitis due to clostridium difficile (infection of the colon caused by the bacteria clostridium difficile resulting in inflammation of the lining of the colon and diarrhea). Review of Resident #41's Annual MDS assessment dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 15, indicating she was cognitively intact. She required moderate assistance with most ADLs. She was frequently incontinent of bowel and bladder. She was receiving an antibiotic. Review of Resident #41's care plan most recently revised on 03/20/2025 revealed no care plan addressing her contact isolation due to recurrent C. difficile infections. Review of the facility's policy and procedure on Comprehensive Person-Centered Care Plans, revised March 2022, revealed: A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive person-centered care plan: describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being include: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. Care plan interventions are chosen only after data gather, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 3 residents (Resident #20) reviewed for accidents and hazards: The facility failed to ensure Resident #20 was thoroughly educated about the risks associated with strapping himself into his wheelchair with a gait belt (device typically used by aides as a transfer aide for more dependent resident to prevent falls). This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health. The findings included: Review of Resident #20's Admission Record, dated 4/9/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fracture of thoracic vertebra with routine healing (upper back). Review of Resident #20's initial MDS Assessment, dated 3/9/25 revealed: He had a mental status of 11 of 15 (indicating moderate cognitive impairment). He had range of motion impairment of the upper and lower extremities on both sides and used a wheelchair. He was totally dependent on staff to transfer from the wheelchair to the bed. Review of Resident #20's Care Plan, revised 3/17/25 revealed: Resident #20 had an ADL self-care performance deficit related to Pneumonia (Fluid in the lungs), Congestive Heart Failure, and Chronic Obstructive Pulmonary Disorder (lung disease causing restricted air flow and breathing problems). Resident #20 will improve current level of function in ADL's through the review date. Transfer: Resident #20 requires maximum assist by staff to move between surfaces. There was no care plan addressing Resident #20's use of a gait belt across his wheelchair. Observation and interview on 4/8/25 at 11:33 a.m. revealed Resident #20 in his wheelchair with a gait belt secured across the arms. Resident #20 stated he put the gait belt across the arms and the staff knew about it and were ok with it. Resident #20 said he had because it took too many people to help him transfer, so he had that around the wheelchair to keep him from falling out. Resident #20 stated he was aware if he fell out of the wheelchair with the gait belt secured across him that the wheelchair would fall on top of him. Resident #20 said he was at the facility for rehab services. Interview on 4/10/25 at 2:30 p.m. the DON stated Resident #20 was here for rehabilitation services and had been at the facility for about a month. The DON said she said if there was anything abnormal, she would expect staff to bring it to her attention. The DON stated she would consider Resident #20 tying a gait belt across his wheelchair abnormal and should have been brought to her attention. The DON said she did not think there was a risk to it since he could take it off himself. The DON said she could not say if there was a risk while he was asleep since she never had anything bad happen. The DON said she did not know what would happen if Resident #20 either slid out of his wheelchair with the gait belt in place or fell forward with the gait belt in place and could not speculate on what would happen. She stated again she did not see it as a hazard to the resident since he could take if off himself. Interview on 4/10/25 at 2:39 p.m. the DCO stated it was the resident's right to tie the gait belt across the wheelchair if it made hm feel safe. The DCO said she did not see how it was a risk. Surveyor attached a gait belt across the arms of the chair the DCO was in and asked if she was asleep, if she slid out of the chair was it a risk. The DCO said it was 50-50 because the wheelchair could go with him. Surveyor pointed out that meant the wheelchair landed on top of the resident. The DON repeated she never saw Resident #20 put the gait belt across his wheelchair. When asked what would happen if the wheelchair landed on a resident the DON responded it never happened, and if Resident #20 felt comfortable with it, it was his right to have it. The DCO stated she did not see how it was an issue. Surveyor asked for a policy for accident hazards to residents. Interview on 4/10/25 at 3:28 p.m. the Physical Therapist M stated he knew Resident #20 put the gait belt across the wheelchair. PT M said he educated Resident #20 about taking it off. PT M said Resident #20 told the therapy department it was too hard to get to the bathroom on time if he (Resident #20) was not already in his wheelchair due to chronic incontinence. PT M said if Resident #20 fell the potential risk was possible injury because Resident #20 restrained himself. Interview on 4/10/25 at 3:33 p.m. the Administrator stated she had previously seen Resident #20 wear the belt and was aware he wore it. No policy for hazards to residents was provided.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #4 and Resident #5) reviewed for care plans. 1. The facility failed to ensure that Resident #4 had a care plan in place for his use of diuretic medication. 2. The facility failed to ensure that Resident #5 had a care plan in place for her use of diuretic medication. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Review of Resident #4's Admission Record dated 5/2/24 revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included end stage renal disease with dependence on renal dialysis, congestive heart failure, and benign prostatic hyperplasia (prostate gland enlargement that can cause difficulty urinating). Review of Resident #4's Admission MDS assessment dated [DATE] revealed his short and long-term recall was ok and he was able to independently make consistent/reasonable decisions. He was independent or required only supervision for all ADLs. He was occasionally incontinent of bowel and bladder. He was taking a diuretic and he was receiving hemodialysis. Review of Resident #4's Order Summary Report dated 5/2/24 revealed the following: Furosemide Oral Tablet 40mg 1 tablet by mouth one time a day for edema (revision date 4/22/24) Review of Resident #4's care plan, most recent revision date 4/22/24, revealed no care plan in place for his diuretic use. Review of Resident #5's Admission Record dated 5/2/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included chronic peripheral venous insufficiency (when the veins in the legs do not allow blood to flow back up to the heart), pulmonary heart disease, and high blood pressure. Review of Resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 6 indicating severe cognitive impairment. She was independent or required setup assistance for all ADLs. She was occasionally incontinent of bladder and was taking a diuretic medication. Review of Resident #5's Order Summary dated 5/2/24 revealed the following: Furosemide Tablet 20mg give 1 tablet by mouth one time a day for edema (revision date 4/12/24) Review of Resident #5's care plan, most recent revision date 11/10/23, revealed no care plan in place for her diuretic use. In an interview on 5/2/24 at 5:05 PM with the MDS Nurse, she stated that she could not believe the care plans for the diuretic were missed for Resident #4 and Resident #5. She stated that all medications should have been care planned with the diagnosis for why the resident was receiving the medication. She stated that interventions should have included what kind of signs and symptoms of the disease process to be aware of, the possible adverse effects the medication could cause, and routine monitoring that would need to be done for the medication being addressed. In an interview on 5/2/24 at 5:32 PM with the DON, she stated that diuretic use should be on a resident's care plan. She stated that the diagnosis associated with the medication's use, side effects of the medication, and monitoring for the medication should all be included in the care plan. She stated that diuretics use would not automatically trigger a care plan from an MDS assessment, so a care plan would have to be put in manually by the MDS Nurse or, if it was a new order, the nurse who took the order. She stated she was not aware that Resident #4 and Resident #5 did not have care plans for their diuretic use. Review of facility's policy titled Care Plans, Comprehensive Person-Centered revision date March 2022, revealed, in part: The comprehensive, person-centered care plan: includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to protect residents' rights to formulate an advance directive for 1 (Resident #161) of 17 residents reviewed for advanced directives. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. Resident #161 had chosen Do Not Resuscitate status. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm after being unable to locate Resident #161's DNR form. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] at 3:05 pm and the immediacy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed the residents at risk of not having their wishes known, respected, and implemented in an emergency. The findings included: Review of Resident #161's Admission Record revealed she was an [AGE] year-old female originally admitted to the facility [DATE] with a most recent admitted [DATE]. She had admission diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), moderate malnutrition, breast cancer, chronic pain, and atrial fibrillation (abnormal heart rhythm). Her code status was listed as Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive). Review of Resident #161's MDS list revealed that at the time of her [DATE] admission, no comprehensive MDS assessment had been initiated. Review of Resident #161's Hospice Clinical Chart revealed that during her intake interview and assessment on [DATE] at 3:52 pm, the resident was a full code but requested DNR paperwork (there was no DNR form located in the resident's EHR during record review) be given to her and her family to fill out. Review of Resident #161's Hospice admission orders dated [DATE] revealed no mention of code status. Review of Resident #161's Admission Assessment/Baseline Care Plan Summary, initiated [DATE] and signed [DATE], revealed in Section O Code Status that she was a DNR. Review of Resident #161's Physician's Progress Notes revealed no mention of code status in the admission note. Review of Resident #161's care plan dated [DATE] revealed Problem: I have chosen DO NOT RESUSCITATE status. Review of Resident #161's Order Listing Report revealed no order for code status. Review of facility's handwritten 24-hour report log for dates [DATE] and [DATE] revealed Resident #161 was reported as being a DNR. The 24-hour report log sheet dated [DATE] stated Resident #161 re-admit, COPD, moderate protein-calorie malnutrition, hospice. The facility was unable to provide the 24-hour report log for [DATE]. In a phone interview on [DATE] at 2:53 PM with the Hospice Administrator she stated that the hospice company never received a copy of Resident #161's DNR from the family as they were told that the family was going to be providing a copy to the nursing home to keep on file. She stated that the hospice company was told that the family had given a copy of the DNR to facility LVN D on Friday [DATE] when the resident was admitted to the facility and that LVN D either had or was going to enter it into the computer system. She stated that the resident had been living in an assisted living facility but was hospitalized and had a significant decline after being discharged from the hospital and the family opted for her to be placed on hospice services and be admitted to the nursing facility. She stated that when all the hospice paperwork was signed by the family, the family kept the DNR paperwork and assured the hospice employee that they would give the nursing home a copy. She stated that the hospice company offered the family a counseling session with their Social Worker to discuss the DNR paperwork and their options, but the family declined because there was already a DNR in place. The Hospice Administrator stated that on [DATE] a facility nurse called the hospice to notify the Hospice RN M that the resident had passed away. She stated that, according to the notes and discussions she had after the incident with Hospice RN M, Hospice RN M arrived at the facility and pronounced a time of death for Resident #161 at on [DATE] at 3:40 PM. She stated that the facility nurse could not locate the DNR and instructed someone to call 911 and they (facility staff) began chest compressions. In an interview on [DATE] at 3:30 PM with LVN C she stated she called 911 at 4:11 PM on [DATE]. She stated she called 911 after about 30 minutes of searching the facility for a copy of Resident #161's DNR after the she had called hospice to notify them that the resident had expired, and the hospice nurse had already pronounced a time of death. She stated that after the hospice nurse pronounced the resident, she (LVN C) realized she had not verified the resident's code status and when she went to check she found there was no DNR on file for the resident. She stated that she should have verified the code status before calling hospice to pronounce. LVN C stated the resident was on hospice for comfort measures but was listed as a full code was her understanding. LVN C stated that Resident #161's MPOA told her that she had given a copy of the DNR to LVN E on the night before the resident passed away ([DATE]). She stated that there were several family members in the room, including the MPOA, when the resident passed and after hospice pronounced a time of death the family left the facility. She stated that whoever received records for the resident's admission would be responsible for making sure there was a DNR on file. In an interview on [DATE] at 10:30 AM with Social Worker, he stated that his role in the code status process was to have a Code Status Discussion with the resident or their representative within 48 hours of admission. He stated the discussion was a simple conversation about what the resident would like to have done if their heart stops while they are a resident, basically CPR or no CPR. He stated he did not get the chance to do the Code Status discussion with Resident #161 due to her admission being after business hours on [DATE] and her passing away on a holiday. He stated he had done a Code Status Discussion with her during her previous admission (,d+[DATE]), and she was a full code. He stated that whoever admitted the resident would have been responsible for getting the copy of the DNR from the family if there was one. He stated if he was the one who takes the DNR from the family he immediately scanned it and uploaded it into the resident's EHR. He stated that he did not have a hard copy DNR book, and he was pretty sure the nurses did not have hard copies of the residents' DNRs either. In an interview on [DATE] at 11:27 AM the Administrator confirmed that facility did not keep hard copies of DNRs on hand in the facility. He stated that all DNRs were kept in resident charts in the facility's EHR and code status was flagged for each resident and that the code status was accessible to all staff with EHR access. In an interview on [DATE] at 04:09 PM ADON stated that when an admission was done, they (staff completing the admission) were supposed to get their own copies of all paperwork including advanced directives. She stated that Resident #161 was a hospice resident, and she feels like they should have provided the facility with the DNR. She stated that the Admission/Readmission Evaluation in the EHR can be initiated by one nurse and finished/signed by a different nurse depending on what time the resident is admitted because of shift change, then the RN signs off on it and there is no way to tell which nurse completed which section. She stated that even if the admission evaluation and the care plan stated that the resident was a DNR, until the facility had the physical copy of the form the resident was considered a full code. In an interview on [DATE] at 04:50 PM LVN D stated he could not remember if he worked [DATE] through [DATE] without looking at a schedule. He stated he did not remember Resident #161 and denied that he was given a DNR for Resident #161 at any time. In a phone interview on [DATE] at 08:55 AM LVN E stated he did not remember Resident #161. He stated the facility had a high amount of resident turnover and if a resident was not long-term it was difficult to remember all the residents. He stated that when he admitted a new resident, he would keep all the admission paperwork at the nurse's desk in a basket for medical records to pick up and scan into the chart. He stated that if he did receive Resident #161's DNR form with her admission paperwork it would have gone into the medical records basket with the other paperwork. He stated that each nurse's station had one of these baskets. LVN E stated all paperwork that the nurses needed scanned into charts went into that basket for medical records. He stated the paperwork in the basket was normally picked up the next day or if it was a weekend, it was picked up Monday morning. He stated that he did not have access to scan documents into resident charts and did not think the other nurses did either. In an interview on [DATE] at 11:31 AM Hospice RN M stated she received the call that Resident #161 had passed away at 3:17 pm on [DATE] and it took her a little while to get to the facility. She stated that when she arrived, she assessed the resident and spoke with the family, and she pronounced the resident's time of death as 3:40 pm. She stated that she explained to the family that she would notify the funeral home and make arrangements for the funeral home to contact the family to set up their next steps and that after the family spent a few minutes with the resident they left the facility. She stated that at some point (she was never told what time the call was placed), either ADON or LVN C notified the DON that they were unable to locate Resident #161's DNR and that the DON told them they had to call 911 and begin CPR because without the DNR in hand Resident #161 was considered a full code. She stated that facility staff began CPR just as EMS arrived and then they (EMS) took over. Hospice RN M stated she explained to the EMTs that the resident was pronounced dead at 3:40 pm and had been down since at least 3:17 pm and asked if they could just call their medical director and have them call a time of death, but they refused because there was no DNR available. She stated that the resident's MPOA told her that she had given the facility the DNR [DATE] and that she (MPOA) had personally handed it to LVN D. She stated that LVN C tore the building apart trying to find the DNR form but was not able to locate it. She stated the facility told the family and hospice that they never received the form. In an interview on [DATE] at 12:48 PM with DON she stated that DNRs were scanned into the charts and nurses, management (DON, ADON, Administrator, Social Worker, MDS) had access to the form once it was scanned in. She stated that CNAs had the code status listed on their Kardex (resident information sheet for non-nurses) but did not have access to the DNR form itself. She stated anyone with EHR access could see a resident's code status but not the DNR form. She stated Resident #161 had been a resident in the facility before and had always been a full code in the past, so she stated that the understanding that she was a DNR on her last admission was strange to her. DON confirmed that there were no hard copies of DNR forms kept in the facility. She stated that any prudent nurse would check for a DNR before taking any action in a code situation. She feels that the facility did everything they were supposed to do regarding Resident #161's admission. She stated she was admitted after business hours so the Social Worker who normally asked the advanced directive questions was not here to do it. She stated that the hospice administrator told her (DON) that there was a copy of the MPOA form so she believed maybe the family thought that was the DNR. DON stated there was no in-service done for the staff after the incident because she was not aware that the resident had been deceased for that amount of time before 911 was called and CPR was started and that there was so much confusion regarding her code status. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated she did not have a copy of the resident's DNR because the copy she gave the LVN E was the original document with a carbon copy attached. She stated that a hospice agent had taken a picture of the DNR with a cell phone for hospice records (surveyor was not able to verify this with any hospice employee). She stated that she gave the DNR to LVN E on [DATE] while he completed Resident #161's admission to the facility. She stated the hospice company had given Resident #161 the DNR paperwork to fill out. MPOA stated that after the resident completed the form, she (MPOA) and two other family members signed as witnesses on [DATE] and then gave the form to LVN E on [DATE]. MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 5:25 PM LVN F (6a-6p) Stated she has a cheat sheet that she worked off when doing admissions, but she stated that a lot of the admission tasks will queue to be done in the EHR system. She stated that the Social Worker was normally the person responsible for the Code Status Discussion but anyone who did an admission had access to that assessment and was able to complete it. She stated that she believed that the Code Status Discussion flagged in the UDAs (user-defined assessments) for nursing staff a few days after admission if it had not been completed. She also stated that if a resident was admitted with a DNR in hand she would not complete the Code Status Discussion. She stated that if she admitted a resident after hours or on a weekend that expressed interest in becoming a DNR she would bypass the Code Status Discussion and go straight to filling out the DNR form, or if a resident that could not communicate was declining, she would call the family and have the code status discussion with them. She stated she would never wait on the Social Worker to have the code status discussion. In an interview on [DATE] at 6:00 PM RN G (6p-6a) stated there was a list of assessments that had to be completed for an admission. She stated that management would let them know they were going to get an admission so she would have everything she needed to do ready; hospitals should give a report so she should know basic information about the resident before they arrived. RN G stated when a new resident arrived the first thing, she checked was code status because even a DNR outside the facility was considered a full code in the facility until they were assessed by the Social Worker. She stated that if a new resident came in with a DNR form in hand she would honor the DNR and notify the DON and document that she received the DNR even if the code status had not yet been set to reflect it. She stated she have the code status discussion with residents, but she has never done the actual assessment in PCC and was not aware it was there. In a follow-up interview on [DATE] at 8:50 AM LVN C stated that she received report from LVN E on [DATE] at 6:00 AM that Resident #161 had been admitted to the facility to die and was a DNR. She stated that she was working Monday through Thursday only during that time due to her school schedule and another nurse was working only weekends, so [DATE] was the first day she had been responsible for the care of Resident #161. She stated that when the family called her into the room, they told her that Resident #161 had stopped breathing. She stated she assessed the resident for a pulse and breath sounds and after finding none, she told the family that she would notify hospice then left the family to be with the resident. She stated that she called to notify hospice that the resident had expired. She stated that the family left almost immediately after Hospice RN M arrived and pronounced the time of death at 3:40 pm. She stated that she was uncertain who realized that the resident did not have a DNR on file and was listed as a full code. She stated that the ADON, who was working the opposite hall, called the DON and notified her that the Resident #161 did not have a DNR on file and was listed as a Full Code, but had been pronounced dead at 3:40 pm by Hospice RN M. At approximately 4:10 pm the ADON came to her nurse's station and notified her that the DON had said that because there was no DNR on file they had to start CPR and call 911. LVN C stated that in the nine hours she was responsible for Resident #161 the family never said anything to her specifically about the resident being a DNR. She did recall the family asking questions about how long it would take for the resident to pass and what to expect and requested that she call the hospice chaplain to come visit with them. She stated that in her opinion the family was aware the resident's death was imminent and their priority was making sure she was comfortable and not suffering in her last hours. She stated she was not aware that she could complete the Code Status Discussion Assessment with new admissions. She stated that she has initiated the DNR form with residents before but was not aware that the form would be honored before the physician had signed it. She stated that she does not have access to scan documents into the resident EHRs so even if she was given a DNR or other form by a resident/family on admission it would have to wait until management or medical records staff was available to upload the document. She stated that when she was looking for Resident #161's DNR form she was unable to find paper copies of any of her admission paperwork in the building. In a phone interview on [DATE] at 10:07 AM Medical Director stated that the facility does address code status on admission. She stated that if the resident was a full code, the facility was very quick to react to the situation. Medical Director stated that in a code situation the staff did compressions and ventilation until EMS arrived and took over resuscitation efforts. She stated that if the resident is a DNR the facility was to honor that and if the resident wished to become a DNR the Social Worker was to assist them in completing the paperwork. She stated that any licensed staff would be able to have the code status discussion with a resident or their representative and if there was an admission on a weekend or holiday the discussion still needed to happen, and it should never be put on hold until the Social Worker came back to work. Medical Director stated that she had not been made aware of the situation regarding Resident #161 and stated that the fact the resident had an MPOA would negate the need for a DNR. She stated that the DON should have instructed the facility nurses to contact the MPOA and get permission to not do CPR after staff realized the DNR was not in the facility rather than instructing them to call 911 and begin CPR. She stated that this was poor advise on the part of the DON. She stated that there was a clear lack of judgement on everyone's part. Review of blank, undated facility form titled Admission Checklist - Morning Clinical Meeting form revealed: Review New Admissions - 'EHR' and other relevant sources - Grey shaded areas with asterisk should be completed within 24 hours, and other items on checklist should be completed within 3 days of admission. Gray shaded areas with asterisk: Vitals, Height, & Weight; Admission Assessment - Schedule Initiated & UDAs Complete; Admission Nurse Narrative Note Completed; Physician Orders Including Diet; Medication Review & Reconciliation; Photograph; Code Status/OOH DNR; Admission MDS Opened by Admission Nurse; Section GG Nursing Documentation Initiated; Physician Certification Initiated Review of undated facility policy titled DNR Policy revealed, in part: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has TWO valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and it has to be honored as long as it is executed properly with the resident's signature, date, and witnesses. A resident with a properly executed DNR should not be considered a FULL CODE while waiting for the physician to acknowledge the DNR. The following steps will be followed to reflect the resident's Do Not Resuscitate status accurately in 'EHR'. 1. Upon admission of a new resident, the charge nurse will determine the resident's code status. If the resident opts to complete an OOH-DNR, you will do the following: A. Review and complete an OOH-DNR with the resident/MPOA/Legal Guardian or next of kin and obtain witnesses or notary signatures on the form. This conversation is documented in the Code Status Discussion UDA. B. Request nursing change resident's code status to Do Not Resuscitate in 'EHR'. C. Scan OOH-DNR form and email to the resident's facility physician for signature. It is recommended to highlight all the places where the physician is to sign/date/license on the document. D. Upon receipt of the signed OOH-DNR, scan and upload to MISC. tab in 'EHR' under 'Advanced Directives'. 2. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with their wishes. Review of undated facility policy titled Full Code Status revealed: The following steps will be followed to reflect the resident's Full Code status accurately in 'EHR'. 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses Full Code, the nurse enters a 'Full Code' order into 'EHR'. 2. During 48-hour care plan meeting, social worker or designee will review code status with resident and/or resident representative This discussion is documented in the Code Status Discussion UDA. 3. Any Advanced Directives such as Medical Power of Attorney or other documents are uploaded to 'EHR' under the Miscellaneous tab under 'Advanced Directives. 4. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with what he/she wants. IJ was identified due to the above failures on [DATE] at 3:59 pm, and the IJ Template was provided to the Administrator. The Plan of Removal was accepted [DATE] at 3:05 pm and included: F578: The facility failed to have a system in place to ensure residents' Advanced Directives are accurately addressed and assessed at time of admission. Identify residents who could be affected. - All residents have the potential to be affected. - Facility census on [DATE] was 55. In-Service Conducted - All staff will be in-serviced on how to obtain the code status for all residents by utilizing the DNR code book found at each nurse's station. - DON, ADON, Regional Nurse Consultant will provide the training beginning [DATE] and continued until completed on [DATE] for current employees and all new hires. - Verbal understanding will be utilized for knowledge retention. Implementation of Changes - DNR and full code status audit was completed by Regional Nurse Consultant and DON on [DATE] for accuracy in 'EHR'. There were no issues identified on this audit, so no corrections were needed . - DON/ADON/Social Worker will audit once weekly for 3 months for 'EHR' accuracy. This audit was 100% of all current residents to include new admissions. - Code Status discussion will be conducted by social worker during business hours Monday through Friday and after 5 pm or weekends, holidays, charge nurses assigned a new admission will be completing code status discussion with residents or resident representative. - Weekend supervisor will verify completion of code status. - Full code or DNR will be put in 'EHR at that time and or assisting with DNR paperwork. Administrator/DON/weekend RN supervisor will verify completion of the discussion daily and accurately documented in 'EHR' beginning [DATE]. - DON/ADON will review code status discussion after hours daily including holidays for new admissions beginning [DATE]. - All new admissions on weekends will be addressed in the morning meeting for accuracy of code status and confirm code status and resident rights, documented in 'EHR', DNR uploaded in 'EHR' and DNR binders at each nurse's station. - In-service will be conducted starting today regarding code status discussion and after-hours process. DNR binders will be at both nurses' stations. - DNR binders are to be easily accessible for new DNR requests and filled out by the charge nurse if requested. - DNR binders are the binders that will contain the completed Out of Hospital DNR for all residents with advanced directives. - Code status will be reviewed quarterly at the care plan conference. - Nurses will be made aware of code status changes by communicating via the 24-hour report which contains all new telephone orders, verbal shift change discussion daily on each shift, social worker may also communicate the change in a code status. Monitoring - DON/ADON will review code status discussions Monday through Friday and weekend supervisor will be monitoring for accuracy. - Any negative outcomes will be reported to the QAPI committee monthly for 3 months and if no concerns, consider it resolved. Involvement of Medical Director - The Medical Director was notified about the immediate jeopardy on [DATE]. The Survey Team conducted POR verification [DATE]. In interviews conducted on [DATE] from 12:04 pm to 4:30 pm, 8 nursing staff and the Director of Rehab confirmed they received in-services on the DNR books, CPR, the Code Status Discussion, and DNR/Code Status paperwork and were able to give the location of the DNR books and how to find a resident's code status in the EHR. Review of facility in-service dated [DATE] titled DNR Book, CPR, Code Status Discussion revealed: 1. Codes Status Discussion will be done on admit and after-hours (weekends) by charge nurses. Social Worker will do them M-F. 2. DNR books on both nurse's stations contain DNR (blank) to fill out upon request. 3. Code status is located under care profile and 2nd confirmation is Code Status book. 4. All nurses must have American Heart or Red Cross for CPR card. If you do not have these, get one ASAP or certification. Review of facility in-service dated [DATE] titled DNR Code Status/Paperwork revealed: 1. DNR CODE BOOK - where - nurse's station at both ends with all current residents; contains DNR paperwork to verify code status - secondary. EHR primary code status access Review of DNR/Code Status Books on [DATE] revealed that each book contained blank OOH-DNR forms in the front pocket. The first page in each book was a disclaimer stating A DNR should not be held as incomplete if there is not a physician's signature. A DNR is considered in effect once it is filled out and awaiting a physician's signature. Once filled out DNR should be sent to the physician for signature and telephone order written. Again, this DNR that has not yet been signed by the physician YET is still IN EFFECT. The books were then divided alphabetically and contained copies of the DNR forms for each resident in the facility who had a form on record. Each book contained the forms for all DNR residents in the facility, not just those residents at the nurse's station the resident was attached to. The back of the books contained several instructional versions of DNR forms that were highlighted with directions on who needed to sign in each area and who to call for questions as well as how to write telephone orders for a resident's code status. The Administrator was notified that the Immediate Jeopardy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to implement written policies that prohibit abuse and neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm (approximately 63 minutes after LVN C was notified she had stopped breathing) due to being unable to locate Resident #161's DNR form. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] at 3:05 pm and the immediacy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of not having their wishes known, respected, and implemented in an emergency and could place residents who are a full code-status (all resuscitative measures to be taken to keep a person alive) at risk of death. The findings included: Review of facility policy titled Abuse, Negelct, Exploitation and Misappropriation Prevention Program revised [DATE], revealed, in part: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Develop and implement policies and protocols to prevent and identify: neglect of residents. Review of Resident #161's admission Record revealed she was an [AGE] year-old female originally admitted to the facility [DATE] with a most recent admission date of [DATE]. She had admission diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), moderate malnutrition, breast cancer, chronic pain, and atrial fibrillation (abnormal heart rhythm). Her code status was listed as Full Code. Review of Resident #161's MDS list revealed that at the time of her [DATE] admission, no comprehensive MDS assessment had been initiated. Review of Resident #161's Hospice Clinical Chart revealed that during her intake interview and assessment on [DATE] at 3:52 pm, the resident was a full code but requested DNR paperwork (there was no DNR form located in the resident's EHR during record review) be given to her and her family to fill out. Review of Resident #161's Hospice admission orders dated [DATE] revealed no mention of code status. Review of Resident #161's admission Assessment/Baseline Care Plan Summary, initiated [DATE] by LVN E and signed [DATE] by LVN C and DON, revealed in Section O Code Status that she was a DNR. Review of Resident #161's Physician's Progress Notes revealed no mention of code status in the admission note. Review of Resident #161's care plan dated [DATE] revealed Problem: I have chosen DO NOT RESUSCITATE status. Review of Resident #161's Order Listing Report revealed no order for code status. Review of facility's handwritten 24-hour report log for dates [DATE] and [DATE] revealed Resident #161 was reported as being a DNR. The 24-hour report log sheet dated [DATE] stated Resident #161 re-admit, COPD, moderate protein-calorie malnutrition, hospice. The facility was unable to provide the 24-hour report log for [DATE]. Review of Resident #161's Progress Notes revealed the following: Nurse's Note by LVN C on [DATE] at 3:12 pm Called to room by family. Resident without respirations or heartbeat. Family remains at bedside. Call placed to hospice requesting on call nurse be notified. Nurse's Note by LVN C on [DATE] at 3:18 pm Chaplain here to see resident and family. Nurse's Note by LVN C on [DATE] at 3:49 pm Hospice RN M with hospice here. Nurse's Note by LVN C on [DATE] at 3:59 pm Hospice nurse notified funeral home of need to pick resident up. There were no further notes found in Resident #161's chart. Review of Resident #161's Hospice Client Coordination Note Report revealed the following: Triage Note dated [DATE]: LVN C called triage nurse [DATE] at 3:17 pm to report Resident #161 had expired with family present. Hospice RN M was notified at 3:22 pm and was en route to the facility. Narrative Note dated [DATE] by Hospice RN M: Patient resting in bed with no breaths noted. HSN auscultated (listened with a stethoscope) for over one minute apical (over the heart). No pulse noted. TOD 1540 (3:40 pm). Funeral Home called 1600 (4:00 pm). CPR started at 1620 (4:20 PM) by paramedics due to facility not able to produce DNR in hand. MPOA called. She wants CPR stopped but per paramedic they cannot stop CPR over the phone with MPOA. Facility staff searching for DNR called maintenance to open the office to find the paper copy. Paramedics continue CPR until 1647 (4:47 pm). HSN filled out paperwork for mortician and facility. Body released to funeral home at 1705 (5:05 pm). Review of Resident #161's EMS Patient Care Record dated [DATE] revealed the following: Incident Narrative: Upon arrival the patient presented in the supine (on back) position in bed. NH staff were ventilating the patient with a BVM. NH staff initially informed EMS that patient stopped breathing at approximately 16:00 (4:00pm) today. EMS palpated (felt with fingers) the patient for a pulse, and none were noted. EMS moved the patient to the floor without incident using a patient carry. EMS began manual compressions and ventilating the patient. A NH employee entered the room and informed EMS that the patient has a DNR, but they are unable to locate it. EMS informed the employee that we must see a valid, physical copy of the DNR in order to cease resuscitative efforts. The NH employee never returned with a physical DNR. EMS attached multi pads (adhesive pads to detect heart rhythm) and the patient's rhythm was asystole (no detectable heartbeat) and remained asystole for the duration of the incident. IO access (technique in which the bone marrow cavity is used as a non-collapsible vascular entry point for delivering fluid or blood products) was gained, and EMS began administering LR (IV fluid). EMS inserted [NAME] (artificial airway used to help ventilate the patient) and attached the ETCO2 monitor and accuvent (attachment to monitor flow of air while ventilating patient). EMS proceeded to follow asystole protocol with pulse checks every 2 minutes and administering epinephrine every 3-5 minutes. EMS administered D10 (IV fluid). EMS obtained a 4-lead EKG. Approximately 15 minutes into the call a NH employee entered the room and informed EMS that the patient had stopped breathing at approximately 15:17 (3:17 pm) today. After approximately 25 minutes of CPR, EMS contacted medical control and informed physician on call of the details and interventions performed and the physician directed EMS to cease resuscitative efforts and called the time of death at 16:47 (4:47 pm) on [DATE]. EMS acquired a signature from the NH staff. EMS cleared the scene and returned to service. In a phone interview on [DATE] at 2:53 PM with the Hospice Administrator she stated that the hospice company never received a copy of Resident #161's DNR from the family as they were told that the family was going to be providing a copy to the nursing home to keep on file. She stated that the hospice company was told that the family had given a copy of the DNR to facility LVN D on Friday [DATE] when the resident was admitted to the facility and that LVN D either had or was going to enter it into the computer system. She stated that the resident had been living in an assisted living facility but was hospitalized and had a significant decline after being discharged from the hospital and the family opted for her to be placed on hospice services and be admitted to the nursing facility. She stated that when all the hospice paperwork was signed by the family, the family kept the DNR paperwork and assured the hospice employee that they would give the nursing home a copy. She stated that the hospice company offered the family a counseling session with their Social Worker to discuss the DNR paperwork and their options, but the family declined because there was already a DNR in place. The Hospice Administrator stated that on [DATE] a facility nurse called the hospice to notify the Hospice RN M that the resident had passed away. She stated that, according to the call log notes, LVN C notified the hospice company on [DATE] at 3:17 pm that Resident #161 had passed away and was requesting a hospice nurse be sent to the facility. She stated that according to Hospice RN M's notes and discussions she had after the incident with Hospice RN M, Hospice RN M arrived at the facility at approximately 3:35 pm and pronounced a time of death for Resident #161 at 3:40 PM. She stated that after Resident #161 had been pronounced deceased , LVN C tried to find the DNR form and when LVN C could not locate the DNR, instructed someone in the facility to call 911 and they (facility staff) began chest compressions. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated she did not have a copy of the resident's DNR because the copy she gave the LVN E was the original document with a carbon copy attached. She stated that a hospice agent had taken a picture of the DNR with a cell phone for hospice records (surveyor was not able to verify this with any hospice employee). She stated that she gave the DNR to LVN E on [DATE] while he completed Resident #161's admission to the facility. She stated the hospice company had given Resident #161 the DNR paperwork to fill out. MPOA stated that after the resident completed the form, she (MPOA) and two other family members signed as witnesses on [DATE] and then gave the form to LVN E on [DATE]. MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 3:30 PM LVN C stated that Resident #161's MPOA told her that she had given a copy of the DNR to LVN E on the night before the resident passed away ([DATE]). She stated that there were several family members in the room, including the MPOA, when the resident passed (she could not recall the exact time she was called to the room but stated she had put a note in the resident's chart documenting the time she was notified by the family that Resident #161 had stopped breathing) and after hospice pronounced a time of death the family left the facility. LVN C stated she called 911 at 4:11 PM on [DATE]. She stated she called 911 after about 30 minutes of searching the facility for a copy of Resident #161's DNR after the she had called hospice to notify them that the resident had expired, and the hospice nurse had already pronounced a time of death. She stated that after the hospice nurse pronounced the resident, she (LVN C) realized she had not verified the resident's code status and when she went to check she found there was no DNR on file for the resident. She stated that she should have verified the code status before calling hospice to pronounce. LVN C stated that when the paramedics arrived, the family had already left the facility, so she called the MPOA, who did not answer, so she called another family member to explain that because they did not have a copy of the DNR they had to try to resuscitate and were calling 911. She stated that Hospice RN M was able to get the MPOA on the phone while the paramedics were doing CPR and she (the MPOA) was telling them to stop, and they refused because there was no way to prove she was who she said she was and there was no DNR. LVN C stated that facility policy was if there was no DNR on file you called 911 and started CPR. LVN C stated the resident was on hospice for comfort measures but was listed as a full code was her understanding, but she had been told during shift report with LVN E that Resident #161 was a DNR. She stated that whoever received records for a new resident's admission would be responsible for making sure there was a DNR on file. In an interview on [DATE] at 10:30 AM with Social Worker, he stated that his role in the code status process was to have a Code Status Discussion with the resident or their representative within 48 hours of admission. He stated the discussion was a simple conversation about what the resident would like to have done if their heart stops while they are a resident, basically CPR or no CPR. He stated he did not get the chance to do the Code Status discussion with Resident #161 due to her admission being after business hours on [DATE] and her passing away on a holiday. He stated he had done a Code Status Discussion with her during her previous admission (7/2023), and she was a full code. He stated that whoever admitted the resident would have been responsible for getting the copy of the DNR from the family if there was one. He stated if he was the one who takes the DNR from the family he immediately scanned it and uploaded it into the resident's EHR. He stated that he did not have a hard copy DNR book, and he was pretty sure the nurses did not have hard copies of the residents' DNRs either. In an interview on [DATE] at 11:27 AM the Administrator confirmed that facility did not keep hard copies of DNRs on hand in the facility. He stated that all DNRs were kept in resident charts in the facility's EHR and code status was flagged for each resident and that the code status was accessible to all staff with EHR access. In an interview on [DATE] at 04:09 PM ADON stated she was working the floor on [DATE]. She stated the DON called her and asked her to go to the other side of the facility to help LVN C with Resident #161, so she grabbed the crash cart (rolling cart containing medication and equipment for emergency resuscitations) and went to the other side of the building and went to the resident's room. She stated that she (ADON) and LVN C had just started CPR as the EMTs arrived and took over. She was unable to give any times for the events of that day. ADON stated that when an admission was done, they (staff completing the admission) were supposed to get their own copies of all paperwork including advanced directives. She stated that Resident #161 was a hospice resident, and she feels like they should have provided the facility with the DNR. She stated that the Admission/readmission Evaluation in the EHR can be initiated by one nurse and finished/signed by a different nurse depending on what time the resident is admitted because of shift change, then the RN signs off on it and there was no way to tell which nurse completed which section, only who initiated the assessment and who signed it. She stated that even if the admission evaluation and the care plan stated that the resident was a DNR, until the facility had the physical copy of the form the resident was considered a full code. In an interview on [DATE] at 04:50 PM LVN D stated he could not remember if he worked [DATE] through [DATE] without looking at a schedule. He stated he did not remember Resident #161 and denied that he was given a DNR for Resident #161 at any time. In a phone interview on [DATE] at 08:55 AM LVN E stated he did not remember Resident #161. He stated the facility had a high amount resident turnover and if a resident was not long-term it was difficult to remember all the residents. He stated that when he admitted a new resident, he would keep all the admission paperwork at the nurse's desk in a basket for medical records to pick up and scan into the chart. He stated that if he did receive Resident #161's DNR form with her admission paperwork it would have gone into the medical records basket with the other paperwork. He stated that each nurse's station had one of these baskets. He stated that each nurse's station had one of these baskets. LVN E stated all paperwork that the nurses needed scanned into charts went into that basket for medical records. He stated the paperwork in the basket was normally picked up the next day or if it was a weekend, it was picked up Monday morning. He stated that he did not have access to scan documents into resident charts and did not think the other nurses did either. In an interview on [DATE] at 11:31 AM Hospice RN M stated she received the call that Resident #161 had passed away at 3:17 pm on [DATE] and it took her a little while to get to the facility. She stated that when she arrived, she assessed the resident and spoke with the family, and she pronounced the resident's time of death as 3:40 pm. She stated that she explained to the family that she would notify the funeral home and make arrangements for the funeral home to contact the family to set up their next steps and that after the family spent a few minutes with the resident they left the facility. She stated that at some point (she was never told what time the call was placed), either ADON or LVN C notified the DON that they were unable to locate Resident #161's DNR and that the DON told them they had to call 911 and begin CPR because without the DNR in hand Resident #161 was considered a full code. She stated that facility staff began CPR just as EMS arrived and then they (EMS) took over. Hospice RN M stated she explained to the EMTs that the resident was pronounced dead at 3:40 pm and had been down since at least 3:17 pm and asked if they could just call their medical director and have them call a time of death, but they refused because there was no DNR available. She stated that the resident's MPOA told her that she had given the facility the DNR [DATE] and that she (MPOA) had personally handed it to LVN D. She stated that LVN C tore the building apart trying to find the DNR form but was not able to locate it. She stated the facility told the family and hospice that they never received the form. In an interview on [DATE] at 12:48 PM with DON she stated that LVN C should have checked Resident #161's code status before calling hospice because a resident can be on hospice without being a DNR. She stated that on [DATE] the ADON called her to notify her that Resident #161 had passed away and the Hospice RN M had pronounced her as deceased but after looking at the EHR, LVN C was unable to locate her DNR. She stated that she instructed the ADON at that time that without a DNR the resident was a full code and they needed to call 911 and start CPR. DON was unable to give a time for when the phone call took place. She stated that she was not informed of how long Resident #161 had been deceased when she was notified of the situation or she would have told the ADON to keep trying to contact the MPOA to verify the resident did not want CPR but because she did not have all the information, she followed facility protocol for a resident with full code status. She stated there was no in-service done for the staff after the incident because she was not aware that the resident had been deceased for such an extended amount of time before 911 was called and CPR was started and that there was so much confusion regarding her code status. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 5:25 PM LVN F (6a-6p) Stated she has a cheat sheet that she worked off when doing admissions, but she stated that a lot of the admission tasks will queue to be done in the EHR system. She stated that the Social Worker was normally the person responsible for the Code Status Discussion but anyone who did an admission had access to that assessment and was able to complete it. She stated that she believed that the Code Status Discussion flagged in the UDAs (user-defined assessments) for nursing staff a few days after admission if it had not been completed. She also stated that if a resident was admitted with a DNR in hand she would not complete the Code Status Discussion. She stated that if she admitted a resident after hours or on a weekend that expressed interest in becoming a DNR she would bypass the Code Status Discussion and go straight to filling out the DNR form, or if a resident that could not communicate was declining, she would call the family and have the code status discussion with them. She stated she would never wait on the Social Worker to have the code status discussion. In an interview on [DATE] at 6:00 PM RN G (6p-6a) stated there was a list of assessments that had to be completed for an admission. She stated that management would let them know they were going to get an admission so she would have everything she needed to do ready; hospitals should give a report so she should know basic information about the resident before they arrived. RN G stated when a new resident arrived the first thing, she checked was code status because even a DNR outside the facility was considered a full code in the facility until they were assessed by the Social Worker. She stated that if a new resident came in with a DNR form in hand she would honor the DNR and notify the DON and document that she received the DNR even if the code status had not yet been set to reflect it. She stated she have the code status discussion with residents, but she has never done the actual assessment in PCC and was not aware it was there. In a follow-up interview on [DATE] at 8:50 AM LVN C stated that she received report from LVN E on [DATE] at 6:00 AM that Resident #161 had been admitted to the facility to die and was a DNR. She stated that she was working Monday through Thursday only during that time due to her school schedule and another nurse was working only weekends, so [DATE] was the first day she had been responsible for the care of Resident #161. She stated that when the family called her into the room, they told her that Resident #161 had stopped breathing. She stated she assessed the resident for a pulse and breath sounds and after finding none, she told the family that she would notify hospice then left the family to be with the resident. She stated that she called to notify hospice that the resident had expired. She stated that the family left almost immediately after Hospice RN M arrived and pronounced the time of death at 3:40 pm. She stated that she was uncertain who realized that the resident did not have a DNR on file and was listed as a full code. She stated that the ADON, who was working the opposite hall, called the DON and notified her that the Resident #161 did not have a DNR on file and was listed as a Full Code, but had been pronounced dead at 3:40 pm by Hospice RN M. At approximately 4:10 pm the ADON came to her nurse's station and notified her that the DON had said that because there was no DNR on file and Resident #161's code status was listed as Full Code, they had to start CPR and call 911. LVN C stated that at approximately 4:15 pm they began CPR with the ADON doing chest compressions and her (LVN C) ventilating Resident #161 with a bag valve mask until EMS arrived and took over. She acknowledged that with the time stamp from her progress note documenting the time the resident's family notified her that Resident #161 had stopped breathing, no less than 63 minutes had passed before CPR was initiated. In a phone interview on [DATE] at 10:07 AM Medical Director stated that the facility does address code status on admission. She stated that if the resident was a full code, the facility was very quick to react to the situation. Medical Director stated that in a code situation the staff did compressions and ventilation until EMS arrived and took over resuscitation efforts. She stated that if the resident is a DNR the facility was to honor that and if the resident wished to become a DNR the Social Worker was to assist them in completing the paperwork. She stated that any licensed staff would be able to have the code status discussion with a resident or their representative and if there was an admission on a weekend or holiday the discussion still needed to happen, and it should never be put on hold until the Social Worker came back to work. Medical Director stated that she had not been made aware of the situation regarding Resident #161 and stated that the fact the resident had an MPOA would negate the need for a DNR. She stated that the DON should have instructed the facility nurses to contact the MPOA and get permission to not do CPR after staff realized the DNR was not in the facility rather than instructing them to call 911 and begin CPR. She stated that this was poor advise on the part of the DON. She stated that there was a clear lack of judgement on everyone's part. In an interview on [DATE] at 1:15 PM Regional Director of Clinical Services stated the facility did not have a CPR policy. She stated the staff that were CPR certified rely on their training to know when to perform CPR. She stated she was the instructor for staff at the facility and they know when to do CPR. Review of blank, undated facility form titled admission Checklist - Morning Clinical Meeting form revealed: Review New Admissions - 'EHR' and other relevant sources - Grey shaded areas with asterisk should be completed within 24 hours, and other items on checklist should be completed within 3 days of admission. Gray shaded areas with asterisk: Vitals, Height, & Weight; admission Assessment - Schedule Initiated & UDAs Complete; admission Nurse Narrative Note Completed; Physician Orders Including Diet; Medication Review & Reconciliation; Photograph; Code Status/OOH DNR; admission MDS Opened by admission Nurse; Section GG Nursing Documentation Initiated; Physician Certification Initiated Review of undated facility policy titled DNR Policy revealed, in part: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has TWO valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and it has to be honored as long as it is executed properly with the resident's signature, date, and witnesses. A resident with a properly executed DNR should not be considered a FULL CODE while waiting for the physician to acknowledge the DNR. The following steps will be followed to reflect the resident's Do Not Resuscitate status accurately in 'EHR'. 1. Upon admission of a new resident, the charge nurse will determine the resident's code status. If the resident opts to complete an OOH-DNR, you will do the following: A. Review and complete an OOH-DNR with the resident/MPOA/Legal Guardian or next of kin and obtain witnesses or notary signatures on the form. This conversation is documented in the Code Status Discussion UDA. B. Request nursing change resident's code status to Do Not Resuscitate in 'EHR'. C. Scan OOH-DNR form and email to the resident's facility physician for signature. It is recommended to highlight all the places where the physician is to sign/date/license on the document. D. Upon receipt of the signed OOH-DNR, scan and upload to MISC. tab in 'EHR' under 'Advanced Directives'. 2. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with their wishes. Review of undated facility policy titled Full Code Status revealed: The following steps will be followed to reflect the resident's Full Code status accurately in 'EHR'. 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses Full Code, the nurse enters a 'Full Code' order into 'EHR'. 2. During 48-hour care plan meeting, social worker or designee will review code status with resident and/or RP. This discussion is documented in the Code Status Discussion UDA. 3. Any Advanced Directives such as Medical Power of Attorney or other documents are uploaded to 'EHR' under the Miscellaneous tab under 'Advanced Directives. 4. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with what he/she wants. An IJ was identified due to the above failures on [DATE] at 3:59 pm, and the IJ Template was provided to the Administrator. The Plan of Removal was accepted [DATE] at 3:05 pm and included: F[TRUNCATED]

Based on interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm (approximately 63 minutes after LVN C was notified she had stopped breathing) due to being unable to locate Resident #161's DNR form. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] at 3:05 pm and the immediacy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of not having their wishes known, respected, and implemented in an emergency and could place residents who are a full code-status (all resuscitative measures to be taken to keep a person alive) at risk of death. The findings included: Review of Resident #161's admission Record revealed she was an [AGE] year-old female originally admitted to the facility [DATE] with a most recent admission date of [DATE]. She had admission diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), moderate malnutrition, breast cancer, chronic pain, and atrial fibrillation (abnormal heart rhythm). Her code status was listed as Full Code. Review of Resident #161's MDS list revealed that at the time of her [DATE] admission, no comprehensive MDS assessment had been initiated. Review of Resident #161's Hospice Clinical Chart revealed that during her intake interview and assessment on [DATE] at 3:52 pm, the resident was a full code but requested DNR paperwork (there was no DNR form located in the resident's EHR during record review) be given to her and her family to fill out. Review of Resident #161's Hospice admission orders dated [DATE] revealed no mention of code status. Review of Resident #161's admission Assessment/Baseline Care Plan Summary, initiated [DATE] by LVN E and signed [DATE] by LVN C and DON, revealed in Section O Code Status that she was a DNR. Review of Resident #161's Physician's Progress Notes revealed no mention of code status in the admission note. Review of Resident #161's care plan dated [DATE] revealed Problem: I have chosen DO NOT RESUSCITATE status. Review of Resident #161's Order Listing Report revealed no order for code status. Review of facility's handwritten 24-hour report log for dates [DATE] and [DATE] revealed Resident #161 was reported as being a DNR. The 24-hour report log sheet dated [DATE] stated Resident #161 re-admit, COPD, moderate protein-calorie malnutrition, hospice. The facility was unable to provide the 24-hour report log for [DATE]. Review of Resident #161's Progress Notes revealed the following: Nurse's Note by LVN C on [DATE] at 3:12 pm Called to room by family. Resident without respirations or heartbeat. Family remains at bedside. Call placed to hospice requesting on call nurse be notified. Nurse's Note by LVN C on [DATE] at 3:18 pm Chaplain here to see resident and family. Nurse's Note by LVN C on [DATE] at 3:49 pm Hospice RN M with hospice here. Nurse's Note by LVN C on [DATE] at 3:59 pm Hospice nurse notified funeral home of need to pick resident up. There were no further notes found in Resident #161's chart. Review of Resident #161's Hospice Client Coordination Note Report revealed the following: Triage Note dated [DATE]: LVN C called triage nurse [DATE] at 3:17 pm to report Resident #161 had expired with family present. Hospice RN M was notified at 3:22 pm and was en route to the facility. Narrative Note dated [DATE] by Hospice RN M: Patient resting in bed with no breaths noted. HSN auscultated (listened with a stethoscope) for over one minute apical (over the heart). No pulse noted. TOD 1540 (3:40 pm). Funeral Home called 1600 (4:00 pm). CPR started at 1620 (4:20 PM) by paramedics due to facility not able to produce DNR in hand. MPOA called. She wants CPR stopped but per paramedic they cannot stop CPR over the phone with MPOA. Facility staff searching for DNR called maintenance to open the office to find the paper copy. Paramedics continue CPR until 1647 (4:47 pm). HSN filled out paperwork for mortician and facility. Body released to funeral home at 1705 (5:05 pm). Review of Resident #161's EMS Patient Care Record dated [DATE] revealed the following: Incident Narrative: Upon arrival the patient presented in the supine (on back) position in bed. NH staff were ventilating the patient with a BVM. NH staff initially informed EMS that patient stopped breathing at approximately 16:00 (4:00pm) today. EMS palpated (felt with fingers) the patient for a pulse, and none were noted. EMS moved the patient to the floor without incident using a patient carry. EMS began manual compressions and ventilating the patient. A NH employee entered the room and informed EMS that the patient has a DNR, but they are unable to locate it. EMS informed the employee that we must see a valid, physical copy of the DNR in order to cease resuscitative efforts. The NH employee never returned with a physical DNR. EMS attached multi pads (adhesive pads to detect heart rhythm) and the patient's rhythm was asystole (no detectable heartbeat) and remained asystole for the duration of the incident. IO access (technique in which the bone marrow cavity is used as a non-collapsible vascular entry point for delivering fluid or blood products) was gained, and EMS began administering LR (IV fluid). EMS inserted [NAME] (artificial airway used to help ventilate the patient) and attached the ETCO2 monitor and accuvent (attachment to monitor flow of air while ventilating patient). EMS proceeded to follow asystole protocol with pulse checks every 2 minutes and administering epinephrine every 3-5 minutes. EMS administered D10 (IV fluid). EMS obtained a 4-lead EKG. Approximately 15 minutes into the call a NH employee entered the room and informed EMS that the patient had stopped breathing at approximately 15:17 (3:17 pm) today. After approximately 25 minutes of CPR, EMS contacted medical control and informed physician on call of the details and interventions performed and the physician directed EMS to cease resuscitative efforts and called the time of death at 16:47 (4:47 pm) on [DATE]. EMS acquired a signature from the NH staff. EMS cleared the scene and returned to service. In a phone interview on [DATE] at 2:53 PM with the Hospice Administrator she stated that the hospice company never received a copy of Resident #161's DNR from the family as they were told that the family was going to be providing a copy to the nursing home to keep on file. She stated that the hospice company was told that the family had given a copy of the DNR to facility LVN D on Friday [DATE] when the resident was admitted to the facility and that LVN D either had or was going to enter it into the computer system. She stated that the resident had been living in an assisted living facility but was hospitalized and had a significant decline after being discharged from the hospital and the family opted for her to be placed on hospice services and be admitted to the nursing facility. She stated that when all the hospice paperwork was signed by the family, the family kept the DNR paperwork and assured the hospice employee that they would give the nursing home a copy. She stated that the hospice company offered the family a counseling session with their Social Worker to discuss the DNR paperwork and their options, but the family declined because there was already a DNR in place. The Hospice Administrator stated that on [DATE] a facility nurse called the hospice to notify the Hospice RN M that the resident had passed away. She stated that, according to the call log notes, LVN C notified the hospice company on [DATE] at 3:17 pm that Resident #161 had passed away and was requesting a hospice nurse be sent to the facility. She stated that according to Hospice RN M's notes and discussions she had after the incident with Hospice RN M, Hospice RN M arrived at the facility at approximately 3:35 pm and pronounced a time of death for Resident #161 at 3:40 PM. She stated that after Resident #161 had been pronounced deceased , LVN C tried to find the DNR form and when LVN C could not locate the DNR, instructed someone in the facility to call 911 and they (facility staff) began chest compressions. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated she did not have a copy of the resident's DNR because the copy she gave the LVN E was the original document with a carbon copy attached. She stated that a hospice agent had taken a picture of the DNR with a cell phone for hospice records (surveyor was not able to verify this with any hospice employee). She stated that she gave the DNR to LVN E on [DATE] while he completed Resident #161's admission to the facility. She stated the hospice company had given Resident #161 the DNR paperwork to fill out. MPOA stated that after the resident completed the form, she (MPOA) and two other family members signed as witnesses on [DATE] and then gave the form to LVN E on [DATE]. MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 3:30 PM LVN C stated that Resident #161's MPOA told her that she had given a copy of the DNR to LVN E on the night before the resident passed away ([DATE]). She stated that there were several family members in the room, including the MPOA, when the resident passed (she could not recall the exact time she was called to the room but stated she had put a note in the resident's chart documenting the time she was notified by the family that Resident #161 had stopped breathing) and after hospice pronounced a time of death the family left the facility. LVN C stated she called 911 at 4:11 PM on [DATE]. She stated she called 911 after about 30 minutes of searching the facility for a copy of Resident #161's DNR after the she had called hospice to notify them that the resident had expired, and the hospice nurse had already pronounced a time of death. She stated that after the hospice nurse pronounced the resident, she (LVN C) realized she had not verified the resident's code status and when she went to check she found there was no DNR on file for the resident. She stated that she should have verified the code status before calling hospice to pronounce. LVN C stated that when the paramedics arrived, the family had already left the facility, so she called the MPOA, who did not answer, so she called another family member to explain that because they did not have a copy of the DNR they had to try to resuscitate and were calling 911. She stated that Hospice RN M was able to get the MPOA on the phone while the paramedics were doing CPR and she (the MPOA) was telling them to stop, and they refused because there was no way to prove she was who she said she was and there was no DNR. LVN C stated that facility policy was if there was no DNR on file you called 911 and started CPR. LVN C stated the resident was on hospice for comfort measures but was listed as a full code was her understanding, but she had been told during shift report with LVN E that Resident #161 was a DNR. She stated that whoever received records for a new resident's admission would be responsible for making sure there was a DNR on file. In an interview on [DATE] at 10:30 AM with Social Worker, he stated that his role in the code status process was to have a Code Status Discussion with the resident or their representative within 48 hours of admission. He stated the discussion was a simple conversation about what the resident would like to have done if their heart stops while they are a resident, basically CPR or no CPR. He stated he did not get the chance to do the Code Status discussion with Resident #161 due to her admission being after business hours on [DATE] and her passing away on a holiday. He stated he had done a Code Status Discussion with her during her previous admission (7/2023), and she was a full code. He stated that whoever admitted the resident would have been responsible for getting the copy of the DNR from the family if there was one. He stated if he was the one who takes the DNR from the family he immediately scanned it and uploaded it into the resident's EHR. He stated that he did not have a hard copy DNR book, and he was pretty sure the nurses did not have hard copies of the residents' DNRs either. In an interview on [DATE] at 11:27 AM the Administrator confirmed that facility did not keep hard copies of DNRs on hand in the facility. He stated that all DNRs were kept in resident charts in the facility's EHR and code status was flagged for each resident and that the code status was accessible to all staff with EHR access. In an interview on [DATE] at 04:09 PM ADON stated she was working the floor on [DATE]. She stated the DON called her and asked her to go to the other side of the facility to help LVN C with Resident #161, so she grabbed the crash cart (rolling cart containing medication and equipment for emergency resuscitations) and went to the other side of the building and went to the resident's room. She stated that she (ADON) and LVN C had just started CPR as the EMTs arrived and took over. She was unable to give any times for the events of that day. ADON stated that when an admission was done, they (staff completing the admission) were supposed to get their own copies of all paperwork including advanced directives. She stated that Resident #161 was a hospice resident, and she feels like they should have provided the facility with the DNR. She stated that the Admission/readmission Evaluation in the EHR can be initiated by one nurse and finished/signed by a different nurse depending on what time the resident is admitted because of shift change, then the RN signs off on it and there was no way to tell which nurse completed which section, only who initiated the assessment and who signed it. She stated that even if the admission evaluation and the care plan stated that the resident was a DNR, until the facility had the physical copy of the form the resident was considered a full code. In an interview on [DATE] at 04:50 PM LVN D stated he could not remember if he worked [DATE] through [DATE] without looking at a schedule. He stated he did not remember Resident #161 and denied that he was given a DNR for Resident #161 at any time. In a phone interview on [DATE] at 08:55 AM LVN E stated he did not remember Resident #161. He stated the facility had a high amount resident turnover and if a resident was not long-term it was difficult to remember all the residents. He stated that when he admitted a new resident, he would keep all the admission paperwork at the nurse's desk in a basket for medical records to pick up and scan into the chart. He stated that if he did receive Resident #161's DNR form with her admission paperwork it would have gone into the medical records basket with the other paperwork. He stated that each nurse's station had one of these baskets. He stated that each nurse's station had one of these baskets. LVN E stated all paperwork that the nurses needed scanned into charts went into that basket for medical records. He stated the paperwork in the basket was normally picked up the next day or if it was a weekend, it was picked up Monday morning. He stated that he did not have access to scan documents into resident charts and did not think the other nurses did either. In an interview on [DATE] at 11:31 AM Hospice RN M stated she received the call that Resident #161 had passed away at 3:17 pm on [DATE] and it took her a little while to get to the facility. She stated that when she arrived, she assessed the resident and spoke with the family, and she pronounced the resident's time of death as 3:40 pm. She stated that she explained to the family that she would notify the funeral home and make arrangements for the funeral home to contact the family to set up their next steps and that after the family spent a few minutes with the resident they left the facility. She stated that at some point (she was never told what time the call was placed), either ADON or LVN C notified the DON that they were unable to locate Resident #161's DNR and that the DON told them they had to call 911 and begin CPR because without the DNR in hand Resident #161 was considered a full code. She stated that facility staff began CPR just as EMS arrived and then they (EMS) took over. Hospice RN M stated she explained to the EMTs that the resident was pronounced dead at 3:40 pm and had been down since at least 3:17 pm and asked if they could just call their medical director and have them call a time of death, but they refused because there was no DNR available. She stated that the resident's MPOA told her that she had given the facility the DNR [DATE] and that she (MPOA) had personally handed it to LVN D. She stated that LVN C tore the building apart trying to find the DNR form but was not able to locate it. She stated the facility told the family and hospice that they never received the form. In an interview on [DATE] at 12:48 PM with DON she stated that LVN C should have checked Resident #161's code status before calling hospice because a resident can be on hospice without being a DNR. She stated that on [DATE] the ADON called her to notify her that Resident #161 had passed away and the Hospice RN M had pronounced her as deceased but after looking at the EHR, LVN C was unable to locate her DNR. She stated that she instructed the ADON at that time that without a DNR the resident was a full code and they needed to call 911 and start CPR. DON was unable to give a time for when the phone call took place. She stated that she was not informed of how long Resident #161 had been deceased when she was notified of the situation or she would have told the ADON to keep trying to contact the MPOA to verify the resident did not want CPR but because she did not have all the information, she followed facility protocol for a resident with full code status. She stated there was no in-service done for the staff after the incident because she was not aware that the resident had been deceased for such an extended amount of time before 911 was called and CPR was started and that there was so much confusion regarding her code status. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 5:25 PM LVN F (6a-6p) Stated she has a cheat sheet that she worked off when doing admissions, but she stated that a lot of the admission tasks will queue to be done in the EHR system. She stated that the Social Worker was normally the person responsible for the Code Status Discussion but anyone who did an admission had access to that assessment and was able to complete it. She stated that she believed that the Code Status Discussion flagged in the UDAs (user-defined assessments) for nursing staff a few days after admission if it had not been completed. She also stated that if a resident was admitted with a DNR in hand she would not complete the Code Status Discussion. She stated that if she admitted a resident after hours or on a weekend that expressed interest in becoming a DNR she would bypass the Code Status Discussion and go straight to filling out the DNR form, or if a resident that could not communicate was declining, she would call the family and have the code status discussion with them. She stated she would never wait on the Social Worker to have the code status discussion. In an interview on [DATE] at 6:00 PM RN G (6p-6a) stated there was a list of assessments that had to be completed for an admission. She stated that management would let them know they were going to get an admission so she would have everything she needed to do ready; hospitals should give a report so she should know basic information about the resident before they arrived. RN G stated when a new resident arrived the first thing, she checked was code status because even a DNR outside the facility was considered a full code in the facility until they were assessed by the Social Worker. She stated that if a new resident came in with a DNR form in hand she would honor the DNR and notify the DON and document that she received the DNR even if the code status had not yet been set to reflect it. She stated she have the code status discussion with residents, but she has never done the actual assessment in PCC and was not aware it was there. In a follow-up interview on [DATE] at 8:50 AM LVN C stated that she received report from LVN E on [DATE] at 6:00 AM that Resident #161 had been admitted to the facility to die and was a DNR. She stated that she was working Monday through Thursday only during that time due to her school schedule and another nurse was working only weekends, so [DATE] was the first day she had been responsible for the care of Resident #161. She stated that when the family called her into the room, they told her that Resident #161 had stopped breathing. She stated she assessed the resident for a pulse and breath sounds and after finding none, she told the family that she would notify hospice then left the family to be with the resident. She stated that she called to notify hospice that the resident had expired. She stated that the family left almost immediately after Hospice RN M arrived and pronounced the time of death at 3:40 pm. She stated that she was uncertain who realized that the resident did not have a DNR on file and was listed as a full code. She stated that the ADON, who was working the opposite hall, called the DON and notified her that the Resident #161 did not have a DNR on file and was listed as a Full Code, but had been pronounced dead at 3:40 pm by Hospice RN M. At approximately 4:10 pm the ADON came to her nurse's station and notified her that the DON had said that because there was no DNR on file and Resident #161's code status was listed as Full Code, they had to start CPR and call 911. LVN C stated that at approximately 4:15 pm they began CPR with the ADON doing chest compressions and her (LVN C) ventilating Resident #161 with a bag valve mask until EMS arrived and took over. She acknowledged that with the time stamp from her progress note documenting the time the resident's family notified her that Resident #161 had stopped breathing, no less than 63 minutes had passed before CPR was initiated. In a phone interview on [DATE] at 10:07 AM Medical Director stated that the facility does address code status on admission. She stated that if the resident was a full code, the facility was very quick to react to the situation. Medical Director stated that in a code situation the staff did compressions and ventilation until EMS arrived and took over resuscitation efforts. She stated that if the resident is a DNR the facility was to honor that and if the resident wished to become a DNR the Social Worker was to assist them in completing the paperwork. She stated that any licensed staff would be able to have the code status discussion with a resident or their representative and if there was an admission on a weekend or holiday the discussion still needed to happen, and it should never be put on hold until the Social Worker came back to work. Medical Director stated that she had not been made aware of the situation regarding Resident #161 and stated that the fact the resident had an MPOA would negate the need for a DNR. She stated that the DON should have instructed the facility nurses to contact the MPOA and get permission to not do CPR after staff realized the DNR was not in the facility rather than instructing them to call 911 and begin CPR. She stated that this was poor advise on the part of the DON. She stated that there was a clear lack of judgement on everyone's part. In an interview on [DATE] at 1:15 PM Regional Director of Clinical Services stated the facility did not have a CPR policy. She stated the staff that were CPR certified rely on their training to know when to perform CPR. She stated she was the instructor for staff at the facility and they know when to do CPR. Review of blank, undated facility form titled admission Checklist - Morning Clinical Meeting form revealed: Review New Admissions - 'EHR' and other relevant sources - Grey shaded areas with asterisk should be completed within 24 hours, and other items on checklist should be completed within 3 days of admission. Gray shaded areas with asterisk: Vitals, Height, & Weight; admission Assessment - Schedule Initiated & UDAs Complete; admission Nurse Narrative Note Completed; Physician Orders Including Diet; Medication Review & Reconciliation; Photograph; Code Status/OOH DNR; admission MDS Opened by admission Nurse; Section GG Nursing Documentation Initiated; Physician Certification Initiated Review of facility policy titled Abuse, Negelct, Exploitation and Misappropriation Prevention Program revised [DATE], revealed, in part: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Develop and implement policies and protocols to prevent and identify: neglect of residents. Review of undated facility policy titled DNR Policy revealed, in part: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has TWO valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and it has to be honored as long as it is executed properly with the resident's signature, date, and witnesses. A resident with a properly executed DNR should not be considered a FULL CODE while waiting for the physician to acknowledge the DNR. The following steps will be followed to reflect the resident's Do Not Resuscitate status accurately in 'EHR'. 1. Upon admission of a new resident, the charge nurse will determine the resident's code status. If the resident opts to complete an OOH-DNR, you will do the following: A. Review and complete an OOH-DNR with the resident/MPOA/Legal Guardian or next of kin and obtain witnesses or notary signatures on the form. This conversation is documented in the Code Status Discussion UDA. B. Request nursing change resident's code status to Do Not Resuscitate in 'EHR'. C. Scan OOH-DNR form and email to the resident's facility physician for signature. It is recommended to highlight all the places where the physician is to sign/date/license on the document. D. Upon receipt of the signed OOH-DNR, scan and upload to MISC. tab in 'EHR' under 'Advanced Directives'. 2. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with their wishes. Review of undated facility policy titled Full Code Status revealed: The following steps will be followed to reflect the resident's Full Code status accurately in 'EHR'. 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses Full Code, the nurse enters a 'Full Code' order into 'EHR'. 2. During 48-hour care plan meeting, social worker or designee will review code status with resident and/or RP. This discussion is documented in the Code Status Discussion UDA. 3. Any Advanced Directives such as Medical Power of Attorney or other documents are uploaded to 'EHR' under the Miscellaneous tab under 'Advanced Directives. 4. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with what he/she wants. An IJ was identified due to the above failures on [DATE] at 3:59 pm, and the IJ Template was provided to the Administrator. The Plan of Removal was accepted [DATE] at 3:05 pm and included: F6[TRUNCATED]

Based on interview and record review, the facility failed to implement written policies that prohibit abuse and neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm (approximately 63 minutes after LVN C was notified she had stopped breathing) due to being unable to locate Resident #161's DNR form. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] at 3:05 pm and the immediacy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of not having their wishes known, respected, and implemented in an emergency and could place residents who are a full code-status (all resuscitative measures to be taken to keep a person alive) at risk of death. The findings included: Review of facility policy titled Abuse, Negelct, Exploitation and Misappropriation Prevention Program revised [DATE], revealed, in part: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Develop and implement policies and protocols to prevent and identify: neglect of residents. Review of Resident #161's Admission Record revealed she was an [AGE] year-old female originally admitted to the facility [DATE] with a most recent admitted [DATE]. She had admission diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), moderate malnutrition, breast cancer, chronic pain, and atrial fibrillation (abnormal heart rhythm). Her code status was listed as Full Code. Review of Resident #161's MDS list revealed that at the time of her [DATE] admission, no comprehensive MDS assessment had been initiated. Review of Resident #161's Hospice Clinical Chart revealed that during her intake interview and assessment on [DATE] at 3:52 pm, the resident was a full code but requested DNR paperwork (there was no DNR form located in the resident's EHR during record review) be given to her and her family to fill out. Review of Resident #161's Hospice admission orders dated [DATE] revealed no mention of code status. Review of Resident #161's Admission Assessment/Baseline Care Plan Summary, initiated [DATE] by LVN E and signed [DATE] by LVN C and DON, revealed in Section O Code Status that she was a DNR. Review of Resident #161's Physician's Progress Notes revealed no mention of code status in the admission note. Review of Resident #161's care plan dated [DATE] revealed Problem: I have chosen DO NOT RESUSCITATE status. Review of Resident #161's Order Listing Report revealed no order for code status. Review of facility's handwritten 24-hour report log for dates [DATE] and [DATE] revealed Resident #161 was reported as being a DNR. The 24-hour report log sheet dated [DATE] stated Resident #161 re-admit, COPD, moderate protein-calorie malnutrition, hospice. The facility was unable to provide the 24-hour report log for [DATE]. Review of Resident #161's Progress Notes revealed the following: Nurse's Note by LVN C on [DATE] at 3:12 pm Called to room by family. Resident without respirations or heartbeat. Family remains at bedside. Call placed to hospice requesting on call nurse be notified. Nurse's Note by LVN C on [DATE] at 3:18 pm Chaplain here to see resident and family. Nurse's Note by LVN C on [DATE] at 3:49 pm Hospice RN M with hospice here. Nurse's Note by LVN C on [DATE] at 3:59 pm Hospice nurse notified funeral home of need to pick resident up. There were no further notes found in Resident #161's chart. Review of Resident #161's Hospice Client Coordination Note Report revealed the following: Triage Note dated [DATE]: LVN C called triage nurse [DATE] at 3:17 pm to report Resident #161 had expired with family present. Hospice RN M was notified at 3:22 pm and was en route to the facility. Narrative Note dated [DATE] by Hospice RN M: Patient resting in bed with no breaths noted. HSN auscultated (listened with a stethoscope) for over one minute apical (over the heart). No pulse noted. TOD 1540 (3:40 pm). Funeral Home called 1600 (4:00 pm). CPR started at 1620 (4:20 PM) by paramedics due to facility not able to produce DNR in hand. MPOA called. She wants CPR stopped but per paramedic they cannot stop CPR over the phone with MPOA. Facility staff searching for DNR called maintenance to open the office to find the paper copy. Paramedics continue CPR until 1647 (4:47 pm). HSN filled out paperwork for mortician and facility. Body released to funeral home at 1705 (5:05 pm). Review of Resident #161's EMS Patient Care Record dated [DATE] revealed the following: Incident Narrative: Upon arrival the patient presented in the supine (on back) position in bed. NH staff were ventilating the patient with a BVM. NH staff initially informed EMS that patient stopped breathing at approximately 16:00 (4:00pm) today. EMS palpated (felt with fingers) the patient for a pulse, and none were noted. EMS moved the patient to the floor without incident using a patient carry. EMS began manual compressions and ventilating the patient. A NH employee entered the room and informed EMS that the patient has a DNR, but they are unable to locate it. EMS informed the employee that we must see a valid, physical copy of the DNR in order to cease resuscitative efforts. The NH employee never returned with a physical DNR. EMS attached multi pads (adhesive pads to detect heart rhythm) and the patient's rhythm was asystole (no detectable heartbeat) and remained asystole for the duration of the incident. IO access (technique in which the bone marrow cavity is used as a non-collapsible vascular entry point for delivering fluid or blood products) was gained, and EMS began administering LR (IV fluid). EMS inserted [NAME] (artificial airway used to help ventilate the patient) and attached the ETCO2 monitor and accuvent (attachment to monitor flow of air while ventilating patient). EMS proceeded to follow asystole protocol with pulse checks every 2 minutes and administering epinephrine every ,d+[DATE] minutes. EMS administered D10 (IV fluid). EMS obtained a 4-lead EKG. Approximately 15 minutes into the call a NH employee entered the room and informed EMS that the patient had stopped breathing at approximately 15:17 (3:17 pm) today. After approximately 25 minutes of CPR, EMS contacted medical control and informed physician on call of the details and interventions performed and the physician directed EMS to cease resuscitative efforts and called the time of death at 16:47 (4:47 pm) on [DATE]. EMS acquired a signature from the NH staff. EMS cleared the scene and returned to service. In a phone interview on [DATE] at 2:53 PM with the Hospice Administrator she stated that the hospice company never received a copy of Resident #161's DNR from the family as they were told that the family was going to be providing a copy to the nursing home to keep on file. She stated that the hospice company was told that the family had given a copy of the DNR to facility LVN D on Friday [DATE] when the resident was admitted to the facility and that LVN D either had or was going to enter it into the computer system. She stated that the resident had been living in an assisted living facility but was hospitalized and had a significant decline after being discharged from the hospital and the family opted for her to be placed on hospice services and be admitted to the nursing facility. She stated that when all the hospice paperwork was signed by the family, the family kept the DNR paperwork and assured the hospice employee that they would give the nursing home a copy. She stated that the hospice company offered the family a counseling session with their Social Worker to discuss the DNR paperwork and their options, but the family declined because there was already a DNR in place. The Hospice Administrator stated that on [DATE] a facility nurse called the hospice to notify the Hospice RN M that the resident had passed away. She stated that, according to the call log notes, LVN C notified the hospice company on [DATE] at 3:17 pm that Resident #161 had passed away and was requesting a hospice nurse be sent to the facility. She stated that according to Hospice RN M's notes and discussions she had after the incident with Hospice RN M, Hospice RN M arrived at the facility at approximately 3:35 pm and pronounced a time of death for Resident #161 at 3:40 PM. She stated that after Resident #161 had been pronounced deceased , LVN C tried to find the DNR form and when LVN C could not locate the DNR, instructed someone in the facility to call 911 and they (facility staff) began chest compressions. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated she did not have a copy of the resident's DNR because the copy she gave the LVN E was the original document with a carbon copy attached. She stated that a hospice agent had taken a picture of the DNR with a cell phone for hospice records (surveyor was not able to verify this with any hospice employee). She stated that she gave the DNR to LVN E on [DATE] while he completed Resident #161's admission to the facility. She stated the hospice company had given Resident #161 the DNR paperwork to fill out. MPOA stated that after the resident completed the form, she (MPOA) and two other family members signed as witnesses on [DATE] and then gave the form to LVN E on [DATE]. MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 3:30 PM LVN C stated that Resident #161's MPOA told her that she had given a copy of the DNR to LVN E on the night before the resident passed away ([DATE]). She stated that there were several family members in the room, including the MPOA, when the resident passed (she could not recall the exact time she was called to the room but stated she had put a note in the resident's chart documenting the time she was notified by the family that Resident #161 had stopped breathing) and after hospice pronounced a time of death the family left the facility. LVN C stated she called 911 at 4:11 PM on [DATE]. She stated she called 911 after about 30 minutes of searching the facility for a copy of Resident #161's DNR after the she had called hospice to notify them that the resident had expired, and the hospice nurse had already pronounced a time of death. She stated that after the hospice nurse pronounced the resident, she (LVN C) realized she had not verified the resident's code status and when she went to check she found there was no DNR on file for the resident. She stated that she should have verified the code status before calling hospice to pronounce. LVN C stated that when the paramedics arrived, the family had already left the facility, so she called the MPOA, who did not answer, so she called another family member to explain that because they did not have a copy of the DNR they had to try to resuscitate and were calling 911. She stated that Hospice RN M was able to get the MPOA on the phone while the paramedics were doing CPR and she (the MPOA) was telling them to stop, and they refused because there was no way to prove she was who she said she was and there was no DNR. LVN C stated that facility policy was if there was no DNR on file you called 911 and started CPR. LVN C stated the resident was on hospice for comfort measures but was listed as a full code was her understanding, but she had been told during shift report with LVN E that Resident #161 was a DNR. She stated that whoever received records for a new resident's admission would be responsible for making sure there was a DNR on file. In an interview on [DATE] at 10:30 AM with Social Worker, he stated that his role in the code status process was to have a Code Status Discussion with the resident or their representative within 48 hours of admission. He stated the discussion was a simple conversation about what the resident would like to have done if their heart stops while they are a resident, basically CPR or no CPR. He stated he did not get the chance to do the Code Status discussion with Resident #161 due to her admission being after business hours on [DATE] and her passing away on a holiday. He stated he had done a Code Status Discussion with her during her previous admission (,d+[DATE]), and she was a full code. He stated that whoever admitted the resident would have been responsible for getting the copy of the DNR from the family if there was one. He stated if he was the one who takes the DNR from the family he immediately scanned it and uploaded it into the resident's EHR. He stated that he did not have a hard copy DNR book, and he was pretty sure the nurses did not have hard copies of the residents' DNRs either. In an interview on [DATE] at 11:27 AM the Administrator confirmed that facility did not keep hard copies of DNRs on hand in the facility. He stated that all DNRs were kept in resident charts in the facility's EHR and code status was flagged for each resident and that the code status was accessible to all staff with EHR access. In an interview on [DATE] at 04:09 PM ADON stated she was working the floor on [DATE]. She stated the DON called her and asked her to go to the other side of the facility to help LVN C with Resident #161, so she grabbed the crash cart (rolling cart containing medication and equipment for emergency resuscitations) and went to the other side of the building and went to the resident's room. She stated that she (ADON) and LVN C had just started CPR as the EMTs arrived and took over. She was unable to give any times for the events of that day. ADON stated that when an admission was done, they (staff completing the admission) were supposed to get their own copies of all paperwork including advanced directives. She stated that Resident #161 was a hospice resident, and she feels like they should have provided the facility with the DNR. She stated that the Admission/Readmission Evaluation in the EHR can be initiated by one nurse and finished/signed by a different nurse depending on what time the resident is admitted because of shift change, then the RN signs off on it and there was no way to tell which nurse completed which section, only who initiated the assessment and who signed it. She stated that even if the admission evaluation and the care plan stated that the resident was a DNR, until the facility had the physical copy of the form the resident was considered a full code. In an interview on [DATE] at 04:50 PM LVN D stated he could not remember if he worked [DATE] through [DATE] without looking at a schedule. He stated he did not remember Resident #161 and denied that he was given a DNR for Resident #161 at any time. In a phone interview on [DATE] at 08:55 AM LVN E stated he did not remember Resident #161. He stated the facility had a high amount resident turnover and if a resident was not long-term it was difficult to remember all the residents. He stated that when he admitted a new resident, he would keep all the admission paperwork at the nurse's desk in a basket for medical records to pick up and scan into the chart. He stated that if he did receive Resident #161's DNR form with her admission paperwork it would have gone into the medical records basket with the other paperwork. He stated that each nurse's station had one of these baskets. He stated that each nurse's station had one of these baskets. LVN E stated all paperwork that the nurses needed scanned into charts went into that basket for medical records. He stated the paperwork in the basket was normally picked up the next day or if it was a weekend, it was picked up Monday morning. He stated that he did not have access to scan documents into resident charts and did not think the other nurses did either. In an interview on [DATE] at 11:31 AM Hospice RN M stated she received the call that Resident #161 had passed away at 3:17 pm on [DATE] and it took her a little while to get to the facility. She stated that when she arrived, she assessed the resident and spoke with the family, and she pronounced the resident's time of death as 3:40 pm. She stated that she explained to the family that she would notify the funeral home and make arrangements for the funeral home to contact the family to set up their next steps and that after the family spent a few minutes with the resident they left the facility. She stated that at some point (she was never told what time the call was placed), either ADON or LVN C notified the DON that they were unable to locate Resident #161's DNR and that the DON told them they had to call 911 and begin CPR because without the DNR in hand Resident #161 was considered a full code. She stated that facility staff began CPR just as EMS arrived and then they (EMS) took over. Hospice RN M stated she explained to the EMTs that the resident was pronounced dead at 3:40 pm and had been down since at least 3:17 pm and asked if they could just call their medical director and have them call a time of death, but they refused because there was no DNR available. She stated that the resident's MPOA told her that she had given the facility the DNR [DATE] and that she (MPOA) had personally handed it to LVN D. She stated that LVN C tore the building apart trying to find the DNR form but was not able to locate it. She stated the facility told the family and hospice that they never received the form. In an interview on [DATE] at 12:48 PM with DON she stated that LVN C should have checked Resident #161's code status before calling hospice because a resident can be on hospice without being a DNR. She stated that on [DATE] the ADON called her to notify her that Resident #161 had passed away and the Hospice RN M had pronounced her as deceased but after looking at the EHR, LVN C was unable to locate her DNR. She stated that she instructed the ADON at that time that without a DNR the resident was a full code and they needed to call 911 and start CPR. DON was unable to give a time for when the phone call took place. She stated that she was not informed of how long Resident #161 had been deceased when she was notified of the situation or she would have told the ADON to keep trying to contact the MPOA to verify the resident did not want CPR but because she did not have all the information, she followed facility protocol for a resident with full code status. She stated there was no in-service done for the staff after the incident because she was not aware that the resident had been deceased for such an extended amount of time before 911 was called and CPR was started and that there was so much confusion regarding her code status. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 5:25 PM LVN F (6a-6p) Stated she has a cheat sheet that she worked off when doing admissions, but she stated that a lot of the admission tasks will queue to be done in the EHR system. She stated that the Social Worker was normally the person responsible for the Code Status Discussion but anyone who did an admission had access to that assessment and was able to complete it. She stated that she believed that the Code Status Discussion flagged in the UDAs (user-defined assessments) for nursing staff a few days after admission if it had not been completed. She also stated that if a resident was admitted with a DNR in hand she would not complete the Code Status Discussion. She stated that if she admitted a resident after hours or on a weekend that expressed interest in becoming a DNR she would bypass the Code Status Discussion and go straight to filling out the DNR form, or if a resident that could not communicate was declining, she would call the family and have the code status discussion with them. She stated she would never wait on the Social Worker to have the code status discussion. In an interview on [DATE] at 6:00 PM RN G (6p-6a) stated there was a list of assessments that had to be completed for an admission. She stated that management would let them know they were going to get an admission so she would have everything she needed to do ready; hospitals should give a report so she should know basic information about the resident before they arrived. RN G stated when a new resident arrived the first thing, she checked was code status because even a DNR outside the facility was considered a full code in the facility until they were assessed by the Social Worker. She stated that if a new resident came in with a DNR form in hand she would honor the DNR and notify the DON and document that she received the DNR even if the code status had not yet been set to reflect it. She stated she have the code status discussion with residents, but she has never done the actual assessment in PCC and was not aware it was there. In a follow-up interview on [DATE] at 8:50 AM LVN C stated that she received report from LVN E on [DATE] at 6:00 AM that Resident #161 had been admitted to the facility to die and was a DNR. She stated that she was working Monday through Thursday only during that time due to her school schedule and another nurse was working only weekends, so [DATE] was the first day she had been responsible for the care of Resident #161. She stated that when the family called her into the room, they told her that Resident #161 had stopped breathing. She stated she assessed the resident for a pulse and breath sounds and after finding none, she told the family that she would notify hospice then left the family to be with the resident. She stated that she called to notify hospice that the resident had expired. She stated that the family left almost immediately after Hospice RN M arrived and pronounced the time of death at 3:40 pm. She stated that she was uncertain who realized that the resident did not have a DNR on file and was listed as a full code. She stated that the ADON, who was working the opposite hall, called the DON and notified her that the Resident #161 did not have a DNR on file and was listed as a Full Code, but had been pronounced dead at 3:40 pm by Hospice RN M. At approximately 4:10 pm the ADON came to her nurse's station and notified her that the DON had said that because there was no DNR on file and Resident #161's code status was listed as Full Code, they had to start CPR and call 911. LVN C stated that at approximately 4:15 pm they began CPR with the ADON doing chest compressions and her (LVN C) ventilating Resident #161 with a bag valve mask until EMS arrived and took over. She acknowledged that with the time stamp from her progress note documenting the time the resident's family notified her that Resident #161 had stopped breathing, no less than 63 minutes had passed before CPR was initiated. In a phone interview on [DATE] at 10:07 AM Medical Director stated that the facility does address code status on admission. She stated that if the resident was a full code, the facility was very quick to react to the situation. Medical Director stated that in a code situation the staff did compressions and ventilation until EMS arrived and took over resuscitation efforts. She stated that if the resident is a DNR the facility was to honor that and if the resident wished to become a DNR the Social Worker was to assist them in completing the paperwork. She stated that any licensed staff would be able to have the code status discussion with a resident or their representative and if there was an admission on a weekend or holiday the discussion still needed to happen, and it should never be put on hold until the Social Worker came back to work. Medical Director stated that she had not been made aware of the situation regarding Resident #161 and stated that the fact the resident had an MPOA would negate the need for a DNR. She stated that the DON should have instructed the facility nurses to contact the MPOA and get permission to not do CPR after staff realized the DNR was not in the facility rather than instructing them to call 911 and begin CPR. She stated that this was poor advise on the part of the DON. She stated that there was a clear lack of judgement on everyone's part. In an interview on [DATE] at 1:15 PM Regional Director of Clinical Services stated the facility did not have a CPR policy. She stated the staff that were CPR certified rely on their training to know when to perform CPR. She stated she was the instructor for staff at the facility and they know when to do CPR. Review of blank, undated facility form titled Admission Checklist - Morning Clinical Meeting form revealed: Review New Admissions - 'EHR' and other relevant sources - Grey shaded areas with asterisk should be completed within 24 hours, and other items on checklist should be completed within 3 days of admission. Gray shaded areas with asterisk: Vitals, Height, & Weight; Admission Assessment - Schedule Initiated & UDAs Complete; Admission Nurse Narrative Note Completed; Physician Orders Including Diet; Medication Review & Reconciliation; Photograph; Code Status/OOH DNR; Admission MDS Opened by Admission Nurse; Section GG Nursing Documentation Initiated; Physician Certification Initiated Review of undated facility policy titled DNR Policy revealed, in part: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has TWO valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and it has to be honored as long as it is executed properly with the resident's signature, date, and witnesses. A resident with a properly executed DNR should not be considered a FULL CODE while waiting for the physician to acknowledge the DNR. The following steps will be followed to reflect the resident's Do Not Resuscitate status accurately in 'EHR'. 1. Upon admission of a new resident, the charge nurse will determine the resident's code status. If the resident opts to complete an OOH-DNR, you will do the following: A. Review and complete an OOH-DNR with the resident/MPOA/Legal Guardian or next of kin and obtain witnesses or notary signatures on the form. This conversation is documented in the Code Status Discussion UDA. B. Request nursing change resident's code status to Do Not Resuscitate in 'EHR'. C. Scan OOH-DNR form and email to the resident's facility physician for signature. It is recommended to highlight all the places where the physician is to sign/date/license on the document. D. Upon receipt of the signed OOH-DNR, scan and upload to MISC. tab in 'EHR' under 'Advanced Directives'. 2. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with their wishes. Review of undated facility policy titled Full Code Status revealed: The following steps will be followed to reflect the resident's Full Code status accurately in 'EHR'. 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses Full Code, the nurse enters a 'Full Code' order into 'EHR'. 2. During 48-hour care plan meeting, social worker or designee will review code status with resident and/or RP. This discussion is documented in the Code Status Discussion UDA. 3. Any Advanced Directives such as Medical Power of Attorney or other documents are uploaded to 'EHR' under the Miscellaneous tab under 'Advanced Directives. 4. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with what he/she wants. An IJ was identified due to the above failures on [DATE] at 3:59 pm, and the IJ Template was provided to the Administrator. The Plan of Removal was accepted [DATE] at 3:05 pm and included: F600: - Facility failed to ensure a resident was free from neglect by failing to follow the resident's advanced directive. - CPR was not initiated for approximately 63 minutes after staff was notified by family that Resident #161 had stopped breathing. - Resident #161 did not

Based on interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. These failures resulted in Hospice RN M pronouncing the resident deceased at 3:40 pm and LVN C calling 911 and initiating CPR on [DATE] at approximately 4:15 pm (approximately 63 minutes after LVN C was notified she had stopped breathing) due to being unable to locate Resident #161's DNR form. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] at 3:05 pm and the immediacy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place the residents at risk of not having their wishes known, respected, and implemented in an emergency and could place residents who are a full code-status (all resuscitative measures to be taken to keep a person alive) at risk of death. The findings included: Review of Resident #161's Admission Record revealed she was an [AGE] year-old female originally admitted to the facility [DATE] with a most recent admitted [DATE]. She had admission diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), moderate malnutrition, breast cancer, chronic pain, and atrial fibrillation (abnormal heart rhythm). Her code status was listed as Full Code. Review of Resident #161's MDS list revealed that at the time of her [DATE] admission, no comprehensive MDS assessment had been initiated. Review of Resident #161's Hospice Clinical Chart revealed that during her intake interview and assessment on [DATE] at 3:52 pm, the resident was a full code but requested DNR paperwork (there was no DNR form located in the resident's EHR during record review) be given to her and her family to fill out. Review of Resident #161's Hospice admission orders dated [DATE] revealed no mention of code status. Review of Resident #161's Admission Assessment/Baseline Care Plan Summary, initiated [DATE] by LVN E and signed [DATE] by LVN C and DON, revealed in Section O Code Status that she was a DNR. Review of Resident #161's Physician's Progress Notes revealed no mention of code status in the admission note. Review of Resident #161's care plan dated [DATE] revealed Problem: I have chosen DO NOT RESUSCITATE status. Review of Resident #161's Order Listing Report revealed no order for code status. Review of facility's handwritten 24-hour report log for dates [DATE] and [DATE] revealed Resident #161 was reported as being a DNR. The 24-hour report log sheet dated [DATE] stated Resident #161 re-admit, COPD, moderate protein-calorie malnutrition, hospice. The facility was unable to provide the 24-hour report log for [DATE]. Review of Resident #161's Progress Notes revealed the following: Nurse's Note by LVN C on [DATE] at 3:12 pm Called to room by family. Resident without respirations or heartbeat. Family remains at bedside. Call placed to hospice requesting on call nurse be notified. Nurse's Note by LVN C on [DATE] at 3:18 pm Chaplain here to see resident and family. Nurse's Note by LVN C on [DATE] at 3:49 pm Hospice RN M with hospice here. Nurse's Note by LVN C on [DATE] at 3:59 pm Hospice nurse notified funeral home of need to pick resident up. There were no further notes found in Resident #161's chart. Review of Resident #161's Hospice Client Coordination Note Report revealed the following: Triage Note dated [DATE]: LVN C called triage nurse [DATE] at 3:17 pm to report Resident #161 had expired with family present. Hospice RN M was notified at 3:22 pm and was en route to the facility. Narrative Note dated [DATE] by Hospice RN M: Patient resting in bed with no breaths noted. HSN auscultated (listened with a stethoscope) for over one minute apical (over the heart). No pulse noted. TOD 1540 (3:40 pm). Funeral Home called 1600 (4:00 pm). CPR started at 1620 (4:20 PM) by paramedics due to facility not able to produce DNR in hand. MPOA called. She wants CPR stopped but per paramedic they cannot stop CPR over the phone with MPOA. Facility staff searching for DNR called maintenance to open the office to find the paper copy. Paramedics continue CPR until 1647 (4:47 pm). HSN filled out paperwork for mortician and facility. Body released to funeral home at 1705 (5:05 pm). Review of Resident #161's EMS Patient Care Record dated [DATE] revealed the following: Incident Narrative: Upon arrival the patient presented in the supine (on back) position in bed. NH staff were ventilating the patient with a BVM. NH staff initially informed EMS that patient stopped breathing at approximately 16:00 (4:00pm) today. EMS palpated (felt with fingers) the patient for a pulse, and none were noted. EMS moved the patient to the floor without incident using a patient carry. EMS began manual compressions and ventilating the patient. A NH employee entered the room and informed EMS that the patient has a DNR, but they are unable to locate it. EMS informed the employee that we must see a valid, physical copy of the DNR in order to cease resuscitative efforts. The NH employee never returned with a physical DNR. EMS attached multi pads (adhesive pads to detect heart rhythm) and the patient's rhythm was asystole (no detectable heartbeat) and remained asystole for the duration of the incident. IO access (technique in which the bone marrow cavity is used as a non-collapsible vascular entry point for delivering fluid or blood products) was gained, and EMS began administering LR (IV fluid). EMS inserted [NAME] (artificial airway used to help ventilate the patient) and attached the ETCO2 monitor and accuvent (attachment to monitor flow of air while ventilating patient). EMS proceeded to follow asystole protocol with pulse checks every 2 minutes and administering epinephrine every ,d+[DATE] minutes. EMS administered D10 (IV fluid). EMS obtained a 4-lead EKG. Approximately 15 minutes into the call a NH employee entered the room and informed EMS that the patient had stopped breathing at approximately 15:17 (3:17 pm) today. After approximately 25 minutes of CPR, EMS contacted medical control and informed physician on call of the details and interventions performed and the physician directed EMS to cease resuscitative efforts and called the time of death at 16:47 (4:47 pm) on [DATE]. EMS acquired a signature from the NH staff. EMS cleared the scene and returned to service. In a phone interview on [DATE] at 2:53 PM with the Hospice Administrator she stated that the hospice company never received a copy of Resident #161's DNR from the family as they were told that the family was going to be providing a copy to the nursing home to keep on file. She stated that the hospice company was told that the family had given a copy of the DNR to facility LVN D on Friday [DATE] when the resident was admitted to the facility and that LVN D either had or was going to enter it into the computer system. She stated that the resident had been living in an assisted living facility but was hospitalized and had a significant decline after being discharged from the hospital and the family opted for her to be placed on hospice services and be admitted to the nursing facility. She stated that when all the hospice paperwork was signed by the family, the family kept the DNR paperwork and assured the hospice employee that they would give the nursing home a copy. She stated that the hospice company offered the family a counseling session with their Social Worker to discuss the DNR paperwork and their options, but the family declined because there was already a DNR in place. The Hospice Administrator stated that on [DATE] a facility nurse called the hospice to notify the Hospice RN M that the resident had passed away. She stated that, according to the call log notes, LVN C notified the hospice company on [DATE] at 3:17 pm that Resident #161 had passed away and was requesting a hospice nurse be sent to the facility. She stated that according to Hospice RN M's notes and discussions she had after the incident with Hospice RN M, Hospice RN M arrived at the facility at approximately 3:35 pm and pronounced a time of death for Resident #161 at 3:40 PM. She stated that after Resident #161 had been pronounced deceased , LVN C tried to find the DNR form and when LVN C could not locate the DNR, instructed someone in the facility to call 911 and they (facility staff) began chest compressions. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated she did not have a copy of the resident's DNR because the copy she gave the LVN E was the original document with a carbon copy attached. She stated that a hospice agent had taken a picture of the DNR with a cell phone for hospice records (surveyor was not able to verify this with any hospice employee). She stated that she gave the DNR to LVN E on [DATE] while he completed Resident #161's admission to the facility. She stated the hospice company had given Resident #161 the DNR paperwork to fill out. MPOA stated that after the resident completed the form, she (MPOA) and two other family members signed as witnesses on [DATE] and then gave the form to LVN E on [DATE]. MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 3:30 PM LVN C stated that Resident #161's MPOA told her that she had given a copy of the DNR to LVN E on the night before the resident passed away ([DATE]). She stated that there were several family members in the room, including the MPOA, when the resident passed (she could not recall the exact time she was called to the room but stated she had put a note in the resident's chart documenting the time she was notified by the family that Resident #161 had stopped breathing) and after hospice pronounced a time of death the family left the facility. LVN C stated she called 911 at 4:11 PM on [DATE]. She stated she called 911 after about 30 minutes of searching the facility for a copy of Resident #161's DNR after the she had called hospice to notify them that the resident had expired, and the hospice nurse had already pronounced a time of death. She stated that after the hospice nurse pronounced the resident, she (LVN C) realized she had not verified the resident's code status and when she went to check she found there was no DNR on file for the resident. She stated that she should have verified the code status before calling hospice to pronounce. LVN C stated that when the paramedics arrived, the family had already left the facility, so she called the MPOA, who did not answer, so she called another family member to explain that because they did not have a copy of the DNR they had to try to resuscitate and were calling 911. She stated that Hospice RN M was able to get the MPOA on the phone while the paramedics were doing CPR and she (the MPOA) was telling them to stop, and they refused because there was no way to prove she was who she said she was and there was no DNR. LVN C stated that facility policy was if there was no DNR on file you called 911 and started CPR. LVN C stated the resident was on hospice for comfort measures but was listed as a full code was her understanding, but she had been told during shift report with LVN E that Resident #161 was a DNR. She stated that whoever received records for a new resident's admission would be responsible for making sure there was a DNR on file. In an interview on [DATE] at 10:30 AM with Social Worker, he stated that his role in the code status process was to have a Code Status Discussion with the resident or their representative within 48 hours of admission. He stated the discussion was a simple conversation about what the resident would like to have done if their heart stops while they are a resident, basically CPR or no CPR. He stated he did not get the chance to do the Code Status discussion with Resident #161 due to her admission being after business hours on [DATE] and her passing away on a holiday. He stated he had done a Code Status Discussion with her during her previous admission (,d+[DATE]), and she was a full code. He stated that whoever admitted the resident would have been responsible for getting the copy of the DNR from the family if there was one. He stated if he was the one who takes the DNR from the family he immediately scanned it and uploaded it into the resident's EHR. He stated that he did not have a hard copy DNR book, and he was pretty sure the nurses did not have hard copies of the residents' DNRs either. In an interview on [DATE] at 11:27 AM the Administrator confirmed that facility did not keep hard copies of DNRs on hand in the facility. He stated that all DNRs were kept in resident charts in the facility's EHR and code status was flagged for each resident and that the code status was accessible to all staff with EHR access. In an interview on [DATE] at 04:09 PM ADON stated she was working the floor on [DATE]. She stated the DON called her and asked her to go to the other side of the facility to help LVN C with Resident #161, so she grabbed the crash cart (rolling cart containing medication and equipment for emergency resuscitations) and went to the other side of the building and went to the resident's room. She stated that she (ADON) and LVN C had just started CPR as the EMTs arrived and took over. She was unable to give any times for the events of that day. ADON stated that when an admission was done, they (staff completing the admission) were supposed to get their own copies of all paperwork including advanced directives. She stated that Resident #161 was a hospice resident, and she feels like they should have provided the facility with the DNR. She stated that the Admission/Readmission Evaluation in the EHR can be initiated by one nurse and finished/signed by a different nurse depending on what time the resident is admitted because of shift change, then the RN signs off on it and there was no way to tell which nurse completed which section, only who initiated the assessment and who signed it. She stated that even if the admission evaluation and the care plan stated that the resident was a DNR, until the facility had the physical copy of the form the resident was considered a full code. In an interview on [DATE] at 04:50 PM LVN D stated he could not remember if he worked [DATE] through [DATE] without looking at a schedule. He stated he did not remember Resident #161 and denied that he was given a DNR for Resident #161 at any time. In a phone interview on [DATE] at 08:55 AM LVN E stated he did not remember Resident #161. He stated the facility had a high amount resident turnover and if a resident was not long-term it was difficult to remember all the residents. He stated that when he admitted a new resident, he would keep all the admission paperwork at the nurse's desk in a basket for medical records to pick up and scan into the chart. He stated that if he did receive Resident #161's DNR form with her admission paperwork it would have gone into the medical records basket with the other paperwork. He stated that each nurse's station had one of these baskets. He stated that each nurse's station had one of these baskets. LVN E stated all paperwork that the nurses needed scanned into charts went into that basket for medical records. He stated the paperwork in the basket was normally picked up the next day or if it was a weekend, it was picked up Monday morning. He stated that he did not have access to scan documents into resident charts and did not think the other nurses did either. In an interview on [DATE] at 11:31 AM Hospice RN M stated she received the call that Resident #161 had passed away at 3:17 pm on [DATE] and it took her a little while to get to the facility. She stated that when she arrived, she assessed the resident and spoke with the family, and she pronounced the resident's time of death as 3:40 pm. She stated that she explained to the family that she would notify the funeral home and make arrangements for the funeral home to contact the family to set up their next steps and that after the family spent a few minutes with the resident they left the facility. She stated that at some point (she was never told what time the call was placed), either ADON or LVN C notified the DON that they were unable to locate Resident #161's DNR and that the DON told them they had to call 911 and begin CPR because without the DNR in hand Resident #161 was considered a full code. She stated that facility staff began CPR just as EMS arrived and then they (EMS) took over. Hospice RN M stated she explained to the EMTs that the resident was pronounced dead at 3:40 pm and had been down since at least 3:17 pm and asked if they could just call their medical director and have them call a time of death, but they refused because there was no DNR available. She stated that the resident's MPOA told her that she had given the facility the DNR [DATE] and that she (MPOA) had personally handed it to LVN D. She stated that LVN C tore the building apart trying to find the DNR form but was not able to locate it. She stated the facility told the family and hospice that they never received the form. In an interview on [DATE] at 12:48 PM with DON she stated that LVN C should have checked Resident #161's code status before calling hospice because a resident can be on hospice without being a DNR. She stated that on [DATE] the ADON called her to notify her that Resident #161 had passed away and the Hospice RN M had pronounced her as deceased but after looking at the EHR, LVN C was unable to locate her DNR. She stated that she instructed the ADON at that time that without a DNR the resident was a full code and they needed to call 911 and start CPR. DON was unable to give a time for when the phone call took place. She stated that she was not informed of how long Resident #161 had been deceased when she was notified of the situation or she would have told the ADON to keep trying to contact the MPOA to verify the resident did not want CPR but because she did not have all the information, she followed facility protocol for a resident with full code status. She stated there was no in-service done for the staff after the incident because she was not aware that the resident had been deceased for such an extended amount of time before 911 was called and CPR was started and that there was so much confusion regarding her code status. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 5:25 PM LVN F (6a-6p) Stated she has a cheat sheet that she worked off when doing admissions, but she stated that a lot of the admission tasks will queue to be done in the EHR system. She stated that the Social Worker was normally the person responsible for the Code Status Discussion but anyone who did an admission had access to that assessment and was able to complete it. She stated that she believed that the Code Status Discussion flagged in the UDAs (user-defined assessments) for nursing staff a few days after admission if it had not been completed. She also stated that if a resident was admitted with a DNR in hand she would not complete the Code Status Discussion. She stated that if she admitted a resident after hours or on a weekend that expressed interest in becoming a DNR she would bypass the Code Status Discussion and go straight to filling out the DNR form, or if a resident that could not communicate was declining, she would call the family and have the code status discussion with them. She stated she would never wait on the Social Worker to have the code status discussion. In an interview on [DATE] at 6:00 PM RN G (6p-6a) stated there was a list of assessments that had to be completed for an admission. She stated that management would let them know they were going to get an admission so she would have everything she needed to do ready; hospitals should give a report so she should know basic information about the resident before they arrived. RN G stated when a new resident arrived the first thing, she checked was code status because even a DNR outside the facility was considered a full code in the facility until they were assessed by the Social Worker. She stated that if a new resident came in with a DNR form in hand she would honor the DNR and notify the DON and document that she received the DNR even if the code status had not yet been set to reflect it. She stated she have the code status discussion with residents, but she has never done the actual assessment in PCC and was not aware it was there. In a follow-up interview on [DATE] at 8:50 AM LVN C stated that she received report from LVN E on [DATE] at 6:00 AM that Resident #161 had been admitted to the facility to die and was a DNR. She stated that she was working Monday through Thursday only during that time due to her school schedule and another nurse was working only weekends, so [DATE] was the first day she had been responsible for the care of Resident #161. She stated that when the family called her into the room, they told her that Resident #161 had stopped breathing. She stated she assessed the resident for a pulse and breath sounds and after finding none, she told the family that she would notify hospice then left the family to be with the resident. She stated that she called to notify hospice that the resident had expired. She stated that the family left almost immediately after Hospice RN M arrived and pronounced the time of death at 3:40 pm. She stated that she was uncertain who realized that the resident did not have a DNR on file and was listed as a full code. She stated that the ADON, who was working the opposite hall, called the DON and notified her that the Resident #161 did not have a DNR on file and was listed as a Full Code, but had been pronounced dead at 3:40 pm by Hospice RN M. At approximately 4:10 pm the ADON came to her nurse's station and notified her that the DON had said that because there was no DNR on file and Resident #161's code status was listed as Full Code, they had to start CPR and call 911. LVN C stated that at approximately 4:15 pm they began CPR with the ADON doing chest compressions and her (LVN C) ventilating Resident #161 with a bag valve mask until EMS arrived and took over. She acknowledged that with the time stamp from her progress note documenting the time the resident's family notified her that Resident #161 had stopped breathing, no less than 63 minutes had passed before CPR was initiated. In a phone interview on [DATE] at 10:07 AM Medical Director stated that the facility does address code status on admission. She stated that if the resident was a full code, the facility was very quick to react to the situation. Medical Director stated that in a code situation the staff did compressions and ventilation until EMS arrived and took over resuscitation efforts. She stated that if the resident is a DNR the facility was to honor that and if the resident wished to become a DNR the Social Worker was to assist them in completing the paperwork. She stated that any licensed staff would be able to have the code status discussion with a resident or their representative and if there was an admission on a weekend or holiday the discussion still needed to happen, and it should never be put on hold until the Social Worker came back to work. Medical Director stated that she had not been made aware of the situation regarding Resident #161 and stated that the fact the resident had an MPOA would negate the need for a DNR. She stated that the DON should have instructed the facility nurses to contact the MPOA and get permission to not do CPR after staff realized the DNR was not in the facility rather than instructing them to call 911 and begin CPR. She stated that this was poor advise on the part of the DON. She stated that there was a clear lack of judgement on everyone's part. In an interview on [DATE] at 1:15 PM Regional Director of Clinical Services stated the facility did not have a CPR policy. She stated the staff that were CPR certified rely on their training to know when to perform CPR. She stated she was the instructor for staff at the facility and they know when to do CPR. Review of blank, undated facility form titled Admission Checklist - Morning Clinical Meeting form revealed: Review New Admissions - 'EHR' and other relevant sources - Grey shaded areas with asterisk should be completed within 24 hours, and other items on checklist should be completed within 3 days of admission. Gray shaded areas with asterisk: Vitals, Height, & Weight; Admission Assessment - Schedule Initiated & UDAs Complete; Admission Nurse Narrative Note Completed; Physician Orders Including Diet; Medication Review & Reconciliation; Photograph; Code Status/OOH DNR; Admission MDS Opened by Admission Nurse; Section GG Nursing Documentation Initiated; Physician Certification Initiated Review of facility policy titled Abuse, Negelct, Exploitation and Misappropriation Prevention Program revised [DATE], revealed, in part: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: Develop and implement policies and protocols to prevent and identify: neglect of residents. Review of undated facility policy titled DNR Policy revealed, in part: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has TWO valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and it has to be honored as long as it is executed properly with the resident's signature, date, and witnesses. A resident with a properly executed DNR should not be considered a FULL CODE while waiting for the physician to acknowledge the DNR. The following steps will be followed to reflect the resident's Do Not Resuscitate status accurately in 'EHR'. 1. Upon admission of a new resident, the charge nurse will determine the resident's code status. If the resident opts to complete an OOH-DNR, you will do the following: A. Review and complete an OOH-DNR with the resident/MPOA/Legal Guardian or next of kin and obtain witnesses or notary signatures on the form. This conversation is documented in the Code Status Discussion UDA. B. Request nursing change resident's code status to Do Not Resuscitate in 'EHR'. C. Scan OOH-DNR form and email to the resident's facility physician for signature. It is recommended to highlight all the places where the physician is to sign/date/license on the document. D. Upon receipt of the signed OOH-DNR, scan and upload to MISC. tab in 'EHR' under 'Advanced Directives'. 2. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with their wishes. Review of undated facility policy titled Full Code Status revealed: The following steps will be followed to reflect the resident's Full Code status accurately in 'EHR'. 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses Full Code, the nurse enters a 'Full Code' order into 'EHR'. 2. During 48-hour care plan meeting, social worker or designee will review code status with resident and/or RP. This discussion is documented in the Code Status Discussion UDA. 3. Any Advanced Directives such as Medical Power of Attorney or other documents are uploaded to 'EHR' under the Miscellaneous tab under 'Advanced Directives. 4. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with what he/she wants. An IJ was identified due to the above failures on [DATE] at 3:59 pm, and the IJ Template was provided to the Administrator. The Plan of Removal was accepted [DATE] at 3:05 pm and included: F600: - Facility failed to ensure a resident was free from neglect by failing to follow the resident's advanced directive. - CPR was not initiated for approximately 63 minutes after staff was notified by family that Resident #161 had stopped breathing. - Resident #16[TRUNCATED]

Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 6 residents (Resident #161) whose records were reviewed for Full code status. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] at 3:05 pm and the immediacy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed the residents at risk of not having their wishes known, respected, and implemented in an emergency. The findings included: Review of Resident #161's admission Record revealed she was an [AGE] year-old female originally admitted to the facility [DATE] with a most recent admission date of [DATE]. She had admission diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), moderate malnutrition, breast cancer, chronic pain, and atrial fibrillation (abnormal heart rhythm). Her code status was listed as Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive). Review of Resident #161's MDS list revealed that at the time of her [DATE] admission, no comprehensive MDS assessment had been initiated. Review of Resident #161's Hospice Clinical Chart revealed that during her intake interview and assessment on [DATE] at 3:52 pm, the resident was a full code but requested DNR paperwork (there was no DNR form located in the resident's EHR during record review) be given to her and her family to fill out. Review of Resident #161's Hospice admission orders dated [DATE] revealed no mention of code status. Review of Resident #161's admission Assessment/Baseline Care Plan Summary, initiated [DATE] and signed [DATE], revealed in Section O Code Status that she was a DNR. Review of Resident #161's Physician's Progress Notes revealed no mention of code status in the admission note. Review of Resident #161's care plan dated [DATE] revealed Problem: I have chosen DO NOT RESUSCITATE status. Review of Resident #161's Order Listing Report revealed no order for code status. Review of facility's handwritten 24-hour report log for dates [DATE] and [DATE] revealed Resident #161 was reported as being a DNR. The 24-hour report log sheet dated [DATE] stated Resident #161 re-admit, COPD, moderate protein-calorie malnutrition, hospice. The facility was unable to provide the 24-hour report log for [DATE]. In a phone interview on [DATE] at 2:53 PM with the Hospice Administrator she stated that the hospice company never received a copy of Resident #161's DNR from the family as they were told that the family was going to be providing a copy to the nursing home to keep on file. She stated that the hospice company was told that the family had given a copy of the DNR to facility LVN D on Friday [DATE] when the resident was admitted to the facility and that LVN D either had or was going to enter it into the computer system. She stated that the resident had been living in an assisted living facility but was hospitalized and had a significant decline after being discharged from the hospital and the family opted for her to be placed on hospice services and be admitted to the nursing facility. She stated that when all the hospice paperwork was signed by the family, the family kept the DNR paperwork and assured the hospice employee that they would give the nursing home a copy. She stated that the hospice company offered the family a counseling session with their Social Worker to discuss the DNR paperwork and their options, but the family declined because there was already a DNR in place. The Hospice Administrator stated that on [DATE] a facility nurse called the hospice to notify the Hospice RN M that the resident had passed away. She stated that, according to the notes and discussions she had after the incident with Hospice RN M, Hospice RN M arrived at the facility and pronounced a time of death for Resident #161 at on [DATE] at 3:40 PM. She stated that the facility nurse could not locate the DNR and instructed someone to call 911 and they (facility staff) began chest compressions. In an interview on [DATE] at 3:30 PM with LVN C she stated she called 911 at 4:11 PM on [DATE]. She stated she called 911 after about 30 minutes of searching the facility for a copy of Resident #161's DNR after the she had called hospice to notify them that the resident had expired, and the hospice nurse had already pronounced a time of death. She stated that after the hospice nurse pronounced the resident, she (LVN C) realized she had not verified the resident's code status and when she went to check she found there was no DNR on file for the resident. She stated that she should have verified the code status before calling hospice to pronounce. LVN C stated the resident was on hospice for comfort measures but was listed as a full code was her understanding. LVN C stated that Resident #161's MPOA told her that she had given a copy of the DNR to LVN E on the night before the resident passed away ([DATE]). She stated that there were several family members in the room, including the MPOA, when the resident passed and after hospice pronounced a time of death the family left the facility. She stated that whoever received records for the resident's admission would be responsible for making sure there was a DNR on file. In an interview on [DATE] at 10:30 AM with Social Worker, he stated that his role in the code status process was to have a Code Status Discussion with the resident or their representative within 48 hours of admission. He stated the discussion was a simple conversation about what the resident would like to have done if their heart stops while they are a resident, basically CPR or no CPR. He stated he did not get the chance to do the Code Status discussion with Resident #161 due to her admission being after business hours on [DATE] and her passing away on a holiday. He stated he had done a Code Status Discussion with her during her previous admission (7/2023), and she was a full code. He stated that whoever admitted the resident would have been responsible for getting the copy of the DNR from the family if there was one. He stated if he was the one who takes the DNR from the family he immediately scanned it and uploaded it into the resident's EHR. He stated that he did not have a hard copy DNR book, and he was pretty sure the nurses did not have hard copies of the residents' DNRs either. In an interview on [DATE] at 11:27 AM the Administrator confirmed that facility did not keep hard copies of DNRs on hand in the facility. He stated that all DNRs were kept in resident charts in the facility's EHR and code status was flagged for each resident and that the code status was accessible to all staff with EHR access. In an interview on [DATE] at 04:09 PM ADON stated that when an admission was done, they (staff completing the admission) were supposed to get their own copies of all paperwork including advanced directives. She stated that Resident #161 was a hospice resident, and she feels like they should have provided the facility with the DNR. She stated that the Admission/readmission Evaluation in the EHR can be initiated by one nurse and finished/signed by a different nurse depending on what time the resident is admitted because of shift change, then the RN signs off on it and there is no way to tell which nurse completed which section. She stated that even if the admission evaluation and the care plan stated that the resident was a DNR, until the facility had the physical copy of the form the resident was considered a full code. In an interview on [DATE] at 04:50 PM LVN D stated he could not remember if he worked [DATE] through [DATE] without looking at a schedule. He stated he did not remember Resident #161 and denied that he was given a DNR for Resident #161 at any time. In a phone interview on [DATE] at 08:55 AM LVN E stated he did not remember Resident #161. He stated the facility had a high amount of resident turnover and if a resident was not long-term it was difficult to remember all the residents. He stated that when he admitted a new resident, he would keep all the admission paperwork at the nurse's desk in a basket for medical records to pick up and scan into the chart. He stated that if he did receive Resident #161's DNR form with her admission paperwork it would have gone into the medical records basket with the other paperwork. He stated that each nurse's station had one of these baskets. LVN E stated all paperwork that the nurses needed scanned into charts went into that basket for medical records. He stated the paperwork in the basket was normally picked up the next day or if it was a weekend, it was picked up Monday morning. He stated that he did not have access to scan documents into resident charts and did not think the other nurses did either. In an interview on [DATE] at 11:31 AM Hospice RN M stated she received the call that Resident #161 had passed away at 3:17 pm on [DATE] and it took her a little while to get to the facility. She stated that when she arrived, she assessed the resident and spoke with the family, and she pronounced the resident's time of death as 3:40 pm. She stated that she explained to the family that she would notify the funeral home and make arrangements for the funeral home to contact the family to set up their next steps and that after the family spent a few minutes with the resident they left the facility. She stated that at some point (she was never told what time the call was placed), either ADON or LVN C notified the DON that they were unable to locate Resident #161's DNR and that the DON told them they had to call 911 and begin CPR because without the DNR in hand Resident #161 was considered a full code. She stated that facility staff began CPR just as EMS arrived and then they (EMS) took over. Hospice RN M stated she explained to the EMTs that the resident was pronounced dead at 3:40 pm and had been down since at least 3:17 pm and asked if they could just call their medical director and have them call a time of death, but they refused because there was no DNR available. She stated that the resident's MPOA told her that she had given the facility the DNR [DATE] and that she (MPOA) had personally handed it to LVN D. She stated that LVN C tore the building apart trying to find the DNR form but was not able to locate it. She stated the facility told the family and hospice that they never received the form. In an interview on [DATE] at 12:48 PM with DON she stated that DNRs were scanned into the charts and nurses, management (DON, ADON, Administrator, Social Worker, MDS) had access to the form once it was scanned in. She stated that CNAs had the code status listed on their Kardex (resident information sheet for non-nurses) but did not have access to the DNR form itself. She stated anyone with EHR access could see a resident's code status but not the DNR form. She stated Resident #161 had been a resident in the facility before and had always been a full code in the past, so she stated that the understanding that she was a DNR on her last admission was strange to her. DON confirmed that there were no hard copies of DNR forms kept in the facility. She stated that any prudent nurse would check for a DNR before taking any action in a code situation. She feels that the facility did everything they were supposed to do regarding Resident #161's admission. She stated she was admitted after business hours so the Social Worker who normally asked the advanced directive questions was not here to do it. She stated that the hospice administrator told her (DON) that there was a copy of the MPOA form so she believed maybe the family thought that was the DNR. DON stated there was no in-service done for the staff after the incident because she was not aware that the resident had been deceased for that amount of time before 911 was called and CPR was started and that there was so much confusion regarding her code status. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated she did not have a copy of the resident's DNR because the copy she gave the LVN E was the original document with a carbon copy attached. She stated that a hospice agent had taken a picture of the DNR with a cell phone for hospice records (surveyor was not able to verify this with any hospice employee). She stated that she gave the DNR to LVN E on [DATE] while he completed Resident #161's admission to the facility. She stated the hospice company had given Resident #161 the DNR paperwork to fill out. MPOA stated that after the resident completed the form, she (MPOA) and two other family members signed as witnesses on [DATE] and then gave the form to LVN E on [DATE]. MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 5:25 PM LVN F (6a-6p) Stated she has a cheat sheet that she worked off when doing admissions, but she stated that a lot of the admission tasks will queue to be done in the EHR system. She stated that the Social Worker was normally the person responsible for the Code Status Discussion but anyone who did an admission had access to that assessment and was able to complete it. She stated that she believed that the Code Status Discussion flagged in the UDAs (user-defined assessments) for nursing staff a few days after admission if it had not been completed. She also stated that if a resident was admitted with a DNR in hand she would not complete the Code Status Discussion. She stated that if she admitted a resident after hours or on a weekend that expressed interest in becoming a DNR she would bypass the Code Status Discussion and go straight to filling out the DNR form, or if a resident that could not communicate was declining, she would call the family and have the code status discussion with them. She stated she would never wait on the Social Worker to have the code status discussion. In an interview on [DATE] at 6:00 PM RN G (6p-6a) stated there was a list of assessments that had to be completed for an admission. She stated that management would let them know they were going to get an admission so she would have everything she needed to do ready; hospitals should give a report so she should know basic information about the resident before they arrived. RN G stated when a new resident arrived the first thing, she checked was code status because even a DNR outside the facility was considered a full code in the facility until they were assessed by the Social Worker. She stated that if a new resident came in with a DNR form in hand she would honor the DNR and notify the DON and document that she received the DNR even if the code status had not yet been set to reflect it. She stated she have the code status discussion with residents, but she has never done the actual assessment in PCC and was not aware it was there. In a follow-up interview on [DATE] at 8:50 AM LVN C stated that she received report from LVN E on [DATE] at 6:00 AM that Resident #161 had been admitted to the facility to die and was a DNR. She stated that she was working Monday through Thursday only during that time due to her school schedule and another nurse was working only weekends, so [DATE] was the first day she had been responsible for the care of Resident #161. She stated that when the family called her into the room, they told her that Resident #161 had stopped breathing. She stated she assessed the resident for a pulse and breath sounds and after finding none, she told the family that she would notify hospice then left the family to be with the resident. She stated that she called to notify hospice that the resident had expired. She stated that the family left almost immediately after Hospice RN M arrived and pronounced the time of death at 3:40 pm. She stated that she was uncertain who realized that the resident did not have a DNR on file and was listed as a full code. She stated that the ADON, who was working the opposite hall, called the DON and notified her that the Resident #161 did not have a DNR on file and was listed as a Full Code, but had been pronounced dead at 3:40 pm by Hospice RN M. At approximately 4:10 pm the ADON came to her nurse's station and notified her that the DON had said that because there was no DNR on file they had to start CPR and call 911. LVN C stated that in the nine hours she was responsible for Resident #161 the family never said anything to her specifically about the resident being a DNR. She did recall the family asking questions about how long it would take for the resident to pass and what to expect and requested that she call the hospice chaplain to come visit with them. She stated that in her opinion the family was aware the resident's death was imminent and their priority was making sure she was comfortable and not suffering in her last hours. She stated she was not aware that she could complete the Code Status Discussion Assessment with new admissions. She stated that she has initiated the DNR form with residents before but was not aware that the form would be honored before the physician had signed it. She stated that she does not have access to scan documents into the resident EHRs so even if she was given a DNR or other form by a resident/family on admission it would have to wait until management or medical records staff was available to upload the document. She stated that when she was looking for Resident #161's DNR form she was unable to find paper copies of any of her admission paperwork in the building. Review of Resident #161's Hospice Client Coordination Note Report revealed the following: Triage Note dated [DATE]: LVN C called triage nurse [DATE] at 3:17 pm to report Resident #161 had expired with family present. Hospice RN M was notified at 3:22 pm and was en route to the facility. Narrative Note dated [DATE] by Hospice RN M: Patient resting in bed with no breaths noted. HSN auscultated (listened with a stethoscope) for over one minute apical (over the heart). No pulse noted. TOD 1540 (3:40 pm). Funeral Home called 1600 (4:00 pm). CPR started at 1620 (4:20 PM) by paramedics due to facility not able to produce DNR in hand. MPOA called. She wants CPR stopped but per paramedic they cannot stop CPR over the phone with MPOA. Facility staff searching for DNR called maintenance to open the office to find the paper copy. Paramedics continue CPR until 1647 (4:47 pm). HSN filled out paperwork for mortician and facility. Body released to funeral home at 1705 (5:05 pm). Review of Resident #161's EMS Patient Care Record dated [DATE] revealed the following: Incident Narrative: Upon arrival the patient presented in the supine (on back) position in bed. NH staff were ventilating the patient with a BVM. NH staff initially informed EMS that patient stopped breathing at approximately 16:00 (4:00pm) today. EMS palpated (felt with fingers) the patient for a pulse, and none were noted. EMS moved the patient to the floor without incident using a patient carry. EMS began manual compressions and ventilating the patient. A NH employee entered the room and informed EMS that the patient has a DNR, but they are unable to locate it. EMS informed the employee that we must see a valid, physical copy of the DNR in order to cease resuscitative efforts. The NH employee never returned with a physical DNR. EMS attached multi pads (adhesive pads to detect heart rhythm) and the patient's rhythm was asystole (no detectable heartbeat) and remained asystole for the duration of the incident. IO access (technique in which the bone marrow cavity is used as a non-collapsible vascular entry point for delivering fluid or blood products) was gained, and EMS began administering LR (IV fluid). EMS inserted [NAME] (artificial airway used to help ventilate the patient) and attached the ETCO2 monitor and accuvent (attachment to monitor flow of air while ventilating patient). EMS proceeded to follow asystole protocol with pulse checks every 2 minutes and administering epinephrine every 3-5 minutes. EMS administered D10 (IV fluid). EMS obtained a 4-lead EKG. Approximately 15 minutes into the call a NH employee entered the room and informed EMS that the patient had stopped breathing at approximately 15:17 (3:17 pm) today. After approximately 25 minutes of CPR, EMS contacted medical control and informed physician on call of the details and interventions performed and the physician directed EMS to cease resuscitative efforts and called the time of death at 16:47 (4:47 pm) on [DATE]. EMS acquired a signature from the NH staff. EMS cleared the scene and returned to service. In an interview on [DATE] at 1:15 PM Regional Director of Clinical Services stated the facility did not have a CPR policy. She stated the staff that were CPR certified rely on their training to know when to perform CPR. She stated she was the instructor for staff at the facility and they know when to do CPR. In a phone interview on [DATE] at 10:07 AM Medical Director stated that the facility does address code status on admission. She stated that if the resident was a full code, the facility was very quick to react to the situation. Medical Director stated that in a code situation the staff did compressions and ventilation until EMS arrived and took over resuscitation efforts. She stated that if the resident is a DNR the facility was to honor that and if the resident wished to become a DNR the Social Worker was to assist them in completing the paperwork. She stated that any licensed staff would be able to have the code status discussion with a resident or their representative and if there was an admission on a weekend or holiday the discussion still needed to happen, and it should never be put on hold until the Social Worker came back to work. Medical Director stated that she had not been made aware of the situation regarding Resident #161 and stated that the fact the resident had an MPOA would negate the need for a DNR. She stated that the DON should have instructed the facility nurses to contact the MPOA and get permission to not do CPR after staff realized the DNR was not in the facility rather than instructing them to call 911 and begin CPR. She stated that this was poor advise on the part of the DON. She stated that there was a clear lack of judgement on everyone's part. Review of blank, undated facility form titled admission Checklist - Morning Clinical Meeting form revealed: Review New Admissions - 'EHR' and other relevant sources - Grey shaded areas with asterisk should be completed within 24 hours, and other items on checklist should be completed within 3 days of admission. Gray shaded areas with asterisk: Vitals, Height, & Weight; admission Assessment - Schedule Initiated & UDAs Complete; admission Nurse Narrative Note Completed; Physician Orders Including Diet; Medication Review & Reconciliation; Photograph; Code Status/OOH DNR; admission MDS Opened by admission Nurse; Section GG Nursing Documentation Initiated; Physician Certification Initiated Review of undated facility policy titled DNR Policy revealed, in part: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has TWO valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and it has to be honored as long as it is executed properly with the resident's signature, date, and witnesses. A resident with a properly executed DNR should not be considered a FULL CODE while waiting for the physician to acknowledge the DNR. The following steps will be followed to reflect the resident's Do Not Resuscitate status accurately in 'EHR'. 1. Upon admission of a new resident, the charge nurse will determine the resident's code status. If the resident opts to complete an OOH-DNR, you will do the following: A. Review and complete an OOH-DNR with the resident/MPOA/Legal Guardian or next of kin and obtain witnesses or notary signatures on the form. This conversation is documented in the Code Status Discussion UDA. B. Request nursing change resident's code status to Do Not Resuscitate in 'EHR'. C. Scan OOH-DNR form and email to the resident's facility physician for signature. It is recommended to highlight all the places where the physician is to sign/date/license on the document. D. Upon receipt of the signed OOH-DNR, scan and upload to MISC. tab in 'EHR' under 'Advanced Directives'. 2. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with their wishes. Review of undated facility policy titled Full Code Status revealed: The following steps will be followed to reflect the resident's Full Code status accurately in 'EHR'. 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses Full Code, the nurse enters a 'Full Code' order into 'EHR'. 2. During 48-hour care plan meeting, social worker or designee will review code status with resident and/or resident representative This discussion is documented in the Code Status Discussion UDA. 3. Any Advanced Directives such as Medical Power of Attorney or other documents are uploaded to 'EHR' under the Miscellaneous tab under 'Advanced Directives. 4. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with what he/she wants. IJ was identified due to the above failures on [DATE] at 3:59 pm, and the IJ Template was provided to the Administrator. The Plan of Removal was accepted [DATE] at 3:05 pm and included: F578: The facility failed to have a system in place to ensure residents' Advanced Directives are accurately addressed and assessed at time of admission. Identify residents who could be affected. - All residents have the potential to be affected. - Facility census on 02-29-2024 was 55. In-Service Conducted - All staff will be in-serviced on how to obtain the code status for all residents by utilizing the DNR code book found at each nurse's station. - DON, ADON, Regional Nurse Consultant will provide the training beginning 2-29-2024 and continued until completed on 3-1-2024 for current employees and all new hires. - Verbal understanding will be utilized for knowledge retention. Implementation of Changes - DNR and full code status audit was completed by Regional Nurse Consultant and DON on 2-28-2024 for accuracy in 'EHR'. There were no issues identified on this audit, so no corrections were needed . - DON/ADON/Social Worker will audit once weekly for 3 months for 'EHR' accuracy. This audit was 100% of all current residents to include new admissions. - Code Status discussion will be conducted by social worker during business hours Monday through Friday and after 5 pm or weekends, holidays, charge nurses assigned a new admission will be completing code status discussion with residents or resident representative. - Weekend supervisor will verify completion of code status. - Full code or DNR will be put in 'EHR at that time and or assisting with DNR paperwork. Administrator/DON/weekend RN supervisor will verify completion of the discussion daily and accurately documented in 'EHR' beginning 2-29-2024. - DON/ADON will review code status discussion after hours daily including holidays for new admissions beginning 2-29-2024. - All new admissions on weekends will be addressed in the morning meeting for accuracy of code status and confirm code status and resident rights, documented in 'EHR', DNR uploaded in 'EHR' and DNR binders at each nurse's station. - In-service will be conducted starting today regarding code status discussion and after-hours process. DNR binders will be at both nurses' stations. - DNR binders are to be easily accessible for new DNR requests and filled out by the charge nurse if requested. - DNR binders are the binders that will contain the completed Out of Hospital DNR for all residents with advanced directives. - Code status will be reviewed quarterly at the care plan conference. - Nurses will be made aware of code status changes by communicating via the 24-hour report which contains all new telephone orders, verbal shift change discussion daily on each shift, social worker may also communicate the change in a code status. Monitoring - DON/ADON will review code status discussions Monday through Friday and weekend supervisor will be monitoring for accuracy. - Any negative outcomes will be reported to the QAPI committee monthly for 3 months and if no concerns, consider it resolved. Involvement of Medical Director - The Medical Director was notified about the immediate jeopardy on

Based on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 6 residents (Resident #161) whose records were reviewed for Full code status. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:59 pm and the IJ Template was provided to the facility Administrator. While the Plan of Removal (POR) was accepted on [DATE] at 3:05 pm and the immediacy was removed on [DATE] at 5:41 pm, the facility remained out of compliance at a scope of isolated at a level of no actual harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed the residents at risk of not having their wishes known, respected, and implemented in an emergency. The findings included: Review of Resident #161's Admission Record revealed she was an [AGE] year-old female originally admitted to the facility [DATE] with a most recent admitted [DATE]. She had admission diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), moderate malnutrition, breast cancer, chronic pain, and atrial fibrillation (abnormal heart rhythm). Her code status was listed as Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive). Review of Resident #161's MDS list revealed that at the time of her [DATE] admission, no comprehensive MDS assessment had been initiated. Review of Resident #161's Hospice Clinical Chart revealed that during her intake interview and assessment on [DATE] at 3:52 pm, the resident was a full code but requested DNR paperwork (there was no DNR form located in the resident's EHR during record review) be given to her and her family to fill out. Review of Resident #161's Hospice admission orders dated [DATE] revealed no mention of code status. Review of Resident #161's Admission Assessment/Baseline Care Plan Summary, initiated [DATE] and signed [DATE], revealed in Section O Code Status that she was a DNR. Review of Resident #161's Physician's Progress Notes revealed no mention of code status in the admission note. Review of Resident #161's care plan dated [DATE] revealed Problem: I have chosen DO NOT RESUSCITATE status. Review of Resident #161's Order Listing Report revealed no order for code status. Review of facility's handwritten 24-hour report log for dates [DATE] and [DATE] revealed Resident #161 was reported as being a DNR. The 24-hour report log sheet dated [DATE] stated Resident #161 re-admit, COPD, moderate protein-calorie malnutrition, hospice. The facility was unable to provide the 24-hour report log for [DATE]. In a phone interview on [DATE] at 2:53 PM with the Hospice Administrator she stated that the hospice company never received a copy of Resident #161's DNR from the family as they were told that the family was going to be providing a copy to the nursing home to keep on file. She stated that the hospice company was told that the family had given a copy of the DNR to facility LVN D on Friday [DATE] when the resident was admitted to the facility and that LVN D either had or was going to enter it into the computer system. She stated that the resident had been living in an assisted living facility but was hospitalized and had a significant decline after being discharged from the hospital and the family opted for her to be placed on hospice services and be admitted to the nursing facility. She stated that when all the hospice paperwork was signed by the family, the family kept the DNR paperwork and assured the hospice employee that they would give the nursing home a copy. She stated that the hospice company offered the family a counseling session with their Social Worker to discuss the DNR paperwork and their options, but the family declined because there was already a DNR in place. The Hospice Administrator stated that on [DATE] a facility nurse called the hospice to notify the Hospice RN M that the resident had passed away. She stated that, according to the notes and discussions she had after the incident with Hospice RN M, Hospice RN M arrived at the facility and pronounced a time of death for Resident #161 at on [DATE] at 3:40 PM. She stated that the facility nurse could not locate the DNR and instructed someone to call 911 and they (facility staff) began chest compressions. In an interview on [DATE] at 3:30 PM with LVN C she stated she called 911 at 4:11 PM on [DATE]. She stated she called 911 after about 30 minutes of searching the facility for a copy of Resident #161's DNR after the she had called hospice to notify them that the resident had expired, and the hospice nurse had already pronounced a time of death. She stated that after the hospice nurse pronounced the resident, she (LVN C) realized she had not verified the resident's code status and when she went to check she found there was no DNR on file for the resident. She stated that she should have verified the code status before calling hospice to pronounce. LVN C stated the resident was on hospice for comfort measures but was listed as a full code was her understanding. LVN C stated that Resident #161's MPOA told her that she had given a copy of the DNR to LVN E on the night before the resident passed away ([DATE]). She stated that there were several family members in the room, including the MPOA, when the resident passed and after hospice pronounced a time of death the family left the facility. She stated that whoever received records for the resident's admission would be responsible for making sure there was a DNR on file. In an interview on [DATE] at 10:30 AM with Social Worker, he stated that his role in the code status process was to have a Code Status Discussion with the resident or their representative within 48 hours of admission. He stated the discussion was a simple conversation about what the resident would like to have done if their heart stops while they are a resident, basically CPR or no CPR. He stated he did not get the chance to do the Code Status discussion with Resident #161 due to her admission being after business hours on [DATE] and her passing away on a holiday. He stated he had done a Code Status Discussion with her during her previous admission (,d+[DATE]), and she was a full code. He stated that whoever admitted the resident would have been responsible for getting the copy of the DNR from the family if there was one. He stated if he was the one who takes the DNR from the family he immediately scanned it and uploaded it into the resident's EHR. He stated that he did not have a hard copy DNR book, and he was pretty sure the nurses did not have hard copies of the residents' DNRs either. In an interview on [DATE] at 11:27 AM the Administrator confirmed that facility did not keep hard copies of DNRs on hand in the facility. He stated that all DNRs were kept in resident charts in the facility's EHR and code status was flagged for each resident and that the code status was accessible to all staff with EHR access. In an interview on [DATE] at 04:09 PM ADON stated that when an admission was done, they (staff completing the admission) were supposed to get their own copies of all paperwork including advanced directives. She stated that Resident #161 was a hospice resident, and she feels like they should have provided the facility with the DNR. She stated that the Admission/Readmission Evaluation in the EHR can be initiated by one nurse and finished/signed by a different nurse depending on what time the resident is admitted because of shift change, then the RN signs off on it and there is no way to tell which nurse completed which section. She stated that even if the admission evaluation and the care plan stated that the resident was a DNR, until the facility had the physical copy of the form the resident was considered a full code. In an interview on [DATE] at 04:50 PM LVN D stated he could not remember if he worked [DATE] through [DATE] without looking at a schedule. He stated he did not remember Resident #161 and denied that he was given a DNR for Resident #161 at any time. In a phone interview on [DATE] at 08:55 AM LVN E stated he did not remember Resident #161. He stated the facility had a high amount of resident turnover and if a resident was not long-term it was difficult to remember all the residents. He stated that when he admitted a new resident, he would keep all the admission paperwork at the nurse's desk in a basket for medical records to pick up and scan into the chart. He stated that if he did receive Resident #161's DNR form with her admission paperwork it would have gone into the medical records basket with the other paperwork. He stated that each nurse's station had one of these baskets. LVN E stated all paperwork that the nurses needed scanned into charts went into that basket for medical records. He stated the paperwork in the basket was normally picked up the next day or if it was a weekend, it was picked up Monday morning. He stated that he did not have access to scan documents into resident charts and did not think the other nurses did either. In an interview on [DATE] at 11:31 AM Hospice RN M stated she received the call that Resident #161 had passed away at 3:17 pm on [DATE] and it took her a little while to get to the facility. She stated that when she arrived, she assessed the resident and spoke with the family, and she pronounced the resident's time of death as 3:40 pm. She stated that she explained to the family that she would notify the funeral home and make arrangements for the funeral home to contact the family to set up their next steps and that after the family spent a few minutes with the resident they left the facility. She stated that at some point (she was never told what time the call was placed), either ADON or LVN C notified the DON that they were unable to locate Resident #161's DNR and that the DON told them they had to call 911 and begin CPR because without the DNR in hand Resident #161 was considered a full code. She stated that facility staff began CPR just as EMS arrived and then they (EMS) took over. Hospice RN M stated she explained to the EMTs that the resident was pronounced dead at 3:40 pm and had been down since at least 3:17 pm and asked if they could just call their medical director and have them call a time of death, but they refused because there was no DNR available. She stated that the resident's MPOA told her that she had given the facility the DNR [DATE] and that she (MPOA) had personally handed it to LVN D. She stated that LVN C tore the building apart trying to find the DNR form but was not able to locate it. She stated the facility told the family and hospice that they never received the form. In an interview on [DATE] at 12:48 PM with DON she stated that DNRs were scanned into the charts and nurses, management (DON, ADON, Administrator, Social Worker, MDS) had access to the form once it was scanned in. She stated that CNAs had the code status listed on their Kardex (resident information sheet for non-nurses) but did not have access to the DNR form itself. She stated anyone with EHR access could see a resident's code status but not the DNR form. She stated Resident #161 had been a resident in the facility before and had always been a full code in the past, so she stated that the understanding that she was a DNR on her last admission was strange to her. DON confirmed that there were no hard copies of DNR forms kept in the facility. She stated that any prudent nurse would check for a DNR before taking any action in a code situation. She feels that the facility did everything they were supposed to do regarding Resident #161's admission. She stated she was admitted after business hours so the Social Worker who normally asked the advanced directive questions was not here to do it. She stated that the hospice administrator told her (DON) that there was a copy of the MPOA form so she believed maybe the family thought that was the DNR. DON stated there was no in-service done for the staff after the incident because she was not aware that the resident had been deceased for that amount of time before 911 was called and CPR was started and that there was so much confusion regarding her code status. In a phone interview on [DATE] at 4:29 PM Resident #161's MPOA stated she did not have a copy of the resident's DNR because the copy she gave the LVN E was the original document with a carbon copy attached. She stated that a hospice agent had taken a picture of the DNR with a cell phone for hospice records (surveyor was not able to verify this with any hospice employee). She stated that she gave the DNR to LVN E on [DATE] while he completed Resident #161's admission to the facility. She stated the hospice company had given Resident #161 the DNR paperwork to fill out. MPOA stated that after the resident completed the form, she (MPOA) and two other family members signed as witnesses on [DATE] and then gave the form to LVN E on [DATE]. MPOA stated that on [DATE] she and several family members were in the room when Resident #161 passed at approximately 3:20 pm. She stated she ran to get LVN C, who came to assess the resident, and that LVN C confirmed that Resident #161 had passed. She stated that LVN C then left the room to call hospice. MPOA stated that Hospice RN M arrived a short time later (she was not sure of the exact time) and pronounced time of death for the resident at 3:40 pm. MPOA stated that the family left the facility after Hospice RN M pronounced Resident #161 deceased . She stated she was called by Hospice RN M a while later to advise her that the facility staff could not locate the DNR and were calling 911 and starting compressions (MPOA was unable to give any exact times for phone calls). She stated that after the EMTs arrived and had taken over CPR, Hospice RN M had her (MPOA) on speaker phone telling the EMTs that she was the MPOA and to stop CPR, but they refused because they did not have the DNR and could not prove she was who she said she was over the phone. She stated she was told by Hospice RN M that the EMTs called their physician for orders to stop CPR and a new time of death was given. In an interview on [DATE] at 5:25 PM LVN F (6a-6p) Stated she has a cheat sheet that she worked off when doing admissions, but she stated that a lot of the admission tasks will queue to be done in the EHR system. She stated that the Social Worker was normally the person responsible for the Code Status Discussion but anyone who did an admission had access to that assessment and was able to complete it. She stated that she believed that the Code Status Discussion flagged in the UDAs (user-defined assessments) for nursing staff a few days after admission if it had not been completed. She also stated that if a resident was admitted with a DNR in hand she would not complete the Code Status Discussion. She stated that if she admitted a resident after hours or on a weekend that expressed interest in becoming a DNR she would bypass the Code Status Discussion and go straight to filling out the DNR form, or if a resident that could not communicate was declining, she would call the family and have the code status discussion with them. She stated she would never wait on the Social Worker to have the code status discussion. In an interview on [DATE] at 6:00 PM RN G (6p-6a) stated there was a list of assessments that had to be completed for an admission. She stated that management would let them know they were going to get an admission so she would have everything she needed to do ready; hospitals should give a report so she should know basic information about the resident before they arrived. RN G stated when a new resident arrived the first thing, she checked was code status because even a DNR outside the facility was considered a full code in the facility until they were assessed by the Social Worker. She stated that if a new resident came in with a DNR form in hand she would honor the DNR and notify the DON and document that she received the DNR even if the code status had not yet been set to reflect it. She stated she have the code status discussion with residents, but she has never done the actual assessment in PCC and was not aware it was there. In a follow-up interview on [DATE] at 8:50 AM LVN C stated that she received report from LVN E on [DATE] at 6:00 AM that Resident #161 had been admitted to the facility to die and was a DNR. She stated that she was working Monday through Thursday only during that time due to her school schedule and another nurse was working only weekends, so [DATE] was the first day she had been responsible for the care of Resident #161. She stated that when the family called her into the room, they told her that Resident #161 had stopped breathing. She stated she assessed the resident for a pulse and breath sounds and after finding none, she told the family that she would notify hospice then left the family to be with the resident. She stated that she called to notify hospice that the resident had expired. She stated that the family left almost immediately after Hospice RN M arrived and pronounced the time of death at 3:40 pm. She stated that she was uncertain who realized that the resident did not have a DNR on file and was listed as a full code. She stated that the ADON, who was working the opposite hall, called the DON and notified her that the Resident #161 did not have a DNR on file and was listed as a Full Code, but had been pronounced dead at 3:40 pm by Hospice RN M. At approximately 4:10 pm the ADON came to her nurse's station and notified her that the DON had said that because there was no DNR on file they had to start CPR and call 911. LVN C stated that in the nine hours she was responsible for Resident #161 the family never said anything to her specifically about the resident being a DNR. She did recall the family asking questions about how long it would take for the resident to pass and what to expect and requested that she call the hospice chaplain to come visit with them. She stated that in her opinion the family was aware the resident's death was imminent and their priority was making sure she was comfortable and not suffering in her last hours. She stated she was not aware that she could complete the Code Status Discussion Assessment with new admissions. She stated that she has initiated the DNR form with residents before but was not aware that the form would be honored before the physician had signed it. She stated that she does not have access to scan documents into the resident EHRs so even if she was given a DNR or other form by a resident/family on admission it would have to wait until management or medical records staff was available to upload the document. She stated that when she was looking for Resident #161's DNR form she was unable to find paper copies of any of her admission paperwork in the building. Review of Resident #161's Hospice Client Coordination Note Report revealed the following: Triage Note dated [DATE]: LVN C called triage nurse [DATE] at 3:17 pm to report Resident #161 had expired with family present. Hospice RN M was notified at 3:22 pm and was en route to the facility. Narrative Note dated [DATE] by Hospice RN M: Patient resting in bed with no breaths noted. HSN auscultated (listened with a stethoscope) for over one minute apical (over the heart). No pulse noted. TOD 1540 (3:40 pm). Funeral Home called 1600 (4:00 pm). CPR started at 1620 (4:20 PM) by paramedics due to facility not able to produce DNR in hand. MPOA called. She wants CPR stopped but per paramedic they cannot stop CPR over the phone with MPOA. Facility staff searching for DNR called maintenance to open the office to find the paper copy. Paramedics continue CPR until 1647 (4:47 pm). HSN filled out paperwork for mortician and facility. Body released to funeral home at 1705 (5:05 pm). Review of Resident #161's EMS Patient Care Record dated [DATE] revealed the following: Incident Narrative: Upon arrival the patient presented in the supine (on back) position in bed. NH staff were ventilating the patient with a BVM. NH staff initially informed EMS that patient stopped breathing at approximately 16:00 (4:00pm) today. EMS palpated (felt with fingers) the patient for a pulse, and none were noted. EMS moved the patient to the floor without incident using a patient carry. EMS began manual compressions and ventilating the patient. A NH employee entered the room and informed EMS that the patient has a DNR, but they are unable to locate it. EMS informed the employee that we must see a valid, physical copy of the DNR in order to cease resuscitative efforts. The NH employee never returned with a physical DNR. EMS attached multi pads (adhesive pads to detect heart rhythm) and the patient's rhythm was asystole (no detectable heartbeat) and remained asystole for the duration of the incident. IO access (technique in which the bone marrow cavity is used as a non-collapsible vascular entry point for delivering fluid or blood products) was gained, and EMS began administering LR (IV fluid). EMS inserted [NAME] (artificial airway used to help ventilate the patient) and attached the ETCO2 monitor and accuvent (attachment to monitor flow of air while ventilating patient). EMS proceeded to follow asystole protocol with pulse checks every 2 minutes and administering epinephrine every ,d+[DATE] minutes. EMS administered D10 (IV fluid). EMS obtained a 4-lead EKG. Approximately 15 minutes into the call a NH employee entered the room and informed EMS that the patient had stopped breathing at approximately 15:17 (3:17 pm) today. After approximately 25 minutes of CPR, EMS contacted medical control and informed physician on call of the details and interventions performed and the physician directed EMS to cease resuscitative efforts and called the time of death at 16:47 (4:47 pm) on [DATE]. EMS acquired a signature from the NH staff. EMS cleared the scene and returned to service. In an interview on [DATE] at 1:15 PM Regional Director of Clinical Services stated the facility did not have a CPR policy. She stated the staff that were CPR certified rely on their training to know when to perform CPR. She stated she was the instructor for staff at the facility and they know when to do CPR. In a phone interview on [DATE] at 10:07 AM Medical Director stated that the facility does address code status on admission. She stated that if the resident was a full code, the facility was very quick to react to the situation. Medical Director stated that in a code situation the staff did compressions and ventilation until EMS arrived and took over resuscitation efforts. She stated that if the resident is a DNR the facility was to honor that and if the resident wished to become a DNR the Social Worker was to assist them in completing the paperwork. She stated that any licensed staff would be able to have the code status discussion with a resident or their representative and if there was an admission on a weekend or holiday the discussion still needed to happen, and it should never be put on hold until the Social Worker came back to work. Medical Director stated that she had not been made aware of the situation regarding Resident #161 and stated that the fact the resident had an MPOA would negate the need for a DNR. She stated that the DON should have instructed the facility nurses to contact the MPOA and get permission to not do CPR after staff realized the DNR was not in the facility rather than instructing them to call 911 and begin CPR. She stated that this was poor advise on the part of the DON. She stated that there was a clear lack of judgement on everyone's part. Review of blank, undated facility form titled Admission Checklist - Morning Clinical Meeting form revealed: Review New Admissions - 'EHR' and other relevant sources - Grey shaded areas with asterisk should be completed within 24 hours, and other items on checklist should be completed within 3 days of admission. Gray shaded areas with asterisk: Vitals, Height, & Weight; Admission Assessment - Schedule Initiated & UDAs Complete; Admission Nurse Narrative Note Completed; Physician Orders Including Diet; Medication Review & Reconciliation; Photograph; Code Status/OOH DNR; Admission MDS Opened by Admission Nurse; Section GG Nursing Documentation Initiated; Physician Certification Initiated Review of undated facility policy titled DNR Policy revealed, in part: The resident has the right to make the decision about completion of the DNR. A DNR signed by the resident that has TWO valid witnesses to the signature and is dated is a valid legal document. Physician signature is only required for acknowledgement purposes and is not an approval for the DNR. The resident has the right to make the decision without the physician's permission and it has to be honored as long as it is executed properly with the resident's signature, date, and witnesses. A resident with a properly executed DNR should not be considered a FULL CODE while waiting for the physician to acknowledge the DNR. The following steps will be followed to reflect the resident's Do Not Resuscitate status accurately in 'EHR'. 1. Upon admission of a new resident, the charge nurse will determine the resident's code status. If the resident opts to complete an OOH-DNR, you will do the following: A. Review and complete an OOH-DNR with the resident/MPOA/Legal Guardian or next of kin and obtain witnesses or notary signatures on the form. This conversation is documented in the Code Status Discussion UDA. B. Request nursing change resident's code status to Do Not Resuscitate in 'EHR'. C. Scan OOH-DNR form and email to the resident's facility physician for signature. It is recommended to highlight all the places where the physician is to sign/date/license on the document. D. Upon receipt of the signed OOH-DNR, scan and upload to MISC. tab in 'EHR' under 'Advanced Directives'. 2. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with their wishes. Review of undated facility policy titled Full Code Status revealed: The following steps will be followed to reflect the resident's Full Code status accurately in 'EHR'. 1. Upon admission of a new resident, the admitting nurse will determine the resident's code status. If the resident chooses Full Code, the nurse enters a 'Full Code' order into 'EHR'. 2. During 48-hour care plan meeting, social worker or designee will review code status with resident and/or resident representative This discussion is documented in the Code Status Discussion UDA. 3. Any Advanced Directives such as Medical Power of Attorney or other documents are uploaded to 'EHR' under the Miscellaneous tab under 'Advanced Directives. 4. Follow up with the resident quarterly and upon change of condition to review/clarify code status, Advanced Directives, Medical Power of Attorney to ensure that what the resident has in place is still consistent with what he/she wants. IJ was identified due to the above failures on [DATE] at 3:59 pm, and the IJ Template was provided to the Administrator. The Plan of Removal was accepted [DATE] at 3:05 pm and included: F578: The facility failed to have a system in place to ensure residents' Advanced Directives are accurately addressed and assessed at time of admission. Identify residents who could be affected. - All residents have the potential to be affected. - Facility census on [DATE] was 55. In-Service Conducted - All staff will be in-serviced on how to obtain the code status for all residents by utilizing the DNR code book found at each nurse's station. - DON, ADON, Regional Nurse Consultant will provide the training beginning [DATE] and continued until completed on [DATE] for current employees and all new hires. - Verbal understanding will be utilized for knowledge retention. Implementation of Changes - DNR and full code status audit was completed by Regional Nurse Consultant and DON on [DATE] for accuracy in 'EHR'. There were no issues identified on this audit, so no corrections were needed . - DON/ADON/Social Worker will audit once weekly for 3 months for 'EHR' accuracy. This audit was 100% of all current residents to include new admissions. - Code Status discussion will be conducted by social worker during business hours Monday through Friday and after 5 pm or weekends, holidays, charge nurses assigned a new admission will be completing code status discussion with residents or resident representative. - Weekend supervisor will verify completion of code status. - Full code or DNR will be put in 'EHR at that time and or assisting with DNR paperwork. Administrator/DON/weekend RN supervisor will verify completion of the discussion daily and accurately documented in 'EHR' beginning [DATE]. - DON/ADON will review code status discussion after hours daily including holidays for new admissions beginning [DATE]. - All new admissions on weekends will be addressed in the morning meeting for accuracy of code status and confirm code status and resident rights, documented in 'EHR', DNR uploaded in 'EHR' and DNR binders at each nurse's station. - In-service will be conducted starting today regarding code status discussion and after-hours process. DNR binders will be at both nurses' stations. - DNR binders are to be easily accessible for new DNR requests and filled out by the charge nurse if requested. - DNR binders are the binders that will contain the completed Out of Hospital DNR for all residents with advanced directives. - Code status will be reviewed quarterly at the care plan conference. - Nurses will be made aware of code status changes by communicating via the 24-hour report which contains all new telephone orders, verbal shift change discussion daily on each shift, social worker may also communicate the change in a code status. Monitoring - DON/ADON will review code status discussions Monday through Friday and weekend supervisor will be monitoring for accuracy. - Any negative outcomes will be reported to the QAPI committee monthly for 3 months and if no concerns, consider it resolved. Involvement of Medical Director - The Medical Director was notified about the immediate jeopardy on [DATE]. The Survey Team conducted POR verification [DATE]. In interviews conducted on [DATE] from 12:04 pm to 4:30 pm, 8 nursing staff and the Director of Rehab confirmed they received in-services on the DNR books, CPR, the Code Status Discussion, and DNR/Code Status paperwork and were able to give the location of the DNR books and how to find a resident's code status in the EHR. Review of facility in-service dated [DATE] titled DNR Book, CPR, Code Status Discussion revealed: 1. Codes Status Discussion will be done on admit and after-hours (weekends) by charge nurses. Social Worker will do them M-F. 2. DNR books on both nurse's stations contain DNR (blank) to fill out upon request. 3. Code status is located under care profile and 2nd confirmation is Code Status book. 4. All nurses must have American Heart or Red Cross for CPR card. If you do not have these, get one ASAP or certification. Review of facility in-service dated [DATE] titled DNR Code Status/Paperwork revealed: 1. DNR CODE BOOK - where - nurse's station at both ends with all current residents; conta[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure at the time each resident was admitted , the facility had a physician order for the resident's immediate care for 1 (Resident #1) of 2 residents reviewed for residents receiving necessary care and services upon admission. The facility failed to follow physician orders for Resident #1 to be non-weight bearing to right foot. As a result, Resident #1 had right leg amputated just below knee. An Immediate Jeopardy (IJ) was identified on 12/22/2023. While the IJ was removed on 12/23/23 at 4:30p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. This failure placed the residents at risk of not receiving adequate care and services, and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 12/27/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included Osteomyelitis (a serious infection of the bone that can be either acute or chronic), Type 2 Diabetes, Hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), anxiety disorder, and Hypertension (High blood pressure is a common condition that affects the body's arteries). Review of Resident #1's Care Plan dated 12/11/23 reflected: *Resident #1 had potential/actual impairment to skin integrity of the right foot related to wound date Initiated: 12/11/2023. *Resident #1 had an ADL self-care performance deficit r/t inability to bear weight on right leg Date Initiated: 12/11/2023. Record review of physician order by Wound Care Physician dated 12/7/23 revealed resident #1 was to be transferred to Facility A with weight bearing status indicating: nwb (non-weight bearing) right foot. Record review of Resident #1's Radiology report, dated 12/1/23 (obtained at the hospital, prior to admission), indicated: there is a small defect in the skin of the right posterior plantar surface concerning for an ulcer. There is prominent latency in the posterior inferior calcaneus concerning for osteomyelitis. Plantar posterior calcaneal enthesophytes are present. The osseous structures are aligned. No fracture, dislocation or other osseous abnormalities are demonstrated. Joint has a normal appearance. No radiopaque foreign bodes are noted. Record review of Resident #1's Radiology results dated 12/19/23 indicated: Ulcer is seen in the right plantar aspect of the hindfoot with soft tissue gas. A comminuted extra-articular fracture is seen in the posterior third of the calcaneus which is new since prior exam. During an interview, on 12/22/23 at 12:30 PM, the DON stated Resident #1 did not admit to the facility with any orders. She stated all the documentation she received on 12/7/23, was to make a follow up appointment with PHYSICIAN A for 12/11/23. She stated that Resident #1 did admit with a boot but had almost no paperwork. She stated she has no idea why Resident #1 did not have any orders, other than to make a follow up appointment, and a boot. She stated when Resident #1 did not show up with orders LVN E should have reached out to the hospital or the wound care physician on what exactly needed to be done for resident #1. She stated she was being honest; she does not believe the hospital, or the physician were contacted and so no orders were received for resident #1. She stated on 12/13/23 she went into electronic medical records and found the orders for Resident #1 to be non-weight bearing to the right foot. She stated she was not sure why this was not done sooner. She stated that she accessed the hospitals electronic medical records that Resident #1 was transferred from and found the orders from physician A dated 12/7/23. She stated she did this on 12/13/23 because of the documentation recieved from wound care for Resident #1 on 12/11/23. During a telephone interview, on 12/23/23 at 3:30PM, LVN E stated she was the nurse that admitted Resident #1, to the facility, on the evening of 12/7/23. She stated Resident #1 had hardly any paperwork, upon admission. She stated the only documents she received was hospital discharge notes, which indicated to make a follow up appointment, with wound care, for 12/11/23, and a boot for the resident's right foot. She stated the first night Resident #1 was at the facility he walked without the boot on, no socks, just his dressing on his right foot for his wound. She stated he walked a lot, in the facility, with the boot on. She stated she should have reached out to the hospital or the primary care physician to know exactly what orders were needed for Resident #1. During a telephone interview on 12/21/23 at 11:40 AM Advocate stated Resident #1 was with home health before being admitted to the hospital from 12/1/23 to 12/7/23 for an infection and surgery to his right foot. She stated Resident #1 was transferred to the facility on [DATE] for IV antibiotics, wound care, and PT. She stated Resident #1 went to wound care at wound care facility (outside of the facility) on 12/11/23 and on 12/18/23. She stated on the visit to wound care on 12/18/12 it was decided by physician A Resident #1 needed to be admitted to ER due to the severity of right foot wound. She stated upon assessment at theER on [DATE], it was determined Resident #1 would have right leg amputation just below the knee on 12/22/23. During an interview/observation of x-rays on Resident #1's right foot on 12/21/23 at 11:35 AM physician A revealed the concern and identified the differences between the x-rays. X-rays were reviewed by this investigator and physician A (we could not print the x-ray pictures). Physician A revealed, on 12/1/23, Resident #1's heel bone was intact, but did have an infection to the bone of the right heel. physician A stated the x-ray obtained on 12/18/23, revealed the heel bone had shattered into multiple pieces, bone shards were identified in the x-ray, showing 4 or more chunks of bone of right heel. He stated he reached out to physician B (podiatrist) who performed the operation, on Resident #1, on 12/1/23, and they both agreed that Resident #1's heel bone shattering could have been prevented. Physician A stated the resident should have been non-Weight bearing, to the right foot. He stated on 12/18/23, Resident #1 walked into wound care appointment with no boot on and was not in a wheelchair. He stated the damage done to the heal was caused by pressure. He stated the shattering of the right heel was caused by the resident failing to be non-weight bearing to the right heel. He stated even when wearing a boot, the resident should not have been walking on that heel. He stated due to Resident #1 walking on that heel and the damage sustained, it was determined that the leg was to be amputated, just below the knee, and the surgery was scheduled to be completed on 12/22/23. During a telephone interview, on 12/23/23, physician B stated Resident #1 had osteomyelitis (infection of the bone) to the right heel bone. He stated that Resident #1 should have never been walking on his right foot. He stated that he consulted with PHYSICIAN A on 12/18/23, requesting PHYSICIAN A review the x-rays of Resident #1's right foot, x-rays from 12/1/23 and 12/19/23. He stated they both agreed that this could have been prevented and the damage sustained to the right heel was directly related to Resident #1 failing to be non-weight bearing to his right foot. He stated due to the injuries of the heel, Resident #1's required a below the knee amputation to his right leg, which was scheduled to be completed on 12/22/23. During an interview, on 12/21/23 at 12:35 PM, LVN C stated resident #1 was always walking around the facility. She stated Resident #1 did have his boot on, but no sock, just his right leg, with its dressing, in the boot. She said he walked a lot in the facility. She stated she did not know that he should not be weight bearing. During an interview, on 12/22/23 at 11:45 AM, LVN D stated Resident #1 had the boot on and was allowed to walk with his walker. He stated during shift change, on 12/8/23, the night nurse informed him Resident #1 was admitted last night and he was allowed to walk with his walker. He stated that the resident #1 never used his walker, resident #1 would walk around the facility in his boot. During an interview on 12/22/23 at 12:45 PM DON stated she did not have any policy for physician orders. She stated she reached out to corporate and did not have any policy for physician orders. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 4:20pm. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template on 12/22/23 at 4:20 PM. The following Plan of Removal was accepted on 12/23/23 at 4:30 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from Quality of Care. The facility failed to ensure the residents are Quality of Care. 1. All residents have the potential to be affected. Facility census on 12-22-2023 was 56. 2. All licensed nurses will be in-serviced on how to determine the weight bearing status for all residents by utilizing the special instructions tab in PCC. All licensed nurses will be in-serviced on 2 nurses verifying orders within 24 hours. 3. Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. 4. Two nurses will be reviewing orders for accuracy upon admission. 5. Non-weight bearing status will be identified in the care profile in the medical record. 6. Two nurses will review all orders for new admissions within 24 hours. 7. Any negative outcomes will be reported to the QAPI committee. 8. Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. 9. DON/designee will review all orders for new admissions within 24 hours. 10. Any negative outcomes will be reported to the QAPI committee. The Medical Director was notified about the immediate jeopardy on 12-22-2023. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/22/2023 at 4:20pm to 12/23/2023 at 4:30pm. Review of the facility's In-service, dated 12/22/23, at 6pm, presented by DON, covering admission process and WB status indicated: Two nurses will review new admission orders during shift change upon admission. Weight bearing status will be noted in electronic medical records under care provide under special instructions. All weight bearing status will be put on care profile. If there are no specific orders for wb status, then there are no restrictions. All nurses must document any non-compliance with weight bearing status and notify physician of any noncompliance. Record review of a Facility Audit, of the resident's medical records, performed by DON, dated 12/23/23, revealed review of orders on new admits since December 1st, verified that all resident orders were correct. She stated she added weight bearing status in electronic medical records under the special instructions. There was a total of 18 residents' records, that were audited. She stated that during the audit process the facility did have to add into special instructions for weight bearing for two residents. During an interview, on 12/23/23 at 1:55 PM, CNA F (morning Shift) revealed she had been working for the facility, since the end of May 2023. She stated she received an in-serviced, over knowing the status of each resident. She stated for example, they discussed weight bearing and what exactly that means. She stated for example a new resident, was admitted , while she was on shift, she would sit down with the charge nurse, and they would go review all orders received for the resident and any needs, such as the resident being non weight bearing status. She stated if she were to observe the resident being non-compliant in any area, she would notate it in electronic medical records, tell her charge nurse, and inform the next CNA's coming on shift, during shift change. During a telephone interview, on 12/23/22 at 2:20 PM, LVN G (night nurse) stated an in-service was provided on this date, before she finished her shift. She stated they went over how to accept a new resident into the facility. She stated the facility staff were to make sure all orders and documentation was received, when receiving a new resident. She stated if everything does not seem like it is with the new resident, she was instructed to reach out, to the DON and the facility liaison. She stated the in-service also went over how to document all noncompliance, by any resident, and to bring that to the DONS's attention, regarding any resident that may be non-weight bearing or any resident that was being non-compliant. She stated for example if she was the nurse on shift when a new resident was admitted to the facility, she was to have 2 nurses sign off to make sure they both feel all new orders were in place and documented correctly. During a telephone interview, on 12/23/23 at 2:45 PM, CNA H (night shift) stated the in-service was at about 6 am in the morning on 12/23/23. She stated the in-service provided information on noncompliance of any resident, where to document that information in PCC, and who to inform (charge nurse). She stated, for example if she was on shift and a new resident was admitted to the facility, she would sit down with the charge nurse and the charge nurse would inform her of all orders for the resident and anything she needed to look out for. She stated for example weight bearing would be mentioned to her in this sit down and then when she was done with her shift and does shift change, she would inform the next CNAs of any noncompliance she had witnessed during her shift. During a phone interview, on 12/23/23 at 3:30 PM, LVN E stated she was in-serviced yesterday evening, 12/22/23. She stated the changes made to have a two nurse sign off on any new admits to the facility. She stated the residents' orders were to be checked and that if anything seemed to be missing or not there, she was to reach out to the DON or the facility liaison, who would then verify all orders were correct and were put in place for the resident. She stated the process was being changed to make sure no orders were missed for any resident in the facility. During an interview, on 12/23/23 at 3:55, PM LVN D stated this entire in-service covered documentation and verifying all information on new admits was received from the previous facility or the hospital. He stated there was now a two nurse sign off on newly admitted residents and this was to verify everything was correct. He stated if any documentation or orders were not received or did not seem correct, he was to inform his DON or the facility liaison to get the proper documentation. The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 4:30pm. The facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 2 residents reviewed for quality of care. The facility failed to ensure staff followed Resident #1's physician's orders by wound care physician for non-weight bearing when ambulating which led to Resident #1 having a below the knee amputation. An Immediate Jeopardy (IJ) was identified on 12/22/2023. While the IJ was removed on 12/23/23 at 4:30p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. This failure could place residents at risk of not receiving adequate care and services, and decreased quality of life. Findings included: Review of Resident #1's face sheet dated 12/27/23 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses included Osteomyelitis (a serious infection of the bone that can be either acute or chronic), Type 2 Diabetes, Hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood), anxiety disorder, and Hypertension (High blood pressure is a common condition that affects the body's arteries). Resident #1 cognitive status reflected moderate to good, depending on day. Review of Resident #1's Care Plan dated 12/11/23 reflected: *Resident #1 had potential/actual impairment to skin integrity of the right foot related to wound date Initiated: 12/11/2023. *Resident #1 had an ADL self-care performance deficit r/t inability to bear weight on right leg Date Initiated: 12/11/2023. Record review of physician order by Wound Care Physician dated 12/7/23 revealed resident #1 was to be transferred to Facility A with weight bearing status indicating: nwb (non-weight bearing) right foot. Record review of Resident #1's Radiology report, dated 12/1/23 (obtained at the hospital, prior to admission), indicated: there is a small defect in the skin of the right posterior plantar surface concerning for an ulcer. There is prominent latency in the posterior inferior calcaneus concerning for osteomyelitis. Plantar posterior calcaneal enthesophytes are present. The osseous structures are aligned. No fracture, dislocation or other osseous abnormalities are demonstrated. Joint has a normal appearance. No radiopaque foreign bodes are noted. Record review of Resident #1's Radiology results dated 12/19/23 indicated: Ulcer is seen in the right plantar aspect of the hindfoot with soft tissue gas. A comminuted extra-articular fracture is seen in the posterior third of the calcaneus which is new since prior exam. During a telephone interview on 12/21/23 at 11:40 AM Advocate stated Resident #1 was with home health before being admitted to the hospital from 12/1/23 to 12/7/23 for an infection and surgery to his right foot. She stated Resident #1 was transferred to the facility on [DATE] for IV antibiotics, wound care, and PT. She stated Resident #1 went to wound care at wound care facility (outside of the facility) on 12/11/23 and on 12/18/23. She stated on the visit to wound care on 12/18/12 it was decided by physician A Resident #1 needed to be admitted to ER due to the severity of right foot wound. She stated upon assessment at theER on [DATE], it was determined Resident #1 would have right leg amputation just below the knee on 12/22/23. During an interview/observation of x-rays on Resident #1's right foot on 12/21/23 at 11:35 AM physician A revealed the concern and identified the differences between the x-rays. X-rays were reviewed by this investigator and physician A (we could not print the x-ray pictures). Physician A revealed, on 12/1/23, Resident #1's heel bone was intact, but did have an infection to the bone of the right heel. physician A stated the x-ray obtained on 12/18/23, revealed the heel bone had shattered into multiple pieces, bone shards were identified in the x-ray, showing 4 or more chunks of bone of right heel. He stated he reached out to physician B (podiatrist) who performed the operation, on Resident #1, on 12/1/23, and they both agreed that Resident #1's heel bone shattering could have been prevented. Physician A stated the resident should have been non-Weight bearing, to the right foot. He stated on 12/18/23, Resident #1 walked into wound care appointment with no boot on and was not in a wheelchair. He stated the damage done to the heal was caused by pressure. He stated the shattering of the right heel was caused by the resident failing to be non-weight bearing to the right heel. He stated even when wearing a boot, the resident should not have been walking on that heel. He stated due to Resident #1 walking on that heel and the damage sustained, it was determined that the leg was to be amputated, just below the knee, and the surgery was scheduled to be completed on 12/22/23. During a telephone interview, on 12/23/23, physician B stated Resident #1 had osteomyelitis (infection of the bone) to the right heel bone. He stated that Resident #1 should have never been walking on his right foot. He stated that he consulted with PHYSICIAN A on 12/18/23, requesting PHYSICIAN A review the x-rays of Resident #1's right foot, x-rays from 12/1/23 and 12/19/23. He stated they both agreed that this could have been prevented and the damage sustained to the right heel was directly related to Resident #1 failing to be non-weight bearing to his right foot. He stated due to the injuries of the heel, Resident #1's required a below the knee amputation to his right leg, which was scheduled to be completed on 12/22/23. During an interview, on 12/21/23 at 12:35 PM, LVN C stated resident #1 was always walking around the facility. She stated Resident #1 did have his boot on, but no sock, just his right leg, with its dressing, in the boot. She said he walked a lot in the facility. She stated she did not know that he should not be weight bearing, so she did not stop him from walking with the boot on. She stated he never complained of pain. During an interview, on 12/22/23 at 11:45 AM, LVN D stated Resident #1 had the boot on and was allowed to walk with his walker. He stated during shift change, on 12/8/23, the night nurse informed him Resident #1 was admitted last night and he was allowed to walk with his walker. He stated that the resident #1 never used his walker, resident #1 would walk around the facility in his boot, he stated because he didnt know the resident was NWB he did not stop the resident from walking. He stated Resident #1 never complained about pain. During an interview, on 12/22/23 at 12:30 PM, the DON stated Resident #1 did not admit to the facility with any orders. She stated all the documentation the facility received on 12/7/23, was to make a follow up appointment with PHYSICIAN A for 12/11/23. She stated that Resident #1 did admit with a boot but had almost no paperwork. She stated she has no idea why Resident #1 did not have any orders, other then to make a follow up appointment, and a boot. She stated when Resident #1 did not show up without orders LVN E should have reached out to the hospital or the wound care physician on what exactly needed to be done for resident #1. She stated she was being honest; she does not believe the hospital, or the physician were contacted and so no orders were received for resident #1. She stated on 12/13/23 she went into electronic medical records and found the orders for Resident #1 to be non-weight bearing to the right foot. She stated she was not sure why this was not done sooner. She stated the resident never complained about pain. She stated that because they did not know about the NWB of the right foot Resident #1 walked on the foot a lot. She stated that they never reached out to the physician to inform him of noncompliance because Resident #1 never complained about pain. During a telephone interview, on 12/23/23 at 3:30PM, LVN E stated she was the nurse that admitted Resident #1, to the facility, on the evening of 12/7/23. She stated Resident #1 had hardly any paperwork, upon admission. She stated the only documents she received was hospital discharge notes, which indicated to make a follow up appointment, with wound care, for 12/11/23, and a boot for the resident's right foot. She stated the first night Resident #1 was at the facility he walked without the boot on, no socks, just his dressing on his right foot for his wound. She stated he walked a lot, in the facility, with the boot on. She stated she should have reached out to the hospital or the primary care physician to know exactly what orders were needed for Resident #1. During an interview on 12/22/23 at 12:45 PM DON stated she did not have any policy for physician orders. She stated she reached out to corporate and did not have any policy for physician orders. This was determined to be an Immediate Jeopardy (IJ) on 12/22/23 at 4:20pm. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template on 12/22/23 at 4:20 PM. The following Plan of Removal was accepted on 12/23/23 at 4:30 PM and included: Please accept the following Plan of Removal of Immediate Jeopardy-Failure to ensure residents are free from Quality of Care. The facility failed to ensure the residents are Quality of Care. 1. All residents have the potential to be affected. Facility census on 12-22-2023 was 56. 2. All licensed nurses will be in-serviced on how to determine the weight bearing status for all residents by utilizing the special instructions tab in PCC. All licensed nurses will be in-serviced on 2 nurses verifying orders within 24 hours. 3. Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. 4. Two nurses will be reviewing orders for accuracy upon admission. 5. Non-weight bearing status will be identified in the care profile in the medical record. 6. Two nurses will review all orders for new admissions within 24 hours. 7. Any negative outcomes will be reported to the QAPI committee. 8. Director of Nursing or designee will audit all new admissions for weight bearing status and for other orders since December 1, 2023. 9. DON/designee will review all orders for new admissions within 24 hours. 10. Any negative outcomes will be reported to the QAPI committee. The Medical Director was notified about the immediate jeopardy on 12-22-2023. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 12/22/2023 at 4:20pm to 12/23/2023 at 4:30pm. Review of the facility's In-service, dated 12/22/23, at 6pm, presented by DON, covering admission process and WB status indicated: Two nurses will review new admission orders during shift change upon admission. Weight bearing status will be noted in electronic medical records under care provide under special instructions. All weight bearing status will be put on care profile. If there are no specific orders for wb status, then there are no restrictions. All nurses must document any non-compliance with weight bearing status and notify physician of any noncompliance. Record review of a Facility Audit, of the resident's medical records, performed by DON, dated 12/23/23, revealed review of orders on new admits since December 1st, verified that all resident orders were correct. She stated she added weight bearing status in electronic medical records under the special instructions. There was a total of 18 residents' records, that were audited. She stated that during the audit process the facility did have to add into special instructions for weight bearing for two residents. During an interview, on 12/23/23 at 1:55 PM, CNA F (morning Shift) revealed she had been working for the facility, since the end of May 2023. She stated she received an in-serviced, over knowing the status of each resident. She stated for example, they discussed weight bearing and what exactly that means. She stated for example a new resident, was admitted , while she was on shift, she would sit down with the charge nurse, and they would go review all orders received for the resident and any needs, such as the resident being non weight bearing status. She stated if she were to observe the resident being non-compliant in any area, she would notate it in electronic medical records, tell her charge nurse, and inform the next CNA's coming on shift, during shift change. During a telephone interview, on 12/23/22 at 2:20 PM, LVN G (night nurse) stated an in-service was provided on this date, before she finished her shift. She stated they went over how to accept a new resident into the facility. She stated the facility staff were to make sure all orders and documentation was received, when receiving a new resident. She stated if everything does not seem like it is with the new resident, she was instructed to reach out, to the DON and the facility liaison. She stated the in-service also went over how to document all noncompliance, by any resident, and to bring that to the DONS's attention, regarding any resident that may be non-weight bearing or any resident that was being non-compliant. She stated for example if she was the nurse on shift when a new resident was admitted to the facility, she was to have 2 nurses sign off to make sure they both feel all new orders were in place and documented correctly. During a telephone interview, on 12/23/23 at 2:45 PM, CNA H (night shift) stated the in-service was at about 6 am in the morning on 12/23/23. She stated the in-service provided information on noncompliance of any resident, where to document that information in PCC, and who to inform (charge nurse). She stated, for example if she was on shift and a new resident was admitted to the facility, she would sit down with the charge nurse and the charge nurse would inform her of all orders for the resident and anything she needed to look out for. She stated for example weight bearing would be mentioned to her in this sit down and then when she was done with her shift and does shift change, she would inform the next CNAs of any noncompliance she had witnessed during her shift. During a phone interview, on 12/23/23 at 3:30 PM, LVN E stated she was in-serviced yesterday evening, 12/22/23. She stated the changes made to have a two nurse sign off on any new admits to the facility. She stated the residents' orders were to be checked and that if anything seemed to be missing or not there, she was to reach out to the DON or the facility liaison, who would then verify all orders were correct and were put in place for the resident. She stated the process was being changed to make sure no orders were missed for any resident in the facility. During an interview, on 12/23/23 at 3:55, PM LVN D stated this entire in-service covered documentation and verifying all information on new admits was received from the previous facility or the hospital. He stated there was now a two nurse sign off on newly admitted residents and this was to verify everything was correct. He stated if any documentation or orders were not received or did not seem correct, he was to inform his DON or the facility liaison to get the proper documentation. The Administrator was informed the Immediate Jeopardy was removed on 12/23/2023 at 4:30pm. The facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to: a) ensure Resident #1 who had a [DIAGNOSES REDACTED]. The family requested she be sent to the hospital at which time the hospital removed 8060 ml of Ascites fluid. b) ensure Resident #1's Physician was notified of a 2 lb.(pound) weight gain as indicated in her care plan. These failures resulted in an IJ on 7/27/18. While the IJ was lowered on 7/27/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure to carry out physician's orders [REDACTED]. Findings included: Record Review of Resident #1's undated Face Sheet revealed an [AGE] year old female admitted to the facility on [DATE]. The residents' [DIAGNOSES REDACTED]. Record Review of Resident #1's Admit History and Assessment by the Nurse Practitioner, dated 5/30/18, indicated that during her hospital stay she had some abdominal distention, and 6300 ml of ascitic fluid (accumulation of fluid in the abdominal cavity) was removed from her abdomen. She had apparently been noncompliant with her [MEDICATION NAME]. Assessment and Plan: Anorexia- [MEDICATION NAME]. Will continue to monitor weights. Generalized weakness and debility- continue with PT/OT. [MEDICAL CONDITION] of the liver with [MEDICAL CONDITION] - Continue with [MEDICATION NAME]. DNR Record Review of Resident #1's Admission assessment dated [DATE] indicated Resident #1's weight was documented at 242.0 lbs. (pounds). Record Review of Resident #1's Admission MDS assessment dated [DATE] revealed the following; Resident #1 had a BIMs (Brief Interview for Mental status) score of 14, indicating cognitive decision-making skills were intact. Record Review of Resident #1's undated Care Plan indicated problems of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #1's care plan included, in part: Focus: [MEDICAL CONDITION] related to [MEDICAL CONDITION] Goal: Resident #1 will have no signs and symptoms of complications related to fluid overload through the review date. Intervention/task: Auscultate heart and lung sounds every shift and document findings. Monitor/document/report as needed the following signs and symptoms; [MEDICAL CONDITION], weight gain of over two pounds a day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, peripheral pulses, level of conscious, monitor breath sounds for crackles. Record Review of Resident #1's Clinical Physician order [REDACTED]. Record Review of Resident #1's Physician order [REDACTED]. Weight was 230.0 pounds. Record Review of Resident #1's Physician order [REDACTED]. Record Review of Resident #1's weight on 07/06/18 was 234 pounds, an increase of 4.0 lbs since 06/21/18. Record Review of Resident #1's Nursing assessment dated [DATE] at 12:05 am indicated the resident's heart rate was at a regular rhythm, the resident had labored respirations, shallow breathing, and oxygen saturation of 92% on 2 liters per nasal cannula. Record Review of Resident #1's Nursing assessment dated [DATE] at 7:59 am indicated shortness of breath. During a telephone interview on 7/24/18 at 12:15 pm with Resident #1's granddaughter, she said that her mother had gone to the nursing home on 07/21/18 and Resident #1 was having trouble breathing and was confused. She said her mother had reported her concerns to the charge nurse and the charge nurses wanted to wait till Monday to call the physician. Resident #1's granddaughter said her mother had requested Resident #1 be sent to the emergency room for evaluation. Resident #1's granddaughter stated the emergency room had put the resident on [MEDICAL CONDITION] (bilevel continuous positive airway pressure) and started intravenous fluids. She said the emergency room Physician had informed her mother the resident was in [MEDICAL CONDITION]. She said the physician had also diagnosed the resident with [MEDICAL CONDITIONS], and stated her kidneys were not working properly. Resident #1's granddaughter said they had to remove 8 liters of fluid from her abdomen and she was very sick. During an interview on 7/24/18 at 3:30 pm, LVN A stated Resident #1 had been sent out to the hospital on [DATE]. She said Resident # 1's respirations where labored. She said Resident #1's respirations were frequently labored, and she frequently had shortness of breath; however, she recovers. She said she did not feel the resident was critical enough to be sent to hospital due to all of her vital signs being within normal range for the resident. LVN A said Resident #1's family requested for the resident to be sent to hospital, so we sent her. Record Review of Resident #1's hospital admission record dated 07/21/18 included the following, in part: History and Physical listed the chief complaint as respiratory distress. Apparently for the last 2 days the patient has been having worsening respiratory difficulties. Her family came to visit her .today noted this and brought her into the ER. There she was tachypneic (rapid respirations) to the 40s. She was placed on [MEDICAL CONDITION] given Solu-[MEDICATION NAME] and a breathing treatment as well as some IV magnesium (an electrolyte) and IV [MEDICATION NAME] (an antibiotic) .The patient and her family also note that she has been unable to lie flat, has to sleep sitting upright. Physical Exam listed a weight of 238 lbs. Clinical Impression: 1. Acute [MEDICAL CONDITION] with hypercapnia, Acute (due to increased amount of carbon [MEDICATION NAME]) 2. Left ventricular failure, Acute (left sided heart failure) Record Review of Resident #1's Hospital Radiology Report dated 07/23/18 at 3:53 pm indicated Radiology Paracentesis (Removal of fluid in a cavity) was preformed and removed 8060 ml (8 Liters) of Ascites fluid. (According to The Merck Manual, 18th Edition, Ascites is the condition in which there is free fluid in the peritoneal cavity (abdomen). Ascites can result from chronic liver diseases. If ascites results in elevation of the diaphram, dyspnea (shortness of breath) may occur. Spontaneous bacterial peritonitis (SBP) is particularly common in cirrhotic ascites .It may produce serious sequelae or death .) During an interview in the hospital on [DATE] at 11:00 am; Resident #1 stated she had been in the hospital since 07/21/18 due to having trouble breathing and being lethargic, she said her daughter had come to see her at the facility and had requested for her to be sent to emergency room . Resident #1 was unable to say if she had a history of [REDACTED]. During an interview on 07/26/18 at 1:35 pm with the DON, she said the physician had not been informed of 4 lb. weight gain from (MONTH) to July, and it was her expectation for residents with [MEDICAL CONDITION] to have the physician orders [REDACTED]. During a telephone interview on 07/26/18 at 1:55 pm with Resident #1's Primary Care Physician G; he said 8 liters was a tremendous amount of fluid to be removed out of the abdomen. He said it was a reasonable standard for weights to be done every 4-days for [MEDICAL CONDITION] to determine if a resident was experiencing fluid overload. He said it had been an oversight on the part of the NP and the order had not been pushed forward in the computer to the Medication Administration Record [REDACTED]. He said he had spoken with the facility and the NP and they would ensure there would be no further omission of orders. Review of the facility's undated policy/procedure, Medication Orders, included the following, in part: Recording Orders: 6. Treatment Orders- When recording treatment orders, specify the treatment, frequency and duration of treatment. Review of the facility's undated policy/procedure, Weighing and Measuring the Resident, included the following, in part:: Purpose: The purposes of this procedures are to determine the resident's weight and height, to provide a baseline an and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height to determine the idea weight of the resident. Preparation: 1. Review the residents care plan to assess for any special needs of the resident . Reporting: 1. Report significant weight loss/weight gain to nurse supervisor. 4. Report other information in accordance with facility policy and professional standards of practice. An Immediate jeopardy (IJ) was identified on 07/27/18 at 11:45 am, the Administrator and Director of Nursing were informed. The Facility's plan of removal of immediate Jeopardy was accepted on 7/27/18 at 3:40 PM 1. In-service for facility staff on noting and initiating new physician orders 2. Nursing administration will review all new physician orders [REDACTED]. 3. A full audit for all unscheduled orders will be completed and corrective action taken. 4. Director of Clinical Operations will educate the facility providers to include physicians Nurse practitioners and or physician extenders regarding entering of physician orders. To be completed: 07/27/18 Any provider who is unavailable for training on the date, will not enter orders until training has been provided. 5. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, social director to review plan of removal. To be completed by 7/27/18. During an Interview on 7/27/18 at 1:35 pm RN D said she had participated in an In-service 7/27/18 regarding how to enter orders into the computer system and transcribe orders on nursing Medication Administration Record. She said following proper transcription of the order, the order pops up as supplemental documentation and once saved, it confirmed and went into the Nursing Medication Administration Record. During Interview and Observation on 7/27/18 at 1:45 pm with LVN B, she said she had participated in the In-service 7/27/18 on how to enter orders on computer, she was able to verbalize the step by step instructions on how to enter orders on Nurse Medication Administration Record [REDACTED]. During an interview on 7/27/18 at 2:00 pm with CNA F said he had participated in the In-service about weighing residents. He was able to verbalize when a task was due on the computer system and how it notified him. During an interview on 7/27/18 at 2:30 pm DON stated the facility has identified a problem when an order has frequencies or steps in the orders. Sometimes the orders will not go straight to Nurse Medication Administration Record [REDACTED]. Staff will not work if they are not in serviced. On 7/27/18 the Administrator and DON were informed that while the IJ was lowered on 7/27/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. According to a List received from the DON on 7/27/18 indicated the facility had identified 29 residents who had Primary Care Physician G and Nurse Pactitioner H. Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #1) reviewed for quality of care. The facility failed to: a) ensure Resident #1 who had a [DIAGNOSES REDACTED]. The family requested she be sent to the hospital at which time the hospital removed 8060 ml of Ascites fluid. b) ensure Resident #1's Physician was notified of a 2 lb.(pound) weight gain as indicated in her care plan. These failures resulted in an IJ on 7/27/18. While the IJ was lowered on 7/27/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure to carry out physician's orders [REDACTED]. Findings included: Record Review of Resident #1's undated Face Sheet revealed an [AGE] year old female admitted to the facility on [DATE]. The residents' [DIAGNOSES REDACTED]. Record Review of Resident #1's Admit History and Assessment by the Nurse Practitioner, dated 5/30/18, indicated that during her hospital stay she had some abdominal distention, and 6300 ml of ascitic fluid (accumulation of fluid in the abdominal cavity) was removed from her abdomen. She had apparently been noncompliant with her [MEDICATION NAME]. Assessment and Plan: Anorexia- [MEDICATION NAME]. Will continue to monitor weights. Generalized weakness and debility- continue with PT/OT. [MEDICAL CONDITION] of the liver with [MEDICAL CONDITION] - Continue with [MEDICATION NAME]. DNR Record Review of Resident #1's Admission assessment dated [DATE] indicated Resident #1's weight was documented at 242.0 lbs. (pounds). Record Review of Resident #1's Admission MDS assessment dated [DATE] revealed the following; Resident #1 had a BIMs (Brief Interview for Mental status) score of 14, indicating cognitive decision-making skills were intact. Record Review of Resident #1's undated Care Plan indicated problems of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #1's care plan included, in part: Focus: [MEDICAL CONDITION] related to [MEDICAL CONDITION] Goal: Resident #1 will have no signs and symptoms of complications related to fluid overload through the review date. Intervention/task: Auscultate heart and lung sounds every shift and document findings. Monitor/document/report as needed the following signs and symptoms; [MEDICAL CONDITION], weight gain of over two pounds a day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, peripheral pulses, level of conscious, monitor breath sounds for crackles. Record Review of Resident #1's Clinical Physician order [REDACTED]. Record Review of Resident #1's Physician order [REDACTED]. Weight was 230.0 pounds. Record Review of Resident #1's Physician order [REDACTED]. Record Review of Resident #1's weight on 07/06/18 was 234 pounds, an increase of 4.0 lbs since 06/21/18. Record Review of Resident #1's Nursing assessment dated [DATE] at 12:05 am indicated the resident's heart rate was at a regular rhythm, the resident had labored respirations, shallow breathing, and oxygen saturation of 92% on 2 liters per nasal cannula. Record Review of Resident #1's Nursing assessment dated [DATE] at 7:59 am indicated shortness of breath. During a telephone interview on 7/24/18 at 12:15 pm with Resident #1's granddaughter, she said that her mother had gone to the nursing home on 07/21/18 and Resident #1 was having trouble breathing and was confused. She said her mother had reported her concerns to the charge nurse and the charge nurses wanted to wait till Monday to call the physician. Resident #1's granddaughter said her mother had requested Resident #1 be sent to the emergency room for evaluation. Resident #1's granddaughter stated the emergency room had put the resident on [MEDICAL CONDITION] (bilevel continuous positive airway pressure) and started intravenous fluids. She said the emergency room Physician had informed her mother the resident was in [MEDICAL CONDITION]. She said the physician had also diagnosed the resident with [MEDICAL CONDITIONS], and stated her kidneys were not working properly. Resident #1's granddaughter said they had to remove 8 liters of fluid from her abdomen and she was very sick. During an interview on 7/24/18 at 3:30 pm, LVN A stated Resident #1 had been sent out to the hospital on [DATE]. She said Resident # 1's respirations where labored. She said Resident #1's respirations were frequently labored, and she frequently had shortness of breath; however, she recovers. She said she did not feel the resident was critical enough to be sent to hospital due to all of her vital signs being within normal range for the resident. LVN A said Resident #1's family requested for the resident to be sent to hospital, so we sent her. Record Review of Resident #1's hospital admission record dated 07/21/18 included the following, in part: History and Physical listed the chief complaint as respiratory distress. Apparently for the last 2 days the patient has been having worsening respiratory difficulties. Her family came to visit her .today noted this and brought her into the ER. There she was tachypneic (rapid respirations) to the 40s. She was placed on [MEDICAL CONDITION] given Solu-[MEDICATION NAME] and a breathing treatment as well as some IV magnesium (an electrolyte) and IV [MEDICATION NAME] (an antibiotic) .The patient and her family also note that she has been unable to lie flat, has to sleep sitting upright. Physical Exam listed a weight of 238 lbs. Clinical Impression: 1. Acute [MEDICAL CONDITION] with hypercapnia, Acute (due to increased amount of carbon [MEDICATION NAME]) 2. Left ventricular failure, Acute (left sided heart failure) Record Review of Resident #1's Hospital Radiology Report dated 07/23/18 at 3:53 pm indicated Radiology Paracentesis (Removal of fluid in a cavity) was preformed and removed 8060 ml (8 Liters) of Ascites fluid. (According to The Merck Manual, 18th Edition, Ascites is the condition in which there is free fluid in the peritoneal cavity (abdomen). Ascites can result from chronic liver diseases. If ascites results in elevation of the diaphram, dyspnea (shortness of breath) may occur. Spontaneous bacterial peritonitis (SBP) is particularly common in cirrhotic ascites .It may produce serious sequelae or death .) During an interview in the hospital on [DATE] at 11:00 am; Resident #1 stated she had been in the hospital since 07/21/18 due to having trouble breathing and being lethargic, she said her daughter had come to see her at the facility and had requested for her to be sent to emergency room . Resident #1 was unable to say if she had a history of [REDACTED]. During an interview on 07/26/18 at 1:35 pm with the DON, she said the physician had not been informed of 4 lb. weight gain from (MONTH) to July, and it was her expectation for residents with [MEDICAL CONDITION] to have the physician orders [REDACTED]. During a telephone interview on 07/26/18 at 1:55 pm with Resident #1's Primary Care Physician G; he said 8 liters was a tremendous amount of fluid to be removed out of the abdomen. He said it was a reasonable standard for weights to be done every 4-days for [MEDICAL CONDITION] to determine if a resident was experiencing fluid overload. He said it had been an oversight on the part of the NP and the order had not been pushed forward in the computer to the Medication Administration Record [REDACTED]. He said he had spoken with the facility and the NP and they would ensure there would be no further omission of orders. Review of the facility's undated policy/procedure, Medication Orders, included the following, in part: Recording Orders: 6. Treatment Orders- When recording treatment orders, specify the treatment, frequency and duration of treatment. Review of the facility's undated policy/procedure, Weighing and Measuring the Resident, included the following, in part:: Purpose: The purposes of this procedures are to determine the resident's weight and height, to provide a baseline an and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height to determine the idea weight of the resident. Preparation: 1. Review the residents care plan to assess for any special needs of the resident . Reporting: 1. Report significant weight loss/weight gain to nurse supervisor. 4. Report other information in accordance with facility policy and professional standards of practice. An Immediate jeopardy (IJ) was identified on 07/27/18 at 11:45 am, the Administrator and Director of Nursing were informed. The Facility's plan of removal of immediate Jeopardy was accepted on 7/27/18 at 3:40 PM 1. In-service for facility staff on noting and initiating new physician orders 2. Nursing administration will review all new physician orders [REDACTED]. 3. A full audit for all unscheduled orders will be completed and corrective action taken. 4. Director of Clinical Operations will educate the facility providers to include physicians Nurse practitioners and or physician extenders regarding entering of physician orders. To be completed: 07/27/18 Any provider who is unavailable for training on the date, will not enter orders until training has been provided. 5. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, social director to review plan of removal. To be completed by 7/27/18. During an Interview on 7/27/18 at 1:35 pm RN D said she had participated in an In-service 7/27/18 regarding how to enter orders into the computer system and transcribe orders on nursing Medication Administration Record. She said following proper transcription of the order, the order pops up as supplemental documentation and once saved, it confirmed and went into the Nursing Medication Administration Record. During Interview and Observation on 7/27/18 at 1:45 pm with LVN B, she said she had participated in the In-service 7/27/18 on how to enter orders on computer, she was able to verbalize the step by step instructions on how to enter orders on Nurse Medication Administration Record [REDACTED]. During an interview on 7/27/18 at 2:00 pm with CNA F said he had participated in the In-service about weighing residents. He was able to verbalize when a task was due on the computer system and how it notified him. During an interview on 7/27/18 at 2:30 pm DON stated the facility has identified a problem when an order has frequencies or steps in the orders. Sometimes the orders will not go straight to Nurse Medication Administration Record [REDACTED]. Staff will not work if they are not in serviced. On 7/27/18 the Administrator and DON were informed that while the IJ was lowered on 7/27/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. According to a List received from the DON on 7/27/18 indicated the facility had identified 29 residents who had Primary Care Physician G and Nurse Pactitioner H.

Based on interview and record review the facility failed to ensure that residents had the right to be free from abuse, neglect, misappropriation of property and exploitation for 1 (Resident #1) of 6 residents reviewed for neglect. The facility failed to: a) ensure Resident #1 who had a [DIAGNOSES REDACTED]. The family requested she be sent to the hospital at which time the hospital removed 8060 ml of Ascites fluid. b) ensure Resident #1's Physician was notified of a 2 lb.(pound) weight gain as indicated in her care plan. These failures resulted in an IJ on 7/27/18. While the IJ was lowered on 7/27/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. This failure to carry out physician's orders [REDACTED]. Findings included: Record Review of Resident #1's undated Face Sheet revealed an [AGE] year old female admitted to the facility on [DATE]. The residents' [DIAGNOSES REDACTED]. Record Review of Resident #1's Admit History and Assessment by the Nurse Practitioner, dated 5/30/18, indicated that during her hospital stay she had some abdominal distention, and 6300 ml of ascitic fluid (accumulation of fluid in the abdominal cavity) was removed from her abdomen. She had apparently been noncompliant with her [MEDICATION NAME]. Assessment and Plan: Anorexia- [MEDICATION NAME]. Will continue to monitor weights. Generalized weakness and debility- continue with PT/OT. [MEDICAL CONDITION] of the liver with [MEDICAL CONDITION] - Continue with [MEDICATION NAME]. DNR Record Review of Resident #1's Admission assessment dated [DATE] indicated Resident #1's weight was documented at 242.0 lbs. (pounds). Record Review of Resident #1's Admission MDS assessment dated [DATE] revealed the following; Resident #1 had a BIMs (Brief Interview for Mental status) score of 14, indicating cognitive decision-making skills were intact. Record Review of Resident #1's undated Care Plan indicated problems of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Resident #1's care plan included, in part: Focus: [MEDICAL CONDITION] related to [MEDICAL CONDITION] Goal: Resident #1 will have no signs and symptoms of complications related to fluid overload through the review date. Intervention/task: Auscultate heart and lung sounds every shift and document findings. Monitor/document/report as needed the following signs and symptoms; [MEDICAL CONDITION], weight gain of over two pounds a day, neck vein distension, difficulty breathing, increased heart rate, elevated blood pressure, skin temperature, peripheral pulses, level of conscious, monitor breath sounds for crackles. Record Review of Resident #1's Clinical Physician order [REDACTED]. Record Review of Resident #1's Physician order [REDACTED]. Weight was 230.0 pounds. Record Review of Resident #1's Physician order [REDACTED]. Record Review of Resident #1's weight on 07/06/18 was 234 pounds, an increase of 4.0 lbs since 06/21/18. Record Review of Resident #1's Nursing assessment dated [DATE] at 12:05 am indicated the resident's heart rate was at a regular rhythm, the resident had labored respirations, shallow breathing, and oxygen saturation of 92% on 2 liters per nasal cannula. Record Review of Resident #1's Nursing assessment dated [DATE] at 7:59 am indicated shortness of breath. During a telephone interview on 7/24/18 at 12:15 pm with Resident #1's granddaughter, she said that her mother had gone to the nursing home on 07/21/18 and Resident #1 was having trouble breathing and was confused. She said her mother had reported her concerns to the charge nurse and the charge nurses wanted to wait till Monday to call the physician. Resident #1's granddaughter said her mother had requested Resident #1 be sent to the emergency room for evaluation. Resident #1's granddaughter stated the emergency room had put the resident on [MEDICAL CONDITION] (bilevel continuous positive airway pressure) and started intravenous fluids. She said the emergency room Physician had informed her mother the resident was in [MEDICAL CONDITION]. She said the physician had also diagnosed the resident with [MEDICAL CONDITIONS], and stated her kidneys were not working properly. Resident #1's granddaughter said they had to remove 8 liters of fluid from her abdomen and she was very sick. During an interview on 7/24/18 at 3:30 pm, LVN A stated Resident #1 had been sent out to the hospital on [DATE]. She said Resident # 1's respirations where labored. She said Resident #1's respirations were frequently labored, and she frequently had shortness of breath; however, she recovers. She said she did not feel the resident was critical enough to be sent to hospital due to all of her vital signs being within normal range for the resident. LVN A said Resident #1's family requested for the resident to be sent to hospital, so we sent her. Record Review of Resident #1's hospital admission record dated 07/21/18 included the following, in part: History and Physical listed the chief complaint as respiratory distress. Apparently for the last 2 days the patient has been having worsening respiratory difficulties. Her family came to visit her .today noted this and brought her into the ER. There she was tachypneic (rapid respirations) to the 40s. She was placed on [MEDICAL CONDITION] given Solu-[MEDICATION NAME] and a breathing treatment as well as some IV magnesium (an electrolyte) and IV [MEDICATION NAME] (an antibiotic) .The patient and her family also note that she has been unable to lie flat, has to sleep sitting upright. Physical Exam listed a weight of 238 lbs. Clinical Impression: 1. Acute [MEDICAL CONDITION] with hypercapnia, Acute (due to increased amount of carbon [MEDICATION NAME]) 2. Left ventricular failure, Acute (left sided heart failure) Record Review of Resident #1's Hospital Radiology Report dated 07/23/18 at 3:53 pm indicated Radiology Paracentesis (Removal of fluid in a cavity) was preformed and removed 8060 ml (8 Liters) of Ascites fluid. (According to The Merck Manual, 18th Edition, Ascites is the condition in which there is free fluid in the peritoneal cavity (abdomen). Ascites can result from chronic liver diseases. If ascites results in elevation of the diaphram, dyspnea (shortness of breath) may occur. Spontaneous bacterial peritonitis (SBP) is particularly common in cirrhotic ascites .It may produce serious sequelae or death .) During an interview in the hospital on [DATE] at 11:00 am; Resident #1 stated she had been in the hospital since 07/21/18 due to having trouble breathing and being lethargic, she said her daughter had come to see her at the facility and had requested for her to be sent to emergency room . Resident #1 was unable to say if she had a history of [REDACTED]. During an interview on 07/26/18 at 1:35 pm with the DON, she said the physician had not been informed of 4 lb. weight gain from (MONTH) to July, and it was her expectation for residents with [MEDICAL CONDITION] to have the physician orders [REDACTED]. During a telephone interview on 07/26/18 at 1:55 pm with Resident #1's Primary Care Physician G; he said 8 liters was a tremendous amount of fluid to be removed out of the abdomen. He said it was a reasonable standard for weights to be done every 4-days for [MEDICAL CONDITION] to determine if a resident was experiencing fluid overload. He said it had been an oversight on the part of the NP and the order had not been pushed forward in the computer to the Medication Administration Record [REDACTED]. He said he had spoken with the facility and the NP and they would ensure there would be no further omission of orders. Review of the facility's undated policy/procedure, Medication Orders, included the following, in part: Recording Orders: 6. Treatment Orders- When recording treatment orders, specify the treatment, frequency and duration of treatment. Review of the facility's undated policy/procedure, Weighing and Measuring the Resident, included the following, in part:: Purpose: The purposes of this procedures are to determine the resident's weight and height, to provide a baseline an and ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height to determine the idea weight of the resident. Preparation: 1. Review the residents care plan to assess for any special needs of the resident . Reporting: 1. Report significant weight loss/weight gain to nurse supervisor. 4. Report other information in accordance with facility policy and professional standards of practice. An Immediate jeopardy (IJ) was identified on 07/27/18 at 11:45 am, the Administrator and Director of Nursing were informed. The Facility's plan of removal of immediate Jeopardy was accepted on 7/27/18 at 3:40 PM 1. In-service for facility staff on noting and initiating new physician orders 2. Nursing administration will review all new physician orders [REDACTED]. 3. A full audit for all unscheduled orders will be completed and corrective action taken. 4. Director of Clinical Operations will educate the facility providers to include physicians Nurse practitioners and or physician extenders regarding entering of physician orders. To be completed: 07/27/18 Any provider who is unavailable for training on the date, will not enter orders until training has been provided. 5. An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, social director to review plan of removal. To be completed by 7/27/18. During an Interview on 7/27/18 at 1:35 pm RN D said she had participated in an In-service 7/27/18 regarding how to enter orders into the computer system and transcribe orders on nursing Medication Administration Record. She said following proper transcription of the order, the order pops up as supplemental documentation and once saved, it confirmed and went into the Nursing Medication Administration Record. During Interview and Observation on 7/27/18 at 1:45 pm with LVN B, she said she had participated in the In-service 7/27/18 on how to enter orders on computer, she was able to verbalize the step by step instructions on how to enter orders on Nurse Medication Administration Record [REDACTED]. During an interview on 7/27/18 at 2:00 pm with CNA F said he had participated in the In-service about weighing residents. He was able to verbalize when a task was due on the computer system and how it notified him. During an interview on 7/27/18 at 2:30 pm DON stated the facility has identified a problem when an order has frequencies or steps in the orders. Sometimes the orders will not go straight to Nurse Medication Administration Record [REDACTED]. Staff will not work if they are not in serviced. On 7/27/18 the Administrator and DON were informed that while the IJ was lowered on 7/27/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. According to a List received from the DON on 7/27/18 indicated the facility had identified 29 residents who had Primary Care Physician G and Nurse Pactitioner H.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, physical, mental, and psychosocial well-being, for one resident (Resident #1) of six residents reviewed for fall risk and pain management, in that: The facility failed to assess Resident #1's signs of pain and change in condition after a fall. He was diagnosed with [REDACTED]. This failure placed 53 high fall risk residents at risk for improper assessments and notification of physician with a change in condition. Findings included: Resident #1's face sheet, dated 02/02/17, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Functional Abilities/Self-Care and Mobility Assessment on 01/17/17 revealed resident's assessment ability to safely come to a standing position from sitting in a chair was not performed due to medical condition or safety concerns; significant fall risk. Fall Risk Assessment revealed on 01/17/17 1. Resident has cognitive status behaviors changed in the last 90 days 2. Incontinent 3. Balance: Not able to attempt without physical help 4. Mobility ambulates without problem and with devices. Score of 10 or more reflects resident is a high risk for falls. Resident #1 score was 20 during fall risk assessment. Fall Prevention Care Plan 01/18/17 revealed resident had a high back wheel chair with anti-tip rollers, fall mat at bedside and low bed resident was monitored by keeping within eye sight of nurse's station. Fall Investigation dated 01/22/17 revealed resident fell on [DATE] at 1:00 p.m. from wheel chair while trying to stand up. LVN E attempted to reach Resident #1 but was unable to reach him in time. Resident was assessed by LVN B and two skin tears were noticed on right elbow, tear was cleaned and steri strips were ordered by physician. Resident #1 family and physician were notified at time of incident. Facility's investigation report summary dated 01/27/17 revealed the following: Resident #1 experienced a witnessed fall at 1:00 p.m. 01/21/17. At that time he was assessed by LVN B and to have two skin tears to his right upper extremity. He complained of mild pain to his right upper extremity and as needed pain medication was administered. During the night shift at approximately 1:00 a.m. the resident began to display non-verbal indicators of pain of his right lower extremity. LVN A administered as needed pain medication. The resident was then toileted and returned to a recliner chair in the TV room where he was observed to be crying and moaning. LVN A did not further intervene by notifying the attending physician of a change in condition. LVN A stated to oncoming nurse LVN B she felt an x-ray would be warranted due to a suspected fracture. LVN E obtained an order for [REDACTED]. Review of Resident #1 history and physical on 01/22/17 revealed Resident #1 was brought to the emergency room , was found to have a fracture in his right femur. I am not able to obtain much history from the patient. He is mumbling, He cannot tell me if he is actively in pain. He can tell me what his name is but that is all the orientation that he possesses at this point in time. Review of hospital x-ray report on 01/22/17 at 10:57 a.m. by Radiologist reflects lateral view or right femur findings/impression: There is a long intramedullary rod with compression nail involving the right femur. Basicervical neck fracture persists. There is a nondisplaced oblique fracture involving the proximal shaft of the femur which is acute. The distal interlocking screws are fractured. Not other acute findings are noted. Review of hospital record on 01/22/17 at 7:12 p.m. reflects orthopedic surgeon saw Resident #1 and will discuss a revisional surgery to the right lower extremity with Resident #1 and his family. Revisional surgery may be referred elsewhere due to the complexity of hardware removal and repair. On 02/01/17 at 9:30 a.m. in an interview the Administrator revealed Resident #1 was sent to another hospital for surgery to repair his right femur. Interview with LVN E on 02/02/17 at 12:10 p.m. revealed he witnessed Resident #1 fall, and LVN B assessed the resident at that time. Resident #1 mentioned to LVN E his right knee was hurting. LVN E told LVN B Resident #1 was complaining of right knee pain right after the fall. LVN E said he initially helped get Resident #1 up into his wheel chair after LVN B assessed him for injury. Interview with LVN G on 02/03/17 at 2:15 p.m. revealed he assisted Resident #1 after his fall, he was already up in his chair and he was complaining his knee was hurting and told LVN B she should keep an eye out for him since he just had a fall. LVN B already assessed Resident #1 after the fall. LVN G did not assess Resident #1 at this time. Interview with CNA F on 02/02/17 at 11:50 a.m. revealed he toileted Resident #1 about 3:00 p.m. on 01/21/17 and Resident #1 complaining of pain to his right leg and groin area but said he was having problems with an old hernia. CNA F said he told LVN A and LVN B Resident #1 was complaining of pain during nurse's report. Interview with LVN A (who worked the night shift on 1/21/17 - 1/22/17) on 02/01/17 at 1:30 p.m. revealed Resident #1 was sitting in a recliner in the T.V. room across from the nurses desk. She said he was rubbing his right leg and crying. LVN A thought he was in pain so LVN A administered [MEDICATION NAME] 50 mg (milligrams) about 1 a.m. and he was asleep at the change of shift. LVN A was aware he had fallen on the day shift and was having a change in condition with the crying and rubbing his leg. When LVN A was asked if she called the physician for an X-ray or other interventions she said she did not. When LVN A was asked if she had previous problems calling the physician, she said she did not have a problem calling the physician but did not on this occasion, however she said she wished she had called the physician. Resident #1's physician's orders [REDACTED]. Resident #1 ' s Controlled Substance Record, dated 01/21/17 through 01/22/17, reflected on 01/21/17 at 1:00 a.m. 1 tablet of [MEDICATION NAME] 50 mg was administered. Resident #1's MAR (medication administration record), dated January 2017, reflected [MEDICATION NAME] 50 mg was given at 1:00 a.m. on 01/21/17, and Resident #1 pain assessment for 6 p.m. to 6 a.m. reflected Resident #1 had a B ( reflects facial expressions for pain) of 9. Review of LVN A signed interview with the DON on 01/22/17 at 5:40 p.m. revealed Resident continued to rub his right leg in thigh area about 1:00 a.m. I gave [MEDICATION NAME] pain pill for pain B scale 8/10 observed. Interview with CNA C on 02/01/17 at 12:45 p.m. revealed he set up Resident #1 breakfast tray around 8 a.m. on 01/22/17 when the resident finished CNA C was asked to take him to the toilet, when CNA C touched his wheel chair he began to cry and rubbing his leg complaining of pain. CNA C told LVN B at the time but LVN B was in the process of sending another resident to the emergency room . Interview with LVN B on 02/02/17 at 12:15 p.m. revealed when she came on duty 01/22/17 LVN A told her Resident #1 had a change in condition and was crying and rubbing his leg complaining of pain. LVN A administered [MEDICATION NAME], LVN A reported she thought he may have fractured his hip and may need and X-ray. LVN B went to check on Resident #1 and he was asleep in the recliner. At the time I prioritized getting another resident, having medical problems to the emergency room . Resident #1 was asleep and my other resident's vital signs were abnormal. CNA C told me Resident #1 was having pain and LVN B asked RN D to please check on him. Resident #1's nurses' note, dated 01/22/17 at 8:00 a.m. LVN B wrote 8:40 a.m. primary care physician notified Resident #1 change in condition and is unable to demonstrate range of motion to right lower extremity. Medicated with pain medication received new order for follow up x-ray, portable x-ray service notified. At 10:15 a.m. Resident transported to to emergency room for increased pain to right hip and discoloration to right lower extremity. Untimed signed statement given by RN D (nurse would not return telephone calls for interview) on 01/22/17 said, LVN B was concerned mobile x-ray had not come or called back in regards to Resident #1, at that time I assessed him and he was grimacing, tearful pointing at his right hip. Right leg was discolored cold and blue with very faint pulses. I called the DON and 911 transport him to the emergency room . Interview with DON on 02/02/17 at 11:00 a.m. revealed when asked what your charge nurses' responsibility is when a resident falls. At the time when Resident #1 fell LVN B thought it was just a skin tear, she notified the physician and family we then got a report on his history and physical he had a fracture femur. LVN A reported a change in condition at 1 a.m. the following shift. Would your expectations of your nurses to be call the attending physician when there was a change if a residents condition? Yes I would expect them to call the physician for guidance. LVN A failed to follow policy and procedure in regards to Resident #1 change in condition. Review of Resident #1 Pain Risk Assessment in Advanced Dementia on 01/17/17 revealed 1. Negative Vocalization - Occasional moan or groan - low level speech with a negative or disapproving quality 2. Body Language - Tense- Distressed pacing - Fidgeting Review of facility Pain Management Policy revised on 3/16 reflects the following: Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's report of pain, or nonverbal signs suggesting pain, be evaluated. .5. If the Resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>Review of facility Acute Condition Changes- Clinical Protocol revised on December 2012 reflects the following: .6. The nursing staff will contact the Physician based on urgency of a situation. For emergencies they will call or page the Physician and request a prompt response. A list of resident provided by DON on 02/03/17 at 2:30 p.m. reflected there were 53 residents at high risk for falls.

Based on observation, record review, and interview, the facility failed to implement their written policy and procedure that prohibited neglect, for one Resident (Resident #1) of six residents reviewed for neglect. The facility failed to assess Resident #1's signs of increased pain and notify the physician of change in condition after a fall which resulted in a fractured right femur. This failure placed 53 high fall risk residents at risk for improper assessments and notification of physician with a change in condition or prevent neglect. Findings included: Undated Abuse/Neglect policy reflects the following: Each resident has the right to be free from .neglect .mental anguish or pain to a resident . Resident #1's face sheet, dated 02/02/17, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Undated Abuse/Neglect policy reflects the following: Each resident has the right to be free from .neglect .mental anguish or paint to a resident . Review of Functional Abilities/Self-Care and Mobility Assessment on 01/17/17 revealed resident's assessment ability to safely come to a standing position from sitting in a chair was not performed due to medical condition or safety concerns; significant fall risk. Fall Risk Assessment revealed on 01/17/17 1. Resident has cognitive status behaviors changed in the last 90 days 2. Incontinent 3. Balance: Not able to attempt without physical help 4. Mobility ambulates without problem and with devices. Score of 10 or more reflects resident is a high risk for falls. Resident #1 score was 20 during fall risk assessment. Fall Prevention Care Plan 01/18/17 revealed resident had a high back wheel chair with anti-tip rollers, fall mat at bedside and low bed resident was monitored by keeping within eye sight of nurse's station. Fall Investigation on 01/22/17 revealed resident fell on [DATE] at 1:00 p.m. from wheel chair while trying to stand up. LVN E attempted to reach Resident #1 but was unable to reach him in time. Resident was assessed by LVN B and two skin tears were noticed on right elbow, tear was cleaned and steri strips were ordered by physician. Resident #1 family and physician were notified at time of incident. Facility's investigation report summary on 01/27/17 revealed the following: Resident #1 experienced a witnessed fall at 1:00 p.m. 01/21/17. At that time he was assessed by LVN B and to have two skin tears to his right upper extremity. He complained of mild pain to his right upper extremity and as needed pain medication was administered. During the night shift at approximately 1:00 a.m. the resident began to display non-verbal indicators of pain of his right lower extremity. LVN A administered as needed pain medication. The resident was then toileted and returned to a recliner chair in the TV room where he was observed to be crying and moaning. LVN A did not further intervene by notifying the attending physician of a change in condition. LVN A stated to oncoming nurse LVN B she felt an x-ray would be warranted due to a suspected fracture. LVN E obtained an order for [REDACTED]. Resident #1's physician's orders [REDACTED]. Resident #1's MAR (medication administration record), dated January 2017, reflected [MEDICATION NAME] 50 mg was given at 1:00 a.m. on 01/21/17,and Resident #1 pain assessment for 6 p.m. to 6 a.m. reflected Resident #1 had a B ( reflects facial expressions for pain) of 9. Review of LVN A signed interview with the DON on 01/22/17 at 5:40 p.m. revealed Resident continued to rub his right leg in thigh area about 1:00 a.m. I gave Tranadol pain pill for pain B scale 8/10 observed. Resident #1 ' s Controlled Substance Record, dated 01/21/17 through 01/22/17, reflected on 01/21/17 at 1:00 a.m. 1 tablet of [MEDICATION NAME] 50 mg was administered. Interview with LVN A on 02/01/17 at 1:30 p.m. revealed Resident #1 was sitting in a recliner in the T.V. room across from the nurses desk. She said he was rubbing his right leg and crying. LVN A thought he was in pain so LVN A administered [MEDICATION NAME] 50 mg (milligrams) about 1 a.m. and he was asleep at the change of shift. LVN A was aware he fell on the day shift and was having a change in condition with the crying and rubbing his leg. When LVN A was asked if she called the physician for an X-ray or other interventions she said she did not. When LVN A was asked if she had previous problems calling the physician, she said she did not have a problem calling the physician but did not on this occasion, however she said she wished she had called the physician. Interview with CNA C on 02/01/17 at 12:45 p.m. revealed he set up Resident #1 breakfast tray around 8 a.m. on 01/22/17 when the resident finished CNA C was asked to take him to the toilet, when CNA C touched his wheel chair he began to cry and rubbing his leg complaining of pain. CNA C told LVN B at the time but LVN B was in the process of sending another resident to the emergency room . Interview with LVN B revealed when she came on duty 01/22/17 LVN A told her Resident #1 had a change in condition and was crying and rubbing his leg complaining of pain. LVN A administered [MEDICATION NAME], LVN A reported she thought he may have fractured his hip and may need and X-ray. LVN B went to check on Resident #1 and he was asleep in the recliner. At the time I prioritized getting another resident, having medical problems to the emergency room . Resident #1 was asleep and my other resident's vital signs were abnormal. CNA C told me Resident #1 was having pain and LVN B asked RN D to please check on him. Signed statement given by RN D ( nurse would not return telephone calls for interview) on 01/22/17 said, LVN B was concerned mobile x-ray had not come or called back in regards to Resident #1, at that time I assessed him and he was grimacing, tearful pointing at his right hip. Right leg was discolored cold and blue with very faint pulses. I called the DON and 911 transport him to the emergency room . Interview with CNA F on 02/02/17 at 11:50 a.m. revealed he toileted Resident #1 about 3:00 p.m. on 01/21/17 and Resident #1 complaining of pain to his right leg and groin area but said he was having problems with an old hernia. CNA F said he told LVN A and LVN B Resident #1 was complaining of pain during nurse's report. Interview with LVN E on 02/02/17 at 12:10 revealed he witness Resident #1 fall and LVN B assessed the resident at this time. Resident #1 mentioned to me his right knee was hurting and I told LVN B he was complaining of right knee pain right after the fall. Interview with LVN G on 02/03/17 at 2:15 p.m. revealed he assisted Resident #1 after his fall, he was already up in his chair and he was complaining his knee was hurting and I told LVN B she should keep an eye out for him since he just had a fall. Interview with DON on 02/02/17 at 11:00 a.m. revealed when asked what your charge nurses' responsibility is when a resident falls. At the time when Resident #1 fell LVN B thought it was just a skin tear, she notified the physician and family we then got a report on his history and physical he had a fracture femur. LVN A reported a change in condition at 1 a.m. the following shift. Would your expectations of your nurses to be call the attending physician when there was a change if a residents condition? Yes I would expect them to call the physician for guidance. LVN A failed to follow policy and procedure in regards to Resident #1 change in condition. Resident #1's nurses' note, dated 01/22/17 at 8:00 a.m. LVN B wrote 8:40 a.m. primary care physician notified Resident #1 change in condition and is unable to demonstrate range of motion to right lower extremity. Medicated with pain medication received new order for follow up x-ray, portable x-ray service notified. At 10:15 a.m. Resident transported to to emergency room for increased pain to right hip and discoloration to right lower extremity. Review of Resident #1 history and physical on 01/22/17 revealed Resident #1 was brought to the emergency room , was found to have a fracture in his right femur. I am not able to obtain much history from the patient. He is mumbling, He cannot tell me if he is actively in pain. He can tell me what his name is but that is all the orientation that he possesses at this point in time. Review of hospital x-ray report on 01/22/17 at 10:57 a.m. by Radiologist reflects lateral view or right femur findings/impression: There is a long intramedullary rod with compression nail involving the right femur. Basicervical neck fracture persists. There is a nondisplaced oblique fracture involving the proximal shaft of the femur which is acute. The distal interlocking screws are fractured. Not other acute findings are noted. Review of hospital record reflects orthopedic physician discuss a revisional surgery to the right lower extremity with Resident #1 and his family. Previsional surgery may be referred elsewhere due to the complexity of hardware removal and repair. On 02/01/17 at 9:30 a.m. in an interview with Administrator revealed Resident #1 was sent to another hospital for surgery to repair his right femur. Review of Resident #1 Pain Risk Assessment in Advanced Dementia on 01/17/17 revealed 1. Negative Vocalization - Occasional moan or groan - low level speech with a negative or disapproving quality 2. Body Language - Tense- Distressed pacing - Fidgeting Review of facility Pain Management Policy revised on 3/16 reflects the following: Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's report of pain, or nonverbal signs suggesting pain, be evaluated. .5. If the Resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>Review of facility Acute Condition Changes- Clinical Protocol revised on December 2012 reflects the following: .6. The nursing staff will contact the Physician based on urgency of a situation. For emergencies they will call or page the Physician and request a prompt response. Undated Abuse/Neglect policy reflects the following: Each resident has the right to be free from .neglect .mental anguish or paint to a resident . A list of resident provided by DON on 02/03/17 at 2:30 p.m. reflected there were 53 residents at high risk for falls.

Based on interview and record review the facility failed ensure the resident has the right to be free from neglect for one resident (Resident #1) of six residents reviewed for neglect: The facility failed to assess Resident #1's signs of increased pain and notify the physician of change in condition after a fall which resulted in a fractured right femur. This failure placed 53 high fall risk residents at risk for improper assessments and notification of physician with a change in condition. Findings included: Resident #1's face sheet, dated 02/02/17, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Functional Abilities/Self-Care and Mobility Assessment on 01/17/17 revealed resident's assessment ability to safely come to a standing position from sitting in a chair was not performed due to medical condition or safety concerns; significant fall risk. Fall Risk Assessment revealed on 01/17/17 1. Resident has cognitive status behaviors changed in the last 90 days 2. Incontinent 3. Balance: Not able to attempt without physical help 4. Mobility ambulates without problem and with devices. Score of 10 or more reflects resident is a high risk for falls. Resident #1 score was 20 during fall risk assessment. Fall Prevention Care Plan 01/18/17 revealed resident had a high back wheel chair with anti-tip rollers, fall mat at bedside and low bed resident was monitored by keeping within eye sight of nurse's station. Fall Investigation dated 01/22/17 revealed resident fell on [DATE] at 1:00 p.m. from wheel chair while trying to stand up. LVN E attempted to reach Resident #1 but was unable to reach him in time. Resident was assessed by LVN B and two skin tears were noticed on right elbow, tear was cleaned and steri strips were ordered by physician. Resident #1 family and physician were notified at time of incident. Facility's investigation report summary dated 01/27/17 revealed the following: Resident #1 experienced a witnessed fall at 1:00 p.m. 01/21/17. At that time he was assessed by LVN B and to have two skin tears to his right upper extremity. He complained of mild pain to his right upper extremity and as needed pain medication was administered. During the night shift at approximately 1:00 a.m. the resident began to display non-verbal indicators of pain of his right lower extremity. LVN A administered as needed pain medication. The resident was then toileted and returned to a recliner chair in the TV room where he was observed to be crying and moaning. LVN A did not further intervene by notifying the attending physician of a change in condition. LVN A stated to oncoming nurse LVN B she felt an x-ray would be warranted due to a suspected fracture. LVN E obtained an order for [REDACTED]. Review of Resident #1 history and physical on 01/22/17 revealed Resident #1 was brought to the emergency room , was found to have a fracture in his right femur. I am not able to obtain much history from the patient. He is mumbling, He cannot tell me if he is actively in pain. He can tell me what his name is but that is all the orientation that he possesses at this point in time. Review of hospital x-ray report on 01/22/17 at 10:57 a.m. by Radiologist reflects lateral view or right femur findings/impression: There is a long intramedullary rod with compression nail involving the right femur. Basicervical neck fracture persists. There is a nondisplaced oblique fracture involving the proximal shaft of the femur which is acute. The distal interlocking screws are fractured. Not other acute findings are noted. Review of hospital record on 01/22/17 at 7:12 p.m. reflects orthopedic surgeon saw Resident #1 and will discuss a revisional surgery to the right lower extremity with Resident #1 and his family. Revisional surgery may be referred elsewhere due to the complexity of hardware removal and repair. On 02/01/17 at 9:30 a.m. in an interview the Administrator revealed Resident #1 was sent to another hospital for surgery to repair his right femur. Interview with LVN E on 02/02/17 at 12:10 p.m. revealed he witnessed Resident #1 fall, and LVN B assessed the resident at that time. Resident #1 mentioned to LVN E his right knee was hurting. LVN E told LVN B Resident #1 was complaining of right knee pain right after the fall. LVN E said he initially helped get Resident #1 up into his wheel chair after LVN B assessed him for injury. Interview with LVN G on 02/03/17 at 2:15 p.m. revealed he assisted Resident #1 after his fall, he was already up in his chair and he was complaining his knee was hurting and told LVN B she should keep an eye out for him since he just had a fall. LVN B already assessed Resident #1 after the fall. LVN G did not assess Resident #1 at this time. Interview with CNA F on 02/02/17 at 11:50 a.m. revealed he toileted Resident #1 about 3:00 p.m. on 01/21/17 and Resident #1 complaining of pain to his right leg and groin area but said he was having problems with an old hernia. CNA F said he told LVN A and LVN B Resident #1 was complaining of pain during nurse's report. Interview with LVN A (who worked the night shift on 1/21/17 - 1/22/17) on 02/01/17 at 1:30 p.m. revealed Resident #1 was sitting in a recliner in the T.V. room across from the nurses desk. She said he was rubbing his right leg and crying. LVN A thought he was in pain so LVN A administered [MEDICATION NAME] 50 mg (milligrams) about 1 a.m. and he was asleep at the change of shift. LVN A was aware he had fallen on the day shift and was having a change in condition with the crying and rubbing his leg. When LVN A was asked if she called the physician for an X-ray or other interventions she said she did not. When LVN A was asked if she had previous problems calling the physician, she said she did not have a problem calling the physician but did not on this occasion, however she said she wished she had called the physician. Resident #1's physician's orders [REDACTED]. Resident #1 ' s Controlled Substance Record, dated 01/21/17 through 01/22/17, reflected on 01/21/17 at 1:00 a.m. 1 tablet of [MEDICATION NAME] 50 mg was administered. Resident #1's MAR (medication administration record), dated January 2017, reflected [MEDICATION NAME] 50 mg was given at 1:00 a.m. on 01/21/17, and Resident #1 pain assessment for 6 p.m. to 6 a.m. reflected Resident #1 had a B ( reflects facial expressions for pain) of 9. Review of LVN A signed interview with the DON on 01/22/17 at 5:40 p.m. revealed Resident continued to rub his right leg in thigh area about 1:00 a.m. I gave [MEDICATION NAME] pain pill for pain B scale 8/10 observed. Interview with CNA C on 02/01/17 at 12:45 p.m. revealed he set up Resident #1 breakfast tray around 8 a.m. on 01/22/17 when the resident finished CNA C was asked to take him to the toilet, when CNA C touched his wheel chair he began to cry and rubbing his leg complaining of pain. CNA C told LVN B at the time but LVN B was in the process of sending another resident to the emergency room . Interview with LVN B on 02/02/17 at 12:15 p.m. revealed when she came on duty 01/22/17 LVN A told her Resident #1 had a change in condition and was crying and rubbing his leg complaining of pain. LVN A administered [MEDICATION NAME], LVN A reported she thought he may have fractured his hip and may need and X-ray. LVN B went to check on Resident #1 and he was asleep in the recliner. At the time I prioritized getting another resident, having medical problems to the emergency room . Resident #1 was asleep and my other resident's vital signs were abnormal. CNA C told me Resident #1 was having pain and LVN B asked RN D to please check on him. Resident #1's nurses' note, dated 01/22/17 at 8:00 a.m. LVN B wrote 8:40 a.m. primary care physician notified Resident #1 change in condition and is unable to demonstrate range of motion to right lower extremity. Medicated with pain medication received new order for follow up x-ray, portable x-ray service notified. At 10:15 a.m. Resident transported to to emergency room for increased pain to right hip and discoloration to right lower extremity. Untimed signed statement given by RN D (nurse would not return telephone calls for interview) on 01/22/17 said, LVN B was concerned mobile x-ray had not come or called back in regards to Resident #1, at that time I assessed him and he was grimacing, tearful pointing at his right hip. Right leg was discolored cold and blue with very faint pulses. I called the DON and 911 transport him to the emergency room . Interview with DON on 02/02/17 at 11:00 a.m. revealed when asked what your charge nurses' responsibility is when a resident falls. At the time when Resident #1 fell LVN B thought it was just a skin tear, she notified the physician and family we then got a report on his history and physical he had a fracture femur. LVN A reported a change in condition at 1 a.m. the following shift. Would your expectations of your nurses to be call the attending physician when there was a change if a residents condition? Yes I would expect them to call the physician for guidance. LVN A failed to follow policy and procedure in regards to Resident #1 change in condition. Review of Resident #1 Pain Risk Assessment in Advanced Dementia on 01/17/17 revealed 1. Negative Vocalization - Occasional moan or groan - low level speech with a negative or disapproving quality 2. Body Language - Tense- Distressed pacing - Fidgeting Review of facility Pain Management Policy revised on 3/16 reflects the following: Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's report of pain, or nonverbal signs suggesting pain, be evaluated. .5. If the Resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>Review of facility Acute Condition Changes- Clinical Protocol revised on December 2012 reflects the following: .6. The nursing staff will contact the Physician based on urgency of a situation. For emergencies they will call or page the Physician and request a prompt response. Undated Abuse/Neglect policy reflects the following: Each resident has the right to be free from .neglect .mental anguish or pain to a resident A list of resident provided by DON on 02/03/17 at 2:30 p.m. reflected there were 53 residents at high risk for falls.

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of six residents reviewed for physician notification. The facility failed to immediately consult with Resident #1's physician when he experienced an increased in pain on 01/22/17 and failed to provide timely intervention and treatment. As a result, Resident #1 went 12 hours without adequate care and services to identify an acute femur [MEDICAL CONDITION] which required surgical repair. Theses failures placed all 53 residents at risk for not receiving timely and appropriate care in the event of a change in condition. Findings included: Resident #1's face sheet, dated 02/02/17, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Functional Abilities/Self-Care and Mobility Assessment on 01/17/17 revealed resident's assessment ability to safely come to a standing position from sitting in a chair was not performed due to medical condition or safety concerns; significant fall risk. Fall Risk Assessment revealed on 01/17/17 1. Resident has cognitive status behaviors changed in the last 90 days 2. Incontinent 3. Balance: Not able to attempt without physical help 4. Mobility ambulates without problem and with devices. Score of 10 or more reflects resident is a high risk for falls. Resident #1 score was 20 during fall risk assessment. Fall Prevention Care Plan 01/18/17 revealed resident had a high back wheel chair with anti-tip rollers, fall mat at bedside and low bed resident was monitored by keeping within eye sight of nurse's station. Fall Investigation dated 01/22/17 revealed resident fell on [DATE] at 1:00 p.m. from wheel chair while trying to stand up. LVN E attempted to reach Resident #1 but was unable to reach him in time. Resident was assessed by LVN B and two skin tears were noticed on right elbow, tear was cleaned and steri strips were ordered by physician. Resident #1 family and physician were notified at time of incident. Facility's investigation report summary dated 01/27/17 revealed the following: Resident #1 experienced a witnessed fall at 1:00 p.m. 01/21/17. At that time he was assessed by LVN B and to have two skin tears to his right upper extremity. He complained of mild pain to his right upper extremity and as needed pain medication was administered. During the night shift at approximately 1:00 a.m. the resident began to display non-verbal indicators of pain of his right lower extremity. LVN A administered as needed pain medication. The resident was then toileted and returned to a recliner chair in the TV room where he was observed to be crying and moaning. LVN A did not further intervene by notifying the attending physician of a change in condition. LVN A stated to oncoming nurse LVN B she felt an x-ray would be warranted due to a suspected fracture. LVN E obtained an order for [REDACTED]. Review of Resident #1 history and physical on 01/22/17 revealed Resident #1 was brought to the emergency room , was found to have a fracture in his right femur. I am not able to obtain much history from the patient. He is mumbling, He cannot tell me if he is actively in pain. He can tell me what his name is but that is all the orientation that he possesses at this point in time. Review of hospital x-ray report on 01/22/17 at 10:57 a.m. by Radiologist reflects lateral view or right femur findings/impression: There is a long intramedullary rod with compression nail involving the right femur. Basicervical neck fracture persists. There is a nondisplaced oblique fracture involving the proximal shaft of the femur which is acute. The distal interlocking screws are fractured. Not other acute findings are noted. Review of hospital record on 01/22/17 at 7:12 p.m. reflects orthopedic surgeon saw Resident #1 and will discuss a revisional surgery to the right lower extremity with Resident #1 and his family. Revisional surgery may be referred elsewhere due to the complexity of hardware removal and repair. On 02/01/17 at 9:30 a.m. in an interview the Administrator revealed Resident #1 was sent to another hospital for surgery to repair his right femur. Interview with LVN E on 02/02/17 at 12:10 p.m. revealed he witnessed Resident #1 fall, and LVN B assessed the resident at that time. Resident #1 mentioned to LVN E his right knee was hurting. LVN E told LVN B Resident #1 was complaining of right knee pain right after the fall. LVN E said he initially helped get Resident #1 up into his wheel chair after LVN B assessed him for injury. Interview with LVN G on 02/03/17 at 2:15 p.m. revealed he assisted Resident #1 after his fall, he was already up in his chair and he was complaining his knee was hurting and told LVN B she should keep an eye out for him since he just had a fall. LVN B already assessed Resident #1 after the fall. LVN G did not assess Resident #1 at this time. Interview with CNA F on 02/02/17 at 11:50 a.m. revealed he toileted Resident #1 about 3:00 p.m. on 01/21/17 and Resident #1 complaining of pain to his right leg and groin area but said he was having problems with an old hernia. CNA F said he told LVN A and LVN B Resident #1 was complaining of pain during nurse's report. Interview with LVN A (who worked the night shift on 1/21/17 - 1/22/17) on 02/01/17 at 1:30 p.m. revealed Resident #1 was sitting in a recliner in the T.V. room across from the nurses desk. She said he was rubbing his right leg and crying. LVN A thought he was in pain so LVN A administered [MEDICATION NAME] 50 mg (milligrams) about 1 a.m. and he was asleep at the change of shift. LVN A was aware he had fallen on the day shift and was having a change in condition with the crying and rubbing his leg. When LVN A was asked if she called the physician for an X-ray or other interventions she said she did not. When LVN A was asked if she had previous problems calling the physician, she said she did not have a problem calling the physician but did not on this occasion, however she said she wished she had called the physician. Resident #1's physician's orders [REDACTED]. Resident #1 ' s Controlled Substance Record, dated 01/21/17 through 01/22/17, reflected on 01/21/17 at 1:00 a.m. 1 tablet of [MEDICATION NAME] 50 mg was administered. Resident #1's MAR (medication administration record), dated January 2017, reflected [MEDICATION NAME] 50 mg was given at 1:00 a.m. on 01/21/17, and Resident #1 pain assessment for 6 p.m. to 6 a.m. reflected Resident #1 had a B ( reflects facial expressions for pain) of 9. Review of LVN A signed interview with the DON on 01/22/17 at 5:40 p.m. revealed Resident continued to rub his right leg in thigh area about 1:00 a.m. I gave [MEDICATION NAME] pain pill for pain B scale 8/10 observed. Interview with CNA C on 02/01/17 at 12:45 p.m. revealed he set up Resident #1 breakfast tray around 8 a.m. on 01/22/17 when the resident finished CNA C was asked to take him to the toilet, when CNA C touched his wheel chair he began to cry and rubbing his leg complaining of pain. CNA C told LVN B at the time but LVN B was in the process of sending another resident to the emergency room . Interview with LVN B on 02/02/17 at 12:15 p.m. revealed when she came on duty 01/22/17 LVN A told her Resident #1 had a change in condition and was crying and rubbing his leg complaining of pain. LVN A administered [MEDICATION NAME], LVN A reported she thought he may have fractured his hip and may need and X-ray. LVN B went to check on Resident #1 and he was asleep in the recliner. At the time I prioritized getting another resident, having medical problems to the emergency room . Resident #1 was asleep and my other resident's vital signs were abnormal. CNA C told me Resident #1 was having pain and LVN B asked RN D to please check on him. Resident #1's nurses' note, dated 01/22/17 at 8:00 a.m. LVN B wrote 8:40 a.m. primary care physician notified Resident #1 change in condition and is unable to demonstrate range of motion to right lower extremity. Medicated with pain medication received new order for follow up x-ray, portable x-ray service notified. At 10:15 a.m. Resident transported to to emergency room for increased pain to right hip and discoloration to right lower extremity. Untimed signed statement given by RN D (nurse would not return telephone calls for interview) on 01/22/17 said, LVN B was concerned mobile x-ray had not come or called back in regards to Resident #1, at that time I assessed him and he was grimacing, tearful pointing at his right hip. Right leg was discolored cold and blue with very faint pulses. I called the DON and 911 transport him to the emergency room . Interview with DON on 02/02/17 at 11:00 a.m. revealed when asked what your charge nurses' responsibility is when a resident falls. At the time when Resident #1 fell LVN B thought it was just a skin tear, she notified the physician and family we then got a report on his history and physical he had a fracture femur. LVN A reported a change in condition at 1 a.m. the following shift. Would your expectations of your nurses to be call the attending physician when there was a change if a residents condition? Yes I would expect them to call the physician for guidance. LVN A failed to follow policy and procedure in regards to Resident #1 change in condition. Review of Resident #1 Pain Risk Assessment in Advanced Dementia on 01/17/17 revealed 1. Negative Vocalization - Occasional moan or groan - low level speech with a negative or disapproving quality 2. Body Language - Tense- Distressed pacing - Fidgeting Review of facility Pain Management Policy revised on 3/16 reflects the following: Nursing home residents are at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. The onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. It is important, therefore, that a resident's report of pain, or nonverbal signs suggesting pain, be evaluated. .5. If the Resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for [REDACTED].>Review of facility Acute Condition Changes- Clinical Protocol revised on December 2012 reflects the following: .6. The nursing staff will contact the Physician based on urgency of a situation. For emergencies they will call or page the Physician and request a prompt response. A list of resident provided by DON on 02/03/17 at 2:30 p.m. reflected there were 53 residents at high risk for falls.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and ensure the environment was free of accident hazards for one (Resident #2) of six residents reviewed for falls. The facility failed to: 1) ensure Resident #2 received adequate supervision to prevent accidents. Resident #2 was assisted to the bathroom by facility staff and left unsupervised while toileting. 2) provide an environment that was free accident and hazardous. Resident #2 fell on [DATE] in her bathroom after being unsupervised and slipping on a wet hand towel placed on the floor by facility staff. This failure resulted in actual harm for Resident #2, who suffered a femur fracture and pain, and could place 33 residents who were identified as requiring assistance with toileting at risk for falls. The findings included: Resident #2 Review of Resident #2 ' s closed clinical record, the Admission Record dated 11/02/2015 indicated the [AGE] year old female resident was admitted to the facility on [DATE]. Resident #2 fell on [DATE], sustained a femur fracture and was discharged to the hospital. Review of Resident #2's history and physical dated 11/02/2015 indicated the following Diagnoses: [REDACTED]. Review of Resident #2 ' s admission Minimum (MDS) data set [DATE] indicated she had moderate cognitive impairment with a BIMS of 12 (a score of 8-12 indicated moderate cognitive impairment). She had no mood or behavior indicators. The resident required extensive assistance of one staff for bed mobility, transfers, dressing and toileting, extensive assistance of two or more staff with bathing. The resident required limited assistance of one staff for personal hygiene. Mobility devices used by the resident included a walker and a wheelchair. The resident was occasionally incontinent of bladder and always continent of bowel. She required limited assistance of one staff for ambulation. The resident had no previous falls and no history of falls. Review of Resident #2 ' s Fall Risk Evaluation dated 10/31/2015 indicated the resident scored 16, a score higher than 10 indicated the resident was at risk for falls. Review of Resident #2's Care Plan dated 11/07/2015 indicated the resident was identified as at high risk for falls related to multiple diagnoses, with the following approaches: monitor and eliminate potential environmental hazards. The Care Plan had no documentation to address what type of supervision or assistance the required for toileting. Review of an Incident and Accident Report dated 12/04/2015 indicated the following: on 12/04/2015 at 8:45 P.M. after RN A completed an assessment of the resident and administered her night medications, the resident asked for help to the restroom, RN A assisted the resident to the restroom, gave her the call light and asked her to call when she finished, the resident agreed. The bathroom call light came on and RN A responded and observed the resident on the floor. The resident stated she slipped on a wash cloth that was on the floor. The incident was documented as unwitnessed. The resident was sent to the hospital for evaluation and treatment. Review of the Falls Investigation Worksheet dated 12/04/2015 indicated at the time of the fall, Resident #2 was attempting to get up from the toilet. The resident required stand by assistance and usually toileted independently. The documented environmental considerations included a wash cloth on the floor. The resident's left leg was flaccid and she complained of pain after staff assisted her back on the toilet. The Recommendations/Interventions listed by RN A indicated : Remind staff and resident to keep linens/towels off of the floor and continue to remind the resident to call for help. Review of Resident #2's Progress Note dated 12/04/2015 at 11:30 P.M indicated: During the med pass RN A assessed the resident, took her vital signs and gave the resident her bedtime medications. The resident told RN A she needed to go to the restroom. RN A provided stand by assist to the toilet, gave the resident the call light and instructed her to call when she was done. At 8:45 P.M. RN A saw the resident's bathroom call light and went to assist. She observed the resident sitting on the floor in front of the toilet with her brief and pants up to her mid buttock, the resident said she slipped on the towel on the floor while trying to pull her pants up. The resident's left leg was noted to be flaccid and the resident was not able to move her left leg. The resident was sent to the hospital by ambulance. Review of the Provider Investigation Report dated 12/10/2015 indicated RN A assisted Resident #2 with toileting and observed water on the floor. RN A reached for the hand towel to wipe up the water and left the towel on the floor near the resident's sink before exited the room. The resident was observed on the floor 3 to 4 minutes later, she stated she had fallen on the towel that had been left on the floor by RN A. RN A received a written counseling, suspension without pay and education as a result of the incident. The education consisted of basic safety precautions, accident prevention, proper cleanup of spills and removal and identification of environmental hazards. During an interview on 12/21/2015 at 11:53 A.M. The DON stated RN A worked for the facility PRN. The DON stated Resident #2 normally self-toileted, RN A assisted the resident to the bathroom and handed her the call light. RN A noted water on the floor and used a bath towel to clean up the water then noted more water on the floor and used a hand towel to dry the second area. RN A then pushed the wet hand towel with her foot on the floor against the sink before leaving the room. During an interview on 12/21/2015 at 12:10 P.M. CNA A stated he had assisted Resident #2 to the toilet previously. CNA A stated the resident normally used her call light to alert staff she needed assistance to the bathroom. CNA A stated after assisting the resident to the toilet he would wait outside the bathroom door, the resident would stand up from the toilet by using her walker then CNA A said he would assist the resident back to bed. During a telephone interview on 12/21/2015 at 2:17 P.M. RN A stated 12/04/2015 was her first night to work alone and she was not familiar with the residents. RN A stated she was doing her medication pass and went in Resident #2 ' s room to administer medications and perform an assessment. RN A stated while in the resident's room she bumped the resident's bedside table which resulted in water spilling onto the floor. RN A stated she proceeded to assist Resident #2 to the restroom and called for another staff member to bring her a towel. RN A stated she cleaned the water spill with the towel and threw the wet towel in the linen barrel located in the resident's room. RN A stated she instructed the resident to use the call light when she was done. RN A noted more water on the floor and used a hand towel to dry the water. RN A stated she left the wet hand towel on the floor and used her foot to push the towel between the toilet and the sink. RN A stated she heard another resident across the hall screaming, she then exited Resident #2's room to assess the screaming resident. RN A stated she then went to the medication cart to prepare medications for another resident. While preparing the medications at the medication cart the bathroom emergency light from Resident #2 ' s room went off. RN A stated she placed the medications into the medication cart and then entered Residents #2 ' s room and saw the resident on the floor. RN A stated the resident was not able to tell her what happened, RN A assumed the resident slipped on the wet towel because the towel was in a different place on the floor from where RN A had left it. RN A stated she noted the residents left leg was flaccid but the resident did not complain of pain. RN A and a CNA assisted the resident to sit back on the toilet and the resident then began to complain of pain to her left leg. RN A stated she did not receive orientation regarding the residents' individual care needs prior to working alone. During an interview on 12/21/2015 at 4:20 P.M CMA A stated she usually asked the other CNA ' s if the residents could be left alone in the bathroom and use the call light. CMA A stated if at any time she was not sure if the resident could be left alone she would stay with the resident until toileting was completed. CMA A stated Resident #2 was capable of using her call light and could be left alone in the bathroom; however, she stayed in the bathroom while Resident #2 toileted. During an interview on 12/21/2015 at 4:30 P.M CNA B stated it was common practice to assist residents to the bathroom and then hand them the call light to use when done. CNA B stated she would not leave a resident alone on the toilet if they needed a lot of help or if they were confused. CNA B stated she recalled toileting Resident #2 but always stayed in the room, Resident #2 would verbally inform CNA B when she was done toileting, CNA B stated she would assist with cleaning her then assist her back to the bed. During an interview on 12/22/2015 at 3:55 P.M. Resident #2's physician said the resident's medical condition had declined. Review of the facility's un-dated Quality of Care Policy indicated based on each resident's comprehensive assessment, appropriate treatment and services are provided for all residents to help them maintain or improve their abilities to perform activities of daily living. According to the CMS-672 dated 12/11/15 33 residents required assistance for toileting.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #3 and #4) of five resident's reviewed for Falls. The facility failed to ensure: 1) Resident #4; who had a history of [REDACTED]. Resident #4 fell twice on 3/24/15 with no preventative interventions and fell again on 3/28/15 and suffered a nasal fracture and lacerations to the face. 2) Resident #3; who had a history of [REDACTED]. This failure resulted in actual harm for Resident #4 and could place 15 residents (including Resident #3) who were identified as high at risk for falls at risk of continued falls causing pain, injuries and a diminished quality of life. The findings included: Resident #4 Review of Resident #4 ' s closed clinical record, the Admission Record dated 3/21/15 indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident was discharged on [DATE]. Review of Resident #4 ' s admission Minimum (MDS) data set [DATE] indicated the facility had identified the resident to required set up help and/or physical assistance of one person for activities of daily living. The resident was identified to be occasionally incontinent of bladder and always continent of bowel. The facility identified the resident had the following fall history: fall during month before admission/reentry, fall 2-6 months before admission/reentry and fracture from falls 6 months pre admit/reentry. The resident had an onset start date for physical and occupational therapy of 2/16/15. Review of Resident #4 ' s clinical record indicated no documented Admission fall risk assessment or Admission Care plan related to the residents risk for falls. Review of an Incident and Accident Report dated 3/04/15 at 10:15 p.m. indicated the following: Resident found on the floor on the right side of the bed with bleeding to face. Was able to clean and assess injury to laceration to right eye (eyebrow) and abrasion to right wrist, elbow, and middle left finger of left hand. The incident was documented as unwitnessed. Review of a Statement for Accidents and Incidents dated 3/04/15 indicated the following: At 10:15 p.m. CNA found Resident #4 on the floor on the right side of her bed. The resident had blood all over her face and complained of pain to her right leg. The resident was able to move her right leg and assisted with standing up on it. Bleeding from the residents ' right eyebrow was heavy and pressure was applied with steri strips applied at 10:30 p.m. The area continued to ooze blood. The resident had an abrasion to her right outer wrist, laceration to her right elbow and a small cut to her left middle finger and the top of her left hand. At 10:45 p.m. the resident continued to have complaints of pain to her right leg. The DON, ADON, resident ' s son and primary care physician were notified. Incident/Accident Action Plan: Conclusion/Summary; Resident was able to state she was getting up to use the bathroom and verbalize understanding of use of the call light. Physician called for use of a low bed and a fall mat. Signed by the DON on 3/05/15. Review of Resident #4 ' s clinical record indicated no documentation on 3/05/15 regarding a physician order, placement or monitoring of the resident receiving a low bed with fall mats and no documented fall risk assessment. Review of Resident #4 ' s Immediate Needs Care Plan dated 3/04/15 indicated the following; Problem/Needs related to: Fall resulting in serious injury. Goals: None documented. Interventions: Neurological checks for 22 hours, vital signs every 30 minutes for 4 hours. Modify the at risk plan. Review of Resident #4 ' s Pain Evaluation dated 3/04/15 with no documented time indicated the following: The resident had complaints of pain to her right leg and right eyebrow. The pain was identified to worsen upon movement. The resident had pain of 6 (more than moderate pain) on a scale of 1-10. The resident reported constant pain and inability to independently perform ADL ' s. Current Plan indicated: No plan. Review of Resident #4 ' s Care Plan dated 3/05/15 indicated the following; Problem: Resident #4 had been identified as at high risk for falls related to unsteady gait. Goal: Resident #4 will be free of injury related to falls for 90 days. Approaches: Therapy to evaluate for decreased muscle strength and need for assistive devices. Review labs and medications for potential factors. Assess for change in condition and alert staff to residents increased needs. Fall risk assessment on admission, readmission, quarterly and with significant change. Evaluate for use of low bed, side rails and personal alarm. Monitor for pattern of risk factors or tendency to fall, Assist with ambulation and transfers, and Monitor degree of disorientation to determine safety needs. ( There was no clinical documentation found in the residents clinical record to indicated the interventions had been implemented.) Review of Resident #4 ' s hospital History and Physical dated 3/05/15 indicated the following: Reason for Admission: Right intertrochanteric femur fracture. History of Present Illness: This is a [AGE] year old female status [REDACTED]. She also hit her head and sustained some skin lacerations to her right elbow. She was brought to the emergency room complaining of pain that was about an 8 on a scale of 1-10, localized to her right elbow and right leg. She describes the pain as sharp in nature, worsening with movement to the right lower extremity. Physical Examination: Right lower extremity shows shortening and external rotation. Impression: Right intertrochanteric femur fracture. Plan: A lengthy discussion was had regarding treatment options. Recommendations for proceeding with a closed reduction and gamma nail fixation of her Right intertrochanteric femur fracture. Review of Resident #4 ' s hospital Operative Report dated 3/05/15 indicated: Closed reduction and gamma nail fixation of her Right intertrochanteric femur fracture. Review of Resident #4 ' s Discharge Summary dated 3/10/15 indicated the following: [AGE] year old female status [REDACTED]. She underwent intramedullary fixation of her intertrochanteric femur fracture. Review of Resident #4 ' s Physician order [REDACTED]. Diagnoses: [REDACTED]. Physical Therapy to evaluate and treat the resident for range of motion and gait training. Review of Resident #4 ' s clinical record indicated no fall risk assessment, no orders for low bed with fall mat, no evaluation for alarms. The residents comprehensive Care Plan had no documented updates or interventions related to the residents fall with fractures. Review of Resident #4 ' s Daily Skilled Nurse ' s Note dated 3/24/15 indicated at 3:00 a.m. Resident #4 had called for assistance to the bathroom. The resident had sat up at her bedside and began to slide to the floor. The resident was being held up by staff, however the floor was very slippery and the resident could not stand up without sliding. The resident and staff member sat down on the floor, no injuries and the resident was instructed not to get out of bed. (No Incident and Accident Report was found regarding this incident) Review of an Incident and Accident Report dated 3/24/15 at 10:15 a.m. indicated the following: While passing Resident #4 ' s room, the resident was found lying on the floor on her back and slightly rolled to her left hip. The resident stated she had been trying to get into her bed, and thought she could make it. The resident said she had hit the right side of her face on the floor. Head to toe assessment performed with no apparent injuries. At 10:45 a.m. - Redness and bruising found to right side of residents face to include the temporal and zygomatic areas. Review of Resident #4 ' s Fall Investigation Worksheet dated 3/24/15 at 10:15 a.m. indicated the following: The resident had fallen in her room attempting to get into her bed. The fall was unwitnessed. Recommendations/Interventions: Educated on use of the call light and monitor the call light is in reach during rounds. Conclusion/Summary: Resident was able to self-report. No injuries noted. Educated resident on use of the call light. To monitor that call light is in reach. Signed by the DON 3/24/15. Review of Resident #4 ' s Daily Skilled Nurse ' s Note dated 3/28/15 at 12:30 a.m. indicated the following: Heard a loud bang and found the resident on the floor. There was a large amount of blood to the resident ' s forehead. Upon assessment it was found there was a laceration to temporal area, nose and forehead and abrasions to right arm. Physician, DON and family notified. Orders received to send resident to the emergency room via ambulance. 4:45 a.m. - Resident was brought back from the emergency room . The resident had 8 sutures to her temporal area and steri strips to nose. (No Incident and Accident Report was found regarding this incident) Review of a hospital emergency room Report dated 3/28/15 at 1:40 a.m. indicated the following: The resident arrived at the emergency room following a fall in which she landed face down, slipping from her bedside commode. Wound repair included: 1) Scalp wound- 4 cm linear wound sutured with 8 sutures. 2) Forehead wound- 1cm linear wound repaired with Dermabond. 3) Face wound - the wound was irregular and repaired with 1 suture. 4) Right wrist wound- the wound was irregular and repaired with Dermabond. The resident had been evaluated and diagnosed with [REDACTED]. The resident was diagnosed with [REDACTED]. Review of Resident #4 ' s Daily Skilled Nurse ' s Note dated 3/28/15 at 9:30 a.m. indicated the following: Resident up to recliner. Multiple bruises to face status [REDACTED]. The family voiced concerns about falls. The resident ' s primary care physician was notified and orders obtained for: Bed and chair alarm for 10 days and low bed with fall mat. Family pleased with orders. Review of Resident #4 ' s Physician order [REDACTED]. Low Bed and fall mats. Diagnosis: [REDACTED]. During a confidential family interview on 4/29/15 at 4:24 p.m. the family member said Resident #4 had been admitted to the facility in February 2015 after living independently for the last [AGE] years. The family member stated there were concerns voiced during the residents admission regarding the resident not calling for assistance and potentially falling. The family member said a request was made at the time of admission for a bed/chair alarm to be placed in the resident ' s rooms to prompt the resident to sit back down and call for assistance. The family member said the nurse explained that the use of alarms required a physician's order [REDACTED]. The family member said in March 2015 the resident had fallen and fractured her femur and required hospitalization and surgery due to getting up without assistance, the resident had fallen again with no injuries due to getting up without assistance and then fallen a third time fracturing her nose due to getting up without assistance. The family member said there had been no measures taken to prevent Resident #4 from getting up without assistance and falling, until she fractured her nose. The family member said then the facility decided to place an alarm on the resident. The family member said they felt there had not been any proactive approaches made to ensure the resident was safe from falls. The family member said when discussing the concerns with the facility; the family was told the resident was being evaluated by physical therapy. The family member said they felt the resident was already receiving scheduled physical therapy and therefore did not feel there had been any extra effort made in protecting the resident from falls. The family member said the resident had been discharged from the facility on 4/02/15 due to the facility ' s inability to properly protect the resident from falls. During an interview on 4/30/15 at 9:05 a.m. LVN A (an agency nurse) said she did not believe she had anyone on her hall that required a bed alarm and was unsure which residents had low beds and fall mats. She said she was unsure of which residents were identified to be high risk for falls due to being an agency nurse. During an interview on 4/30/15 at 9:15 a.m. CNA B said she was unsure which residents had physician orders [REDACTED]. She said she would have to go room to room to determine who had fall mats and low beds. During an interview on 4/30/15 at 9:20 a.m. the DON said the facility currently had one resident who had physician ordered bed/chair alarms. She said the facility/corporation was attempting to limit the amount of bed/chair alarms in the building. She said the corporation did not feel the bed/chair alarms prevented residents from falling and it was a long process to get alarms put into place, monitor and then discontinue them. The DON said all of the charge nurses scheduled for the 6:00 a.m. to 6:00 p.m. shift on 4/30/15 were agency nurses. During an interview on 4/30/15 at 2:20 p.m. the DON said she was unsure; however she thought Resident #4 had been placed on a low bed with fall mats following the resident falling and fracturing her femur. During review of the residents clinical record the DON was unable to locate a physician's order [REDACTED]. She said the resident had been identified to require only minimal assistance of one person; however the resident had poor safety awareness. She said she was unsure of the date; however she had spoken with Resident #4 ' s son who had requested a bed/chair alarm be put into place and the physician was notified and a the alarms were put into place. The DON was unable to locate any documentation of implemented interventions regarding the residents risk for falls prior to the order obtained on 3/28/15 for alarms and low bed with fall mats. During an interview on 4/30/15 at 3:15 p.m. the CNP (Corporate Nurse Practitioner) said the policy of the corporation was not to prevent falls; however to prevent major injuries related to falls. She said bed/chair alarms had not been found to prevent falls. She said Fall Risk Assessments were to be completed quarterly and not with each individual incident of falls. During an interview on 5/01/15 at 8:35 a.m. the DON said she was unable to locate any incident and accident report regarding the 3/24/15 or 3/28/15 incidents. She said it was her expectation for an incident and accident report to be documented for each incident. She said she especially felt an incident report should be completed when the resident required transfer to the emergency roiagnom on [DATE]. She said she was unable to find any documentation in Resident #4 ' s clinical record to indicate the residents fall care plan had been revised/updated following the residents falls. She said she was unable to locate any monitoring of the resident receiving physician ordered low bed with mats and bed/chair alarms prior to 3/28/15. During an interview on 5/01/15 at 4:30 p.m. LVN C (an agency nurse) said she was aware of one resident who required bed/chair alarms on her assigned halls. She said she was unsure of each specific residents who had physician orders [REDACTED]. She said she had received 30 minutes of orientation prior to working on the floor as the charge nurse. During an interview on 5/01/15 at 4:40 p.m. CNA D said she had provided care for Resident #4 when she resided at the facility. She said the resident often attempted to self transfer without staff assistance. CNA D said the staff had to continuously reeducate the resident on using her call light. She said the resident had been a one person assist for transfers. Resident #3 Review of Resident #3 ' s Admission Record dated 1/24/15 indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #3 ' s Admission Nursing Evaluation dated 12/30/14 at 5:00 p.m. indicated the following: The resident was identified to have had falls within the last 30 days prior to admission. Review of Resident #3 ' s Fall Risk assessment dated [DATE] indicated the resident had a score of 22. (Instructions: When a resident ' s score is 10 or more, interventions should promptly be put in place) Review of Resident #3 ' s Nurse Progress Notes dated 1/01/15 at 2:15 a.m. indicated the following: Resident noted on the floor sitting on her buttocks. The resident was attempting to transfer herself to the bathroom. Neurological checks initiated. (No Incident and Accident Report was located regarding the incident) Review of Resident #3 ' s Immediate Needs Care Plan dated 1/01/15 indicated the resident had a fall with no injuries. Interventions were: Neurological checks and resident education. Review of Resident #3 ' s Physician order [REDACTED]. Diagnoses: [REDACTED]. Review of Resident #3 ' s Nurse Progress Notes dated 1/10/15 at 3:00 p.m. indicated the resident had been found on the floor, scooting herself on her buttocks towards the door. The resident reported she had slipped off her bed. No injuries or complaints of pain or discomfort. Resident ' s physician, family and ADON were notified. Neurological checks initiated. (No Incident and Accident Report was located regarding the incident) Review of Resident #3 ' s Nurse Progress Notes dated 1/11/15 at 11:45 a.m. indicated the residents responsible party had been notified and gave permission to move the resident to another room due to room contamination. Review of Resident #3 ' s admission Minimum (MDS) data set [DATE] indicated the following: The resident was identified as requiring extensive assistance of one person for transfers, limited assistance of one person for walking in room and walking in the corridor did not happen. The resident was identified as having lower extremity range of motion limitation impairment on both sides. The resident was identified as having falls during the month prior to admission, falls 2-6 months prior to admission and two or more falls since admission. Review of Resident #3 ' s comprehensive Care Plan dated 1/12/15 indicated the following; Problem: Resident #3 has been identified as at high risk for falls related to weakness. Goals: Resident #3 will be free of fall related injuries over the next 90 days. Approaches: Therapy to evaluate for decreased muscle strength, Review labs and medications for potentiating factors, Assess for change in condition and alert staff to resident increased needs, Monitor for risk factors or tendency to fall, Analyze previous falls to determine causative factors, Assist with ambulation and transfers. Review of Resident #3 ' s Nurse Progress Notes dated 2/19/15 at 7:20 p.m. indicated the resident was observed on the floor by a passing CNA. The resident had been up to the bathroom without assistance and stated she had fallen. The resident was found next to her bed. The resident had full range of motion to all extremities and vital signs were within normal range. The resident had a bruised raised area to the back of her head. The resident was assisted back to bed. 9:00 p.m. Physician called and new order obtained for ice pack as tolerated and Triple antibiotic ointment to right lower extremity daily and when needed until healed. The resident ' s family and DON notified. Neurological checks initiated. Resident educated to call for assistance with getting out of bed. Review of Resident #3 ' s Nurse Progress Notes dated 2/20/15 at 9:50 a.m. indicated the resident was confused and talking to her sister that is not present. Vital signs stable. Resident has complaints of pain to head. Bruise is present. Resident was unsteady and had poor balance. Resident oriented to self only. Physician notified and order received to send resident to emergency room for evaluation and treatment. At 2:30, resident returned to the facility via the facility van. Review of a hospital emergency room Discharge Instructions dated 2/20/15 indicated the following: Diagnosis: [REDACTED]. Discharge instructions to include: Concussion and Brain Injury, Fall Prevention and Home safety. Follow up with primary care physician in 1-2 days. No new orders. Review of Resident #3 ' s Nurse Progress Notes dated 2/20/15 at 6:00 p.m. indicated the nurse observed the resident sitting on the floor between her bed and her wheelchair. The resident ' s roommate said the resident had not fallen; however had slid down slowly from the bed to the floor. Spoke with the resident ' s son who was requesting a bed alarm. The resident denied any pain or injuries. Notified physician and received orders at 7:00 p.m. for low bed with fall mat. Review of Resident #3 ' s Nurse Progress Notes dated 2/21/15 at 3:00 p.m. indicated the resident was found on the floor beside her bed. She had attempted to self-transfer and slipped on the floor mat. No injuries with exception to the bruise on the back of her head from her previous fall. Neurological checks initiated. Physician and family notified. Review of Resident #3 ' s Nurse Progress Notes dated 2/22/15 at 6:30 a.m. indicated the resident was found on the bathroom floor. The resident had fallen attempting to self-transfer. No injuries noted. Physician and family notified. Review of Resident #3 ' s Physician order [REDACTED]. Review of Resident #3 ' s comprehensive Care Plan updated 2/25/15 indicated; Problem: Multiple Falls. Goal: Decrease risk of falls and fall related injuries. Approaches: Physical Therapy evaluated and receiving therapy. Medications reviewed. Medication and dosing times changed 2/22/15. Pressure alarm to chair and bed for 7 days dated 2/22/15. Moved to room closer to nursing station for increased monitoring mid-February dated 5/01/15. Review of Resident #3 ' s Physician order [REDACTED]. Review of Resident #3 ' s Nurse Progress Notes dated 3/04/15 at 3:45 p.m. indicated Called to the resident ' s room. Resident observed sitting on the floor with her back against the bed. The resident said she had been attempting to get up to get in her chair and her legs had given out on her. No injuries found. Physician, family and DON notified. Review of Resident #3 ' s Physician order [REDACTED]. Review of Resident #3 ' s Nurse Progress Notes dated 3/11/15 at 6:50 a.m. indicated Resident noted on the floor on her knees. Resident was attempting to get up for breakfast without assistance. No injuries noted. Neurological checks initiated. Physician and family notified. Review of Resident #3 ' s Nurse Progress Notes dated 3/12/15 at 12:30 a.m. indicated Responded to resident s room and found resident lying on the floor on her left side by the bathroom door. A skin assessment showed a lump to the back of the resident ' s head. Resident was alert and oriented to self. Good range of motion to all extremities will continue to monitor. Review of Resident #3 ' s Nurse Progress Notes dated 3/12/15 (6:00 a.m. to 6:00 p.m. shift) indicated the resident had been wandering the facility in her wheelchair. Staff was unable to redirect resident. The resident continued to try to stand and walk on her own. The resident was very confused, weak and had an unsteady balance. Physician notified and family present and aware. (No Incident and Accident Report was located regarding the incident) Review of Resident #3 ' s Physician order [REDACTED]. Review of Resident #3 ' s Nurse Progress Notes dated 3/26/15 at 9:00 a.m. indicated the resident was up in her wheelchair for mobility, self-propelled and wandering the facility. The resident attempts to stand without assistance. Resident was confused and oriented to self only. Review of Resident #3 ' s Nurse Progress Notes dated 3/27/15 with no documented time indicated the resident was found on the floor. No apparent injuries found. Resident voiced no pain or discomfort. Resident ' s fall was unwitnessed from wheelchair. Physician and family notified. Review of Resident #3 ' s Nurse Progress Notes dated 3/28/15 at 1:48 a.m. indicated the resident self-propelled and wandered the facility. The resident was very confused. The resident had an unsteady gait and overall general weakness. The resident required assistance of one staff for transfers and toileting. The resident attempts to transfer without assistance. The resident was high risk for falls due to poor safety awareness. Review of an Incident and Accident Report dated 4/07/15 indicated the resident had been found on the floor under a bed with her wheelchair at her feet. The resident had no signs of injury. The fall was unwitnessed. The resident ' s mental status was listed as confused. Review of Resident #3 ' s Immediate Needs Care Plan dated 4/07/15 indicated the resident had a fall with no apparent injuries. No Goals or Interventions were documented. Review of Resident #3 ' s Nurse Progress Notes dated 4/07/15 at 7:15 p.m. indicated the resident was found on the floor. No apparent injuries. Neurological checks initiated. Review of an Incident and Accident Report dated 4/18/15 indicted the resident had been found on the floor in another resident's room between her wheelchair and the bed. The resident had not called for assistance. Conclusion/Summary: Incident Reviewed, Medications reviewed, Discussed use of alarms which have been used in the past, will discuss options to reinstate. Resident had increased weakness and confusion. Continue to orient to room as needed. Recommendations: Resident may benefit from chair alarm. Review of Resident #3 ' s Nurse Progress Notes dated 4/18/15 at 9:05 p.m. indicated Resident heard by staff calling out from another resident ' s room. The resident was observed on the floor between her wheelchair the bed. The resident was not able to state what had happened or to give details of the fall. Notified family and DON and faxed physician regarding the fall. The DON was to review the residents care plan for a chair alarm. Resident had complaints of her bottom hurting. No bruising or skin tears noted. During an interview on 4/30/15 at 9:05 a.m. LVN A (an agency nurse) said she did not believe she had anyone on her hall that required a bed alarm and was unsure which residents had low beds and fall mats. She said she was unsure of which residents were identified to be high risk for falls due to being an agency nurse. During an interview on 4/30/15 at 9:15 a.m. CNA B said she was unsure which residents had physician orders [REDACTED]. She said she would have to go room to room to determine who had fall mats and low beds. During an interview on 4/30/15 at 9:20 a.m. the DON said the facility currently had one resident who had physician ordered bed/chair alarms. She said the facility/corporation was attempting to limit the amount of bed/chair alarms in the building. She said the corporation did not feel the bed/chair alarms prevented residents from falling and it was a long process to get alarms put into place, monitor and then discontinue them. The DON said all of the charge nurses scheduled for the 6:00 a.m. to 6:00 p.m. shift on 4/30/15 were agency nurses. During an interview on 4/30/15 at 2:20 p.m. the DON said Resident #3 was identified as high risk for falls and the facility had implemented bed/chair alarms for the resident on several occasions. She said if a resident was issued a bed/chair alarm and did not have any falls during the evaluation period the alarm was removed. She said Resident #3 was very independent for most areas of her ADL ' s but required assistance with transfers. She said Resident #3 had poor safety awareness and frequently attempted to transfer herself without calling for assistance. The DON was not aware of Resident #3's Care Plan not being updated. During an interview on 5/01/15 at 8:35 a.m. the DON said she was unable to locate Incident and Accident Reports for 1/01/15, 1/10/15 and 3/27/15 for Resident #3. She said it was her expectation for an incident and accident report to be documented for each incident. During an interview on 5/01/15 at 4:30 p.m. LVN C (an agency nurse) said Resident #3 resided on her assigned hall. She said the resident was very confused and wandered the facility. She said the resident needed frequent redirection regarding going into other residents rooms and getting into their things. LVN C said she was aware of one resident who required bed/chair alarms on her assigned halls. She said she was unsure of each specific residents who had physician orders [REDACTED]. She said she had received 30 minutes of orientation prior to working on the floor as the charge nurse. During an interview on 5/01/15 at 4:40 p.m. CNA D said she provided care for Resident #3. She said the resident was very anxious and paranoid. She said the resident frequently attempted to get up without assistance. She said she could not recall how long the resident had a low bed and fall mat. She said the resident wandered around the halls and was very confused. She said the resident had poor safety awareness and needed continual redirection. Review of the Policy and Procedure Accidents with no documented dated indicated the following: The facility shall remain as free of accident hazards as possible. Each resident receives adequate supervision and assistive devices, based on the comprehensive assessment to prevent accidents. According to the facility CMS-802 dated 4/30/15 indicated the facility had identified 15 residents with falls including falls with fractures.

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for 1 (Resident #4) of 5 residents reviewed for high risk for falls. The facility failed to ensure: 1) Resident #4; who had a history of [REDACTED]. Resident #4 fell twice on 3/24/15 with no preventative interventions and fell again on 3/28/15 and suffered a nasal fracture and lacerations to the face. This deficient practice contributed to actual harm for one of one resident (Resident #4) and could affect 15 additional residents with risk for falls resulting in a decline and potential delay in rehabilitation. The findings included: Review of the Policy and Procedure; Neglect (Provider Letter No.14-13) dated 8/19/14 indicated the following: Neglect - the failure to provide goods and services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. The facility must determine is an injury, harm to or death of a resident was due to a facility failure to provide services, treatment or care to a resident. Resident #4 Review of Resident #4 ' s, closed clinical record, the Admission Record indicated the [AGE] year old female resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident was discharged on [DATE]. Review of Resident #4 ' s admission Minimum (MDS) data set [DATE] indicated the facility had identified the resident to required set up help and/or physical assistance of one person for activities of daily living. The resident was identified to be occasionally incontinent of bladder and always continent of bowel. The facility identified the resident had the following fall history: fall during month before admission/reentry, fall 2-6 months before admission/reentry and fracture from falls 6 months pre admit/reentry. The resident had an onset start date for physical and occupational therapy of 2/16/15. Review of Resident #4 ' s clinical record indicated no documented fall risk assessment or Admission Care plan related to the residents risk for falls. Review of an Incident and Accident Report dated 3/04/15 at 10:15 p.m. indicated the following: Resident found on the floor on the right side of the bed with bleeding to face. Was able to clean and assess injury to laceration to right eye (eyebrow) and abrasion to right wrist, elbow, and middle left finger of left hand. The incident was documented as unwitnessed. Review of a Statement for Accidents and Incidents dated 3/04/15 indicated the following: At 10:15 p.m. CNA found Resident #4 on the floor on the right side of her bed. The resident had blood all over her face and complained of pain to her right leg. The resident was able to move her right leg and assisted with standing up on it. Bleeding from the residents ' right eyebrow was heavy and pressure was applied with steri strips applied at 10:30 p.m. The area continued to ooze blood. The resident had an abrasion to her right outer wrist, laceration to her right elbow and a small cut to her left middle finger and the top of her left hand. At 10:45 p.m. the resident continued to have complaints of pain to her right leg. The DON, ADON, resident ' s son and primary care physician were notified. Incident/Accident Action Plan: Conclusion/Summary; Resident was able to state she was getting up to use the bathroom and verbalize understanding of use of the call light. Physician called for use of a low bed and a fall mat. Signed by the DON on 3/05/15. Review of Resident #4 ' s clinical record indicated no documented physician order, placement or monitoring of the resident receiving a low bed with fall mats and no documented fall risk assessment. Review of Resident #4 ' s Immediate Needs Care Plan dated 3/04/15 indicated the following; Problem/Needs related to: Fall resulting in serious injury. Goals: None documented. Interventions: Neurological checks for 22 hours, vital signs every 30 minutes for 4 hours. Modify the at risk plan. Review of Resident #4 ' s Pain Evaluation dated 3/04/15 with no documented time indicated the following: The resident had complaints of pain to her right leg and right eyebrow. The pain was identified to worsen upon movement. The resident had pain of 6 (more than moderate pain) on a scale of 1-10. The resident reported constant pain and inability to independently perform ADL ' s. Current Plan indicated: No plan. Review of Resident #4 ' s Care Plan dated 3/05/15 indicated the following; Problem: Resident #4 had been identified as at high risk for falls related to unsteady gait. Goal: Resident #4 will be free of injury related to falls for 90 days. Approaches: Therapy to evaluate for decreased muscle strength and need for assistive devices. Review labs and medications for potential factors. Assess for change in condition and alert staff to residents increased needs. Fall risk assessment on admission, readmission, quarterly and with significant change. Evaluate for use of low bed, side rails and personal alarm. Monitor for pattern of risk factors or tendency to fall, Assist with ambulation and transfers, and Monitor degree of disorientation to determine safety needs. Review of Resident #4 ' s hospital History and Physical dated 3/05/15 indicated the following: Reason for Admission: Right intertrochanteric femur fracture. History of Present Illness: This is a [AGE] year old female status [REDACTED]. She also hit her head and sustained some skin lacerations to her right elbow. She was brought to the emergency room complaining of pain that was about an 8 on a scale of 1-10, localized to her right elbow and right leg. She describes the pain as sharp in nature, worsening with movement to the right lower extremity. Physical Examination: Right lower extremity shows shortening and external rotation. Impression: Right intertrochanteric femur fracture. Plan: A lengthy discussion was had regarding treatment options. Recommendations for proceeding with a closed reduction and gamma nail fixation of her Right intertrochanteric femur fracture. Review of Resident #4 ' s hospital Operative Report dated 3/05/15 indicated: Closed reduction and gamma nail fixation of her Right intertrochanteric femur fracture. Review of Resident #4 ' s Discharge Summary dated 3/10/15 indicated the following: [AGE] year old female status [REDACTED]. She underwent intramedullary fixation of her intertrochanteric femur fracture. Review of Resident #4 ' s Physician order [REDACTED]. Diagnoses: [REDACTED]. Physical Therapy to evaluate and treat the resident for range of motion and gait training. Review of Resident #4 ' s clinical record indicated no fall risk assessment, no orders for low bed with fall mat, no evaluation for alarms. The residents comprehensive Care Plan had no documented updates or interventions related to the residents fall with fractures. Review of Resident #4 ' s Daily Skilled Nurse ' s Note dated 3/24/15 indicated at 3:00 a.m. Resident #4 had called for assistance to the bathroom. The resident had sat up at her bedside and began to slide to the floor. The resident was being held up by staff, however the floor was very slippery and the resident could not stand up without sliding. The resident and staff member sat down on the floor, no injuries and the resident was instructed not to get out of bed. (No Incident and Accident Report was found regarding this incident) Review of an Incident and Accident Report dated 3/24/15 at 10:15 a.m. indicated the following: While passing Resident #4 ' s room, the resident was found lying on the floor on her back and slightly rolled to her left hip. The resident stated she had been trying to get into her bed, and thought she could make it. The resident said she had hit the right side of her face on the floor. Head to toe assessment performed with no apparent injuries. At 10:45 a.m. - Redness and bruising found to right side of residents face to include the temporal and zygomatic areas. Review of Resident #4 ' s Fall Investigation Worksheet dated 3/24/15 at 10:15 a.m. indicated the following: The resident had fallen in her room attempting to get into her bed. The fall was unwitnessed. Recommendations/Interventions: Educated on use of the call light and monitor the call light is in reach during rounds. Conclusion/Summary: Resident was able to self-report. No injuries noted. Educated resident on use of the call light. To monitor that call light is in reach. Signed by the DON 3/24/15. Review of Resident #4 ' s Daily Skilled Nurse ' s Note dated 3/28/15 at 12:30 a.m. indicated the following: Heard a loud bang and found the resident on the floor. There was a large amount of blood to the resident ' s forehead. Upon assessment it was found there was a laceration to temporal area, nose and forehead and abrasions to right arm. Physician, DON and family notified. Orders received to send resident to the emergency room via ambulance. 4:45 a.m. - Resident was brought back from the emergency room . The resident had 8 sutures to her temporal area and steri strips to nose. (No Incident and Accident Report was found regarding this incident) Review of a hospital emergency room Report dated 3/28/15 at 1:40 a.m. indicated the following: The resident arrived at the emergency room following a fall in which she landed face down, slipping from her bedside commode. Wound repair included: 1) Scalp wound- 4 cm linear wound sutured with 8 sutures. 2) Forehead wound- 1cm linear wound repaired with Dermabond. 3) Face wound - the wound was irregular and repaired with 1 suture. 4) Right wrist wound- the wound was irregular and repaired with Dermabond. The resident had been evaluated and diagnosed with [REDACTED]. The resident was diagnosed with [REDACTED]. Review of Resident #4 ' s Daily Skilled Nurse ' s Note dated 3/28/15 at 9:30 a.m. indicated the following: Resident up to recliner. Multiple bruises to face status [REDACTED]. The family voiced concerns about falls. The resident ' s primary care physician was notified and orders obtained for: Bed and chair alarm for 10 days and low bed with fall mat. Family pleased with orders. Review of Resident #4 ' s Physician order [REDACTED]. Low Bed and fall mats. Diagnosis: [REDACTED]. During a confidential family interview on 4/29/15 at 4:24 p.m. the family member said Resident #4 had been admitted to the facility in February 2015 after living independently for the last [AGE] years. The family member stated there were concerns voiced during the residents admission regarding the resident not calling for assistance and potentially falling. The family member said a request was made at the time of admission for a bed/chair alarm to be placed in the resident ' s rooms to prompt the resident to sit back down and call for assistance. The family member said the nurse explained that the use of alarms required a physician's order [REDACTED]. The family member said in March 2015 the resident had fallen and fractured her femur and required hospitalization and surgery due to getting up without assistance, the resident had fallen again with no injuries due to getting up without assistance and then fallen a third time fracturing her nose due to getting up without assistance. The family member said there had been no measures taken to prevent Resident #4 from getting up without assistance and falling, until she fractured her nose. The family member said then the facility decided to place an alarm on the resident. The family member said they felt there had not been any proactive approaches made to ensure the resident was safe from falls. The family member said when discussing the concerns with the facility; the family was told the resident was being evaluated by physical therapy. The family member said they felt the resident was already receiving scheduled physical therapy and therefore did not feel there had been any extra effort made in protecting the resident from falls. The family member said the resident had been discharged from the facility on 4/02/15 due to the facility ' s inability to properly protect the resident from falls. During an interview on 4/30/15 at 9:05 a.m. LVN A (an agency nurse) said she did not believe she had anyone on her hall that required a bed alarm and was unsure which residents had low beds and fall mats. She said she was unsure of which residents were identified to be high risk for falls due to being an agency nurse. During an interview on 4/30/15 at 9:15 a.m. CNA B said she was unsure which residents had physician orders [REDACTED]. She said she would have to go room to room to determine who had fall mats and low beds. During an interview on 4/30/15 at 9:20 a.m. the DON said the facility currently had one resident who had physician ordered bed/chair alarms. She said the facility/corporation was attempting to limit the amount of bed/chair alarms in the building. She said the corporation did not feel the bed/chair alarms prevented residents from falling and it was a long process to get alarms put into place, monitor and then discontinue them. The DON said all of the charge nurses scheduled for the 6:00 a.m. to 6:00 p.m. shift on 4/30/15 were agency nurses. During an interview on 4/30/15 at 2:20 p.m. the DON said she was unsure; however she thought Resident #4 had been placed on a low bed with fall mats following the resident falling and fracturing her femur. During review of the residents clinical record the DON was unable to locate a physician's order [REDACTED]. She said the resident had been identified to require only minimal assistance of one person; however the resident had poor safety awareness. She said she was unsure of the date; however she had spoken with Resident #4 ' s son who had requested a bed/chair alarm be put into place and the physician was notified and a the alarms were put into place. The DON was unable to locate any documentation of implemented interventions regarding the residents risk for falls prior to the order obtained on 3/28/15 for alarms and low bed with fall mats. During an interview on 4/30/15 at 3:15 p.m. the CNP (Corporate Nurse Practitioner) said the policy of the corporation was not to prevent falls; however to prevent major injuries related to falls. She said bed/chair alarms had not been found to prevent falls. She said Fall Risk Assessments were to be completed quarterly and not with each individual incident of falls. During an interview on 5/01/15 at 8:35 a.m. the DON said she was unable to locate any incident and accident report regarding the 3/24/15 or 3/28/15 incidents. She said it was her expectation for an incident and accident report to be documented for each incident. She said she especially felt an incident report should be completed when the resident required transfer to the emergency roiagnom on [DATE]. She said she was unable to find any documentation in Resident #4 ' s clinical record to indicate the residents fall care plan had been revised/updated following the residents falls. She said she was unable to locate any monitoring of the resident receiving physician ordered low bed with mats and bed/chair alarms prior to 3/28/15. During an interview on 5/01/15 at 4:30 p.m. LVN C (an agency nurse) said she was aware of one resident who required bed/chair alarms on her assigned halls. She said she was unsure of each specific residents who had physician orders [REDACTED]. She said she had received 30 minutes of orientation prior to working on the floor as the charge nurse. During an interview on 5/01/15 at 4:40 p.m. CNA D said she had provided care for Resident #4 when she resided at the facility. She said the resident often attempted to self transfer without staff assistance. CNA D said the staff had to continuously reeducate the resident on using her call light. She said the resident had been a one person assist for transfers. According to the facility CMS-802 dated 4/30/15 indicated the facility had identified 15 residents with falls including falls with fractures.

Based on interviews and record review the facility failed to develop and implement written policies and procedures that prohibit neglect of residents for 1 of 8 residents (Resident #5) reviewed for neglect related to safety devices and injuries of unknown source. The facility failed to implement their policies to thoroughly investigate and report to the State agency when Resident #5 was diagnosed with [REDACTED]. On [DATE] an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on [DATE] 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. These failures could place 10 other residents who had bed and/or chair alarms by placing them at risk for injuries of unknown origin related to possible abuse and/or neglect. Findings included: Review of the facility's Accident Incident policy dated [DATE] indicated the charge and/or department director or supervisor should conduct an immediate investigation of the accident or incident. The following data, as it may apply, should be included on the Accident Investigation Report form: the circumstances surrounding the accident/incident, names of any witnesses and/or individuals involved and detailed written statement of their account of the accident/incident, the injured person ' s account of the accident/incident, corrective action taken and other pertinent data as necessary or required. Review of the facility's un-dated Reporting Abuse and Neglect Policy indicated the following incident of abuse and/or neglect must be reported to the State agency immediately upon learning of the incident. A written investigation report must be sent no later than the firth working day after the oral report: Neglect: the facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident. The following examples of reportable neglect are not all-inclusive, the following is an example from the policy; a resident with a doctor ' s order for close supervision due to unsteady gait is left unsupervised or inadequately supervised, resulting in his falling and fracturing his hip. Facility actions, when conducting an investigation, must be documented and include: observations, interviews and record reviews of all residents involved; interviews of all witnesses, including residents, staff and family members; notifying the physician, family and/or responsible party of the involved residents and recording all relevant findings. The policy included the State Provider Letter ,[DATE] dated [DATE] regarding Abuse, Neglect, Exploitation and Other Incident that must be reported which indicated: Neglect: the facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident. The following examples of reportable neglect; a resident with a doctor ' s order for close supervision due to unsteady gait is left unsupervised or inadequately supervised, resulting in his falling and fracturing his hip. suspicious injuries of unknown source; an injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. Resident #5 Review of Resident #5's closed clinical record, admission orders [REDACTED]. Bed and chair alarms were ordered. The resident expired on [DATE]. Review of Resident #5's Admission Nursing Evaluation dated [DATE] indicated the resident had a history of [REDACTED]. A chair and bed alarm were to be used. The evaluation indicated the resident had fallen in the past 90 days and was being admitted with [DIAGNOSES REDACTED]. The resident was alert, oriented to person only, confused and had memory problems. The resident was fearful, anxious with delusions and disruptive behaviors. Review of Resident #5's admission MDS dated [DATE] indicated the resident had short and long-term memory problems. She was severely impaired for daily decision making. She required extensive assistance of one staff for bed mobility and dressing. The resident required extensive assistance of two staff for toilet use and transfers. She required limited assistance of one staff for personal hygiene. She was totally dependent of one staff for bathing. The resident was frequently incontinent of bowel and bladder. She was not ambulatory. She had a history of [REDACTED]. Review of Resident #5's Care Plan dated [DATE] indicated the resident was at risk for falls related to a history of falls and falls since admission. The resident had short-term and long-term memory problems and did not always remember she was too weak to transfer independently. The goal was for the resident to not sustain serious injury related to falls. The approaches included bed/chair alarm, monitor for pattern of risk factors, or tendency to fall, monitor and eliminate potential environmental hazards, instruct and encourage call light use and request for assistance and analyze previous falls to determine causative factors, and implement changes. Fall on [DATE] Review of Resident #5's Incident/Accident Report dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. Staff (LVN F) responded by entering the resident's room. The resident was next to the right side of her bed lying on the floor mat. She said she was trying to reach over "there" and pointed to her night stand. The resident was instructed to use her call light when she needed help and voiced understanding. She said she hit her head "a little". The resident had no injury and denied any pain. The bed alarm was not in use. The report indicated the action taken included care plan update and staff re-education. The report was signed by the Administrator and DON on [DATE]. There was no documentation of a Falls Investigation Worksheet or Action Plan or any documentation to explain why the resident's bed alarm was not in use at the time of this incident. During an interview on [DATE] at 11:52 am DON S said there was no investigation regarding the circumstances surrounding Resident #5's fall on [DATE]. Review of Resident #5's Progress Note dated [DATE] at 10:30 am the resident was shouting "Josie" repeatedly. This nurse (LVN F) responded to the resident's room. The resident was on the floor lying on the mat next to her bed. She reported hitting her head a "little bit". She denied pain. The resident reported, "I was reaching for that" and pointed to the nightstand. She was unable to recall the exact item she was reaching for. The resident was able to move all her extremities. She was assisted to bed and neuros were initiated. The resident's physician, family, the DON and ADON were all notified of the incident. There was no documentation regarding the resident's bed alarm and why it was not in use at the time of the resident's fall. During a telephone interview on [DATE] at 3:24 pm Charge Nurse, LVN F, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . She said she thought the alarm did not sound because the battery was dead so she changed out the alarm battery. She said the resident did not usually report pain and seemed to be fine after the fall. She said she called the ADON to inform her of the fall and that the alarm did not sound. During an interview on [DATE] at 3:45 pm the ADON said LVN F called her on [DATE] to report Resident #5's fall. She said she informed LVN F she needed to contact the DON regarding the resident's fall. She said she did not know anything about the resident's alarm not sounding. She said the facility did not have a policy and/or procedure to ensure bed/chair alarms were functioning. Review of Resident #5's Progress Note dated [DATE] at 12:15 am indicated the resident was being monitored for signs of injury due to her recent fall ([DATE]) with no new injuries noted. The resident continued to attempt to get out of bed without calling for assistance. The resident had her usual range of motion to all extremities. She voiced no complaint of pain and no acute distress was noted. At 2:53 pm neuros were continued from the previous fall. No injuries were noted. The resident was up in her wheelchair for meals. Will continue to monitor closely. Fall on [DATE] Review of Resident #5's Incident/Accident Report dated [DATE] at 8:15 pm indicated staff (LVN G) heard the resident calling out for help and upon entering her room the resident had fallen out of bed and was laying on the floor in a half sitting position by her recliner. The resident had a skin tear to her left elbow and she complained of pain to her left hip. The resident's bed alarm was not in use due to dead batteries. The Administrator and DON signed the incident report on [DATE]. The Falls Investigation Report, with the incident report, indicated the resident was having wandering behaviors at the time of this fall. The fall was unwitnessed. The resident had two previous falls in the last 30 days. The Action Plan for the incident, completed by the DON on [DATE], indicated two x-rays were negative but the resident continued to report pain and a final x-ray showed a pelvic fracture. The resident was referred to therapy again. Hospice increased the resident's pain medications. The DON documented the resident was very impulsive and refused to call for assistance. The plan did not include any action related to ensuring the alarms were functional. Review of Resident #5's Progress Note dated [DATE] at 8:15 pm indicated staff heard the resident calling for help and, upon entering the resident's room, the resident was in a half sitting position by her recliner. A skin tear to the resident's left elbow was noted. The resident denied pain at this time and was assisted to the bed. The alarm was checked and found to be inoperable (battery); while doing further assessment the resident started to complain of pain to her hip. The skin tear was treated per protocol, the physician was called for an x-ray order, and the responsible party was called and notified of the fall. The responsible party said he had been at the facility earlier and had trouble keeping the resident in her wheelchair. The x-ray company was called, the resident continued to complain of pain to her left hip, no discoloration or bruising was noted. At 8:30 pm the x-ray was done and the resident continued to complain of pain when moved. At 10:23 pm the x-ray showed no fracture. During a telephone interview on [DATE] at 3:37 pm Charge Nurse, LVN G, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . He said the alarm failed to go off for some reason. He said the resident was too confused to tell staff what happened. He said he thought the alarm batteries were dead and put another alarm on the resident's bed. He said the resident did not report pain, at first, but later began reporting pain. He said the first x-ray was negative for any fractures but another x-ray showed a pelvic fracture. He said prior to this fall, earlier in the day on [DATE], the resident was anxious and trying to get up out of her wheelchair without assistance. He said after the resident fell on [DATE] she was in too much pain to try to get out of bed. Review of Resident #5's Progress Note dated [DATE] at 10:00 am indicated the resident had severe pain to her left side from her hip down. The resident was unable to pinpoint the exact location. The hospice nurse assessed the resident and obtained an order for [REDACTED]. Will continue to monitor closely. At 2:00 pm mobile x-ray at the facility to perform the x-rays. The resident continued to be in severe pain anytime she is repositioned. At 4:45 pm a call was received from hospice; the resident had a [MEDICAL CONDITION] ramus (a part of the pelvis). An order was received to send the resident to the emergency room for an evaluation and treatment. The DON, Administrator and resident's responsible party were notified. At 5:00 pm the ambulance arrived to transport the resident to the emergency room . At 8:30 pm the resident returned from the emergency room via non-emergency ambulance with a [DIAGNOSES REDACTED]. The resident's pm medications were given. The resident was awake and showed signs of pain. Review of Resident #5's Progress Note dated [DATE] at 5:15 am indicated the resident expired. During a telephone interview on [DATE] at 4:00 pm the former Administrator (whose last day of employment was [DATE]) said she believed Resident #5 turned her alarm off and did not know LVN G documented on [DATE] the alarm failed to sound due to dead batteries. She said a few days after the resident fell on [DATE] she began hurting and was diagnosed with [REDACTED].#5's injury was not reported to the State agency because she thought the resident was able to tell staff what happened. She said she reviewed the information regarding the incident with the corporate office and it was decided the incident was not reportable. During a telephone interview on [DATE] at 4:15 the former DON (DON A, whose last day of employment was [DATE]) said she did not remember the exact details regarding Resident #5's falls on [DATE] and [DATE]. She said the Administrator and the corporate office discussed the incident and decided it was not reportable. During an interview on [DATE] at 2:48 pm the Interim Administrator (who began her employment on [DATE]) said when Resident #5 was diagnosed with [REDACTED]. The Interim Administrator was notified of the Immediate Jeopardy situation on [DATE] at 4:26 pm. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE] at 1:55 pm. The plan included the following: 1) Incidents will be reviewed by the Administrator and Director of Nursing in the morning stand-up meeting, with thorough investigative follow-up. 2) Any suspected abuse, neglect, exploitation of a resident or injury of unknown source will be called to the State agency. 3) The Administrator and DON have been re-educated on [DATE] by the Director of Education that all allegations of abuse, neglect, exploitation of a resident and an injury of unknown source have been reported to the State agency within 24 hours of identification, thoroughly investigated, documented and the results of that investigation reported in 5 working days to the State agency, by the Administrator and/or Regional Vice President. Facility staff was re-educated regarding abuse prohibition. The Quality Assurance Performance Improvement Committee will review allegations (incidents) monthly for three months and then quarterly until the committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Validation of the Plan of Removal by the DADS surveyor was conducted on [DATE] and [DATE]. Review of in-services conducted on [DATE], [DATE] and [DATE] indicated staff was being educated on reporting procedures. Review of the documentation of monitoring by administrative staff was found to be in place and appropriately completed and signed off on. Interviews with Nurses and CNAs indicated they understood the reporting procedures. The Immediate Jeopardy was removed prior to exit on [DATE], effective [DATE], 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 residents from injuries related to possible abuse and/or neglect. Review of a list of residents with bed and/or chair alarms provided by the ADON on [DATE] at 10:30 am indicated 10 residents with alarms.

Based on observation, interview and record review the facility failed to ensure 5 of 8 residents (Resident #2, #5, #6, #7 and #8) reviewed for falls received adequate supervision and assistive devices to prevent accidents. The facility failed to: 1) provide Resident #5, who had a history of [REDACTED]. The resident fell on [DATE] and [DATE] when her physician ordered bed alarm was not functioning. The resident sustained [REDACTED]. 2) ensure Resident #2's physician ordered bed/chair alarm and fall precautions were in place while she was in bed and while she was in her wheelchair. 3) ensure Resident #6's physician ordered chair alarm was in place while she was in her wheelchair. 4) ensure Resident 7's physician ordered chair alarm was in place while she was in her wheelchair. 5) ensure Resident #8's chair alarm was in place while she was in her wheelchair. On [DATE] an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on [DATE] 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. These failures could place 10 other residents who had bed and/or chair alarms by placing them at risk for falls and injuries. Findings included: Resident #5 Review of Resident #5's closed clinical record, admission orders [REDACTED]. Bed and chair alarms were ordered. The resident received methadone 5 mg one by mouth at night and hydrocodone ,[DATE] one by mouth at 8:00 am, 2:00 pm, 8:00 pm and 2:00 am both are narcotic pain medication for chronic back pain. The resident expired on [DATE]. Review of Resident #5's Admission Nursing Evaluation dated [DATE] indicated the resident had a history of [REDACTED]. A chair and bed alarm were to be used. The evaluation indicated the resident had fallen in the past 90 days and was being admitted with [DIAGNOSES REDACTED]. The resident was alert, oriented to person only, confused and had memory problems. The resident was fearful, anxious with delusions and disruptive behaviors. Review of Resident #5's Fall Risk Evaluation dated [DATE] indicated the resident scored a 20 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #5's Daily Skilled Nurse's Note dated [DATE] at 3:09 am indicated the resident was alert, confused and able to make some needs known. She did not use her call light and staff anticipated her needs. The resident required extensive assistance with all her activities of daily living. She denied any pain or discomfort. The resident had decreased balance, general weakness and decreased movement to all extremities. She received routine pain medication as ordered. The resident had a history of [REDACTED]. Review of Resident #5's Incident/Accident Report dated [DATE] at 6:45 pm indicated the resident tried to transfer herself from her wheelchair to her bed and slipped to the floor next to her bed. The resident was sitting on her buttocks and denied hitting her head. The resident had no apparent injury and the chair alarm was in use. The Fall Investigation Worksheet, with the incident report, indicated the CNA took the resident to her room and then went to get a pad for the resident's bed. Upon returning to the room, the resident's chair alarm sounded and the resident called for help as she slid to the floor. The resident was sitting on the floor when the CNA entered the room. The Action Plan for the incident, completed by the DON on [DATE], indicated staff was educated to bring supplies and linen to the room before or with the resident due to the resident's impatience and impulsivity. The resident was counseled to wait for assistance with transfers and referred to therapy. Review of Resident #5's Daily Skilled Nurse's Note dated [DATE] at 7:45 pm the resident was transported to her room by a CNA because the resident requested to go to bed. The resident was in her wheelchair when the CNA got a pad for the resident's bed. The resident's chair alarm sounded and the resident called out for help. The resident was sitting in the floor on her buttocks. She denied hitting her head. The resident denied any pain. Review of Resident #5's Pain Evaluation dated [DATE] indicated the resident denied any pain, rarely reported pain and was taking routine narcotic pain medication. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall with no apparent injury; the goal was for the resident to resume her usual activities without further incident. The interventions included neuros and to check range of motion daily for 72 hours. Interventions were continued. Review of Resident #5's admission MDS dated [DATE] indicated the resident had short and long-term memory problems. She was severely impaired for daily decision making. She required extensive assistance of one staff for bed mobility and dressing. The resident required extensive assistance of two staff for toilet use and transfers. She required limited assistance of one staff for personal hygiene. She was totally dependent of one staff for bathing. The resident was frequently incontinent of bowel and bladder. She was not ambulatory. She had a history of [REDACTED]. Review of Resident #5's Care Plan dated [DATE] indicated the resident was at risk for falls related to a history of falls and falls since admission. The resident had short-term and long-term memory problems and did not always remember she was too weak to transfer independently. The goal was for the resident to not sustain serious injury related to falls. The approaches included bed/chair alarm, monitor for pattern of risk factors, or tendency to fall, monitor and eliminate potential environmental hazards, instruct and encourage call light use and request for assistance and analyze previous falls to determine causative factors, and implement changes. Review of Resident #5's Incident/Accident Report dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. Staff (LVN F) responded by entering the resident's room. The resident was next to the right side of her bed lying on the floor mat. She said she was trying to reach over "there" and pointed to her night stand. The resident was instructed to use her call light when she needed help and voiced understanding. She said she hit her head "a little". The resident had no injury and denied any pain. The bed alarm was not in use. The report indicated the action taken included care plan update and staff re-education. The report was signed by the Administrator and DON on [DATE]. There was no documentation of a Falls Investigation Worksheet or Action Plan or any documentation to explain why the resident's bed alarm was not in use at the time of this incident. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall with no apparent injury; the goal was for the resident to resume her usual activities without further incident. The approach was to do neuros. There were no other interventions or changes made to the resident's care plan. During an interview on [DATE] at 11:52 am DON S said there was no Falls Investigation Worksheet or Action Plan for Resident #5's fall on [DATE]. Review of Resident #5's Progress Note dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. This nurse (LVN F) responded to the resident's room. The resident was on the floor lying on the mat next to her bed. She reported hitting her head a "little bit". she denied pain. The resident reported, "I was reaching for that" and pointed to the nightstand. She was unable to recall the exact item she was reaching for. The resident was able to move all her extremities. She was assisted to bed and neuros were initiated. The resident's physician, family, the DON and ADON were all notified of the incident. There was no documentation regarding the resident's bed alarm and why it was not in use at the time of the resident's fall. During a telephone interview on [DATE] at 3:24 pm Charge Nurse, LVN F, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . She said she thought the alarm did not sound because the battery was dead so she changed out the alarm battery. She said the resident did not usually report pain and seemed to be fine after the fall. She said she called the ADON to inform her of the fall and that the alarm did not sound. During an interview on [DATE] at 3:45 pm the ADON said LVN F called her on [DATE] to report Resident #5's fall. She said she informed LVN F she needed to contact the DON regarding the resident's fall. She said she did not know anything about the resident's alarm not sounding. She said the facility did not have a policy and/or procedure to ensure bed/chair alarms were functioning. Review of Resident #5's Progress Note dated [DATE] at 12:15 am the resident was being monitored for signs of injury due to her recent fall ([DATE]) with no new injuries noted. The resident continued to attempt to get out of bed without calling for assistance. The resident had her usual range of motion to all extremities. She voiced no complaint of pain and no acute distress was noted. At 2:53 pm neuros were continued from the previous fall. No injuries were noted. The resident was up in her wheelchair for meals. Will continue to monitor closely. Review of Resident #5's Incident/Accident Report dated [DATE] at 8:15 pm indicated staff (LVN G) heard the resident calling out for help and upon entering her room the resident had fallen out of bed and was laying on the floor in a half sitting position by her recliner. The resident had a skin tear to her left elbow and she complained of pain to her left hip. The resident's bed alarm was not in use due to dead batteries. The Administrator and DON signed the incident report on [DATE]. The Falls Investigation Report, with the incident report, indicated the resident was having wandering behaviors at the time of this fall. The fall was unwitnessed. The resident had two previous falls in the last 30 days. The Action Plan for the incident, completed by the DON on [DATE], indicated two x-rays were negative but the resident continued to report pain and a final x-ray showed a pelvic fracture. The resident was referred to therapy again. Hospice increased the resident's pain medications. The DON documented the resident was very impulsive and refused to call for assistance. The plan did not include any action related to ensuring the alarms were functional. Review of Resident #5's Progress Note dated [DATE] at 8:15 pm indicated staff heard the resident calling for help and, upon entering the resident's room, the resident was in a half sitting position by her recliner. A skin tear to the resident's left elbow was noted. The resident denied pain at this time and was assisted to the bed. The alarm was checked and found to be inoperable (battery); while doing further assessment the resident started to complain of pain to her hip. The skin tear was treated per protocol, the physician was called for an x-ray order, and the responsible party was called and notified of the fall. The responsible party said he had been at the facility earlier and had trouble keeping the resident in her wheelchair. The x-ray company was called, the resident continued to complain of pain to her left hip, no discoloration or bruising was noted. At 8:30 pm the x-ray was done and the resident continued to complain of pain when moved. At 10:23 pm the x-ray showed no fracture. During a telephone interview on [DATE] at 3:37 pm Charge Nurse, LVN G, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . He said the alarm failed to go off for some reason. He said the resident was too confused to tell staff what happened. He said he thought the alarm batteries were dead and put another alarm on the resident's bed. He said the resident did not report pain, at first, but later began reporting pain. He said the first x-ray was negative for any fractures but another x-ray showed a pelvic fracture. He said prior to this fall, earlier in the day on [DATE], the resident was anxious and trying to get up out of her wheelchair without assistance. He said after the resident fell on [DATE] she was in too much pain to try to get out of bed. During a telephone interview on [DATE] at 3:52 pm Charge Nurse, LVN H, said she was not aware Resident #5's bed alarm failed to sound on [DATE] and on [DATE]. She said the facility did not have a specific policy and/or procedures to ensure the alarms were functioning. She said Resident #5 seemed okay after her fall on [DATE]. She said after the resident fell on [DATE] staff could not touch the resident without her hollering out in pain. She said the resident's pain was unmanageable and not controlled with the pain medication ordered. She said the last x-ray showed a pelvic fracture and the resident was sent to the emergency room but returned to the facility without further treatment except for a change in her pain medication. She said after the resident's pain medication was changed she still experienced some pain when she was moved but it was manageable. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall; the goal was for the resident to resume her usual activities without further incident and involved areas will resolve without complications. The approach was to do neuros for 72 hours. There were no other interventions or changes made to the resident's care plan. Review of Resident #5's Progress Note dated [DATE] at 10:30 am indicated the hospice nurse was in to see the resident and said the resident was tender in her hip area and ordered another x-ray to be taken through the hospice company (the x-ray was negative). Review of Resident #5's Progress Note dated [DATE] at 2:17 am indicated the resident denied pain or discomfort and was medicated with routine pain medication as per orders. The resident continued to yell out at intervals. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated the resident continued to complain of pain in her left hip; pain medications given as ordered. Review of Resident #5's Progress Note dated [DATE] at 4:44 am indicated the resident continued to complain of pain to her left hip and was medicated with routine pain medication as per orders. The resident continued to yell out at intervals. Review of Resident #5's Progress Note dated [DATE] at 10:00 am indicated the resident had severe pain to her left side from her hip down. The resident was unable to pinpoint the exact location. The hospice nurse assessed the resident and obtained an order for [REDACTED]. The resident yelled out when her left side was touched. Will continue to monitor closely. At 2:00 pm mobile x-ray at the facility to perform the x-rays. The resident continued to be in severe pain anytime she is repositioned. At 4:45 pm a call was received from hospice; the resident had a fracture of the left ramus (a part of the pelvis). An order was received to send the resident to the emergency room for an evaluation and treatment. The DON, Administrator and resident's responsible party were notified. At 5:00 pm the ambulance arrived to transport the resident to the emergency room . At 8:30 pm the resident returned from the emergency room via non-emergency ambulance with a [DIAGNOSES REDACTED]. The resident's pm medications were given. The resident was awake and showed signs of pain. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident was awake twice during the night moaning as if in pain, quiets shortly when medications are given, and also moans when turned. The resident made no attempt to get out of bed. Alarm in place. At 10:45 am the resident continued to have uncontrolled pain. Notified hospice and received new orders to discontinue all previous methadone and Norco orders; methadone 5 mg one by mouth every four hours around the clock, Norco ,[DATE] mg one by mouth every four hours around the clock, alternate methadone and Norco so the resident receives pain medication every two hours around the clock. Medication given as per orders and resident appears more relaxed, resting with her eyes closed. Will continue to closely monitor. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident responded well to pain therapy every two hours. The resident had less moaning during the night and awakened for short periods when medications were given. The resident does show signs of severe pain when awake. Checked on resident frequently and assisted with activities of daily living as needed. Review of Resident #5's Care Plan dated [DATE] indicated the resident fell from her bed on [DATE]. The goal was to decrease the resident's risk for falls. The approaches included a follow-up x-ray on [DATE] indicated a pelvic fracture, pain medication as ordered, bed alarm, staff to respond as soon as possible, reposition every two hours for pain relief. Review of Resident #5's Progress Note dated [DATE] at 1:30 am indicated the resident continued to be medicated for pain every two hours around the clock. The resident moans constantly while awake, yells out when moved. Pain medications are effective, lays in bed asleep for long periods of time awakens and takes medications with difficulty. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated the resident continued to be in pain when moved, pain medication given as ordered. New order to change diet to pureed. Review of Resident #5's Progress Note dated [DATE] at 4:20 am indicated the resident continued to receive pain medication as ordered. The resident yells out at intervals, especially when she is moved. Pain medications are effective when given and the yelling and moaning is less frequent. Turning and repositioning every two hours and as needed for pressure relief and comfort. Alarm in place and functioning properly. Review of Resident #5's Progress Note dated [DATE] at 2:32 pm indicated the resident continued on around the clock Norco and methadone. Medications effective until resident is moved. Review of Resident #5's Progress Note dated [DATE] at 12:57 pm indicated the resident continues to have discomfort when repositioned. Medicated as ordered. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident was mostly unresponsive during the night, responded weakly when crushed medications were given. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated a new order for morphine 0.5 ml by mouth, sublingual or nebulize TID every two hours and as needed for pain. Turn and reposition resident every two hours. Resident no longer swallowing medications by mouth without difficulty, clamps mouth shut when attempting to give medications. Liquid morphine given and medication was effective. Review of Resident #5's Progress Note dated [DATE] at 5:15 am indicated the resident expired. During a telephone interview on [DATE] at 4:00 pm the former Administrator (whose last day of employment was [DATE]) said she believed Resident #5 turned her alarm off and did not know LVN G documented on [DATE] the alarm failed to sound due to dead batteries. She said a few days after the resident fell on [DATE] she began hurting and was diagnosed with [REDACTED]. During a telephone interview on [DATE] at 4:15 the former DON (DON A, whose last day of employment was [DATE]) said she did not remember the exact details regarding Resident #5's falls on [DATE] and [DATE] but she would have instructed staff to change out the alarms. She said the nurses should check to make sure the alarms were working but there was not a place on the medication or treatment record to document the alarm functioning. During an interview on [DATE] at 3:30 pm the Interim Administrator (who began her employment on [DATE]) said the facility did not have a specific policy and procedure regarding bed/chair alarms. Resident #2 Review of Resident #2's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's physician's orders [REDACTED]. A personal alarm (bed/chair alarm) to alert staff of attempts to transfer self. Review of Resident #2's Fall Risk Evaluation dated [DATE] indicated the resident scored a 14 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #2's revised Care Plan dated [DATE] indicated the resident had been identified as at risk for falls due to poor safety awareness, unsteady gait and poor strength in her knees. The goal was for the resident to be free of injury related to falls. The approaches included the use of a tab alarm (bed/chair alarm) as a reminder if ordered. Review of Resident #2's quarterly MDS dated [DATE] indicated she had short and long-term memory impairment and was severely impaired for decision making. She required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use. She was not ambulatory. The resident was always incontinent of bowel and bladder. She had not fallen. During an observation on [DATE] at 3:38 pm Resident #2 was observed sitting outside in her wheelchair attending an activity. The resident had a chair alarm on the back of her wheelchair but the cord (a cord attached to the resident's clothing with a clip and ending with a magnet that activates when the resident exceeds the length of the cord) was not clipped to the resident. During an observation on [DATE] at 3:40 pm Resident #2 was propelling herself in her wheelchair. The resident's chair alarm was not clipped to her clothing. DON A observed the resident's alarm was not clipped to the resident and she clipped the cord to the back of the resident's shirt. During an observation on [DATE] at 9:40 am Resident #2 was sitting up in bed eating breakfast, no staff was present. The resident's bed was in the high position with her tray table in front of her. The resident's fall mat was folded up and away from her bed. Her bed alarm was on the bed but the cord was not clipped to the resident. The cord was observed to be clipped to the alarm box. During an interview and observation on [DATE] at 9:42 am CNA C said Resident #2's bed alarm should be clipped to the resident's clothing. She said she did not know why the cord was clipped to the alarm box and not to the resident. She said the resident's bed was in the high position without the fall mat by the bed so the resident could use her tray table to eat breakfast in bed. Resident #6 Review of Resident #6's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #6's Fall Risk Evaluation dated [DATE] indicated the resident scored a 19 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #6's revised Care Plan dated [DATE] indicated the resident had been identified as a high risk for falls or had a history of [REDACTED]. The approaches included the use of a personal alarm (bed/chair alarm). Review of Resident #6's quarterly MDS dated [DATE] indicated the resident had moderate cognitive impairment with a BIMS score of 11 (a score of ,[DATE] indicated moderate cognitive impairment). She required extensive assistance of one staff for bed mobility, transfers, dressing and toilet use. She required supervision of one staff for ambulation. She was occasionally incontinent of bowel and bladder. She was at risk for falls and had one fall with no injury since the prior assessment. Review of Resident #6's Incident/Accident Report dated [DATE] at 5:30 pm indicated the resident's alarm sounded and she was observed sitting on the floor in front of her wheelchair. The resident had no apparent injury and said she bent over to get meat off of the floor. During an observation on [DATE] at 11:09 am Resident #6 was propelling herself in her wheelchair. The light on the resident's chair alarm was not flashing to indicate it was turned on. During an interview and observation on [DATE] at 11:09 am LVN E said Resident #6's alarm was not turned on. She said she did not know why the resident's alarm was not on but thought maybe when staff transferred the resident into her wheelchair they did not turn the alarm on. She turned the resident's alarm on. Resident #7 Review of Resident #7's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's physician order [REDACTED]. Review of Resident #7's revised Care Plan dated [DATE] indicated the resident had been identified as at risk for falls due to poor safety awareness. The goal was for the resident to be free of injury related to falls. The approaches included the use of a tab alarm (bed/chair alarm) as a reminder if ordered. Review of Resident #7's significant change MDS dated [DATE] indicated the resident had moderate cognitive impairment with a BIMS score of 8 (a score of ,[DATE] indicated moderate cognitive impairment). She required extensive assistance of one staff for bed mobility and toilet use. The resident required limited assistance of one staff for transfers and dressing. She required supervision of one staff for ambulation. She was occasionally incontinent of bowel and frequently incontinent of bladder. The resident had not fallen. Review of Resident #7's Fall Risk Evaluation dated [DATE] indicated the resident scored a 15 and was high risk for falls (a resident who scores a 10 or higher is at risk). During an observation on [DATE] at 11:13 am Resident #7 was sitting in her wheelchair in the dining room, no staff was present. The resident's chair alarm was in place but the cord was not clipped to the resident. The cord was clipped to her wheelchair. During an interview and observation on [DATE] at 11:15 am Hospitality Aide D said Resident #7's chair alarm cord should be clipped to the resident's clothing. She said she did not know who assisted the resident to the dining room. She clipped the alarm cord to the back of the resident's shirt. Resident #8 Review of Resident #8's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's physician order [REDACTED]. A chair alarm was not ordered. Review of Resident #8's revised Care Plan dated [DATE] indicated the resident had been identified as at his risk for falls or had a history of [REDACTED]. The goal was for the resident to be free of injury related to falls. The approaches included a low bed, as ordered, to decrease the resident's risk of injury and bed/chair alarm to alert staff and remind resident to call for assistance with transfers. Review of Resident #8's Fall Risk Evaluation dated [DATE] indicated the resident scored a 26 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #8's quarterly MDS dated [DATE] indicated the resident had short and long-term memory impairment and was severely impaired for decision making. She required extensive assistance of two staff for bed mobility and transfers. She required extensive assistance of one staff for dressing and toilet use. She was ambulatory with supervision. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. She had not fallen. During an observation on [DATE] at 3:48 pm Resident #8 was propelling herself in her wheelchair. The light on the resident's chair alarm was not flashing to indicate it was on. During an interview and observation on [DATE] at 3:49 pm LVN B said Resident #8's alarm was not turned on. She turned the alarm on. During an observation and interview on [DATE] at 4:51 pm Resident #8 was propelling herself in her wheelchair. The resident's chair alarm box was on her wheelchair but the alarm cord was not clipped to the resident. DON S (who began her employment on [DATE]) said the resident's alarm cord should be clipped to the resident's clothing. DON S clipped the alarm cord to the back of the resident's shirt. During an interview on [DATE] at 1:42 pm DON S said Resident #8 did not have an order for [REDACTED]. The Interim Administrator was notified of the Immediate Jeopardy situation on [DATE] at 4:26 pm. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE] at 1:55 pm. The plan included the following: An audit was completed on [DATE] to identify residents that utilized a bed and/or chair alarm. Facility residents that utilized a chair and/or bed alarm had the alarm batteries replaced and the batteries were dated for monitoring. The new un-dated bed/pressure/personal alarms procedure/staff education/in-service indicated: --staff would be educated on proper placement/use of alarms, including: display current models of alarms, review proper pad placement, ensure "in use" light is blinking, review reasons for decreased effectiveness for the alarm (thick cushions, removal by residents, etc.), ensure personal alarms are attached to the resident at all times, check placement and function of the alarm each time a resident is moved to or from bed/chair Re-education was started immediately on [DATE] with staff in the facility related to validating the alarms are functioning and in place, to include action to take if the alarm is not functioning. Staff is to change the batteries in non-functioning alarms; if changing the batteries does not resolve the issues, staff is to change the alarm. This education was presented by the Medical Director. Employees will receive this education prior to working the floor. Replacement alarms will be stored in central supply and replacement alarm batteries will be kept at the nurses' station in the event of a non-functioning alarm, batteries and/or alarms can be replaced immediately. Alarm checks have been added to the residents' Medication Administration Record and will be checked each shift by the licensed staff to validate the alarm is functioning properly. CNAs will check alarm function and position during transfers. The DON or designee will monitor the alarm check documentation and spot check alarm placement and functionality, daily for 7 days, then weekly for 3 weeks, then 2 times a month for 2 months. Alarm batteries will be changed on the 15th of each month; this has also been added to the Medication Administration Record. Incidents will be reviewed by the Administrator and DON in the morning stand-up meeting, with thorough investigation and follow-up. The Quality Assurance Performance Improvement Committee will review results of the above monitoring monthly for three months

Based on interview, observations and record review the facility failed to implement policies and procedures that prohibit neglect for 5 of 8 residents (Resident #2, #5, #6, #7 and #8) reviewed for neglect. The facility failed to: 1) provide Resident #5, who had a history of [REDACTED]. The resident fell on [DATE] and [DATE] when her physician ordered bed alarm was not functioning. The resident sustained [REDACTED]. 2) ensure Resident #2's physician ordered bed/chair alarm and fall precautions were in place while she was in bed and while she was in her wheelchair. 3) ensure Resident #6's physician ordered chair alarm was in place while she was in her wheelchair. 4) ensure Resident 7's physician ordered chair alarm was in place while she was in her wheelchair. 5) ensure Resident #8's chair alarm was in place while she was in her wheelchair. On [DATE] an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on [DATE] 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. These failures could place 10 other residents who had bed and/or chair alarms by placing them at risk for falls and injuries. Findings included: Resident #5 Review of Resident #5's closed clinical record, admission orders [REDACTED]. Bed and chair alarms were ordered. The resident received [MEDICATION NAME] 5 mg one by mouth at night and [MEDICATION NAME] ,[DATE] one by mouth at 8:00 am, 2:00 pm, 8:00 pm and 2:00 am both are narcotic pain medication for chronic back pain. The resident expired on [DATE]. Review of Resident #5's Admission Nursing Evaluation dated [DATE] indicated the resident had a history of [REDACTED]. A chair and bed alarm were to be used. The evaluation indicated the resident had fallen in the past 90 days and was being admitted with [DIAGNOSES REDACTED]. The resident was alert, oriented to person only, confused and had memory problems. The resident was fearful, anxious with delusions and disruptive behaviors. Review of Resident #5's Fall Risk Evaluation dated [DATE] indicated the resident scored a 20 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #5's Daily Skilled Nurse's Note dated [DATE] at 3:09 am indicated the resident was alert, confused and able to make some needs known. She did not use her call light and staff anticipated her needs. The resident required extensive assistance with all her activities of daily living. She denied any pain or discomfort. The resident had decreased balance, general weakness and decreased movement to all extremities. She received routine pain medication as ordered. The resident had a history of [REDACTED]. Review of Resident #5's Incident/Accident Report dated [DATE] at 6:45 pm indicated the resident tried to transfer herself from her wheelchair to her bed and slipped to the floor next to her bed. The resident was sitting on her buttocks and denied hitting her head. The resident had no apparent injury and the chair alarm was in use. The Fall Investigation Worksheet, with the incident report, indicated the CNA took the resident to her room and then went to get a pad for the resident's bed. Upon returning to the room, the resident's chair alarm sounded and the resident called for help as she slid to the floor. The resident was sitting on the floor when the CNA entered the room. The Action Plan for the incident, completed by the DON on [DATE], indicated staff was educated to bring supplies and linen to the room before or with the resident due to the resident's impatience and impulsivity. The resident was counseled to wait for assistance with transfers and referred to therapy. Review of Resident #5's Daily Skilled Nurse's Note dated [DATE] at 7:45 pm the resident was transported to her room by a CNA because the resident requested to go to bed. The resident was in her wheelchair when the CNA got a pad for the resident's bed. The resident's chair alarm sounded and the resident called out for help. The resident was sitting in the floor on her buttocks. She denied hitting her head. The resident denied any pain. Review of Resident #5's Pain Evaluation dated [DATE] indicated the resident denied any pain, rarely reported pain and was taking routine narcotic pain medication. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall with no apparent injury; the goal was for the resident to resume her usual activities without further incident. The interventions included neuros and to check range of motion daily for 72 hours. Interventions were continued. Review of Resident #5's admission MDS dated [DATE] indicated the resident had short and long-term memory problems. She was severely impaired for daily decision making. She required extensive assistance of one staff for bed mobility and dressing. The resident required extensive assistance of two staff for toilet use and transfers. She required limited assistance of one staff for personal hygiene. She was totally dependent of one staff for bathing. The resident was frequently incontinent of bowel and bladder. She was not ambulatory. She had a history of [REDACTED]. Review of Resident #5's Care Plan dated [DATE] indicated the resident was at risk for falls related to a history of falls and falls since admission. The resident had short-term and long-term memory problems and did not always remember she was too weak to transfer independently. The goal was for the resident to not sustain serious injury related to falls. The approaches included bed/chair alarm, monitor for pattern of risk factors, or tendency to fall, monitor and eliminate potential environmental hazards, instruct and encourage call light use and request for assistance and analyze previous falls to determine causative factors, and implement changes. Review of Resident #5's Incident/Accident Report dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. Staff (LVN F) responded by entering the resident's room. The resident was next to the right side of her bed lying on the floor mat. She said she was trying to reach over "there" and pointed to her night stand. The resident was instructed to use her call light when she needed help and voiced understanding. She said she hit her head "a little". The resident had no injury and denied any pain. The bed alarm was not in use. The report indicated the action taken included care plan update and staff re-education. The report was signed by the Administrator and DON on [DATE]. There was no documentation of a Falls Investigation Worksheet or Action Plan or any documentation to explain why the resident's bed alarm was not in use at the time of this incident. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall with no apparent injury; the goal was for the resident to resume her usual activities without further incident. The approach was to do neuros. There were no other interventions or changes made to the resident's care plan. During an interview on [DATE] at 11:52 am DON S said there was no investigation regarding the circumstances surrounding Resident #5's fall on [DATE]. Review of Resident #5's Progress Note dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. This nurse (LVN F) responded to the resident's room. The resident was on the floor lying on the mat next to her bed. She reported hitting her head a "little bit". she denied pain. The resident reported, "I was reaching for that" and pointed to the nightstand. She was unable to recall the exact item she was reaching for. The resident was able to move all her extremities. She was assisted to bed and neuros were initiated. The resident's physician, family, the DON and ADON were all notified of the incident. There was no documentation regarding the resident's bed alarm and why it was not in use at the time of the resident's fall. During a telephone interview on [DATE] at 3:24 pm Charge Nurse, LVN F, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . She said she thought the alarm did not sound because the battery was dead so she changed out the alarm battery. She said the resident did not usually report pain and seemed to be fine after the fall. She said she called the ADON to inform her of the fall and that the alarm did not sound. During an interview on [DATE] at 3:45 pm the ADON said LVN F called her on [DATE] to report Resident #5's fall. She said she informed LVN F she needed to contact the DON regarding the resident's fall. She said she did not know anything about the resident's alarm not sounding. She said the facility did not have a policy and/or procedure to ensure bed/chair alarms were functioning. Review of Resident #5's Progress Note dated [DATE] at 12:15 am the resident was being monitored for signs of injury due to her recent fall ([DATE]) with no new injuries noted. The resident continued to attempt to get out of bed without calling for assistance. The resident had her usual range of motion to all extremities. She voiced no complaint of pain and no acute distress was noted. At 2:53 pm neuros were continued from the previous fall. No injuries were noted. The resident was up in her wheelchair for meals. Will continue to monitor closely. Review of Resident #5's Incident/Accident Report dated [DATE] at 8:15 pm indicated staff (LVN G) heard the resident calling out for help and upon entering her room the resident had fallen out of bed and was laying on the floor in a half sitting position by her recliner. The resident had a skin tear to her left elbow and she complained of pain to her left hip. The resident's bed alarm was not in use due to dead batteries. The Administrator and DON signed the incident report on [DATE]. The Falls Investigation Report, with the incident report, indicated the resident was having wandering behaviors at the time of this fall. The fall was unwitnessed. The resident had two previous falls in the last 30 days. The Action Plan for the incident, completed by the DON on [DATE], indicated two x-rays were negative but the resident continued to report pain and a final x-ray showed a pelvic fracture. The resident was referred to therapy again. Hospice increased the resident's pain medications. The DON documented the resident was very impulsive and refused to call for assistance. The plan did not include any action related to ensuring the alarms were functional. Review of Resident #5's Progress Note dated [DATE] at 8:15 pm indicated staff heard the resident calling for help and, upon entering the resident's room, the resident was in a half sitting position by her recliner. A skin tear to the resident's left elbow was noted. The resident denied pain at this time and was assisted to the bed. The alarm was checked and found to be inoperable (battery); while doing further assessment the resident started to complain of pain to her hip. The skin tear was treated per protocol, the physician was called for an x-ray order, and the responsible party was called and notified of the fall. The responsible party said he had been at the facility earlier and had trouble keeping the resident in her wheelchair. The x-ray company was called, the resident continued to complain of pain to her left hip, no discoloration or bruising was noted. At 8:30 pm the x-ray was done and the resident continued to complain of pain when moved. At 10:23 pm the x-ray showed no fracture. During a telephone interview on [DATE] at 3:37 pm Charge Nurse, LVN G, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . He said the alarm failed to go off for some reason. He said the resident was too confused to tell staff what happened. He said he thought the alarm batteries were dead and put another alarm on the resident's bed. He said the resident did not report pain, at first, but later began reporting pain. He said the first x-ray was negative for any fractures but another x-ray showed a pelvic fracture. He said prior to this fall, earlier in the day on [DATE], the resident was anxious and trying to get up out of her wheelchair without assistance. He said after the resident fell on [DATE] she was in too much pain to try to get out of bed. During a telephone interview on [DATE] at 3:52 pm Charge Nurse, LVN H, said she was not aware Resident #5's bed alarm failed to sound on [DATE] and on [DATE]. She said the facility did not have a specific policy and/or procedures to ensure the alarms were functioning. She said Resident #5 seemed okay after her fall on [DATE]. She said after the resident fell on [DATE] staff could not touch the resident without her hollering out in pain. She said the resident's pain was unmanageable and not controlled with the pain medication ordered. She said the last x-ray showed a pelvic fracture and the resident was sent to the emergency room but returned to the facility without further treatment except for a change in her pain medication. She said after the resident's pain medication was changed she still experienced some pain when she was moved but it was manageable. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall; the goal was for the resident to resume her usual activities without further incident and involved areas will resolve without complications. The approach was to do neuros for 72 hours. There were no other interventions or changes made to the resident's care plan. Review of Resident #5's Progress Note dated [DATE] at 10:30 am indicated the hospice nurse was in to see the resident and said the resident was tender in her hip area and ordered another x-ray to be taken through the hospice company (the x-ray was negative). Review of Resident #5's Progress Note dated [DATE] at 2:17 am indicated the resident denied pain or discomfort and was medicated with routine pain medication as per orders. The resident continued to yell out at intervals. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated the resident continued to complain of pain in her left hip; pain medications given as ordered. Review of Resident #5's Progress Note dated [DATE] at 4:44 am indicated the resident continued to complain of pain to her left hip and was medicated with routine pain medication as per orders. The resident continued to yell out at intervals. Review of Resident #5's Progress Note dated [DATE] at 10:00 am indicated the resident had severe pain to her left side from her hip down. The resident was unable to pinpoint the exact location. The hospice nurse assessed the resident and obtained an order for [REDACTED]. Will continue to monitor closely. At 2:00 pm mobile x-ray at the facility to perform the x-rays. The resident continued to be in severe pain anytime she is repositioned. At 4:45 pm a call was received from hospice; the resident had a [MEDICAL CONDITION] ramus (a part of the pelvis). An order was received to send the resident to the emergency room for an evaluation and treatment. The DON, Administrator and resident's responsible party were notified. At 5:00 pm the ambulance arrived to transport the resident to the emergency room . At 8:30 pm the resident returned from the emergency room via non-emergency ambulance with a [DIAGNOSES REDACTED]. The resident's pm medications were given. The resident was awake and showed signs of pain. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident was awake twice during the night moaning as if in pain, quiets shortly when medications are given, and also moans when turned. The resident made no attempt to get out of bed. Alarm in place. At 10:45 am the resident continued to have uncontrolled pain. Notified hospice and received new orders to discontinue all previous [MEDICATION NAME] and [MEDICATION NAME] orders; [MEDICATION NAME] 5 mg one by mouth every four hours around the clock, [MEDICATION NAME] ,[DATE] mg one by mouth every four hours around the clock, alternate [MEDICATION NAME] and [MEDICATION NAME] so the resident receives pain medication every two hours around the clock. Medication given as per orders and resident appears more relaxed, resting with her eyes closed. Will continue to closely monitor. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident responded well to pain therapy every two hours. The resident had less moaning during the night and awakened for short periods when medications were given. The resident does show signs of severe pain when awake. Checked on resident frequently and assisted with activities of daily living as needed. Review of Resident #5's Care Plan dated [DATE] indicated the resident fell from her bed on [DATE]. The goal was to decrease the resident's risk for falls. The approaches included a follow-up x-ray on [DATE] indicated a pelvic fracture, pain medication as ordered, bed alarm, staff to respond as soon as possible, reposition every two hours for pain relief. Review of Resident #5's Progress Note dated [DATE] at 1:30 am indicated the resident continued to be medicated for pain every two hours around the clock. The resident moans constantly while awake, yells out when moved. Pain medications are effective, lays in bed asleep for long periods of time awakens and takes medications with difficulty. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated the resident continued to be in pain when moved, pain medication given as ordered. New order to change diet to pureed. Review of Resident #5's Progress Note dated [DATE] at 4:20 am indicated the resident continued to receive pain medication as ordered. The resident yells out at intervals, especially when she is moved. Pain medications are effective when given and the yelling and moaning is less frequent. Turning and repositioning every two hours and as needed for pressure relief and comfort. Alarm in place and functioning properly. Review of Resident #5's Progress Note dated [DATE] at 2:32 pm indicated the resident continued on around the clock [MEDICATION NAME] and [MEDICATION NAME]. Medications effective until resident is moved. Review of Resident #5's Progress Note dated [DATE] at 12:57 pm indicated the resident continues to have discomfort when repositioned. Medicated as ordered. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident was mostly unresponsive during the night, responded weakly when crushed medications were given. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated a new order for [MEDICATION NAME] 0.5 ml by mouth, sublingual or nebulize TID every two hours and as needed for pain. Turn and reposition resident every two hours. Resident no longer swallowing medications by mouth without difficulty, clamps mouth shut when attempting to give medications. Liquid [MEDICATION NAME] given and medication was effective. Review of Resident #5's Progress Note dated [DATE] at 5:15 am indicated the resident expired. During a telephone interview on [DATE] at 4:00 pm the former Administrator (whose last day of employment was [DATE]) said she believed Resident #5 turned her alarm off and did not know LVN G documented on [DATE] the alarm failed to sound due to dead batteries. She said a few days after the resident fell on [DATE] she began hurting and was diagnosed with [REDACTED]. During a telephone interview on [DATE] at 4:15 the former DON (DON A, whose last day of employment was [DATE]) said she did not remember the exact details regarding Resident #5's falls on [DATE] and [DATE] but she would have instructed staff to change out the alarms. She said the nurses should check to make sure the alarms were working but there was not a place on the medication or treatment record to document the alarm functioning. During an interview on [DATE] at 3:30 pm the Interim Administrator (who began her employment on [DATE]) said the facility did not have a specific policy and procedure regarding bed/chair alarms. Resident #2 Review of Resident #2's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's physician's orders [REDACTED]. A personal alarm (bed/chair alarm) to alert staff of attempts to transfer self. Review of Resident #2's Fall Risk Evaluation dated [DATE] indicated the resident scored a 14 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #2's revised Care Plan dated [DATE] indicated the resident had been identified as at risk for falls due to poor safety awareness, unsteady gait and poor strength in her knees. The goal was for the resident to be free of injury related to falls. The approaches included the use of a tab alarm (bed/chair alarm) as a reminder if ordered. Review of Resident #2's quarterly MDS dated [DATE] indicated she had short and long-term memory impairment and was severely impaired for decision making. She required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use. She was not ambulatory. The resident was always incontinent of bowel and bladder. She had not fallen. During an observation on [DATE] at 3:38 pm Resident #2 was observed sitting outside in her wheelchair attending an activity. The resident had a chair alarm on the back of her wheelchair but the cord (a cord attached to the resident's clothing with a clip and ending with a magnet that activates when the resident exceeds the length of the cord) was not clipped to the resident. During an observation on [DATE] at 3:40 pm Resident #2 was propelling herself in her wheelchair. The resident's chair alarm was not clipped to her clothing. DON A observed the resident's alarm was not clipped to the resident and she clipped the cord to the back of the resident's shirt. During an observation on [DATE] at 9:40 am Resident #2 was sitting up in bed eating breakfast, no staff was present. The resident's bed was in the high position with her tray table in front of her. The resident's fall mat was folded up and away from her bed. Her bed alarm was on the bed but the cord was not clipped to the resident. The cord was observed to be clipped to the alarm box. During an interview and observation on [DATE] at 9:42 am CNA C said Resident #2's bed alarm should be clipped to the resident's clothing. She said she did not know why the cord was clipped to the alarm box and not to the resident. She said the resident's bed was in the high position without the fall mat by the bed so the resident could use her tray table to eat breakfast in bed. Resident #6 Review of Resident #6's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #6's Fall Risk Evaluation dated [DATE] indicated the resident scored a 19 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #6's revised Care Plan dated [DATE] indicated the resident had been identified as a high risk for falls or had a history of [REDACTED]. The approaches included the use of a personal alarm (bed/chair alarm). Review of Resident #6's quarterly MDS dated [DATE] indicated the resident had moderate cognitive impairment with a BIMS score of 11 (a score of ,[DATE] indicated moderate cognitive impairment). She required extensive assistance of one staff for bed mobility, transfers, dressing and toilet use. She required supervision of one staff for ambulation. She was occasionally incontinent of bowel and bladder. She was at risk for falls and had one fall with no injury since the prior assessment. Review of Resident #6's Incident/Accident Report dated [DATE] at 5:30 pm indicated the resident's alarm sounded and she was observed sitting on the floor in front of her wheelchair. The resident had no apparent injury and said she bent over to get meat off of the floor. During an observation on [DATE] at 11:09 am Resident #6 was propelling herself in her wheelchair. The light on the resident's chair alarm was not flashing to indicate it was turned on. During an interview and observation on [DATE] at 11:09 am LVN E said Resident #6's alarm was not turned on. She said she did not know why the resident's alarm was not on but thought maybe when staff transferred the resident into her wheelchair they did not turn the alarm on. She turned the resident's alarm on. Resident #7 Review of Resident #7's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's physician order [REDACTED]. Review of Resident #7's revised Care Plan dated [DATE] indicated the resident had been identified as at risk for falls due to poor safety awareness. The goal was for the resident to be free of injury related to falls. The approaches included the use of a tab alarm (bed/chair alarm) as a reminder if ordered. Review of Resident #7's significant change MDS dated [DATE] indicated the resident had moderate cognitive impairment with a BIMS score of 8 (a score of ,[DATE] indicated moderate cognitive impairment). She required extensive assistance of one staff for bed mobility and toilet use. The resident required limited assistance of one staff for transfers and dressing. She required supervision of one staff for ambulation. She was occasionally incontinent of bowel and frequently incontinent of bladder. The resident had not fallen. Review of Resident #7's Fall Risk Evaluation dated [DATE] indicated the resident scored a 15 and was high risk for falls (a resident who scores a 10 or higher is at risk). During an observation on [DATE] at 11:13 am Resident #7 was sitting in her wheelchair in the dining room, no staff was present. The resident's chair alarm was in place but the cord was not clipped to the resident. The cord was clipped to her wheelchair. During an interview and observation on [DATE] at 11:15 am Hospitality Aide D said Resident #7's chair alarm cord should be clipped to the resident's clothing. She said she did not know who assisted the resident to the dining room. She clipped the alarm cord to the back of the resident's shirt. Resident #8 Review of Resident #8's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's physician order [REDACTED]. A chair alarm was not ordered. Review of Resident #8's revised Care Plan dated [DATE] indicated the resident had been identified as at his risk for falls or had a history of [REDACTED]. The goal was for the resident to be free of injury related to falls. The approaches included a low bed, as ordered, to decrease the resident's risk of injury and bed/chair alarm to alert staff and remind resident to call for assistance with transfers. Review of Resident #8's Fall Risk Evaluation dated [DATE] indicated the resident scored a 26 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #8's quarterly MDS dated [DATE] indicated the resident had short and long-term memory impairment and was severely impaired for decision making. She required extensive assistance of two staff for bed mobility and transfers. She required extensive assistance of one staff for dressing and toilet use. She was ambulatory with supervision. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. She had not fallen. During an observation on [DATE] at 3:48 pm Resident #8 was propelling herself in her wheelchair. The light on the resident's chair alarm was not flashing to indicate it was on. During an interview and observation on [DATE] at 3:49 pm LVN B said Resident #8's alarm was not turned on. She turned the alarm on. During an observation and interview on [DATE] at 4:51 pm Resident #8 was propelling herself in her wheelchair. The resident's chair alarm box was on her wheelchair but the alarm cord was not clipped to the resident. DON S (who began her employment on [DATE]) said the resident's alarm cord should be clipped to the resident's clothing. DON S clipped the alarm cord to the back of the resident's shirt. During an interview on [DATE] at 1:42 pm DON S said Resident #8 did not have an order for [REDACTED]. Review of the facility ' s Abuse Prohibition policy dated [DATE] indicated he facility has developed operational policies and procedures for screening and training employees, protection of residents and the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment; and misappropriation of property. The facility's purpose is to assure the facility is doing all that is within their control to prevent occurrences. The Interim Administrator was notified of the Immediate Jeopardy situation on [DATE] at 4:26 pm. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE] at 1:55 pm. The plan included the following: An audit was completed on [DATE] to identify residents that utilized a bed and/or chair alarm. Facility residents that utilized a chair and/or bed alarm had the alarm batteries replaced and the batteries were dated for monitoring. The new un-dated bed/pressure/personal alarms procedure/staff education/in-service indicated: --staff would be educated on proper placement/use of alarms, including: display current models of alarms, review proper pad placement, ensure "in use" light is blinking, review reasons for decreased effectiveness for the alarm (thick cushions, removal by residents, etc.), ensure personal alarms are attached to the resident at all times, check placement and function of the alarm each time a resident is moved to or from bed/chair Re-education was started immediately on [DATE] with staff in the facility related to validating the alarms are functioning and in place, to include action to take if the alarm is not functioning. Staff is to change the batteries in non-functioning alarms; if changing the batteries does not resolve the issues, staff is to change the alarm. This education was presented by the Medical Director. Employees will receive this education prior to working the floor. Replacement alarms will be stored in central supply and replacement alarm batteries will be kept at the nurses' station in the event of a non-functioning alarm, batteries and/or alarms can be replaced immediately. Alarm checks have been added to the residents' Medication Administration Record [REDACTED]. CNAs will check alarm function and position during transfers. The DON or designee will monitor the alarm check documentation and spot check alarm placement and functionality, daily for 7 days, then weekly for 3 wee

Based on interview, observation and record review, the Administrator and 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 5 of 8 residents (Resident #2, #5, #6, #7 and #8) reviewed for falls received adequate supervision and assistive devices to prevent accidents. 1) The Administrator failed to implement the facility's abuse and neglect policy by not adequately investigating and reporting Resident #5's falls on [DATE] and [DATE], when her bed alarm was not functioning properly and she fell out of bed. The resident sustained [REDACTED]. 2) The Administrator and Interim Administrator failed to supervise the nursing staff to ensure Resident #2, #5, #6, #7 and #8 received adequate supervision and assistive devices to prevent accidents. 3) DON A and DON S failed to supervise the nursing staff to ensure Resident #2, #5, #6, #7 and #8 received adequate supervision and assistive devices to prevent accidents. On [DATE] an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on [DATE] 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. The failure of Administrative Staff to effectively manage the resources of the facility could place 10 other residents with bed and/or chair alarms at risk for neglect, accidents, and injuries Findings included: Resident #5 Review of Resident #5's closed clinical record, admission orders [REDACTED]. Bed and chair alarms were ordered. The resident received [MEDICATION NAME] 5 mg one by mouth at night and [MEDICATION NAME] ,[DATE] one by mouth at 8:00 am, 2:00 pm, 8:00 pm and 2:00 am both are narcotic pain medication for chronic back pain. The resident expired on [DATE]. Review of Resident #5's Admission Nursing Evaluation dated [DATE] indicated the resident had a history of [REDACTED]. A chair and bed alarm were to be used. The evaluation indicated the resident had fallen in the past 90 days and was being admitted with [DIAGNOSES REDACTED]. The resident was alert, oriented to person only, confused and had memory problems. The resident was fearful, anxious with delusions and disruptive behaviors. Review of Resident #5's Fall Risk Evaluation dated [DATE] indicated the resident scored a 20 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #5's Daily Skilled Nurse's Note dated [DATE] at 3:09 am indicated the resident was alert, confused and able to make some needs known. She did not use her call light and staff anticipated her needs. The resident required extensive assistance with all her activities of daily living. She denied any pain or discomfort. The resident had decreased balance, general weakness and decreased movement to all extremities. She received routine pain medication as ordered. The resident had a history of [REDACTED]. Review of Resident #5's Incident/Accident Report dated [DATE] at 6:45 pm indicated the resident tried to transfer herself from her wheelchair to her bed and slipped to the floor next to her bed. The resident was sitting on her buttocks and denied hitting her head. The resident had no apparent injury and the chair alarm was in use. The Fall Investigation Worksheet, with the incident report, indicated the CNA took the resident to her room and then went to get a pad for the resident's bed. Upon returning to the room, the resident's chair alarm sounded and the resident called for help as she slid to the floor. The resident was sitting on the floor when the CNA entered the room. The Action Plan for the incident, completed by the DON on [DATE], indicated staff was educated to bring supplies and linen to the room before or with the resident due to the resident's impatience and impulsivity. The resident was counseled to wait for assistance with transfers and referred to therapy. Review of Resident #5's Daily Skilled Nurse's Note dated [DATE] at 7:45 pm the resident was transported to her room by a CNA because the resident requested to go to bed. The resident was in her wheelchair when the CNA got a pad for the resident's bed. The resident's chair alarm sounded and the resident called out for help. The resident was sitting in the floor on her buttocks. She denied hitting her head. The resident denied any pain. Review of Resident #5's Pain Evaluation dated [DATE] indicated the resident denied any pain, rarely reported pain and was taking routine narcotic pain medication. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall with no apparent injury; the goal was for the resident to resume her usual activities without further incident. The interventions included neuros and to check range of motion daily for 72 hours. Interventions were continued. Review of Resident #5's admission MDS dated [DATE] indicated the resident had short and long-term memory problems. She was severely impaired for daily decision making. She required extensive assistance of one staff for bed mobility and dressing. The resident required extensive assistance of two staff for toilet use and transfers. She required limited assistance of one staff for personal hygiene. She was totally dependent of one staff for bathing. The resident was frequently incontinent of bowel and bladder. She was not ambulatory. She had a history of [REDACTED]. Review of Resident #5's Care Plan dated [DATE] indicated the resident was at risk for falls related to a history of falls and falls since admission. The resident had short-term and long-term memory problems and did not always remember she was too weak to transfer independently. The goal was for the resident to not sustain serious injury related to falls. The approaches included bed/chair alarm, monitor for pattern of risk factors, or tendency to fall, monitor and eliminate potential environmental hazards, instruct and encourage call light use and request for assistance and analyze previous falls to determine causative factors, and implement changes. Review of Resident #5's Incident/Accident Report dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. Staff (LVN F) responded by entering the resident's room. The resident was next to the right side of her bed lying on the floor mat. She said she was trying to reach over "there" and pointed to her night stand. The resident was instructed to use her call light when she needed help and voiced understanding. She said she hit her head "a little". The resident had no injury and denied any pain. The bed alarm was not in use. The report indicated the action taken included care plan update and staff re-education. The report was signed by the Administrator and DON on [DATE]. There was no documentation of a Falls Investigation Worksheet or Action Plan or any documentation to explain why the resident's bed alarm was not in use at the time of this incident. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall with no apparent injury; the goal was for the resident to resume her usual activities without further incident. The approach was to do neuros. There were no other interventions or changes made to the resident's care plan. During an interview on [DATE] at 11:52 am DON S said there was no investigation regarding the circumstances surrounding Resident #5's falls. Review of Resident #5's Progress Note dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. This nurse (LVN F) responded to the resident's room. The resident was on the floor lying on the mat next to her bed. She reported hitting her head a "little bit". she denied pain. The resident reported, "I was reaching for that" and pointed to the nightstand. She was unable to recall the exact item she was reaching for. The resident was able to move all her extremities. She was assisted to bed and neuros were initiated. The resident's physician, family, the DON and ADON were all notified of the incident. There was no documentation regarding the resident's bed alarm and why it was not in use at the time of the resident's fall. During a telephone interview on [DATE] at 3:24 pm Charge Nurse, LVN F, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . She said she thought the alarm did not sound because the battery was dead so she changed out the alarm battery. She said the resident did not usually report pain and seemed to be fine after the fall. She said she called the ADON to inform her of the fall and that the alarm did not sound. During an interview on [DATE] at 3:45 pm the ADON said LVN F called her on [DATE] to report Resident #5's fall. She said she informed LVN F she needed to contact the DON regarding the resident's fall. She said she did not know anything about the resident's alarm not sounding. She said the facility did not have a policy and/or procedure to ensure bed/chair alarms were functioning. Review of Resident #5's Progress Note dated [DATE] at 12:15 am the resident was being monitored for signs of injury due to her recent fall ([DATE]) with no new injuries noted. The resident continued to attempt to get out of bed without calling for assistance. The resident had her usual range of motion to all extremities. She voiced no complaint of pain and no acute distress was noted. At 2:53 pm neuros were continued from the previous fall. No injuries were noted. The resident was up in her wheelchair for meals. Will continue to monitor closely. Review of Resident #5's Incident/Accident Report dated [DATE] at 8:15 pm indicated staff (LVN G) heard the resident calling out for help and upon entering her room the resident had fallen out of bed and was laying on the floor in a half sitting position by her recliner. The resident had a skin tear to her left elbow and she complained of pain to her left hip. The resident's bed alarm was not in use due to dead batteries. The Administrator and DON signed the incident report on [DATE]. The Falls Investigation Report, with the incident report, indicated the resident was having wandering behaviors at the time of this fall. The fall was unwitnessed. The resident had two previous falls in the last 30 days. The Action Plan for the incident, completed by the DON on [DATE], indicated two x-rays were negative but the resident continued to report pain and a final x-ray showed a pelvic fracture. The resident was referred to therapy again. Hospice increased the resident's pain medications. The DON documented the resident was very impulsive and refused to call for assistance. The plan did not include any action related to ensuring the alarms were functional. Review of Resident #5's Progress Note dated [DATE] at 8:15 pm indicated staff heard the resident calling for help and, upon entering the resident's room, the resident was in a half sitting position by her recliner. A skin tear to the resident's left elbow was noted. The resident denied pain at this time and was assisted to the bed. The alarm was checked and found to be inoperable (battery); while doing further assessment the resident started to complain of pain to her hip. The skin tear was treated per protocol, the physician was called for an x-ray order, and the responsible party was called and notified of the fall. The responsible party said he had been at the facility earlier and had trouble keeping the resident in her wheelchair. The x-ray company was called, the resident continued to complain of pain to her left hip, no discoloration or bruising was noted. At 8:30 pm the x-ray was done and the resident continued to complain of pain when moved. At 10:23 pm the x-ray showed no fracture. During a telephone interview on [DATE] at 3:37 pm Charge Nurse, LVN G, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . He said the alarm failed to go off for some reason. He said the resident was too confused to tell staff what happened. He said he thought the alarm batteries were dead and put another alarm on the resident's bed. He said the resident did not report pain, at first, but later began reporting pain. He said the first x-ray was negative for any fractures but another x-ray showed a pelvic fracture. He said prior to this fall, earlier in the day on [DATE], the resident was anxious and trying to get up out of her wheelchair without assistance. He said after the resident fell on [DATE] she was in too much pain to try to get out of bed. During a telephone interview on [DATE] at 3:52 pm Charge Nurse, LVN H, said she was not aware Resident #5's bed alarm failed to sound on [DATE] and on [DATE]. She said the facility did not have a specific policy and/or procedures to ensure the alarms were functioning. She said Resident #5 seemed okay after her fall on [DATE]. She said after the resident fell on [DATE] staff could not touch the resident without her hollering out in pain. She said the resident's pain was unmanageable and not controlled with the pain medication ordered. She said the last x-ray showed a pelvic fracture and the resident was sent to the emergency room but returned to the facility without further treatment except for a change in her pain medication. She said after the resident's pain medication was changed she still experienced some pain when she was moved but it was manageable. Review of Resident #5's Immediate Needs Care Plan dated [DATE] indicated the resident had a fall; the goal was for the resident to resume her usual activities without further incident and involved areas will resolve without complications. The approach was to do neuros for 72 hours. There were no other interventions or changes made to the resident's care plan. Review of Resident #5's Progress Note dated [DATE] at 10:30 am indicated the hospice nurse was in to see the resident and said the resident was tender in her hip area and ordered another x-ray to be taken through the hospice company (the x-ray was negative). Review of Resident #5's Progress Note dated [DATE] at 2:17 am indicated the resident denied pain or discomfort and was medicated with routine pain medication as per orders. The resident continued to yell out at intervals. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated the resident continued to complain of pain in her left hip; pain medications given as ordered. Review of Resident #5's Progress Note dated [DATE] at 4:44 am indicated the resident continued to complain of pain to her left hip and was medicated with routine pain medication as per orders. The resident continued to yell out at intervals. Review of Resident #5's Progress Note dated [DATE] at 10:00 am indicated the resident had severe pain to her left side from her hip down. The resident was unable to pinpoint the exact location. The hospice nurse assessed the resident and obtained an order for [REDACTED]. Will continue to monitor closely. At 2:00 pm mobile x-ray at the facility to perform the x-rays. The resident continued to be in severe pain anytime she is repositioned. At 4:45 pm a call was received from hospice; the resident had a [MEDICAL CONDITION] ramus (a part of the pelvis). An order was received to send the resident to the emergency room for an evaluation and treatment. The DON, Administrator and resident's responsible party were notified. At 5:00 pm the ambulance arrived to transport the resident to the emergency room . At 8:30 pm the resident returned from the emergency room via non-emergency ambulance with a [DIAGNOSES REDACTED]. The resident's pm medications were given. The resident was awake and showed signs of pain. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident was awake twice during the night moaning as if in pain, quiets shortly when medications are given, and also moans when turned. The resident made no attempt to get out of bed. Alarm in place. At 10:45 am the resident continued to have uncontrolled pain. Notified hospice and received new orders to discontinue all previous [MEDICATION NAME] and [MEDICATION NAME] orders; [MEDICATION NAME] 5 mg one by mouth every four hours around the clock, [MEDICATION NAME] ,[DATE] mg one by mouth every four hours around the clock, alternate [MEDICATION NAME] and [MEDICATION NAME] so the resident receives pain medication every two hours around the clock. Medication given as per orders and resident appears more relaxed, resting with her eyes closed. Will continue to closely monitor. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident responded well to pain therapy every two hours. The resident had less moaning during the night and awakened for short periods when medications were given. The resident does show signs of severe pain when awake. Checked on resident frequently and assisted with activities of daily living as needed. Review of Resident #5's Care Plan dated [DATE] indicated the resident fell from her bed on [DATE]. The goal was to decrease the resident's risk for falls. The approaches included a follow-up x-ray on [DATE] indicated a pelvic fracture, pain medication as ordered, bed alarm, staff to respond as soon as possible, reposition every two hours for pain relief. Review of Resident #5's Progress Note dated [DATE] at 1:30 am indicated the resident continued to be medicated for pain every two hours around the clock. The resident moans constantly while awake, yells out when moved. Pain medications are effective, lays in bed asleep for long periods of time awakens and takes medications with difficulty. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated the resident continued to be in pain when moved, pain medication given as ordered. New order to change diet to pureed. Review of Resident #5's Progress Note dated [DATE] at 4:20 am indicated the resident continued to receive pain medication as ordered. The resident yells out at intervals, especially when she is moved. Pain medications are effective when given and the yelling and moaning is less frequent. Turning and repositioning every two hours and as needed for pressure relief and comfort. Alarm in place and functioning properly. Review of Resident #5's Progress Note dated [DATE] at 2:32 pm indicated the resident continued on around the clock [MEDICATION NAME] and [MEDICATION NAME]. Medications effective until resident is moved. Review of Resident #5's Progress Note dated [DATE] at 12:57 pm indicated the resident continues to have discomfort when repositioned. Medicated as ordered. Review of Resident #5's Progress Note dated [DATE] at 5:30 am indicated the resident was mostly unresponsive during the night, responded weakly when crushed medications were given. Review of Resident #5's Progress Note dated [DATE] (not timed) indicated a new order for [MEDICATION NAME] 0.5 ml by mouth, sublingual or nebulize TID every two hours and as needed for pain. Turn and reposition resident every two hours. Resident no longer swallowing medications by mouth without difficulty, clamps mouth shut when attempting to give medications. Liquid [MEDICATION NAME] given and medication was effective. Review of Resident #5's Progress Note dated [DATE] at 5:15 am indicated the resident expired. During a telephone interview on [DATE] at 4:00 pm the former Administrator (whose last day of employment was [DATE]) said she believed Resident #5 turned her alarm off and did not know LVN G documented on [DATE] the alarm failed to sound due to dead batteries. She said a few days after the resident fell on [DATE] she began hurting and was diagnosed with [REDACTED]. She said Resident #5's injury was not reported to the State agency because she thought the resident was able to tell staff what happened. She said she reviewed the information regarding the incident with the corporate office and it was decided the incident was not reportable. During a telephone interview on [DATE] at 4:15 the former DON (DON A, whose last day of employment was [DATE]) said she did not remember the exact details regarding Resident #5's falls on [DATE] and [DATE] but she would have instructed staff to change out the alarms. She said the nurses should check to make sure the alarms were working but there was not a place on the medication or treatment record to document the alarm functioning. She said the Administrator and the corporate office discussed the incident and decided it was not reportable. During an interview on [DATE] at 3:30 pm the Interim Administrator (who began her employment on [DATE]) said the facility did not have a specific policy and procedure regarding bed/chair alarms. Resident #2 Review of Resident #2's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's physician's orders [REDACTED]. A personal alarm (bed/chair alarm) to alert staff of attempts to transfer self. Review of Resident #2's Fall Risk Evaluation dated [DATE] indicated the resident scored a 14 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #2's revised Care Plan dated [DATE] indicated the resident had been identified as at risk for falls due to poor safety awareness, unsteady gait and poor strength in her knees. The goal was for the resident to be free of injury related to falls. The approaches included the use of a tab alarm (bed/chair alarm) as a reminder if ordered. Review of Resident #2's quarterly MDS dated [DATE] indicated she had short and long-term memory impairment and was severely impaired for decision making. She required extensive assistance of two staff for bed mobility, transfers, dressing and toilet use. She was not ambulatory. The resident was always incontinent of bowel and bladder. She had not fallen. During an observation on [DATE] at 3:38 pm Resident #2 was observed sitting outside in her wheelchair attending an activity. The resident had a chair alarm on the back of her wheelchair but the cord (a cord attached to the resident's clothing with a clip and ending with a magnet that activates when the resident exceeds the length of the cord) was not clipped to the resident. During an observation on [DATE] at 3:40 pm Resident #2 was propelling herself in her wheelchair. The resident's chair alarm was not clipped to her clothing. DON A observed the resident's alarm was not clipped to the resident and she clipped the cord to the back of the resident's shirt. During an observation on [DATE] at 9:40 am Resident #2 was sitting up in bed eating breakfast, no staff was present. The resident's bed was in the high position with her tray table in front of her. The resident's fall mat was folded up and away from her bed. Her bed alarm was on the bed but the cord was not clipped to the resident. The cord was observed to be clipped to the alarm box. During an interview and observation on [DATE] at 9:42 am CNA C said Resident #2's bed alarm should be clipped to the resident's clothing. She said she did not know why the cord was clipped to the alarm box and not to the resident. She said the resident's bed was in the high position without the fall mat by the bed so the resident could use her tray table to eat breakfast in bed. Resident #6 Review of Resident #6's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of Resident #6's Fall Risk Evaluation dated [DATE] indicated the resident scored a 19 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #6's revised Care Plan dated [DATE] indicated the resident had been identified as a high risk for falls or had a history of [REDACTED]. The approaches included the use of a personal alarm (bed/chair alarm). Review of Resident #6's quarterly MDS dated [DATE] indicated the resident had moderate cognitive impairment with a BIMS score of 11 (a score of ,[DATE] indicated moderate cognitive impairment). She required extensive assistance of one staff for bed mobility, transfers, dressing and toilet use. She required supervision of one staff for ambulation. She was occasionally incontinent of bowel and bladder. She was at risk for falls and had one fall with no injury since the prior assessment. Review of Resident #6's Incident/Accident Report dated [DATE] at 5:30 pm indicated the resident's alarm sounded and she was observed sitting on the floor in front of her wheelchair. The resident had no apparent injury and said she bent over to get meat off of the floor. During an observation on [DATE] at 11:09 am Resident #6 was propelling herself in her wheelchair. The light on the resident's chair alarm was not flashing to indicate it was turned on. During an interview and observation on [DATE] at 11:09 am LVN E said Resident #6's alarm was not turned on. She said she did not know why the resident's alarm was not on but thought maybe when staff transferred the resident into her wheelchair they did not turn the alarm on. She turned the resident's alarm on. Resident #7 Review of Resident #7's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #7's physician order [REDACTED]. Review of Resident #7's revised Care Plan dated [DATE] indicated the resident had been identified as at risk for falls due to poor safety awareness. The goal was for the resident to be free of injury related to falls. The approaches included the use of a tab alarm (bed/chair alarm) as a reminder if ordered. Review of Resident #7's significant change MDS dated [DATE] indicated the resident had moderate cognitive impairment with a BIMS score of 8 (a score of ,[DATE] indicated moderate cognitive impairment). She required extensive assistance of one staff for bed mobility and toilet use. The resident required limited assistance of one staff for transfers and dressing. She required supervision of one staff for ambulation. She was occasionally incontinent of bowel and frequently incontinent of bladder. The resident had not fallen. Review of Resident #7's Fall Risk Evaluation dated [DATE] indicated the resident scored a 15 and was high risk for falls (a resident who scores a 10 or higher is at risk). During an observation on [DATE] at 11:13 am Resident #7 was sitting in her wheelchair in the dining room, no staff was present. The resident's chair alarm was in place but the cord was not clipped to the resident. The cord was clipped to her wheelchair. During an interview and observation on [DATE] at 11:15 am Hospitality Aide D said Resident #7's chair alarm cord should be clipped to the resident's clothing. She said she did not know who assisted the resident to the dining room. She clipped the alarm cord to the back of the resident's shirt. Resident #8 Review of Resident #8's Face Sheet dated [DATE] indicated the [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #8's physician order [REDACTED]. A chair alarm was not ordered. Review of Resident #8's revised Care Plan dated [DATE] indicated the resident had been identified as at his risk for falls or had a history of [REDACTED]. The goal was for the resident to be free of injury related to falls. The approaches included a low bed, as ordered, to decrease the resident's risk of injury and bed/chair alarm to alert staff and remind resident to call for assistance with transfers. Review of Resident #8's Fall Risk Evaluation dated [DATE] indicated the resident scored a 26 and was high risk for falls (a resident who scores a 10 or higher is at risk). Review of Resident #8's quarterly MDS dated [DATE] indicated the resident had short and long-term memory impairment and was severely impaired for decision making. She required extensive assistance of two staff for bed mobility and transfers. She required extensive assistance of one staff for dressing and toilet use. She was ambulatory with supervision. The resident was frequently incontinent of bladder and occasionally incontinent of bowel. She had not fallen. During an observation on [DATE] at 3:48 pm Resident #8 was propelling herself in her wheelchair. The light on the resident's chair alarm was not flashing to indicate it was on. During an interview and observation on [DATE] at 3:49 pm LVN B said Resident #8's alarm was not turned on. She turned the alarm on. During an observation and interview on [DATE] at 4:51 pm Resident #8 was propelling herself in her wheelchair. The resident's chair alarm box was on her wheelchair but the alarm cord was not clipped to the resident. DON S (who began her employment on [DATE]) said the resident's alarm cord should be clipped to the resident's clothing. DON S clipped the alarm cord to the back of the resident's shirt. During an interview on [DATE] at 1:42 pm DON S said Resident #8 did not have an order for [REDACTED]. The Interim Administrator was notified of the Immediate Jeopardy situation on [DATE] at 4:26 pm. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE] at 1:55 pm. The plan included the following: An audit was completed on [DATE] to identify residents that utilized a bed and/or chair alarm. Facility residents that utilized a chair and/or bed alarm had the alarm batteries replaced and the batteries were dated for monitoring. The new un-dated bed/pressure/personal alarms procedure/staff education/in-service indicated: --staff would be educated on proper placement/use of alarms, including: display current models of alarms, review proper pad placement, ensure "in use" light is blinking, review reasons for decreased effectiveness for the alarm (thick cushions, removal by residents, etc.), ensure personal alarms are attached to the resident at all times, check placement and function of the alarm each time a resident is moved to or from bed/chair Re-education was started immediately on [DATE] with staff in the facility related to validating the alarms are functioning and in place, to include action to take if the alarm is not functioning. Staff is to change the batteries in non-functioning alarms; if changing the batteries does not resolve the issues, staff is to change the alarm. This education was presented by the Medical Director. Employees will receive this education prior to working the floor. Replacement alarms will be stored in central supply and replacement alarm batteries will be kept at the nurses' station in the event of a non-functioning alarm, batteries and/or alarms can be replaced immediately. Alarm checks have been added to the residents' Medication Administration Record [REDACTED]. CNAs will check alarm function and position during transfers. The

Based on interviews and record review the facility failed to report, in accordance with State law, injuries of unknown source for 1 of 8 residents (Resident #5) reviewed for reporting neglect related to safety devices and injuries of unknown source. The facility failed to thoroughly investigate and report to the State agency when Resident #5 was diagnosed with [REDACTED]. On [DATE] an Immediate Jeopardy was identified. While the Immediate Jeopardy was removed on [DATE] 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. These failures could place 10 other residents who had bed and/or chair alarms by placing them at risk for injuries of unknown source related to possible abuse and/or neglect. Findings included: Resident #5 Review of Resident #5's closed clinical record, admission orders [REDACTED]. Bed and chair alarms were ordered. The resident expired on [DATE]. Review of Resident #5's Admission Nursing Evaluation dated [DATE] indicated the resident had a history of [REDACTED]. A chair and bed alarm were to be used. The evaluation indicated the resident had fallen in the past 90 days and was being admitted with [DIAGNOSES REDACTED]. The resident was alert, oriented to person only, confused and had memory problems. The resident was fearful, anxious with delusions and disruptive behaviors. Review of Resident #5's admission MDS dated [DATE] indicated the resident had short and long-term memory problems. She was severely impaired for daily decision making. She required extensive assistance of one staff for bed mobility and dressing. The resident required extensive assistance of two staff for toilet use and transfers. She required limited assistance of one staff for personal hygiene. She was totally dependent of one staff for bathing. The resident was frequently incontinent of bowel and bladder. She was not ambulatory. She had a history of [REDACTED]. Review of Resident #5's Care Plan dated [DATE] indicated the resident was at risk for falls related to a history of falls and falls since admission. The resident had short-term and long-term memory problems and did not always remember she was too weak to transfer independently. The goal was for the resident to not sustain serious injury related to falls. The approaches included bed/chair alarm, monitor for pattern of risk factors, or tendency to fall, monitor and eliminate potential environmental hazards, instruct and encourage call light use and request for assistance and analyze previous falls to determine causative factors, and implement changes. Fall on [DATE] Review of Resident #5's Incident/Accident Report dated [DATE] at 10:30 am indicated the resident was shouting "Josie" repeatedly. Staff (LVN F) responded by entering the resident's room. The resident was next to the right side of her bed lying on the floor mat. She said she was trying to reach over "there" and pointed to her night stand. The resident was instructed to use her call light when she needed help and voiced understanding. She said she hit her head "a little". The resident had no injury and denied any pain. The bed alarm was not in use. The report indicated the action taken included care plan update and staff re-education. The report was signed by the Administrator and DON on [DATE]. There was no documentation of a Falls Investigation Worksheet or Action Plan or any documentation to explain why the resident's bed alarm was not in use at the time of this incident. During an interview on [DATE] at 11:52 am DON S said there was no investigation regarding the circumstances surrounding Resident #5's fall on [DATE]. Review of Resident #5's Progress Note dated [DATE] at 10:30 am the resident was shouting "Josie" repeatedly. This nurse (LVN F) responded to the resident's room. The resident was on the floor lying on the mat next to her bed. She reported hitting her head a "little bit". She denied pain. The resident reported, "I was reaching for that" and pointed to the nightstand. She was unable to recall the exact item she was reaching for. The resident was able to move all her extremities. She was assisted to bed and neuros were initiated. The resident's physician, family, the DON and ADON were all notified of the incident. There was no documentation regarding the resident's bed alarm and why it was not in use at the time of the resident's fall. During a telephone interview on [DATE] at 3:24 pm Charge Nurse, LVN F, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . She said she thought the alarm did not sound because the battery was dead so she changed out the alarm battery. She said the resident did not usually report pain and seemed to be fine after the fall. She said she called the ADON to inform her of the fall and that the alarm did not sound. During an interview on [DATE] at 3:45 pm the ADON said LVN F called her on [DATE] to report Resident #5's fall. She said she informed LVN F she needed to contact the DON regarding the resident's fall. She said she did not know anything about the resident's alarm not sounding. She said the facility did not have a policy and/or procedure to ensure bed/chair alarms were functioning. Review of Resident #5's Progress Note dated [DATE] at 12:15 am indicated the resident was being monitored for signs of injury due to her recent fall ([DATE]) with no new injuries noted. The resident continued to attempt to get out of bed without calling for assistance. The resident had her usual range of motion to all extremities. She voiced no complaint of pain and no acute distress was noted. At 2:53 pm neuros were continued from the previous fall. No injuries were noted. The resident was up in her wheelchair for meals. Will continue to monitor closely. Fall on [DATE] Review of Resident #5's Incident/Accident Report dated [DATE] at 8:15 pm indicated staff (LVN G) heard the resident calling out for help and upon entering her room the resident had fallen out of bed and was laying on the floor in a half sitting position by her recliner. The resident had a skin tear to her left elbow and she complained of pain to her left hip. The resident's bed alarm was not in use due to dead batteries. The Administrator and DON signed the incident report on [DATE]. The Falls Investigation Report, with the incident report, indicated the resident was having wandering behaviors at the time of this fall. The fall was unwitnessed. The resident had two previous falls in the last 30 days. The Action Plan for the incident, completed by the DON on [DATE], indicated two x-rays were negative but the resident continued to report pain and a final x-ray showed a pelvic fracture. The resident was referred to therapy again. Hospice increased the resident's pain medications. The DON documented the resident was very impulsive and refused to call for assistance. The plan did not include any action related to ensuring the alarms were functional. Review of Resident #5's Progress Note dated [DATE] at 8:15 pm indicated staff heard the resident calling for help and, upon entering the resident's room, the resident was in a half sitting position by her recliner. A skin tear to the resident's left elbow was noted. The resident denied pain at this time and was assisted to the bed. The alarm was checked and found to be inoperable (battery); while doing further assessment the resident started to complain of pain to her hip. The skin tear was treated per protocol, the physician was called for an x-ray order, and the responsible party was called and notified of the fall. The responsible party said he had been at the facility earlier and had trouble keeping the resident in her wheelchair. The x-ray company was called, the resident continued to complain of pain to her left hip, no discoloration or bruising was noted. At 8:30 pm the x-ray was done and the resident continued to complain of pain when moved. At 10:23 pm the x-ray showed no fracture. During a telephone interview on [DATE] at 3:37 pm Charge Nurse, LVN G, said on [DATE] Resident #5's bed alarm failed to sound and the resident fell . He said the alarm failed to go off for some reason. He said the resident was too confused to tell staff what happened. He said he thought the alarm batteries were dead and put another alarm on the resident's bed. He said the resident did not report pain, at first, but later began reporting pain. He said the first x-ray was negative for any fractures but another x-ray showed a pelvic fracture. He said prior to this fall, earlier in the day on [DATE], the resident was anxious and trying to get up out of her wheelchair without assistance. He said after the resident fell on [DATE] she was in too much pain to try to get out of bed. Review of Resident #5's Progress Note dated [DATE] at 10:00 am indicated the resident had severe pain to her left side from her hip down. The resident was unable to pinpoint the exact location. The hospice nurse assessed the resident and obtained an order for [REDACTED]. Will continue to monitor closely. At 2:00 pm mobile x-ray at the facility to perform the x-rays. The resident continued to be in severe pain anytime she is repositioned. At 4:45 pm a call was received from hospice; the resident had a [MEDICAL CONDITION] ramus (a part of the pelvis). An order was received to send the resident to the emergency room for an evaluation and treatment. The DON, Administrator and resident's responsible party were notified. At 5:00 pm the ambulance arrived to transport the resident to the emergency room . At 8:30 pm the resident returned from the emergency room via non-emergency ambulance with a [DIAGNOSES REDACTED]. The resident's pm medications were given. The resident was awake and showed signs of pain. Review of Resident #5's Progress Note dated [DATE] at 5:15 am indicated the resident expired. During a telephone interview on [DATE] at 4:00 pm the former Administrator (whose last day of employment was [DATE]) said she believed Resident #5 turned her alarm off and did not know LVN G documented on [DATE] the alarm failed to sound due to dead batteries. She said a few days after the resident fell on [DATE] she began hurting and was diagnosed with [REDACTED].#5's injury was not reported to the State agency because she thought the resident was able to tell staff what happened. She said she reviewed the information regarding the incident with the corporate office and it was decided the incident was not reportable. During a telephone interview on [DATE] at 4:15 the former DON (DON A, whose last day of employment was [DATE]) said she did not remember the exact details regarding Resident #5's falls on [DATE] and [DATE]. She said the Administrator and the corporate office discussed the incident and decided it was not reportable. During an interview on [DATE] at 2:48 pm the Interim Administrator (who began her employment on [DATE]) said when Resident #5 was diagnosed with [REDACTED]. Review of the facility's Accident Incident policy dated [DATE] indicated the charge and/or department director or supervisor should conduct an immediate investigation of the accident or incident. The following data, as it may apply, should be included on the Accident Investigation Report form: the circumstances surrounding the accident/incident, names of any witnesses and/or individuals involved and detailed written statement of their account of the accident/incident, the injured person ' s account of the accident/incident, corrective action taken and other pertinent data as necessary or required. Review of the facility ' s un-dated Reporting Abuse and Neglect Policy indicated the following incident of abuse and/or neglect must be reported to the State agency immediately upon learning of the incident. A written investigation report must be sent no later than the firth working day after the oral report: Neglect: the facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident. The following examples of reportable neglect are not all-inclusive, the following is an example from the policy; a resident with a doctor ' s order for close supervision due to unsteady gait is left unsupervised or inadequately supervised, resulting in his falling and fracturing his hip. Facility actions, when conducting an investigation, must be documented and include: observations, interviews and record reviews of all residents involved; interviews of all witnesses, including residents, staff and family members; notifying the physician, family and/or responsible party of the involved residents and recording all relevant findings. The policy included the State Provider Letter ,[DATE] dated [DATE] regarding Abuse, Neglect, Exploitation and Other Incident that must be reported which indicated: Neglect: the facility must determine if an injury, harm or death of a resident was due to facility failure to provide services, treatment or care to a resident. The following examples of reportable neglect; a resident with a doctor's order for close supervision due to unsteady gait is left unsupervised or inadequately supervised, resulting in his falling and fracturing his hip. suspicious injuries of unknown source; an injury was not observed by any person or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time. The Interim Administrator was notified of the Immediate Jeopardy situation on [DATE] at 4:26 pm. The facility's plan of removal of Immediate Jeopardy was accepted as being completed on [DATE] at 1:55 pm. The plan included the following: 1) Incidents will be reviewed by the Administrator and Director of Nursing in the morning stand-up meeting, with thorough investigative follow-up. 2) Any suspected abuse, neglect, exploitation of a resident or injury of unknown source will be called to the State agency. 3) The Administrator and DON have been re-educated on [DATE] by the Director of Education that all allegations of abuse, neglect, exploitation of a resident and an injury of unknown source have been reported to the State agency within 24 hours of identification, thoroughly investigated, documented and the results of that investigation reported in 5 working days to the State agency, by the Administrator and/or Regional Vice President. Facility staff was re-educated regarding abuse prohibition. The Quality Assurance Performance Improvement Committee will review allegations (incidents) monthly for three months and then quarterly until the committee deems it no longer necessary. Any areas of concern will be addressed at the time of discovery for further interventions. Validation of the Plan of Removal by the DADS surveyor was conducted on [DATE] and [DATE]. Review of in-services conducted on [DATE], [DATE] and [DATE] indicated staff was being educated on reporting procedures. Review of the documentation of monitoring by administrative staff was found to be in place and appropriately completed and signed off on. Interviews with Nurses and CNAs indicated they understood the reporting procedures. The Immediate Jeopardy was removed prior to exit on [DATE], effective [DATE], 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 residents from injuries related to possible abuse and/or neglect. Review of a list of residents with bed and/or chair alarms provided by the ADON on [DATE] at 10:30 am indicated 10 residents with alarms.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 5 residents (Resident #1, #3 and #4) reviewed for accidents. The facility failed to: 1) Secure Resident #1 properly in the facility van. On 3/13/13 Resident #1 slid out of her wheelchair onto the floor of the van which resulted in three fractures to her right leg and an injury to her right foot. The resident experienced pain that required a change in her medication as a result of the fractures. 2) Ensure Resident #1 had appropriate assistance devices and interventions to prevent her from sliding down and out of her wheelchair. 3) Ensure the Van Driver A was trained properly on the van operating instructions and safety devices to secure residents. 4) Ensure Van Driver A and B properly used the van's lift and safety devices according to the manufacturer's instructions for Resident's #3 and #4. The facility's failure to follow the lift instructions placed 20 residents who utilized wheelchairs and were transported in the van at risk for injuries. Findings included: The Provider Investigation Report dated 3/13/13 indicated on 3/13/13 at 10:00 am Resident #1 was picked up from an appointment by the facility Van Driver A. The van driver applied the brakes to come to a stop at a red light and Resident #1 slid out of her wheelchair onto the floor of the van. The resident sustained [REDACTED]. The investigation determined Resident #1 had a tendency to slide down in her wheelchair, due to pressure relieving devices in her wheelchair; also she was not adequately restrained in the van. The report indicated the resident had increased fragility due to her [DIAGNOSES REDACTED]. The report noted Resident #1 was stable and her pain was being aggressively treated. The facility in-serviced and re-educated Van Driver A and other staff regarding all van proficiencies including wheelchair locking, securing of residents and lift safety. Resident #1's quarterly MDS dated [DATE] indicated the [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She scored 11 on her Brief Interview for Mental Status (a score of 8-11 indicated moderate cognitive impairment). She was dependent on 1-2 staff persons for all her activities of daily living. She was not ambulatory. She was frequently incontinent of urine and always continent of bowel. She experienced pain occasionally. She had no history of falls. She weighed 69 pounds and was 4 feet tall. She was at risk for developing pressure ulcers but had no current skin issues. Bed rails were used daily but no other restraints were used. Resident #1's care plan dated 9/17/12 and updated on 4/13/13 indicated the resident had the potential for skin breakdown related to her immobility secondary to her [DIAGNOSES REDACTED]. The care plan failed to address the resident's tendency to slide down in her wheelchair due to the use of the pressure relieving devices and failed to provide any approaches to ensure the resident would not slide out of her wheelchair. The last fall risk assessment dated [DATE] indicated the resident ' s score was (8). A score of 10 or higher indicates a high risk for falls. Resident #1's Nurse's Notes indicated on 3/13/13 at 10:00 am the resident was being transported in the van and slid forward out of her wheelchair onto the floor. The resident had a 0.25 cm laceration to the base of her third toe on her right foot and a red area to the base of her right knee. The resident physician was notified. At 8:00 pm the resident was crying and stated her leg hurt. The resident's pain was located to her right knee and shin. The resident's physician was notified and x-rays were ordered. The resident cried from pain during the x-ray. The x-ray showed multiple right knee fractures; an impacted fracture of the distal femur (a fracture in which one broken end is wedged into the other broken end) and proximal tibia and fibula fractures, as well as diffuse bone demineralization. The resident's physician was notified of the x-ray results and the resident was sent to the emergency room via ambulance at 10:30 pm. Nurse's note dated 3/14/13 at 2:00 am documented the emergency room informed the facility the resident was being sent back to the facility with an immobilizer to her right leg and an order for [REDACTED]. At 4:00 am the resident was heard crying from the hallway. The resident complained of pain to her right leg and pain medication was administered. The resident's comfort level improved. At 1:00 pm the resident was resting quietly in bed. According to the Nurses' note the resident complained of increased pain even after her routine pain medication was given. A fax request was sent by the nurse to the physician on 03/14/13 (time unknown) which read: Resident fell from wheelchair on 03/13/13 sustaining multiple fractures to right leg, femur, multiple knee and tibia/fibula fractures. Seen at emergency room and then sent back with orders to see orthropedist in one week. The fax documented "she is in a great deal of pain, can you adjust her current dose or increase it or suggest something else. Think an increase of her Hydrocodone might be affective." An order was received to increase the resident's hydrocodone 10/325 to (2) tablets every six hours routine. The new dose was administered and the resident was resting quietly without complaint. On 3/15/13 at 11:00 pm Nurse's note indicated the resident reported right leg and toe pain. Pain medication was given as ordered with good relief reported by the resident. On 3/17/13 at 11:10 pm Nurse's note indicated the resident reported right leg and toe pain, a prn dose of pain medication was given and the resident said her pain was "better". During an observation and interview on 4/26/13 at 2:45 pm Resident #1 was in bed. She said on the day of the incident Van Driver A put her in the van without a seat belt and when the van came to a quick stop she fell out of her wheelchair onto the floor. She said her leg hurt as a result of the incident. Resident #1's right leg was immobilized from her knee to her ankle. The resident's laceration to her right toe was healed. During an interview and observation on 4/26/13 at 10:18 am Van Driver A said on 3/13/13 around 10:00 am she picked up Resident #1 at the wound care clinic. Resident # 1 was receiving treatment at the clinic for a necrotic area to her left great toe. The Van Driver said when she arrived at the clinic she and a clinic nurse had to reposition the resident in her wheelchair because the resident's pressure relieving cushions made her slide down in the wheelchair. She said after the incident the residents' cushion was put in storage and was no longer being used. An observation of the cushion, at this time, indicated it was made of a puffy cotton material formed in the shape of a chair to cushion the back, bottom and sides of the wheelchair. The bottom of the cushion was covered in a slick polyester material. The cushion had straps to attach it to the wheelchair. She said the resident had a history of [REDACTED]. Van Driver A said, on the day of the incident, she thought she was going to have to pick up another resident at dialysis, so she had placed Resident #1 in the middle section of the van to allow room in the back to accommodate the other resident. She said she applied Resident #1's wheelchair brakes and locked the wheelchair into place in the van. She said she applied the lap belt around the resident's waist but there was no shoulder strap in the van for the middle section (the shoulder strap attached to the lap belt). She said she had been driving the van since December 2012 and this was the first time she had transported a resident in the middle section of the van. Van Driver A said in December 2012 she and the activity director were going to take residents on an activity and they could not find the middle section shoulder strap. She said she and the activity director told the former administrator there was no shoulder strap for the middle section and he said he would look into it. Van Driver A said she never thought about it again because she had not used the middle section of the van until 3/13/13 (the day of the incident). She said she received a call that the other resident was not finished at dialysis and would need to be picked up at a later time so she proceeded to the facility. She said she got to a red light and came to a normal stop at the light. Van Driver A said she heard Resident #1 slide out of her wheelchair and saw her lying in the floor of the van with the lap belt still in place. She said she had never had an incident in the van until 3/13/13. Van Driver A said she had no training on how to use the van lift or the wheelchair securing devices and straps until after the incident. She said after the incident the van was searched and the shoulder strap for the middle section was found hidden behind one of the seats. During an interview on 4/26/13 at 2:15 pm the Activity Director said she and Van Driver A were taking residents on an activity in December 2012 and there was a lap belt for the middle section but not a shoulder strap. The Activity Director said she told the former administrator and he said as long as there was a lap belt it should be fine. She said she wondered about it but thought he knew, so it should be okay. Van Driver A's employee file indicated she was hired on 3/06/10 as a CNA and became the van driver in December 2012. There was no documented training regarding the operation of the van, lift or securing devices until after the incident on 3/13/13. During an interview on 4/26/13 at 2:45 pm the Administrator said Van Driver A had no training on the van, lift or securing devices until after the incident on 3/13/13. During an observation and interview on 4/30/13 at 12:40 pm Van Driver A demonstrated how the middle shoulder strap fit into the top of the van and then clipped to the lap belt to secure the residents. She said on 3/13/13 she did not have the shoulder strap and she placed the lap belt around the front of Resident #1's wheelchair because the arms of the wheelchair cushion did not give her enough room to place the lap belt around the resident's waist and as a result the resident slid out of the wheelchair under the lap belt and onto the floor of the van. During an interview on 4/25/13 at 2:40 pm the Administrator said on 3/13/13 the van driver did not properly secure Resident #1 in the van. She said the resident had a history of [REDACTED]. She said the resident was to wear the immobilizer until the fractures healed. She said there had been no other incidents or accidents involving the van driver or the van. During an interview on 4/30/13 at 9:02 am Van Driver A said no other residents had a wheelchair cushion like Resident #1's. During an interview on 4/30/13 at 9:05 am the Administrator said Resident #1 brought the wheelchair cushion from home and no other residents had a wheelchair cushion like it. She said she could not find any manufacturer's instructions regarding the cushion. During an interview on 4/30/13 at 9:07 am CNA C said Resident #1 would slide down in her wheelchair sometimes and staff would have to pick her back up. She said staff just watched to see if the resident was sliding. She reported no other interventions. During an interview on 4/30/13 at 9:15 am CNA D said Resident #1 slid down in her wheelchair some with the wheelchair pad and a gel cushion on top of the pad. She said staff would reposition the resident if she slid down in her wheelchair. She reported no other interventions. During interviews on 4/30/13 at 11:20 am the DON and Administrator said Resident #1 had a lap belt in place but not the shoulder strap on at the time of the incident on 3/13/13. They said the shoulder strap was found under a seat in the van after the incident. They said the resident had never fallen out of her wheelchair before and there were no interventions in place to keep her from sliding before the incident on 3/13/13. They said now the resident gets up to a Geri chair (a reclining chair with wheels) instead of her wheelchair. During a telephone interview on 4/30/13 at 11:30 am LVN E said on 3/13/13, when she assessed Resident #1, the resident was on the floor of the van with her head under the wheelchair and her legs out in front of her under the passenger side front seat. She said the resident was calm and did not appear to be hurt badly. She said the resident had the cut to her right toe and a red area above her right knee. LVN E said the resident did not report pain and bruising did not appear until later on in the evening after the incident. She said because of the resident's size and the wheelchair cushion it was possible the resident could have slid out from under the lap belt. LVN E said the resident's wheelchair cushion was still attached to the wheelchair but the gel cushion had fallen out of the seat. During a telephone interview on 4/30/13 at 11:38 am Resident #1's physician said the resident did experience pain after the incident as a result of the fractures. He said he and the staff worked aggressively to control the resident's pain. The physician said the resident had a history of [REDACTED]. Van Lift The van Operator's Manual dated March 2010 indicated under the Operation Notes and Details section on page 22 of the manual regarding the van lift: "Do not attempt to load or unload a passenger in a wheelchair or other apparatus that does not fit on the platform area. Do not exceed 800 pound load capacity of the lift. The lift attendant should not ride on the platform with the passenger". According to the manufacturer's representative an attendant should not ride on the platform with the passenger because of safety concerns related to the weight distribution and possible shifting of the lift. During an observation on 4/26/13 at 8:40 am Resident #3 was on the van lift in her wheelchair. Van Driver B was standing behind her riding down with her on the lift. During an observation on 4/26/13 at 10:11 am Van Driver B was assisted Resident #4 onto the van lift. The resident was sitting in her wheelchair and the van driver rode up on the lift with the resident. Van Driver B's in-service attendance sheet indicated on 3/23/13 he was trained on the van's lift and safety devices. Despite being trained on 3/23/13, Van Driver B continued to ride up and down on the lift with the residents. During an interview on 4/26/13 at 10:18 am Van Driver A said the van drivers ride up and down on the lift with the residents to help the residents feel safer. During an interview on 4/26/13 at 1:00 pm the Administrator said the van drivers ride up and down on the lift to help the residents feel safer because some of the residents feel anxious on the lift by themselves. She said she was aware the operator's manual said the lift attendant should not ride on the platform with the passenger. A list provided by the DON on 4/26/13 indicated 20 residents, who utilized wheelchairs and had ridden in the van.

Based on observation, interview and record review, the facility failed to develop and implement policies and procedures that prohibit neglect for 3 of 5 residents (Resident #1, #3 and #4) reviewed for neglect. The facility failed to: 1) Secure Resident #1 properly in the facility van. On 3/13/13 Resident #1 slid out of her wheelchair onto the floor of the van which resulted in three fractures to her right leg and an injury to her right foot. The resident experienced pain that required a change in her medication as a result of the fractures. 2) Ensure Resident #1 had appropriate assistance devices and interventions to prevent her from sliding down and out of her wheelchair. 3) Ensure the Van Driver A was trained on the van and lift operating instructions and safety devices to secure residents. 4) Ensure Van Driver A and B properly used the van's lift and safety devices according to the manufacturer's instructions for Resident's #3 and #4. The facility's failure to follow the lift instructions placed 20 residents who utilized wheelchairs and were transported in the van at risk for neglect/injuries. Findings included: The facility's un-dated abuse and neglect policies indicated neglect was failure to provide services, treatment or care to a resident. The policy did not contain any specific information on the use of the van or lift. The Provider Investigation Report dated 3/13/13 indicated on 3/13/13 at 10:00 am Resident #1 was picked up from an appointment by the facility Van Driver A. The van driver applied the brakes to come to a stop at a red light and Resident #1 slid out of her wheelchair onto the floor of the van. The resident sustained [REDACTED]. The investigation determined Resident #1 had a tendency to slide down in her wheelchair, due to pressure relieving devices in her wheelchair; also she was not adequately restrained in the van. The report indicated the resident had increased fragility due to her [DIAGNOSES REDACTED]. The report noted Resident #1 was stable and her pain was being aggressively treated. The facility in-serviced and re-educated Van Driver A and other staff regarding all van proficiencies including wheelchair locking, securing of residents and lift safety. Resident #1's quarterly MDS dated [DATE] indicated the [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She scored 11 on her Brief Interview for Mental Status (a score of 8-11 indicated moderate cognitive impairment). She was dependent on 1-2 staff persons for all her activities of daily living. She was not ambulatory. She was frequently incontinent of urine and always continent of bowel. She experienced pain occasionally. She had no history of falls. She weighed 69 pounds and was 4 feet tall. She was at risk for developing pressure ulcers but had no current skin issues. Bed rails were used daily but no other restraints were used. Resident #1's care plan dated 9/17/12 and updated on 4/13/13 indicated the resident had the potential for skin breakdown related to her immobility secondary to her [DIAGNOSES REDACTED]. The care plan failed to address the resident's tendency to slide down in her wheelchair due to the use of the pressure relieving devices and failed to provide any approaches to ensure the resident would not slide out of her wheelchair. The last fall risk assessment dated [DATE] indicated the resident ' s score was (8). A score of 10 or higher indicates a high risk for falls. Resident #1's Nurse's Notes indicated on 3/13/13 at 10:00 am the resident was being transported in the van and slid forward out of her wheelchair onto the floor. The resident had a 0.25 cm laceration to the base of her third toe on her right foot and a red area to the base of her right knee. The resident physician was notified. At 8:00 pm the resident was crying and stated her leg hurt. The resident's pain was located to her right knee and shin. The resident's physician was notified and x-rays were ordered. The resident cried from pain during the x-ray. The x-ray showed multiple right knee fractures; an impacted [MEDICAL CONDITION] femur (a fracture in which one broken end is wedged into the other broken end) and proximal tibia and fibula fractures, as well as diffuse bone demineralization. The resident's physician was notified of the x-ray results and the resident was sent to the emergency room via ambulance at 10:30 pm. Nurse's note dated 3/14/13 at 2:00 am documented the emergency room informed the facility the resident was being sent back to the facility with an immobilizer to her right leg and an order for [REDACTED]. The resident complained of pain to her right leg and pain medication was administered. The resident's comfort level improved. At 1:00 pm the resident was resting quietly in bed. According to the Nurses' note the resident complained of increased pain even after her routine pain medication was given. A fax request was sent by the nurse to the physician on 03/14/13 (time unknown) which read: Resident fell from wheelchair on 03/13/13 sustaining multiple fractures to right leg, femur, multiple knee and tibia/fibula fractures. Seen at emergency room and then sent back with orders to see orthopedist in one week. The fax documented "she is in a great deal of pain, can you adjust her current dose or increase it or suggest something else. Think an increase of her [MEDICATION NAME] might be affective." An order was received to increase the resident's [MEDICATION NAME] 10/325 to (2) tablets every six hours routine. The new dose was administered and the resident was resting quietly without complaint. On 3/15/13 at 11:00 pm Nurse's note indicated the resident reported right leg and toe pain. Pain medication was given as ordered with good relief reported by the resident. On 3/17/13 at 11:10 pm Nurse's note indicated the resident reported right leg and toe pain, a prn dose of pain medication was given and the resident said her pain was "better". During an observation and interview on 4/26/13 at 2:45 pm Resident #1 was in bed. She said on the day of the incident Van Driver A put her in the van without a seat belt and when the van came to a quick stop she fell out of her wheelchair onto the floor. She said her leg hurt as a result of the incident. Resident #1's right leg was immobilized from her knee to her ankle. The resident's laceration to her right toe was healed. During an interview and observation on 4/26/13 at 10:18 am Van Driver A said on 3/13/13 around 10:00 am she picked up Resident #1 at the wound care clinic. Resident # 1 was receiving treatment at the clinic for a necrotic area to her left great toe. The Van Driver said when she arrived at the clinic she and a clinic nurse had to reposition the resident in her wheelchair because the resident's pressure relieving cushions made her slide down in the wheelchair. She said after the incident the residents' cushion was put in storage and was no longer being used. An observation of the cushion, at this time, indicated it was made of a puffy cotton material formed in the shape of a chair to cushion the back, bottom and sides of the wheelchair. The bottom of the cushion was covered in a slick polyester material. The cushion had straps to attach it to the wheelchair. She said the resident had a history of [REDACTED]. Van Driver A said, on the day of the incident, she thought she was going to have to pick up another resident at [MEDICAL TREATMENT], so she had placed Resident #1 in the middle section of the van to allow room in the back to accommodate the other resident. She said she applied Resident #1's wheelchair brakes and locked the wheelchair into place in the van. She said she applied the lap belt around the resident's waist but there was no shoulder strap in the van for the middle section (the shoulder strap attached to the lap belt). She said she had been driving the van since December 2012 and this was the first time she had transported a resident in the middle section of the van. Van Driver A said in December 2012 she and the activity director were going to take residents on an activity and they could not find the middle section shoulder strap. She said she and the activity director told the former administrator there was no shoulder strap for the middle section and he said he would look into it. Van Driver A said she never thought about it again because she had not used the middle section of the van until 3/13/13 (the day of the incident). She said she received a call that the other resident was not finished at [MEDICAL TREATMENT] and would need to be picked up at a later time so she proceeded to the facility. She said she got to a red light and came to a normal stop at the light. Van Driver A said she heard Resident #1 slide out of her wheelchair and saw her lying in the floor of the van with the lap belt still in place. She said she had never had an incident in the van until 3/13/13. Van Driver A said she had no training on how to use the van lift or the wheelchair securing devices and straps until after the incident. She said after the incident the van was searched and the shoulder strap for the middle section was found hidden behind one of the seats. During an interview on 4/26/13 at 2:15 pm the Activity Director said she and Van Driver A were taking residents on an activity in December 2012 and there was a lap belt for the middle section but not a shoulder strap. The Activity Director said she told the former administrator and he said as long as there was a lap belt it should be fine. She said she wondered about it but thought he knew, so it should be okay. Van Driver A's employee file indicated she was hired on 3/06/10 as a CNA and became the van driver in December 2012. There was no documented training regarding the operation of the van, lift or securing devices until after the incident on 3/13/13. During an interview on 4/26/13 at 2:45 pm the Administrator said Van Driver A had no training on the van, lift or securing devices until after the incident on 3/13/13. During an observation and interview on 4/30/13 at 12:40 pm Van Driver A demonstrated how the middle shoulder strap fit into the top of the van and then clipped to the lap belt to secure the residents. She said on 3/13/13 she did not have the shoulder strap and she placed the lap belt around the front of Resident #1's wheelchair because the arms of the wheelchair cushion did not give her enough room to place the lap belt around the resident's waist and as a result the resident slid out of the wheelchair under the lap belt and onto the floor of the van. During an interview on 4/25/13 at 2:40 pm the Administrator said on 3/13/13 the van driver did not properly secure Resident #1 in the van. She said the resident had a history of [REDACTED]. She said the resident was to wear the immobilizer until the fractures healed. She said there had been no other incidents or accidents involving the van driver or the van. During an interview on 4/30/13 at 9:02 am Van Driver A said no other residents had a wheelchair cushion like Resident #1's. During an interview on 4/30/13 at 9:05 am the Administrator said Resident #1 brought the wheelchair cushion from home and no other residents had a wheelchair cushion like it. She said she could not find any manufacturer's instructions regarding the cushion. During an interview on 4/30/13 at 9:07 am CNA C said Resident #1 would slide down in her wheelchair sometimes and staff would have to pick her back up. She said staff just watched to see if the resident was sliding. She reported no other interventions. During an interview on 4/30/13 at 9:15 am CNA D said Resident #1 slid down in her wheelchair some with the wheelchair pad and a gel cushion on top of the pad. She said staff would reposition the resident if she slid down in her wheelchair. She reported no other interventions. During interviews on 4/30/13 at 11:20 am the DON and Administrator said Resident #1 had a lap belt in place but not the shoulder strap on at the time of the incident on 3/13/13. They said the shoulder strap was found under a seat in the van after the incident. They said the resident had never fallen out of her wheelchair before and there were no interventions in place to keep her from sliding before the incident on 3/13/13. They said now the resident gets up to a Geri chair (a reclining chair with wheels) instead of her wheelchair. During a telephone interview on 4/30/13 at 11:30 am LVN E said on 3/13/13, when she assessed Resident #1, the resident was on the floor of the van with her head under the wheelchair and her legs out in front of her under the passenger side front seat. She said the resident was calm and did not appear to be hurt badly. She said the resident had the cut to her right toe and a red area above her right knee. LVN E said the resident did not report pain and bruising did not appear until later on in the evening after the incident. She said because of the resident's size and the wheelchair cushion it was possible the resident could have slid out from under the lap belt. LVN E said the resident's wheelchair cushion was still attached to the wheelchair but the gel cushion had fallen out of the seat. During a telephone interview on 4/30/13 at 11:38 am Resident #1's physician said the resident did experience pain after the incident as a result of the fractures. He said he and the staff worked aggressively to control the resident's pain. The physician said the resident had a history of [REDACTED]. Van Lift The van Operator's Manual dated March 2010 indicated under the Operation Notes and Details section on page 22 of the manual regarding the van lift: "Do not attempt to load or unload a passenger in a wheelchair or other apparatus that does not fit on the platform area. Do not exceed 800 pound load capacity of the lift. The lift attendant should not ride on the platform with the passenger". According to the manufacturer's representative an attendant should not ride on the platform with the passenger because of safety concerns related to the weight distribution and possible shifting of the lift. During an observation on 4/26/13 at 8:40 am Resident #3 was on the van lift in her wheelchair. Van Driver B was standing behind her riding down with her on the lift. During an observation on 4/26/13 at 10:11 am Van Driver B was assisted Resident #4 onto the van lift. The resident was sitting in her wheelchair and the van driver rode up on the lift with the resident. Van Driver B's in-service attendance sheet indicated on 3/23/13 he was trained on the van's lift and safety devices. Despite being trained on 3/23/13, Van Driver B continued to ride up and down on the lift with the residents. During an interview on 4/26/13 at 10:18 am Van Driver A said the van drivers ride up and down on the lift with the residents to help the residents feel safer. During an interview on 4/26/13 at 1:00 pm the Administrator said the van drivers ride up and down on the lift to help the residents feel safer because some of the residents feel anxious on the lift by themselves. She said she was aware the operator's manual said the lift attendant should not ride on the platform with the passenger. A list provided by the DON on 4/26/13 indicated 20 residents, who utilized wheelchairs and had ridden in the van.