Every finding on record at Azalea Gardens Nursing Center

Based on observation, interviews, and facility policy review, the facility failed to store and maintain food under sanitary conditions by failing to remove produce with visible biological growth from refrigerated storage and by storing an ice scoop directly on consumable ice for one (1) of two (2) kitchen observations.Findings include:A review of the facility's policy titled, Food Safety Policy, dated [DATE], revealed, .Policy Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process.b. Storage of food in a manner that helps prevent deterioration.6. All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination .On 08/03/2026 at 9:51 AM, during an initial kitchen observation and interview with the Dietary Manager (DM), five (5) tomatoes with visible white biological growth were observed in the walk-in cooler. The ice scoop was observed lying directly on top of the ice in the ice bin, with the handle positioned over the consumable ice, creating the potential for hand contact with the ice when retrieving the scoop. The DM acknowledged the tomatoes were not of acceptable quality and were not appropriate for food service. The DM stated she would increase monitoring of refrigerated produce and inspect produce at the time of delivery. The DM acknowledged the ice scoop should not be stored directly on the ice and stated a scoop holder would be installed outside the ice bin.On 08/06/2026 at 10:19 AM, during an interview, the Administrator stated she had been informed of the tomatoes with visible biological growth and the ice scoop being stored directly on the ice. The Administrator stated dietary staff were expected to monitor produce and maintain sanitary food storage practices. She reported staff would begin conducting daily checks of produce for deterioration and confirmed the ice scoop had been relocated to a holder outside the ice bin.

Based on record review and staff interview, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency; specifically, the facility was cited for failing to maintain food under sanitary conditions related to produce with visible white biological growth during the 2025 annual recertification survey and was cited again for the same deficient practice during the current 2026 annual recertification survey, demonstrating the QAPI program failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of eight (8) deficiencies cited (F812).Findings include:Record review of the Provider History Report revealed the facility received a citation during the annual recertification survey for F0812 - Food Procurement, Store/Prepare/Serve-Sanitary.A record review of the facility's 2025 Statement of Deficiencies (CMS Form 2567) revealed the facility was cited during the 2025 annual recertification survey for deficient food storage practices in the Dietary Department, which included produce with visible white biological growth stored in a refrigerator.A record review of the facility's Plan of Correction dated 03/10/2025 revealed the Certified Dietary Manager (CDM) or Administrator would inspect fresh produce three times per week for four weeks. The Plan of Correction further revealed the Registered Dietitian or Administrator would conduct weekly audits of food storage areas for four weeks beginning 04/07/2025, with audit findings presented to the Quality Assessment and Assurance (QAA) Committee beginning 04/10/2025 and reviewed by the committee for two months.On 08/03/2026 at 9:51 AM, during an observation of the Dietary Department as part of the current annual recertification survey, five (5) tomatoes with visible white biological growth were observed in the walk-in cooler.On 08/06/2026 at 3:15 PM, during an interview, the Administrator acknowledged the facility had received a repeat finding related to food storage practices in the Dietary Department. She stated that following the 2025 annual recertification survey, the facility implemented weekly dietary audits for a specified period and reduced the frequency to monthly audits after the monitoring period was completed. The Administrator stated the facility attempted to identify and correct concerns identified through the audit process; however, based on the repeat finding identified during the current survey, the Dietary Department would resume weekly audits. The Administrator further stated the facility planned to revise its food storage practices by storing tomatoes in dry storage rather than the cooler to improve air circulation and reduce moisture accumulation.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure appropriate care and clinical follow-up for a resident's percutaneous endoscopic gastrostomy (PEG) tube site after sutures were placed during PEG tube replacement, including obtaining clarification regarding suture monitoring and removal, for one (1) of one (1) resident reviewed for tube feeding. Resident #7.Findings include: A record review of the facility's policy titled, Gastrostomy Site Care Policy with date [DATE] revealed It is the policy of this facility to perform gastrostomy site care as ordered. Policy Guidelines: 1. Verify there is a physician order for gastrostomy site care . 24. Report any complications promptly to the physician, and supervisor. On 08/05/2026 at 1:20 PM, during an observation and interview with Registered Nurse (RN) #1, two sutures were observed securing the external PEG tube bumper to the resident's abdomen. Yellow-brown dried material was observed at the suture sites, the surrounding skin appeared pink, and scant serosanguineous drainage was observed on the removed dressing. RN #1 stated Resident #7 had returned from the emergency department following PEG tube replacement with sutures securing the tube and stated she believed the sutures had been present for more than two weeks. RN #1 stated PEG site care was performed daily by nursing staff or the hospice nurse and acknowledged she expected the sutures would have been addressed during that period.On 08/06/2026 at 1:15 PM, during a telephone interview, the Nurse Practitioner (NP) stated she was unaware sutures had been placed when Resident #7's PEG tube was replaced and stated facility staff had not notified her of the sutures. The NP stated sutures were generally removed within approximately 14 days and should be monitored for signs of infection and removed when clinically appropriate. The NP stated she would need to assess the PEG site to determine whether the remaining sutures were ready for removal.On 08/06/2026 at 1:45 PM, during an interview, the Director of Nursing (DON) stated she was aware Resident #7 returned from the emergency department with sutures securing the PEG tube. The DON stated the facility did not remove sutures and the resident returned without specific instructions addressing suture care; however, she confirmed facility staff had not obtained follow-up or clarification from the physician or NP regarding monitoring or removal of the sutures. The DON stated she had reviewed the emergency department documentation, which identified two sutures as having been placed. The DON stated the NP, or physician would assess the PEG site as soon as possible.A record review of Resident #7's admission Record revealed the facility admitted the resident on 12/21/2022 with diagnoses including Gastrostomy Status.A record review of Resident #7's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2026, revealed the Staff Assessment for Mental Status identified short- and long-term memory problems and cognitive skills for daily decision-making as severely impaired. Section K identified the resident as having a feeding tube and receiving 51% or more of total calories through parenteral or tube feeding.A record review of Resident #7's Emergency Documentation with service date 07/16/2026 revealed the resident underwent PEG tube replacement and documented, .The peg tube was sewed in with some 4.0 (Proper Name) sutures. 2 stitches placed.A record review of Resident #7's General Emergency Department Discharge Instructions dated 07/16/2026 revealed instructions to follow up with the resident's primary care physician within one week.A record review of Resident #7's Order Summary Report, with active orders as of 08/06/2026, revealed orders for PEG tube feeding, use of an abdominal binder, and PEG site care. No physician orders addressing monitoring or removal of the PEG tube sutures were identified.A record review of Resident #7's Treatment Administration Records (TARs) for July and August 2026 revealed no documentation of monitoring specific to the PEG tube sutures.A record review of Resident #7's Progress Notes from 07/01/2026 through 08/06/2026 revealed an entry dated 07/16/2026, completed by Registered Nurse (RN) #4, which documented, .Resident returned to facility.peg tube to left abdomen intact with 4 sutures, site without bleeding, insertion site pink, no dressing present on arrival, abdominal binder in place. No subsequent progress-note documentation addressing monitoring, provider notification, follow-up, or removal of the sutures was identified.On 08/06/2026 at 2:00 PM, during an interview, RN #4 stated she was working when Resident #7 returned from the emergency department following PEG tube replacement on 07/16/2026 and documented the presence of sutures at the PEG tube site. RN #4 stated the resident returned without orders addressing suture care. RN #4 acknowledged she did not obtain clarification regarding care or removal of the sutures and could not recall notifying the physician or NP of their presence.On 08/06/2026 at 3:15 PM, during an interview with the Administrator, she reported that she expects all staff to follow the facility's policy and procedures and expects to notify the interdisciplinary team and the NP or primary physician of any change in a resident's status.

Based on interviews, record review, and facility policy review, the facility failed to revise comprehensive care plans to reflect changes in residents' care needs related to percutaneous endoscopic gastrostomy (PEG) tube replacement with placement of sutures and significant weight loss, for two (2) of (16) sampled residents. (Residents #7 and #44).Findings include:A record review of the facility's policy titled, Care Plan Revisions Upon Status Change with date of [DATE] revealed, . The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Guidelines: 1. The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change. 2. f. Care plans will be modified as needed by the MDS (Minimum Data Set) Coordinator or other designated staff member.Resident #7A record review of Resident #7's admission Record revealed the facility admitted the resident on 12/21/2022 with diagnoses including Gastrostomy Status and Senile Degeneration of the Brain.A record review of Resident #7's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/03/2026, revealed the Staff Assessment for Mental Status identified short- and long-term memory problems and cognitive skills for daily decision-making as severely impaired. Section K identified the resident as having a feeding tube and receiving 51% or more of total calories through parenteral or tube feeding.A record review of Resident #7's hospice Physician Order dated 07/16/2026 revealed, patients Peg tube displaced. Facility to send patient out to hospital to have Peg replaced.A record review of Resident #7's Emergency Documentation with service date 07/16/2026 revealed . Peg tube replacement procedure . The peg tube was sewed in with some 4.0 (Proper Name) sutures. 2 stitches placed.A record review of Resident #7's General Emergency Department Discharge Instructions dated 07/16/2026 revealed . follow up with your primary care physician within 1 week.A record review of Resident #7's Care Plan Report revealed a focus for High Risk for altered nutrition related to the resident's PEG tube and documented the PEG tube dislodgement on 07/15/2026. The care plan was not revised following the resident's return from the emergency department on 07/16/2026 to reflect the PEG tube replacement and the presence of two sutures placed to secure the PEG tube.Resident #44A record review of Resident #44's admission Record revealed the facility admitted the resident on 12/13/2024 with the diagnoses including Alzheimer's Disease, Unspecified, Personal History of Malignant Neoplasm of Bone, and Personal History of Other Malignant Neoplasm of Skin/Personal History of Malignant Neoplasm of Breast. A record review of Resident #44's Order Summary Report revealed an active physician order for a nutritional supplement, 120 cubic centimeters (cc) or four ounces (oz), three times daily for nutritional support, with a start date of 01/17/2026.A record review of Resident #44's Quarterly MDS, with an ARD of 07/20/2026, revealed a BIMS summary score of 2, indicating severe cognitive impairment. Section K documented a weight of 140 pounds, weight loss of 5% or more in the last month or 10% or more in the last six months, and use of a mechanically altered diet.A record review of Resident #44's Care Plan Report revealed a focus for high risk for altered nutrition related to gastroesophageal reflux disease (GERD), dysphagia, mechanically altered diet, gastroparesis with vomiting, and significant unplanned weight loss in July 2026. The care plan did not include new or revised interventions addressing the resident's significant weight loss and did not include the physician-ordered nutritional supplement initiated on 01/17/2026.A record review of Resident #44's Weights and Vitals Summary revealed that on 07/10/2026, the resident weighed 140.2 pounds, reflecting an 18-pound (11.4%) weight loss from the comparison weight of 158.2 pounds documented on 01/10/2026. The record further revealed that on 04/10/2026, the resident weighed 145.6 pounds, reflecting a 26.4-pound (15.3%) weight loss from the comparison weight of 172 pounds documented on 11/10/2025.On 08/06/2026 at 12:00 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated she was responsible for completing MDS assessments and care plans. LPN #1 stated the facility used a working care plan that was reviewed and updated as changes occurred. She confirmed Resident #7 returned from the emergency department with sutures securing the PEG tube and acknowledged the care plan was not revised to address the PEG tube site or sutures.LPN #1 further confirmed Resident #44 experienced significant weight loss in April and July 2026; however, no new interventions were added to the care plan in response to the weight loss. She also confirmed the nutritional supplement ordered in January 2026 had not been added to the care plan and stated she had missed adding the intervention. LPN #1 stated the purpose of the care plan was to direct staff in providing care and should include interventions addressing each resident's identified needs.On 08/06/2026 at 2:12 PM, during an interview, the Director of Nursing (DON) stated comprehensive care plans were used to direct resident care and were expected to remain current and reflect each resident's assessed care needs.On 08/06/2026 at 3:15 PM, during an interview, the Administrator stated she expected comprehensive care plans to be revised in accordance with facility policy when a resident experienced a change in condition or care needs.

Based on staff interviews, record review, and facility policy review, the facility failed to identify, assess, and respond to significant weight loss documented in the medical record for one (1) of two (2) residents reviewed for nutritional status. Resident #44.Findings include:A record review of the facility's policy titled, Aberrant Weight Policy dated December 2018 revealed . Based on the resident's comprehensive assessment, the facility will strive to ensure that all residents maintain acceptable parameters of nutritional status . Policy Guidelines: . 2. Monthly, weekly and daily weights will be monitored for abnormalities at the time they are obtained or as soon as possible. 3. All weights will be monitored by the Quality Assessment and Assurance Nurse and the Interdisciplinary Team. 4. Aberrant weights will be rechecked before they are recorded in the clinical record. 5. Significant weight changes will require interventions implemented, monitored, and modified (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards to maintain acceptable parameters of nutritional status.A record review of Resident #44 admission Record revealed the facility admitted the resident on 12/13/2024 with diagnoses including Alzheimer's Disease, Unspecified, Personal History of Malignant Neoplasm of Bone, and Personal History of Other Malignant Neoplasm of Skin/Personal History of Malignant Neoplasm of Breast. A record review of Resident #44's Order Summary Report revealed active physician orders for regular diet, mechanical soft with ground meat texture, honey consistency with order date 4/20/26 and nutritional supplement three times a day 120 cc (cubic centimeters) or 4 oz (ounces) supplement for nutrition support with order date 1/17/26.A record review of Resident #44's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/20/2026, revealed a Brief Interview for Mental Status (BIMS) summary score of 2, which indicated severe cognitive impairment. Section K documented a weight of 140 pounds, weight loss of 5% or more in the last month or 10% or more in the last six months, and use of a mechanically altered diet.A record review of Resident #44's Weights and Vitals Summary revealed that on 07/10/2026, the resident weighed 140.2 pounds, reflecting an 18-pound (11.4%) weight loss from the comparison weight of 158.2 pounds documented on 01/10/2026. The record further revealed that on 04/10/2026, the resident weighed 145.6 pounds, reflecting a 26.4-pound (15.3%) weight loss from the comparison weight of 172 pounds documented on 11/10/2025.A record review of Resident #44's Nutrition Quarterly assessments dated 04/15/2026 and 07/14/2026 revealed no documentation addressing the significant weight loss identified in the resident's weight record. The 04/15/2026 assessment documented a weight of 145.6 pounds, and the 07/14/2026 assessment documented a weight of 140.2 pounds.A record review of Resident #44's Nutritional Evaluation dated 01/14/2026 revealed the resident weighed 158.2 pounds and had poor-to-fair intake. The assessment identified a weight change and documented initiation of a nutritional supplement three times daily.A record review of Resident #44's Physician's Progress Notes dated 05/21/2026, 06/04/2026, and 07/30/2026 revealed no documentation addressing the resident's significant weight loss.A record review of Resident #44's Progress Note dated 07/19/2026, completed by the Care Plan Nurse, revealed no documentation addressing the resident's significant weight loss.On 08/04/2026 at 12:29 PM, during an interview, the Director of Nursing (DON) stated Resident #44 had experienced a decline in condition and weight loss several months earlier. The DON stated the resident's appetite varied and reported the Registered Dietitian (RD) assessed residents annually and when significant weight loss occurred.On 08/04/2026 at 2:15 PM, during an interview, Dietary Department #3 confirmed an RD assessment was not completed when Resident #44 experienced significant weight loss in April or July 2026. She stated the resident's last RD assessment was completed in January 2026 and acknowledged the resident was missed for follow-up evaluation.On 08/04/2026 at 3:30 PM, during an interview, the DON stated Resident #44 should have been assessed by the RD when significant weight loss occurred. The DON reviewed the resident's medical record and confirmed the April and July nutritional assessments did not address the significant weight loss and she could not identify documentation that the RD, Nurse Practitioner (NP), or physician assessed or addressed the significant weight loss.On 08/05/2026 at 11:00 AM, during an interview, Dietary Department #1 stated significant weight loss was expected to be documented in the nutritional evaluation and communicated to the interdisciplinary team, including the physician or NP, RD, nursing staff, Quality Assurance nurse, and DON. She confirmed Resident #44's April and July quarterly nutritional assessments did not identify the significant weight loss and acknowledged the resident was missed for RD evaluation.On 08/06/2026 at 11:45 AM, during a telephone interview, Dietary Department #2 stated she had recently begun completing quarterly nutritional assessments and used the resident's medical record, including the most recent weight and physician orders, to complete the assessments. She stated she was unaware significant weight loss was required to be included in the nutritional assessment.On 08/06/2026 at 12:00 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated resident weights were obtained from the weight section of the electronic medical record and that she used information available in the medical record when completing Resident #44's comprehensive assessment. LPN #1 confirmed Resident #44 had significant weight loss documented in the medical record and acknowledged the MDS charting note she completed for the quarterly review did not address the significant weight loss.On 08/06/2026 at 1:15 PM, during a telephone interview, the NP stated she could not recall being notified of Resident #44's significant weight loss and confirmed her progress notes did not address the weight loss. The NP stated she expected facility staff to notify her or the physician of changes in the resident's condition.On 08/06/2026 at 2:12 PM, during an interview, the DON stated she believed some of Resident #44's documented weights may have been entered incorrectly. The DON stated staff were expected to notify the interdisciplinary team of weight discrepancies and obtain a reweight and that new interventions were expected when significant weight loss was identified.On 08/06/2026 at 2:25 PM, during an interview, Registered Nurse (RN) #3 stated Resident #44 was receiving weekly weights related to weight loss; however, the weekly weights were maintained in a separate book and were not entered into the electronic medical record. RN #3 confirmed the weights documented in the electronic medical record were available for providers and staff to review. RN #3 stated weight changes greater than two pounds were expected to be reported to the physician and RD.On 08/06/2026 at 3:15 PM, during an interview, the Administrator stated she was aware of Resident #44's weight loss and believed some documented weights may have been entered incorrectly. The Administrator stated she expected staff to follow facility policy, notify the interdisciplinary team and provider of significant weight loss, and document the identified change.

Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan that addressed hospice services for one (1) of (16) residents sampled. (Resident #9).Findings include:A review of the facility's policy titled, Comprehensive Care Plan Policy dated [DATE] revealed, .Policy Guidelines 1. The care planning process will include an assessment of the resident's.needs. 3. The Comprehensive care plan will describe.a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.On 08/06/2026 at 11:15 AM, during an interview, Licensed Practical Nurse (LPN) #1, Minimum Data Set (MDS) Coordinator, stated she was responsible for developing resident care plans at the facility. LPN #1 acknowledged she had not developed a hospice care plan for Resident #9. She explained Resident #9 had experienced two recent significant changes in condition, which contributed to the hospice care plan being overlooked. LPN #1 stated the hospice care plan was used to identify the care and services provided by the facility and those provided by the hospice provider. LPN #1 stated she would ensure all residents receiving hospice services had a hospice care plan.On 08/06/2026 at 11:19 AM, during an interview, the Director of Nursing (DON) confirmed Resident #9's comprehensive care plan did not address the resident's hospice services. The DON stated the comprehensive care plan was used to direct staff regarding the resident's care needs and that she expected residents receiving hospice services to have those services addressed in their comprehensive care plans.A record review of the facility's admission Record revealed the facility admitted Resident #9 on 11/09/2018 with diagnoses including Peripheral Vascular Disease.A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/21/2026 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. Section O0110, K1, Hospice Care, was coded Yes.A record review of Resident #9's Order Summary Report revealed an active physician order dated 05/15/2026 to admit the resident to (Proper name initials for hospice company).A record review of Resident #9's Care Plan Report revealed no care plan focus, goals, or interventions addressing the resident's hospice services.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide a safe and homelike environment by failing to ensure an overhead bed light pull cord was accessible to a resident with limited mobility, resulting in the resident requiring staff assistance to operate the light while in bed for one (1) of (16) residents reviewed for environment. (Resident #6).Findings include:A review of the facility's policy titled, Safe and Homelike Environment Policy, dated Oct. 2024 revealed, .Policy Guidelines.6. The facility will provide and maintain adequate and comfortable lighting levels in all areas.On 08/03/2026 at 11:28 AM, during an observation and interview, Resident #6 requested assistance turning off the overhead bed light. The overhead light pull cord was observed outside the resident's reach while she was in bed. Resident #6 stated the pull cord was too short for her to reach and reported the light frequently remained on until staff were available to turn it off.On 08/05/2026 at 1:12 PM, during an observation, a Physical Therapist Assistant (PTA) returned Resident #6 to bed following therapy. Resident #6 requested the PTA turn off the overhead light because she could not reach the pull cord from the bed.On 08/05/2026 at 1:15 PM, during an interview, Resident #6 stated she routinely requested staff assistance to turn the overhead light on or off because she could not reach the pull cord while in bed.On 08/06/2026 at 10:18 AM, during an interview, the Administrator stated she was unaware Resident #6 could not reach the overhead light pull cord from the bed. She stated another resident had an extended overhead light pull cord that could be reached from the bed and acknowledged the same accommodation could have been provided for Resident #6.On 08/06/2026 at 12:05 PM, during an interview, Housekeeping/Maintenance (HM #1) stated the overhead bed light pull cord was extended after notification from the Administrator.On 08/06/2026 at 3:15 PM, during a post-exit interview, the Administrator stated Resident #6 had occupied the room for approximately two weeks following the room change and acknowledged the overhead light pull cord could have been adjusted during that time.A record review of the admission Record for Resident #6 revealed the facility admitted the resident on 8/21/2022 with the diagnoses including aftercare following joint replacement surgery.A record review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/21/2026 for Resident #6 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. Section GG revealed the resident required substantial/maximal assistance with mobility.A record review of Resident #6's Care Plan Report revealed interventions to ensure the resident's room had adequate lighting and to keep personal items within reach.

Based on observations, interviews, record review, and facility policy review, the facility failed to protect residents' rights to personal privacy and confidentiality by failing to provide visual privacy for one resident whose shoulder and a portion of the chest were exposed and visible from the doorway and by posting residents' personal care information on the walls without evidence the residents or their representatives requested the information be displayed, for three (3) of (16) sampled residents (Residents #7, #21, and #52).Findings include: A record review of the facility's policy titled, Resident Rights Policy, dated Jun2026, revealed, .Policy Guidelines.11. Staff members are educated on the rights of residents, and the responsibility of the facility is to properly care for its residents . Resident #21 On 8/3/26 at 12:18 PM, during an observation of Resident #21, the resident was asleep in bed and visible from the doorway because the privacy curtain had not been pulled. The resident's right shoulder and a portion of the chest were exposed. On 8/5/26 at 1:15 PM, during an observation of Resident #21, the privacy curtain was not closed. The resident's right shoulder and a small portion of the chest were visible from the doorway. The resident remained visible for approximately five minutes while the roommate was transferred to bed. On 8/5/26 at 1:38 PM, an interview with Certified Nursing Assistant (CNA #1) for Resident #21 revealed the resident chewed on the right side of the gown because the resident's head remained turned in that direction. CNA #1 reported the gown was removed from that side to reduce the risk of choking and confirmed staff were expected to pull the privacy curtain to maintain the resident's privacy. On 08/06/2026 at 3:15 PM, during an interview, the Administrator stated Resident #21's right shoulder remained uncovered because the resident chewed on clothing and the resident's roommate preferred the privacy curtain remain open to view hallway activity. The Administrator acknowledged Resident #21 depended on staff to protect the resident's privacy because the resident was unable to independently close the privacy curtain or maintain clothing over the exposed area. A record review of the admission Record for Resident #21 revealed the facility admitted the resident on 1/12/2025 with diagnoses including Senile Degeneration of Brain, Not Elsewhere Classified. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/10/2026 for Resident #21 revealed cognitive skills for daily decision making were severely impaired. A record review of the Care Plan Report for Resident #21 revealed interventions to encourage the resident not to chew clothing. A record review of the Resident Rights in-service dated February 16–20, 2026, revealed staff received education regarding resident privacy. The in-service instructed staff to maintain resident privacy by closing room doors, pulling privacy curtains, and providing appropriate clothing or draping to prevent unnecessary exposure of body parts during care. Resident #7 On 08/03/2026 at 12:25 PM, during an observation of Resident #7, the State Agency (SA) observed a sign posted on the wall above the resident's bed that read, Keep Head of Bed elevated as tolerated. On 08/04/2026 at 10:53 AM, during an observation of Resident #7, the sign stating, Keep Head of Bed elevated as tolerated, remained posted on the wall above the resident's bed. On 08/05/2026 at 3:22 PM, during a telephone interview, Resident #7's Resident Representative (RR) stated she was unaware of the sign posted above the resident's bed directing staff to keep the head of the bed elevated. The RR stated the resident's tube-feeding care information should be maintained in the medical record rather than posted on the wall. A record review of Resident #7's admission Record revealed the facility admitted the resident on 12/21/2022 with the diagnoses of Senile Degeneration of Brain, Not Elsewhere Classified, Unspecified Dementia, Unspecified Severity, With Other Behavioral Disturbance and Gastrostomy Status. A record review of Resident #7's Order Summary Report, with active orders as of 08/06/2026, revealed orders for NPO (nothing by mouth) diet, Percutaneous Endoscopic Gastrostomy (PEG) tube feeding, use of an abdominal binder, PEG site care, and Head of bed (HOB) elevated above 30 degrees. A record review of Resident #7's Significant Change MDS, with an ARD of 06/03/2026, revealed the Staff Assessment for Mental Status identified short- and long-term memory problems and cognitive skills for daily decision-making as severely impaired. Section K identified the resident as having a feeding tube and receiving 51% or more of total calories through parenteral or tube feeding. Resident #52 On 08/03/2026 at 12:25 PM, during an observation of Resident #52's room, the SA observed a sign posted on the wall above the resident's bed that stated, NPO. On 08/03/2026 at 3:19 PM, during an interview, Resident #52 stated she did not know who posted the NPO sign above her bed or how long it had been displayed. Resident #52 stated she did not like the sign because it informed others that she could not receive food or fluids by mouth. On 08/04/2026 at 10:10 AM, during an observation with Registered Nurse (RN) #2 of Resident #52, the NPO sign remained posted on the wall above the resident's bed. On 08/05/2026 at 10:10 AM, during an interview, RN #2 stated staff were aware that signs containing residents' personal care or medical information were not to be posted in residents' rooms due to privacy concerns. On 08/05/2026 at 1:20 PM, during an observation and interview, RN #1 confirmed the Keep Head of Bed elevated as tolerated sign remained posted above Resident #7's bed and the NPO sign remained posted above Resident #52's bed. RN #1 confirmed the information displayed on the signs was available in the residents' medical records. On 08/06/2026 at 10:19 AM, during an interview and observation, the Director of Nursing (DON) confirmed the signs remained posted above Residents #7's and #52's beds. The DON acknowledged the signs communicated personal care information that was available in the residents' medical records and stated the information should not have been posted on the walls. The DON removed the signs during the observation and stated she expected staff to protect residents' privacy. On 08/06/2026 at 3:15 PM, during an interview, the Administrator stated residents' personal health information was expected to remain private and staff were expected to protect each resident's privacy. A record review of Resident #52's admission Record revealed the facility admitted the resident on 10/07/2024 with diagnoses including Traumatic Subdural Hemorrhage Without Loss of Consciousness, Subsequent Encounter and Gastrostomy Status. A record review of Resident #52's Order Summary Report revealed active physician orders dated 8/6/26 for NPO diet NPO texture, NPO consistency, for dysphagia and Enteral Feed four times a day. A record review of Resident #52's Quarterly MDS, with an ARD of 05/10/2026, revealed a Brief Interview for Mental Status (BIMS) Summary Score of 11, indicating moderate cognitive impairment. Section K identified the resident as having a PEG tube and receiving 51% or more of total calories through parenteral or tube feeding.

Based on observation, staff interview, and facility policy review, the facility failed to use hand hygiene, discard overly ripe produce, and failed to calibrate a food thermometer prior to checking food temperatures, for two (2) of two (2) kitchen observations. Findings included: A review of the facility's Food Safety Policy, dated November 2023, revealed, Food will . be stored, prepared . with professional standards for food service safety. Policy Guidelines 1. Food safety practices shall be followed throughout the facility's entire food handing process .Elements of the process include the following .b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from the growth of microorganisms . 3. Facility shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage .7. Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects. a. Staff shall wash hands according to facility procedures . A review of the facility's Record of Food Temperatures Policy, dated November 2023, revealed, .It is the policy of this facility to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled .Policy Guidelines .14. Food temperatures will be verified using a thermometer which is . calibrated to ensure accuracy . On 03/03/2025 at 10:17 AM, during an observation of the kitchen and an interview with the Certified Dietary Manager (CDM), seven (7) sweet potatoes and one (1) onion with soft spots and white biological growth were observed in the pantry. Additionally, a bag of raisins was found open and exposed. Dietary Aide (DA) #2 was observed placing cartons of juice in the refrigerator and retrieved a plastic drink lid from the floor, discarded it, and continued placing five (5) juice cartons into the refrigerator without washing her hands. The CDM acknowledged that the staff member should have performed hand hygiene after retrieving the plastic drink lid from the floor and confirmed the presence of overly ripe produce and opened and exposed food items in the pantry. The CDM further stated that she and the Assistant Dietary Manager (ADM) were the only staff responsible for selecting produce from storage for the food preparation area, ensuring that no staff member would have mistakenly used the overly ripe produce. On 03/03/2025 at 10:30 AM, during an interview, DA #2 confirmed that she retrieved the plastic drink lid from the floor and continued handling food items without performing hand hygiene. She acknowledged that she should have stopped and washed her hands before continuing food preparation. The Dietary Aide stated that staff receive monthly in-service training on infection control. On 03/04/2025 at 11:00 AM, during an observation of the meal tray line and an interview the [NAME] was unable to explain how to properly calibrate a food thermometer before checking and recording food temperatures. The [NAME] stated that the thermometer should be calibrated to 22 degrees but did not use ice to calibrate the thermometer, despite the ADM providing ice for the process. The [NAME] acknowledged that she failed to properly calibrate the thermometer and stated that she was nervous. The [NAME] further stated that she normally would have calibrated the food thermometer using ice. On 03/04/2025 at 11:20 AM, during an interview with the ADM, she confirmed that the [NAME] should have properly calibrated the food thermometer before use, which was why she had placed ice near her. The ADM emphasized the importance of ensuring thermometer accuracy to obtain correct food temperature readings. The ADM stated that her expectation was that all staff would correctly calibrate thermometers before use. The ADM also stated that staff receive monthly in-service training on infection control. On 03/06/2025 at 10:24 AM, during an interview, the Administrator acknowledged that she was aware of the presence of overly ripe and opened and exposed food items in the pantry, the Dietary Aide's failure to use hand hygiene after retrieving an item from the floor, and the Cook's failure to calibrate the food thermometer. The Administrator stated that she expected staff to correctly monitor food temperatures for safety reasons and to ensure that food items were not stored in a deteriorated state. The Administrator confirmed that staff were expected to follow appropriate handwashing procedures to maintain food safety.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a nurse performed hand hygiene, changed gloves, and discarded a feeding tube syringe after it was dropped onto the floor during a medication administration observation for one (1) of three (3) residents reviewed for medication administration. (Resident #31) Findings included: A review of the facility's Infection Prevention and Control Program Policy, dated February 2024, revealed, .The facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Policy Guidelines .d. Standard Precautions .b. Hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures .d. Licensed staff shall adhere to safe injection and medication administration practices, as described in relevant facility policies .p. Staff Education .a. Facility staff receive training relevant to their specific roles and responsibilities regarding the facility's infection prevention and control program, including policies and procedures related to their job function . A record review of the facility's In-Service Attendance Record, dated 01/13/2025, 01/14/2025, and 01/17/2025, revealed that staff receiving training related to Infection Control Principles, including importance of hand hygiene . On 03/04/2025 at 8:16 AM, during a medication administration observation for Resident #31, Licensed Practical Nurse (LPN) #2, while wearing gloves, retrieved the Percutaneous Endoscopic Gastrostomy (peg) tube syringe, which fell to the floor. LPN #2 picked up the syringe and proceeded to administer medications via the resident's peg tube without discarding the contaminated syringe, performing hand hygiene, or changing her gloves. On 03/05/2025 at 8:20 AM, during an interview, LPN #2 confirmed she failed to change gloves, wash hands, or use a new syringe. LPN #2 stated the resident could develop an infection from using contaminated gloves and syringe. She explained that she should have removed the gloves, sanitized her hands, and used a new syringe. LPN #2 stated she was nervous and was not thinking clearly. On 03/05/2025 at 1:00 PM, during an interview, the Director of Nursing (DON) stated that LPN #2 should have changed her gloves, sanitized her hands, and used a new syringe to prevent the resident from developing an infection. On 03/06/2025 at 1:41 PM, during an interview, Registered Nurse (RN)#2/Infection Preventionist stated that the nurse should have changed her gloves, sanitized her hands, and used a new syringe. RN #2 also confirmed that LPN #2 had been trained regarding infection control practices. On 03/06/2025 at 1:43 PM, during an interview, the Administrator stated that she expects staff to follow infection control policies to prevent residents from acquiring infections. A record review of Resident #31's Admission Record revealed the facility admitted the resident on 01/10/2024 with diagnoses including Unspecified Dementia. A record review of Resident #31's Significant Change In Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2024 revealed he had a Brief Interview for Mental Status (BIMS) score of 3, which indicated his cognition was severely impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to post the daily nursing staffing hours in a location readily accessible to residents and visitors and failed to update the posted staffing for three (3) of four (4) days of survey. This deficient practice had the potential to affect all 63 residents residing in the facility. Findings included: A review of the facility's Nurse Staffing Posting Information Policy, dated 10/2023, revealed, .It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines 1. The nurse staffing information will be posted on a daily basis .2. The facility will post the nurse staffing data at the beginning of each shift. 3. The information posted will be presented a. Presented in a clear and readable format. B. In a prominent place readily accessible to residents and visitors . A record review of the facility's posted staffing information revealed that the last update was on 03/03/2025. On 03/03/2025 at 10:00 AM, during an observation, the staffing information was located at the back of the facility near the vending machines. No residents or family members were observed near the area. This location was identified as the staff entryway, not a central location accessible to residents or visitors. On 03/04/2025 at 9:55 AM, during an observation, the staffing information posted was dated 03/03/2025 and was not updated with current information. The posted form remained near the back door of the facility where there were no residents or family members observed. On 03/04/2025 at 1:00 PM, during an interview with a family member of Resident #11, she stated that she had not seen the staffing information posted and did not know where it was located. On 03/05/2025 at 3:15 PM, during an observation conducted with Licensed Practical Nurse (LPN) #1, the staffing information remained posted at the back door near the vending machines and was still dated 03/03/2025. No residents or family members were observed in the area. On 03/05/2025 at 3:45 PM, during an interview, the Director of Nursing (DON) and Administrator confirmed that the staffing information had not been updated since Monday, 03/03/2025. The DON acknowledged that she had gotten sidetracked and forgot to update the staffing information. The Administrator stated that she believed family members and residents frequently visited the back area to get drinks and snacks from the vending machines. However, both the Administrator and the DON later confirmed that the staffing information was not centrally located, and that residents and family members typically did not enter through this door, as it was primarily used as a staff entrance.

Based on record review, staff interview, and facility policy review, the facility failed to develop a care plan for physical restraints related to the use of full length bed rails and a lap buddy (a form of chair restraint) for 10 of 19 residents sampled. Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61. Findings include: A record review of the facility's policy Comprehensive Care Plans, dated September 2018, revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . A record review of the medical record revealed there was no care plan developed related to the use of restraints for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61. During an interview on 06/22/23 at 10:30 AM, with the Administrator and the Director of Nursing (DON), they confirmed the facility used full bed rails for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61 and these residents were unable to lower or remove the bed rails without assistance. They also confirmed that Resident #41 used a lab buddy for positioning and is unable to remove the devices without assistance. Both the DON and Administrator explained that a care plan should have been developed for restraints for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61. On 06/22/23 at 11:10 AM, during an interview with Licensed Practical Nurse (LPN)#2/Minimum Data Set (MDS)-Care Plan Nurse, she confirmed she did not develop or initiate care plans related to restraints for Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61. She stated that any residents with a restraint should have a care plan in place for the restraint.

Based on observations, interviews, record review, and facility policy review, the facility failed to identify physical restraints related to the use of full-length bed rails and a lap buddy (type of chair restraint) for ten (10) of 19 sampled residents. Resident #1, Resident #10, Resident #13, Resident #19, Resident #41, Resident #45, Resident #54, Resident #58, Resident #60, and Resident #61. Findings Include: A record review of the facility's policy Physical Restraint Application Policy, dated January 2018, revealed Policy: The purpose of this procedure is to provide safety or postural support of a resident to prevent injury to the resident or others when the resident has medical symptoms that warrant the use of restraints . Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . If a resident cannot mentally and physically self-release, then the device is considered a restraint . Resident #1 On 06/19/23 at 01:17 PM, during an observation, Resident # 1 was lying in bed with head of bed elevated and there were two (2) full-length bed rails that were raised. A record review of the Admission Record revealed the facility admitted Resident #1 on 10/10/2007 with diagnoses including Unspecified Convulsions, Spastic Hemiplegia Affecting Right Dominant Side, and on 08/06/2021, a new diagnosis of Spastic Hemiplegia Affecting Left Nondominant Side. A record review of the Order Review History Report revealed Resident #1 had a Physician's Order, dated 6/27/2016, for .full (length) padded side rails up x (times) 2 r/t (related to) convulsions and spastic hemiplegia . Resident #10 On 06/19/23 at 11:03 AM, the SA observed Resident #10 lying in bed, with two (2) full-length side rails that were raised on both sides. A record review of the Admission Record revealed the facility admitted Resident #10 on 06/30/2010 with diagnoses including Epilepsy and Hemiplegia. A new diagnosis was added on 05/16/2016 of Conversion Disorder with Seizures or Convulsions. A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #10 had a Physician's Order, dated 5/8/2018 for . full padded side rails up x2 for safety and seizure precautions . Resident #13 On 06/19/23 at 11:15 AM, Resident #13 was observed lying in the bed with two (2) full-length side rails that were raised. On 06/21/23 at 01:00 PM, during an interview and an observation, Resident #13 was lying in bed and both full-length side rails were raised. Resident #13 confirmed she could not release the rails on her own and that the bed rails were used to prevent her from falling out of bed. A record review of the Admission Record revealed the facility admitted Resident #13 on 02/09/2023 with diagnoses including Multiple Sclerosis and Other Muscle Spasm. A record review of the Order Summary Report with active orders as of 06/22/2023, revealed Resident #13 had a Physician's Order, dated 2/9/2023, for . Full side rails up x 2 for safety per res (resident) request . A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/16/2023 revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident #19 On 06/21/23 at 02:25 PM, Resident #19 was observed lying in bed and he had two (2) raised full-length bed rails. A record review of the Admission Record revealed the facility admitted Resident #19 on 08/17/2019 and she had diagnoses including Unspecified Psychosis, Cerebrovascular Disease, and Dementia. A record review of the Order Review History Report revealed Resident #19 had a Physician's Order, dated 8/17/2019, for Full side rails up x2 to define bed boundaries . Resident #41 On 06/19/23 at 11:35 AM, during an observation, Resident #41 was sitting in the day room in a wheelchair. The wheelchair had a lap buddy (a form of chair restraint) with Velcro straps to the side of the chair. Resident #41 was confused and was not oriented. On 06/19/23 at 02:06 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained Resident #41 had Alzheimer's Disease and was unable to make her needs known. She confirmed that Resident #41 could not remove the lap buddy and that it was used to prevent Resident #41 from leaning forward and falling out of the wheelchair. On 06/20/23 at 10:15 AM, during an interview with Licensed Practical Nurse (LPN) #1, she explained Resident #41 always wore the lap buddy when she was in her wheelchair for positioning and to prevent her from leaning forward out of the chair. She stated that without the lap buddy, Resident #41 would fall forward. She confirmed that Resident #41 was unable to remove the lap buddy due to her Dementia. On 06/20/23 at 1:20 PM, Resident #41 was lying in bed with two (2) raised full-length padded bed rails. On 06/20/23 at 1:50 PM, during an interview with CNA #2, she explained Resident #41 had the lap buddy and the padded bed rails in place for fall prevention. She explained that Resident #41 was unable to remove the lap buddy or the bed rails on her own. A record review of the Admission Record revealed the facility admitted Resident #41 on 02/25/2019 and she had diagnoses including Alzheimer's Disease and Vascular Dementia. Record review of the Order Summary Report with active orders as of 06/22/2023, revealed Resident #41 had a Physician's Order, dated 10/6/2021, for May utilize lap buddy to w/c (wheelchair) as needed to assist with positioning r/t poor trunk control and a Physician's Order, dated 7/20/2021 for Full siderails up x 2 for bed mobility and safety . Resident #45 On 06/19/23 at 11:20 AM, in an observation, there were two full-length bed rails on the resident's bed. The resident was not in the room at the time of the observation. On 06/20/23 at 10:00 AM, during an interview with LPN #1, she explained Resident #45 had not had any recent falls and that he had full-length bed rails that were raised for bed mobility and safety. On 06/20/23 02:22 PM, during an interview with CNA #3, she confirmed Resident #45 was unable to lower the bed rails on her own. On 06/20/23 at 02:45 PM, observed Resident #45 lying in bed with full-length bed rails that were raised. A record review of the Admission Record revealed the facility admitted Resident #45 on 02/28/2018 and she had diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, and Unspecified Dementia. A record review of the Order Summary Report with active orders a of 06/20/2022, revealed Resident #45 had a Physician's Order, dated 3/24/2022, for . Full side rails up x2 for bed mobility and safety . Resident #54 On 06/21/23 at 01:43 PM, during an observation and interview, Resident #54 was lying in bed with two raised full-length bed rails. Resident #54 explained staff pulled up both full-length bed rails to prevent him from falling. Resident #54 reported he could not lower the bed rails on his own if he wanted to. A record review of the Admission Record revealed the facility admitted Resident #54 on 01/25/2022 with a diagnosis of Metabolic Encephalopathy. A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #54 had a Physician's Order, dated 6/19/2023 . Full side rails up x2 for bed mobility & (and) per resident request . A record review of the Quarterly MDS with an ARD of 04/11/2023, revealed Resident #54 had a BIMS score of 13, which indicated he was cognitively intact. Resident #58 On 06/19/23 at 11:50 AM, observed Resident #58 in his room sitting in a wheelchair. There were two raised full-length bed rails on his bed. On 06/21/23 at 02:00 PM, during an interview with CNA #4, she explained bed rails are always used for safety when Resident #58 is in his bed. CNA #4 also confirmed that Resident #58 was unable to lower the bed rails on his own. On 06/22/23 at 09:00 AM, during an interview with Resident #58, he explained the staff always raised the bed rails when he is in bed for safety and that he could not lower them if he wanted to. Resident #58 denied any recent falls or seizures. A record review of the Admission Sheet revealed the facility admitted Resident #58 on 12/07/2021, and he had diagnoses including Encounter for Orthopedic Aftercare Following Surgical Amputation, Acquired Absence of Right Leg Above Knee, Epilepsy, and Acquired Absence of Left Leg Above Knee. A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #58 had a Physician's Order, dated 09/28/2022, for Full padded side rails up x2 for safety and seizure precautions. A record review of the Quarterly MDS with an ARD of 05/06/2023 revealed Resident #58 had a BIMS score of 8, which indicated his cognition was moderately impaired. Resident #60 On 06/19/23 at 11:29 AM, during an interview and observation, Resident #60 was lying in bed and had two (2) raised full-length bed rails. Resident #60 explained the bed rails were raised for safety for fear of falling out of bed. On 06/20/23 at 10:00 AM, during an interview with LPN #1, she explained Resident #60 had full-length bed rails that were raised for safety but stated that Resident #60 could not lower the bed rails on her own. A record review of the Admission Record revealed the facility admitted Resident #60 on 03/06/2023 and she had diagnoses including Secondary Malignant Neoplasm of Brain and Hemiplegia Unspecified Affecting Left Nondominant Side. A record review of the Order Summary Report with active orders as of 06/23/2023, revealed Resident #60 had a Physician's Order, dated 03/11/2023, for Full side rails up x 2 per resident request for bed mobility and fear of falling out of bed. A record review of the Quarterly MDS with an ARD of 06/12/23 revealed Resident #60 had a BIMS score of 13, which indicated she was cognitively intact. Resident #61 On 06/19/23 at 02:44 PM, during an observation, Resident #61 was lying in bed and had two (2) raised full-length bed rails. A record review of the Admission Record revealed the facility admitted Resident #61 on 03/23/2023 and she had diagnoses including of Heart Failure and Unspecified Psychosis. A record review of the Order Summary Report with active orders as of 06/20/2023, revealed Resident #61 had a Physician's Order dated 6/19/2023, for Full assist rails on bed as requested by resident for bed mobility. On 06/19/23 at 03:00 PM, during an interview with the Administrator, she explained the facility is a no restraint facility. On 06/22/23 at 10:30 AM, during an interview with Administration and the Director of Nursing (DON), they confirmed the facility does use full bed rails per resident/family request and for safety measures. They explained they understand the definition of restraints and the residents cannot lower or remove the full bed rails on their own. They confirmed the lap buddy can not be removed by Resident #41. The facility did not try the least restrictive measures before implementing the full bed rails and did not assess residents for entrapment. The Administrator reported the owner advised the facility to remove all full-length bed rails on Monday 06/19/23 after the State Agency entered the facility but it was explained to the owner an assessment would need to be completed on the resident's prior to removing the bed rails.

Based on interviews, record review and facility policy review, the facility failed to provide a written notice of transfer to the Responsible Representative (RR) for one (1) of three (3) sampled residents. Resident #1 Findings include: Review of the facility's Transfer and Discharge .Policy with a revision date of May 2020 revealed, .Policy Guidelines .7. Emergency Transfers/Discharges .j. Provide transfer notice as soon as practicable to resident and representative . A record review of the Admission Record revealed the facility admitted Resident #1 on 1/4/13 with diagnoses including Type 2 Diabetes Mellitus, Parkinson's Disease, and Cerebral Aneurysm. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/9/23 revealed Resident #1 was discharged to an acute hospital. Record review of the Significant Change MDS with an ARD on 1/29/23, revealed the Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. A record review of Progress Notes revealed a Nurses Note dated 1/9/23 at 6:13 PM which indicated Resident #1 was transferred to an acute hospital at 5:50 PM. On 3/2/23 at 9:40 AM, in an interview with Resident #1 revealed, he has no problems to report at the facility, everyone takes real good care of him and answer his call lights. On 3/2/23 at 10:22 AM, in an interview with the Business Office Manager (BOM), she stated the facility will usually email or mail a copy of the notification of transfer and she will keep a copy for her records. She was unable to produce confirmation that she had emailed or mailed the notification to the RR for Resident #1. On 3/2/23 at 11:00 AM, during an interview with the Administrator, she confirmed that the facility did not provide a written notice of transfer to Resident #1's RR and that it was a mistake of the facility.

Based on observation, interviews, record review, and facility policy review, the facility failed to have a sufficient number of staff to provide a resident with supervision required and needed to prevent choking, injury and death during meal consumption for one (1) of four (4) residents reviewed for choking, Resident #1. On 05/15/2020, Resident #1 was left unattended, with food, in the Memory Care Dining Room. Resident #1 choked and aspirated on his breakfast meal, which caused him to die in the facility. There were no licensed personnel in the dining room at this time. The facility's failure to provide supervision and leaving Resident #1 unattended, placed other residents in a situation that could potentially cause harm, injury, impairment and or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 05/15/2020, when the facility left Resident #1 unsupervised, with food in the dining room. Resident #1 was known for shoveling food in his mouth and was a choking risk. There were no licensed personnel in the dining room during mealtime. The facility's Administrator was notified of the IJ on 09/02/2020. The facility submitted an acceptable credible Removal Plan on 09/05/2020, in which the facility alleged all corrective actions were completed as of 09/04/2020, and the IJ was removed on 09/05/2020. The State Agency (SA) validated the Removal Plan and determined the IJ to be removed as of 09/05/2020, prior to exit. Therefore, the scope and severity for the IJ at CFR(s): 483.35(a)(1)(2) Sufficient Staffing, (F725), was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's, Nursing Services and Sufficient Staff Policy, dated November 2018, revealed, it is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility's census, acuity and [DIAGNOSES REDACTED]. The facility will supply services by enough numbers of each of the following personnel types on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Review of the facility's Nurses Notes for Resident #1, dated 11/05/2019, documented, a nurse was called to the Memory Care Unit. The Certified Nursing Assistant (CNA) reported Resident #1 shoved a roll into his mouth and choked. The CNA also reported she had to dig the roll out of Resident #1's mouth. The CNA revealed Resident #1 choked yesterday on green beans because eats so fast. A review of the Nurses' Notes, dated 12/31/2019, revealed, the resident fed himself with cueing and supervision. Resident #1 would gulp food unless monitored. Record review of the Physicians Notes for Resident #1, dated 05/15/2020 at 7:45 AM, revealed, Resident #1 was eating breakfast without swallowing, and aspirated with collapse. The [MEDICATION NAME] and mouth sweeps were performed by the nursing code team. Large chunks of scrambled eggs were removed from Resident #1's airway before he arrived from down the hall. Resident #1 was awake, eyes opened, sitting up, no coughing, but spontaneous respirations. Within a minute, Resident #1 collapsed again, was transferred to bed. The staff yanker suctioned more food debris. Resident #1 was noted to be a Do Not Resuscitate (DNR). No spontaneous respiration effort, no gag reflex, oxygen added, ambulance in route, agonal heartbeat but no pulse, no heartbeat, eyes fixed and dilated. Ambulance canceled. Resident #1 pronounced at 7:28 AM. A review of Resident #1's Death Certificate, dated 05/27/2020, revealed, the cause of death was [MEDICAL CONDITION] due to airway obstruction and aspiration of food. During an interview, on 09/03/2020 at 10:15 AM, Certified Nursing Assistant (CNA) #2 revealed she worked the Memory Care Unit on 05/15/2020 (day of incident). CNA #2 stated Resident #1 came out of the dining room, and CNA #1 was patting Resident #1 on his back because he had stuffed food in his mouth. She stated Resident #1 fell to the floor, and CNA #1 was trying to get food out of his mouth. There was not a nurse in the dining room at that time. CNA #2 stated the nurse made rounds on the unit periodically. CNA #2 stated she called for help and the Nurses came on the unit and pulled eggs out of Resident #1's mouth. CNA #2 revealed Resident #1 would hoard food and pocket food in his mouth. CNA #2 said she was in-serviced by the Speech Therapist to make sure Resident #1 ate last and to monitor his eating because he had a history of [REDACTED]. CNA #2 stated Resident #1 also wandered, was an elopement risk and had inappropriate sexual behaviors. There were 10 residents on the memory care unit on 05/15/2020. An observation on, 09/03/2020 at 11:45 AM, of the lunch meal on the Memory Care Unit, revealed, two (2) CNAs assisting residents with lunch. The residents were spread out around the dining room. There were no nurses in the dining room during the meal. During an interview, on 09/03/2020 at 12:30 PM, CNA #1 stated she was assisting Resident #1 with his breakfast on 05/15/2020. CNA #1 stated another resident came into the dining room. CNA #1 revealed there were 10 residents on the unit at that time. CNA #1 stated she left Resident #1 at the table to assist the other resident, by unwrapping her food and setting up her tray. She stated CNA #2 was assisting another resident at that time. CNA #1 stated when she turned around to check on Resident #1, she noticed him shoveling food into his mouth from his tray and another resident's tray. She stated Resident #1 was turning gray. CNA #1 revealed she tried to get Resident #1 to open his mouth, but he clenched his teeth together. CNA #1 said she tried to assist Resident #1 to the bathroom to clean his mouth. She stated Resident #1 started turning blue and fell to the ground in the day area by the nurse's station. CNA #2 stated CNA #1 tried to take the food out of Resident #1's mouth. She stated that CNA #2 called for a nurse, but there were no nurses on the unit. CNA #1 stated the nurses are not on the unit during meals. CNA #1 stated she was in-serviced by the Speech Therapist to give Resident #1 his meals last, and to assist him with meals because he stuffed food in his mouth that would choke him. CNA #1 stated that she should have asked CNA #2 to assist with the other resident's breakfast. She stated that she should not have left Resident #1 unattended, because Resident #1 was impulsive and had shoved food in his mouth in the past. During an interview, on 09/03/2020 at 1:00 PM, Registered Nurse (RN) #1 revealed, she was called into the Memory Care Unit by CNA #1 on 05/15/2020 (day of the incident). RN #1 stated she was the Supervisor for the day. RN #1 stated Resident #1 was blue and laying on the floor when she entered the unit. RN #1 stated she performed the [MEDICATION NAME] maneuver and was not successful. RN #1 stated Resident #1 was taken to his room, suctioning was started, and a large amount of scrambled eggs was removed from his mouth. RN #1 stated Resident #1 had a history of [REDACTED]. She stated Resident #1 needed one on one supervision with meals. An interview, on 09/04/2020 at 5:00 PM, the Director of Nursing (DON) confirmed, the facility does not have a licensed nurse in the dining room during meals in the Memory Care dining room. The DON stated she discussed this with the Administrator and the Owner of the facility, and they decided to only have two (2) CNAs in this dining room at the time. She stated the nurses would come in and out during meals to make sure the residents have the correct diets. Review of the facility's Removal Plan, revealed, the facility took the following actions to remove the Immediate Jeopardy: 1. Sixty-three (63) residents were assessed by the Licensed Social Worker and the Social Services Director for behaviors that may lead to self-injury or harm on September 4, 2020 completed at 12:30 PM. Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. 2. Sixty-three (63) residents were assessed by the Speech Therapist for swallowing difficulties and choking. Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 2:30 PM. 3. Eight (8) of eight (8) Registered Nurses (RN), seven (7) of 13 Licensed Practical Nurses(LPN), 30 of 38 Certified Nursing Assistants (CNA), four (4) of 12 Dietary Aides, five (5) of seven (7) Housekeepers, five (5) of seven (7) Activity Personnel, two (2) of three (3) Laundry Personnel, one (1) of three (3) Therapist, four (4) of four (4) Administrative Staff were in-serviced on September 2, 2020 by the Assistant Director of Nursing (ADON) from 2:30 PM until 3:00 PM on supervising and monitoring risk for aspiration and choking hazards. 4. A total of 64 residents' charts were reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/ Quality Assurance Nurse. All 64 residents' charts were reviewed and assessed based on their prescribed diets and [DIAGNOSES REDACTED]. A total of 64 residents care plans were reviewed at this time with 100% accuracy. The chart reviews were completed on September 2, 2020 at 5:30 PM. 5. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on September 2-3, 2020 by the Social Services Director and the ADON from 6:00 PM until 10:00 AM on Meal Supervision and Assistance Policy. 6. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPN's, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in- serviced on September 2, 2020 by the Owner of the facility from 2:30 PM until 3:00 PM on the accessibility of care plans and nutritional systems location. 7. Eight (8) of eight (8) RNs, 22 of 38 CNA's, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when, and how to report to the State Agency. 8. The Quality Assurance Committee (QA) comprised of the Medical Director, Administrator, Director of Nursing, Infection Control Preventionist, Quality Assurance, Owner of facility, Certified Recreational Therapist, Certified Dietary Manager, Assistant Director of Nursing, Licensed Social Worker, Social Services Director, Admissions Nurse, Minimum Data Set Nurse, Medical Records Nurse and Care Plan Nurse met on September 2, 2020 at 1:00 PM. A plan of action was implemented at this time to ensure that all staff is in-serviced on supervising and monitoring risk for aspiration and choking hazards, Meal Supervision and Assistance Policy, systematic communication within the facility related to residents that are deemed to be at risk for aspiration or a choking hazard, implementation of the nursing/therapy communication form, accessibility of care plans and nutritional systems location. If a resident is identified as being a choking or aspiration risk, the resident will be assessed by a Speech Therapist to determine the adequate level of supervision needed. This determination will be based on the individual needs of the resident and identified hazards. A nursing/therapy communication form was implemented at this time to ensure all residents that are deemed at risk for aspiration or choking will be reviewed and discussed by the Interdisciplinary Team (IDT) and reviewed by the Quality Assurance Committee. The Care Plan Nurse will review all charts and diet orders of the resident who is at risk for aspiration or choking and refer to the Quality Assurance Committee for review and implementation of any negative outcomes. All residents' charts that were identified according to their prescribed diet and aspiration risk have been reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/Quality Assurance Nurse. A total of 64 residents care plans were updated on September 2, 2020 at 5:30 PM by the Care Plan Nurse. The IDT reviewed all policy and procedures related to the adverse event and deemed all policies and procedures do not require any revision at this time. QA reviewed the state and federal regulation and facility guideline requirements for reporting incidents to the State Agency and the Attorney General's office. All reported incidents will be reviewed in the monthly QA meeting. 9. The QA Committee met on September 4, 2020 at 8:00 AM for review and implementation to have all 63 residents assessed for behaviors that may lead to self-injury or harm, to identify anyone who is at risk and implement person centered interventions, and to in-service all staff members on recognizing behaviors and potential for self-harm and injury and whom to report to. The findings were as followed: Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. The QA Committee determined all 63 residents will be assessed by the Speech Therapist for difficulty swallowing and choking and to review and implement a plan of care to prevent any adverse reactions related to findings by the Speech Therapist. The findings were as followed Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. All residents that have a diet order or diet changes will be reviewed during the weekly care plan meeting by the IDT to prevent any further adverse events. All residents that are reported on the Nurse/Therapy documentation form will be immediately reviewed by the IDT, recommendations discussed, and a plan of care will be put into effect. The Nurse/Therapy documentation forms will be reviewed weekly during the care plan meeting with the IDT to prevent any further adverse events. No staff will be allowed to work until they are in-serviced. The facility alleges the immediate jeopardy be removed on September 5, 2020. The State Agency (SA) validated the facility's Corrective Actions through observation, interview, record review, and review of sign-in sheets. 1. The SA validated through interviews and record review of all residents were assessed by the licensed Social Worker and the director of Social Services for behaviors that may lead to self-injury or harm. 2. The SA validated through interviews and record review of all residents were assessed by the speech therapist for swallowing difficulties and choking aspiration. 3. The SA validated through interviews and were in-serviced on supervising and monitoring risk for aspiration and choking hazards. 4. The SA validated through record review that all residents in the facility charts were reviewed by the care plan nurse for accuracy of all Residents diets. 5. The SA validated through interviews and in-services by the Social Worker on meal Supervision. 6. The SA validated through interview and in-services on the accessibility of care plans and nutritional systems location. 7. The SA validated through interview and in-services on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when and how to report to the State Agency. 8. The SA validated a Quality Assessment and Assurance Committee meeting was held on September 2, 2020 and September 4, 2020 by interview and review of the sign-in sheet. 9. The SA validated that all corrective actions listed were accomplished by 09/05/2020. 10. The SA validated through interviews and record review that staff were not allowed to work until in-serviced. 11. The SA validated that all corrective actions were completed as of 09/05/2020, and the IJ was removed prior to exit on 09/05/2020.

Based on observation, interviews, record review and facility policy review the facility failed to provide a resident with supervision required and needed to prevent accidents and hazards, choking injury and death during meal consumption for one (1) of four (4) residents reviewed for choking, Resident #1. Resident #1 was left unattended in the Memory Care Dining Room. Resident #1 choked and aspirated on breakfast meal which caused him to die in the facility. The facility's failure to provide supervision and leaving Resident #1 unattended placed other residents in a situation caused harm, injury, impairment and death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 05/15/2020, when the facility left Resident #1 unsupervised with food in the dining room. Resident #1 had was known for shoveling food in his mouth and a choking risk. There were no licensed personnel in the dining room. The facility ' s Administrator was notified of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 09/02/2020. The facility submitted an acceptable credible Removal Plan on 09/05/2020, in which the facility alleged all corrective actions were completed as of 09/04/2020, and the IJ and SQC was removed on 09/05/2020. The SA validated the Removal Plan and determined the IJ to be removed as of 09/02/2020, prior to exit. Therefore, the scope and severity for the IJ at CFR(s): 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F-689), was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Accident and Supervision Policy, dated November 2018, revealed, the facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents. Using specific interventions to try to reduce a resident's risk from hazards in the environment by communicating interventions with staff, assigning responsibility, providing training, ensuring that the interventions are put into action. The facility's definition of supervision is an intervention and a means of mitigating accident risk. He facility will provide adequate supervision to prevent accident. Adequacy of supervision. A review of the facility's Meal Supervision and Assistance Policy, dated November 2018, revealed, the resident will be prepared for a well-balanced meal in a calm environment, location of his/her preference and with adequate supervision and assistance to prevent accidents, provide adequate nutrition, and assure an enjoyable event this includes identifying hazards and risk, evaluating and analyzing hazards and risk, implementing interventions to reduce hazards and risks, monitoring for effectiveness and modifying interventions when necessary. He facility will utilize a systemic approach to ensure safety throughout the resident's environment and among all staff. Do not serve the meal until attendant is ready to assist the resident. Supervision/adequate supervision refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and frequency of supervision needed. This determination is based on individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. A review of the facility's Nurses' Notes for Resident #1, dated 11/05/2019, documented, a nurse was called to the Memory Care Unit. The notes revealed, a Certified Nursing Assistant (CNA) reported Resident #1 shoved a roll into his mouth and choked. The CNA also reported she had to dig the roll out of his mouth. The CNA further revealed the resident choked yesterday on green beans because eats so fast. Review of the facility's Nurses' Notes for Resident #1, dated 12/31/2019, revealed, Resident #1 fed himself with cueing and supervision. Resident #1 gulps food unless monitored. A review of Resident #1's Nurses' Notes, dated 05/15/2020, documented by Registered Nurse (RN) #1, revealed she entered the Memory Care Unit and observed Resident #1 standing up with a bluish-gray, pale tint to his face and around his lips. Resident #1 appeared to be choking. Resident #1 was unable to cough to clear his airway. The [MEDICATION NAME] maneuver performed times two (2). Resident #1 became weak and collapsed to the floor. Mouth sweeps were performed with food particles removed. Resident #1 was transferred to his room. The Medical Doctor was at bedside, Oxygen administer as well as suctioning. Food particles were removed from Resident #1's airway. The staff was unable to clear airway. The Medical Doctor pronounced Resident #1 at 7:28 AM. Record review of the facility's Physicians Notes, dated 05/15/2020 at 7:45 AM, revealed, Resident #1 was eating breakfast without swallowing, and aspirated with collapse. The [MEDICATION NAME] and mouth sweeps performed by the nursing code team. Large chunks of scrambled eggs removed from air way before he arrived from down the hall. Resident #1 was awake, eyes open sitting up, no coughing but spontaneous respirations. Within a minute Resident #1 collapsed again, transferred to bed the staff yanker suctioned more food debris. Resident #1 noted to be a Do Not Resuscitate (DNR), no spontaneous respiration effort, no gag reflex, oxygen added, ambulance in route, agonal heartbeat but no pulse, no heartbeat, eyes fixed and dilated. Ambulance canceled. Resident #1 pronounced at 7:28 AM. A review of the facility's Speech Therapy Plan of Care, dated 11/08/2019, revealed, Resident #1 was referred to Speech Therapy because he exhibit new onsets of decreased safety during oral intake, coughing, choking during oral intake, risk for aspiration, decreased safety awareness, increased behaviors, decreased verbal communication, increased need for assistance from others, decreased ability to use compensatory strategies and cognitive-communicative deficits placing patient at risk for aspiration, weight loss and further decline in functions and falls. The Speech Therapist revealed, Resident #1 was at risk for aspiration, had impulsive tendencies, to restrict the resident's performance in unsupervised tasks, reduce background noise, stand directly in front of the resident and speak in a deep voice when communicating. The Speech Therapist recommended a Mechanical Soft Diet with supervision and assistance required being determined by the resident's mood and impulsive tendencies at that moment dated 01/02/2020. Record review of the Speech Therapy Plan of Care, dated 05/01/2020, revealed, Resident #1 was referred to Speech after a new onset of decreased safety during a meal which was evidenced by Resident #1 severely choking during a meal when food was stuck in the resident's throat. As a result, nursing monitored Resident #1 and took Pneumonia precautions with X-ray, after the resident's temperature spiked. ATherapist standardized test dated 05/01/2020, revealed, Resident #1 was given the bedside Dysphagia evaluation, which Resident #1 was found to have both oral and pharyngeal dysphagia which put him at risk for aspiration. Resident #1 was impulsive and put large spoon/bites in mouth and sometimes two (2) or more spoon/bites in his mouth causing severe choking episodes. Resident #1 was found to be a candidate for skilled dysphagia therapy to implement training strategies for both resident and caregivers to decrease choking risk. A record review of in-service instructions related to Resident #1, dated 05/01/2020, by the Speech Therapist, revealed, Certified Nursing Assistant (CNA) #1 and CNA #2 was in-serviced on: purpose of a small spoon, to encourage liquids between swallows during meal time, strategies to recognize impulsive behavior during meal time also have the ability to recognize mood of patient and determine level of assistance needed that day. Then, implement use of compensatory strategies (i.e. Hand over Hand, diet modifications not giving roll, removing tray from patient and calming patient down, giving meal tray last, and being one-on-one, handing patient something to drink in between bites and ultimately removing tray from patient and feeding patient) to decrease impulsive behavior and to ensure meal time safety. An interview, on 09/03/2020 at 10:15 AM, with CNA #2, revealed, she was assisting another resident in the dining room. CNA #2 stated Resident #1 came out of the dining room with CNA #1 patting him on his back, because he had stuffed food in his mouth. CNA #2 stated Resident #1 fell to the floor, and CNA #1 was trying to get food out of his mouth. She revealed there was not a nurse in the dining room at that time. CNA #2 stated the nurse made rounds on the unit periodically. CNA #2 stated she called for help, and Registered Nurse (RN) #1 came on the unit and pulled eggs out of Resident #1 mouth. CNA #2 revealed Resident #1 would hoard food and pocket food in his mouth. CNA #2 stated the Speech Therapist in-serviced all the CNAs on the Memory Care unit instructing that Resident #1 should eat last, should drink in between bites, and should be supervised during meals because he had a history of [REDACTED]. CNA #2 stated Resident #1 had several behaviors that required one on one supervision. Observation of the lunch meal, on the Memory Care Unit, on 09/03/2020 at 11:45 AM, revealed, two (2) CNAs assisting eight (8) residents with lunch. The residents were spread out around the dining room. There were no licensed nurses noted in the dining room during the meal. The CNAs uncovered the lunch trays and the residents fed themselves without difficulty. During an interview, on 09/03/2020 at 12:30 PM, with CNA #1, she stated that she was assisting Resident #1 with his breakfast on 05/15/2020 (day of incident). CNA #1 stated another resident came into the dining room. CNA #1 confirmed she left Resident #1 at the table unattended. CNA #1 revealed she assisted another resident by unwrapping her food and setting up her tray, and CNA #2 was assisting another resident at that time. CNA #1 stated when she turned around to check on Resident #1, she noticed Resident #1 stuffing food from his tray and another resident's tray, into his mouth. She revealed Resident #1 was turning gray. CNA #1 stated she tried to get Resident #1 to open his mouth, but he clenched his teeth together. CNA #1 stated she tried to assist Resident #1 to the bathroom to clean his mouth, and he started turning blue, and fell to the ground in the day area by the nurse's station. She stated that CNA #2 called for a nurse. There were no nurses on the unit at that time. CNA #1 stated the nurses are not on the unit during meals. CNA #1 stated she was in-serviced by the Speech Therapist to give Resident #1 meals last and to assist him with his meals, because he stuffed food in his mouth that would choke him. CNA #1 further stated she should have asked CNA #2 to assist with the other resident's breakfast. CNA #1 confirmed Resident #1 should not have been left unattended because he was impulsive and had a history of [REDACTED]. During an interview, on 09/03/2020 at 1:00 PM, with Registered Nurse (RN) #1, revealed, she was called into the Memory Care Unit by CNA #1. RN #1 stated she was the Supervisor for the day. RN #1 revealed Resident #1 was blue when she entered the unit and lying on the floor. RN #1 revealed she performed the [MEDICATION NAME] maneuver and was not successful. RN #1 said Resident #1 was taken to his room and suction was initiated. She stated large amounts of scrambled eggs were removed from Resident #1's mouth. RN #1 also stated, Resident #1 had a history of [REDACTED]. RN #1 confirmed Resident #1 needed one on one supervision with meals. During an interview, on 09/03/2020 at 1:30 PM, the Speech Therapist (ST) revealed, Resident #1 had a history of [REDACTED].#1 was impulsive and shoveled food in his mouth. The ST stated there were several things put in place for Resident #1's behavior medication and safety, such as: Resident #1 should receive his tray last, one on one supervision with meals, ordered a small spoon and receive sips of water between each bite. The ST stated she in-serviced the CNAs on May 1, 2020 of Resident #1's feeding instructions. She also stated that she talked to the Director of Nursing (DON) about Resident #1's behavior modification and safety. The Speech Therapist stated the facility refused to follow her recommendations. She stated, on 04/31/2020, the Assistant Director of Nursing (ADON) told her that Resident #1 had swallowed a roll whole. She stated Resident #1 was able to cough up the roll with her (ADON) and RN #3 patting him on his back. She stated RN #3 received an order to consult Speech Therapy on 04/31/2020. The ST stated Resident #1 was re-evaluated on 05/01/2020. The Speech Therapist stated she also in-serviced the CNAs with instructions on how to provide behavior modifications to keep Resident #1 from choking. The ST stated she in-serviced the CNAs because they were the ones taking care of Resident #1. She stated she place instructions for Resident #1 in her notes. The ST said the facility had a communication issue between Nursing and Therapy. She stated that she monitored the CNAs for several days to make sure they followed the protocol. The ST stated the CNAs demonstrated passing out the other resident's trays first, and Resident #1 received his tray last. She revealed Resident #1 had one on one supervision, sips of water in between each bite, and a small spoon used with no difficulty. The ST revealed, the facility had a Utilization Review (UR) Meeting on Fridays, which included the Medical Doctor (MD), Director of Nursing (DON), Care Plan Nurse, Minimum Data Set (MDS), Therapy, and Quality Assurance. During an interview, on 09/04/2020 at 9:30 AM, RN #3/Nursing Supervisor stated she observed Resident #1 laying on his right side, on the floor. She stated Resident #1 was gray in color, and had scrambled eggs noted on his shirt sleeves. RN #3 stated that RN #1 was pulling eggs out of Resident #1's mouth with finger sweeps. She stated Resident #1 was slumped over and unresponsive. She stated suction was set up and RN #1 suctioned pieces of food out of his mouth, mainly eggs. She revealed Resident #1 remained unresponsive. RN #3 stated the MD pronounced Resident #1 at that time. RN #3 confirmed Resident #1 had a history of [REDACTED]. RN #3 stated Resident #1 should have always been supervised during meals because he shoved large amounts of food in his mouth. She revealed Resident #1 had an incident on 04/29/2020, when a roll was stuck in his throat. RN #3 stated Resident #1 was able to cough up the roll with assistance. RN #3 also stated the doctor ordered an X-ray, speech was consulted, and antibiotics ordered. An interview, on 09/04/2020 at 10:00 AM, with the Medical Director (MD) revealed, he stated that Resident #1 had a history of [REDACTED].#1 was impulsive and had several other behaviors. He revealed Resident #1 should have had one on one supervision 24 hours a day due to all of his behaviors. The MD revealed he was called to the Memory Care Unit, on 05/15/2020 (day of incident), and was at the bedside while the staff suctioned the food particles from Resident #1's mouth. The MD said Resident #1 became unresponsive, stopped breathing, and was pronounced at 7:28 AM. The MD confirmed the cause of death was [MEDICAL CONDITION] due to Resident #1 choking and aspirating his breakfast. During an interview, on 09/04/2020 at 5:00 PM, the Director of Nursing (DON) confirmed Resident #1 had a history of [REDACTED]. The DON stated she did not know the Speech Therapist had requested a special spoon to prevent choking until 05/01/2020 during a meeting. The DON stated the staff informed her that Resident #1 was not getting the spoon with all meals because the facility only had one. The DON stated she told the Dietary Manager to order more spoons. The DON further stated she was not aware that the Speech Therapist had recommended one on one supervision for Resident #1, to serve Resident #1 last, and to offer him sips of water in between bites, until after the resident's death. The DON stated she did not know the Speech Therapist had in-serviced the CNAs on 05/01/2020 with behavior modifications for Resident #1. The DON revealed she discussed with the Administrator and the Owner of the facility, that the Memory Care Unit should have a nurse during meals, but the Administrator and Owner refused. Review of the facility's Removal Plan revealed the facility took the following actions to remove the Immediate Jeopardy: 1. Sixty-three (63) residents were assessed by the Licensed Social Worker and the Social Services Director for behaviors that may lead to self-injury or harm on September 4, 2020 completed at 12:30 PM. Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. 2. Sixty-three (63) residents were assessed by the Speech Therapist for swallowing difficulties and choking. Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 2:30 PM. 3. Eight (8) of eight (8) Registered Nurses(RN), seven (7) of 13 Licensed Practical Nurses(LPN), 30 of 38 Certified Nursing Assistants (CNA), four (4) of 12 Dietary Aides, five (5) of seven (7) Housekeepers, five (5) of seven (7) Activity Personnel, two (2) of three (3) Laundry Personnel, one (1) of three (3) Therapist, four (4) of four (4) Administrative Staff were in-serviced on September 2, 2020 by the Assistant Director of Nursing (ADON) from 2:30 PM until 3:00 PM on supervising and monitoring risk for aspiration and choking hazards. 4. A total of 64 residents' charts were reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/ Quality Assurance Nurse. All 64 residents' charts were reviewed and assessed based on their prescribed diets and [DIAGNOSES REDACTED]. A total of 64 residents care plans were reviewed at this time with 100% accuracy. The chart reviews were completed on September 2, 2020 at 5:30 PM. 5. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on September 2-3, 2020 by the Social Services Director and the ADON from 6:00 PM until 10:00 AM on Meal Supervision and Assistance Policy. 6. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in- serviced on September 2, 2020 by the Owner of the facility from 2:30 PM until 3:00 PM on the accessibility of care plans and nutritional systems location. 7. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on the facility's Abuse, Neglect, and exploitation policy to include information regarding who, when, and how to report to the State Agency. 8. The Quality Assurance Committee (QA) comprised of the Medical Director, Administrator, Director of Nursing, Infection Control Preventionist, Quality Assurance, Owner of facility, Certified Recreational Therapist, Certified Dietary Manager, Assistant Director of Nursing, Licensed Social Worker, Social Services Director, Admissions Nurse, Minimum Data Set Nurse, Medical Records Nurse and Care Plan Nurse met on September 2, 2020 at 1:00 PM. A plan of action was implemented at this time to ensure that all staff is in-serviced on supervising and monitoring risk for aspiration and choking hazards, Meal Supervision and Assistance Policy, systematic communication within the facility related to residents that are deemed to be at risk for aspiration or a choking hazard, implementation of the nursing/therapy communication form, accessibility of care plans and nutritional systems location. If a resident is identified as being a choking or aspiration risk, the resident will be assessed by a Speech Therapist to determine the adequate level of supervision needed. This determination will be based on the individual needs of the resident and identified hazards. A nursing/therapy communication form was implemented at this time to ensure all residents that are deemed at risk for aspiration or choking will be reviewed and discussed by the Interdisciplinary Team (IDT) and reviewed by the Quality Assurance Committee. The Care Plan Nurse will review all charts and diet orders of the resident who is at risk for aspiration or choking and refer to the Quality Assurance Committee for review and implementation of any negative outcomes. All residents' charts that were identified according to their prescribed diet and aspiration risk have been reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/Quality Assurance Nurse. A total of 64 residents care plans were updated on September 2, 2020 at 5:30 PM by the Care Plan Nurse. The IDT reviewed all policy and procedures related to the adverse event and deemed all policies and procedures do not require any revision at this time. QA reviewed the state and federal regulation and facility guideline requirements for reporting incidents to the State Agency and the Attorney General's office. All reported incidents will be reviewed in the monthly QA meeting. 9. The QA Committee met on September 4, 2020 at 8:00 AM for review and implementation to have all 63 residents assessed for behaviors that may lead to self-injury or harm, to identify anyone who is at risk and implement person centered interventions, and to in-service all staff members on recognizing behaviors and potential for self-harm and injury and whom to report to. The findings were as followed: Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. The QA Committee determined all 63 residents will be assessed by the Speech Therapist for difficulty swallowing and choking and to review and implement a plan of care to prevent any adverse reactions related to findings by the Speech Therapist. The findings were as followed Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. All residents that have a diet order or diet changes will be reviewed during the weekly care plan meeting by the IDT to prevent any further adverse events. All residents that are reported on the Nurse/Therapy documentation form will be immediately reviewed by the IDT, recommendations discussed, and a plan of care will be put into effect. The Nurse/Therapy documentation forms will be reviewed weekly during the care plan meeting with the IDT to prevent any further adverse events. No staff will be allowed to work until they are in-serviced. The facility alleges the Immediate Jeopardy and SQC removed on September 5, 2020. The State Agency (SA) validated the facility's Corrective Actions through observation, interview, record review, and review of sign-in sheets. 1. The SA validated through interviews and record review of all residents were assessed by the licensed Social Worker and the director of Social Services for behaviors that may lead to self-injury or harm. 2. The SA validated through interviews and record review of all residents were assessed by the Speech Therapist for swallowing difficulties and choking aspiration. 3. The SA validated through interviews and were in-serviced on supervising and monitoring risk for aspiration and choking hazards. 4. The SA validated through record review that all residents in the facility charts were reviewed by the care plan nurse for accuracy of all Residents diets. 5. The SA validated through interviews and in-services by the Social Worker on meal Supervision. 6. The SA validated through interview and in-services on the accessibility of care plans and nutritional systems location. 7. The SA validated through interview and in-services on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when and how to report to the State Agency. 8. The SA validated a Quality Assessment and Assurance Committee meeting was held on September 2, 2020 and September 4, 2020 by interview and review of the sign-in sheet. 9. The SA validated that all corrective actions listed were accomplished by 09/05/2020. 10. The SA validated through interviews and record review that staff were not allowed to work until in-serviced. 11. The SA validated that all corrective actions were completed as of 09/05/2020, and the IJ was removed prior to exit on 09/5/2020.

Based on observation, facility investigation, record review, staff interview, and facility policy review, the facility failed to ensure a resident was free of neglect and provide the necessary care and services to avoid physical harm, as evidenced by, Resident #1, who had behaviors of shoveling food in his mouth and was a known choking risk, was left unattended in the dining room with food, for one (1) of four (4) residents reviewed for behaviors/choking risk. On [DATE], the State Agency (SA) received a complaint from the local Ombudsman, which revealed, the facility failed to provide one on one supervision with Resident #1 to prevent choking and aspiration. On [DATE] at 6:44 AM, Resident #1 was left unattended with food at the dining room table. Resident #1 shoveled his food, along with another resident's food, in his mouth, which caused Resident #1 to aspirate and die at the facility. The facility's failure to ensure a resident's right to be free from neglect, placed Resident #1 and other residents with behaviors and choking risks, in a situation that would likely cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE], when the facility left Resident #1 unsupervised with food, in the dining room. Resident #1 was known by staff for shoveling food in his mouth and was a choking risk. There was no licensed personnel in the dining room at the time of the incident. The facility's Administrator was notified of the IJ and SQC on [DATE]. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA validated the Removal Plan and determined the IJ and SQC was removed as of [DATE], prior to exit. Therefore, the scope and severity for the IJ and SQC at 42 CFR(s): 483.12(a)(1) - Freedom from Abuse/Neglect, (F600), was lowered to a D, while the facility develops and implements a plan of correction and monitors effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse, Neglect and Exploitation Policy, dated ,[DATE], revealed: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of residential property. The policy also revealed the definition of neglect as: Failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Record review of the facility's Speech Therapy Plan of Care, dated [DATE], revealed, Resident #1 was referred to Speech Therapy because he exhibited new onsets of decreased safety during oral intake, coughing, choking during oral intake, risk for aspiration, decreased safety awareness, increased behaviors, decreased verbal communication, increased need for assistance from others, decreased ability to use compensatory strategies and cognitive-communicative deficits placing patient at risk for aspiration, weight loss and further decline in functions and falls. The Speech Therapist also indicated Resident #1 was at risk for aspiration, had impulsive tendencies, to restrict the resident's performance in unsupervised tasks, reduce background noise, stand directly in front of the resident and speak in a deep voice when communicating. The Speech Therapist recommended a Mechanical Soft Diet with supervision, and assistance required being determined by the resident's mood and impulsive tendencies at that moment dated [DATE]. A review of Resident #1's Nurses' Notes dated [DATE], revealed, a nurse was called to the Memory Care Unit. The Certified Nursing Assistant (CNA) reported Resident #1 shoved a roll into his mouth and choked. The CNA also stated she had to dig the roll out of his mouth. The CNA revealed, the resident choked yesterday on green beans because he eats so fast. Review of the facility's Nurses' Notes for Resident #1, dated [DATE], revealed, Resident #1 feeds self with cueing and supervision. Resident #1 gulps food unless monitored. Record review of the Speech Therapy's Plan of Care, dated [DATE], revealed, Resident #1 was referred to Speech Therapy after a new onset of decreased safety during a meal, which was evidenced by Resident #1 severely choking during a meal when food was stuck in the resident's throat. As a result, nursing monitored Resident #1 and took Pneumonia precautions with X-ray, after the resident's temperature spiked. The Therapist standardized test, dated [DATE], revealed, Resident #1 was given the bedside dysphagia evaluation, in which Resident #1 was found to have both Oral and Pharyngeal Dysphagia, which put him at risk for aspiration. The test indicated Resident #1 was impulsive and put large spoons/bites in his mouth and sometimes two (2) or more spoons/bites in his mouth causing severe choking episodes. Resident #1 was found to be a candidate for skilled dysphagia therapy to implement training strategies for both Resident and caregivers to decrease choking risk. A record review of the Speech Therapist's in-service instructions for Resident #1, dated [DATE], revealed, Certified Nursing Assistant (CNA) #1 and CNA #2 was in-serviced on: Purpose of a small spoon, to encourage liquids between swallows during meal time, strategies to recognize impulsive behavior during meal time also have the ability to recognize mood of patient and determine level of assistance needed that day. Implement use of compensatory strategies (i.e. Hand over Hand, diet modifications not giving roll, removing tray from patient and calming patient down, giving meal tray last, and being one-on-one, handing patient something to drink in between bites and ultimately removing tray from patient and feeding patient) to decrease impulsive behavior and to ensure meal time safety. Record review of Resident #1's Nurses' Notes, dated [DATE], revealed, Resident #1 was noted to be coughing and choked on some food during lunch. Resident #1 was trying to put too much food in his mouth at one time, swallowed it whole, and choked on it. On [DATE], Registered Nurse (RN) #1 documented, Resident #1 feeds self with tray set up help. Resident #1 over stuffs mouth with food. Resident #1 is encouraged to slow down and take his time eating. Resident #1 is offered fluids with meals. On [DATE], Resident #1 choked on food due to him shoveling food in his mouth. A record review of the facility's nurses' note for Resident #1, dated [DATE], revealed, RN #1 was called to the Memory Care Unit where she observed Resident #1 standing up with a bluish-gray pale tint to his face and around his lips. Resident #1 appeared to be choking. The resident was unable to cough to clear his airway. The [MEDICATION NAME] maneuver was performed. Resident #1 became weak and collapsed to the floor. Mouth sweeps were performed with food particles removed. Resident #1 was placed in a wheelchair and taken to his room. The Medical Doctor (MD) was at bedside. Oxygen was administered, as well as suctioning. Food particles were removed from Resident #1's airway. The staff was unable to clear airway. The MD pronounced Resident #1 at 7:28 AM. Record review of the Physicians Notes for Resident #1, dated [DATE] at 7:45 AM, revealed, Resident #1 was eating breakfast without swallowing, and aspirated with collapse. The [MEDICATION NAME] and mouth sweeps were performed by the nursing code team. Large chunks of scrambled eggs were removed from Resident #1's airway before he arrived from down the hall. Resident #1 was awake, eyes opened, sitting up, no coughing, but spontaneous respirations. Within a minute, Resident #1 collapsed again, was transferred to the bed, and suctioned with more food debris. Resident #1 noted to be a Do Not Resuscitate (DNR), no spontaneous respiration effort, no gag reflex, oxygen added, ambulance in route, agonal heartbeat but no pulse, no heartbeat, eyes fixed and dilated. Ambulance canceled. Resident #1 pronounced at 7:28 AM. A review of Resident #1's Death Certificate, dated [DATE], revealed the cause of death was [MEDICAL CONDITION] due to airway obstruction and aspiration of food. Record review of the Physician order [REDACTED].#1 was ordered a Mechanical Soft Diet with chopped meat texture consistency. Chopped meats in gravy. Resident #1 would receive a small spoon with all meals to lower risk of choking due to impulsive and big spoons of food during oral consumption. On [DATE], the State Agency (SA) received a complaint from the local Ombudsmen stating the facility failed to provide one on one care with Resident #1, causing him to choke, aspiration and die. During an interview with the local Ombudsman on [DATE], she revealed, Resident #1's family called and stated the facility gave Resident #1 the wrong diet, which caused him to aspirate and die. The family said this incident happened on [DATE]. An interview via phone, on [DATE] at 9:30 AM, with Resident #1's daughter, revealed, she called the local Ombudsman and stated Resident #1 had behaviors and was in the Memory Care Unit at the facility. Resident #1's daughter stated the facility gave Resident #1 the wrong diet which caused him to aspirate and die. The daughter also stated two (2) weeks prior to Resident #1's death, the facility called her mother and said Resident #1 had choked on a roll and aspirated. Resident #1 was placed on an antibiotic for aspiration and [MEDICAL CONDITION]. Resident #1's daughter stated two (2) weeks later, the facility called and stated Resident #1 had choked and died . The family asked for a copy of Resident #1's medical records. She stated the facility did not return their calls. During an interview, on [DATE] at 10:15 AM, Certified Nursing Assistant (CNA) #2 revealed, she worked the Memory Care Unit on [DATE]. CNA #2 stated Resident #1 came out of the dining room, with CNA #1 patting him on his back, because he had stuffed food in his mouth. She stated Resident #1 fell to the floor. CNA #1 was trying to get food out of his mouth. She revealed the nurse was not in the dining room. CNA #2 stated the nurse made rounds on the unit periodically. CNA #2 stated she called for help and Registered Nurse (RN) #1 came on the unit and pulled eggs out of Resident #1's mouth. CNA #2 stated Resident #1 would hoard food and pocket food in his mouth. CNA #2 stated the Speech Therapist in-serviced all the CNAs on the Memory Care Unit indicating Resident #1 should eat last, should drink in between bites and should be supervised during meals because he has a history of choking by shoveling large amounts of food down his throat. CNA #2 stated Resident #1 had several behaviors that required one on one supervision. An observation of the lunch meal, on the Memory Care Unit, on [DATE] at 11:45 AM, revealed, two (2) CNAs assisting residents with lunch. The residents were spread out around the dining room. There were no licensed nurses in the dining room during the meal. The CNAs uncovered the residents' lunch trays, and they fed themselves without difficulty. During an interview, on [DATE] at 12:30 PM, CNA #1 stated she was assisting Resident #1 with his breakfast on [DATE], when another resident came into the dining room. CNA #1 confirmed she left Resident #1 at the table to assist the other resident with unwrapping her food and setting up her tray. CNA #1 stated when she turned around to check on Resident #1, she noticed Resident #1 stuffing food in his mouth from his tray and another resident's tray. She stated Resident #1 was turning gray and that she tried to get him to open his mouth. She stated Resident #1 clenched his teeth together. CNA #1 revealed she tried to assist Resident #1 to the bathroom to clean his mouth, but he started turning blue and fell to the ground in the day area by the nurses' station. CNA #2 stated she tried to take the food out of Resident #1 mouth. She revealed that CNA #2 called for a nurse, because there were no nurses on the unit. CNA #1 stated the nurses were not on the unit during meals. CNA #1 stated she was in-serviced by the Speech Therapist to give Resident #1 his meals last and to assist him with his meals, because he stuffed food in his mouth that would choke him. CNA #1 stated she should have asked CNA #2 to assist with the other resident's breakfast. CNA #1 confirmed Resident #1 should not have been left unattended because he was impulsive and had a history of [REDACTED]. During an interview, on [DATE] at 1:00 PM, RN #1 revealed, she was called into the Memory Care Unit by CNA #1. RN #1 stated she was the supervisor on the day of the choking incident. RN #1 stated Resident #1 was blue when she entered the unit and was laying on the floor. RN #1 stated she performed the [MEDICATION NAME] maneuver, but was not successful. RN #1 revealed Resident #1 was taken to his room and suction was initiated. She stated a large amount of scrambled eggs was removed from Resident #1's mouth. RN #1 also stated Resident #1 had a history of [REDACTED]. RN #1 confirmed Resident #1 needed one on one supervision with meals. During an interview, on [DATE] at 1:30 PM, the Speech Therapist (ST) revealed, Resident #1 had a history of [REDACTED].#1 was impulsive and shoveled food into his mouth. The ST stated she had put several things in place for Resident #1's behavior medication and safety, such as: Resident #1 should receive his tray last, one on one supervision with meals, ordered a small spoon and receive sips of water between each bite. The ST said she in-serviced the CNAs on [DATE] on Resident #1's feeding instructions. The ST also stated she talked to the Director of Nursing (DON) about Resident #1's behavior modification and safety. The Speech Therapist revealed, she recommended the facility have a nurse in all the dining rooms to promote patient safety. The ST further stated, the Assistant Director of Nursing (ADON) told her that Resident #1 swallowed a whole roll and coughed the roll up. The Speech Therapist stated Resident #1 was re-evaluated on [DATE]. The Speech Therapist revealed, she in-serviced the CNAs with instructions on how to provide behavior modifications to keep the resident from choking. The ST stated she in-serviced the CNAs because they were the ones taking care of the resident. The Speech Therapist stated she placed instructions in her notes. The ST stated the facility had a communication issue between Nursing and Therapy. During an interview, on [DATE] at 9:30 AM, RN #3/Nursing Supervisor, revealed, she observed Resident #1 lying on his right side on the floor. She stated Resident #1 was gray in color. Scrambled eggs were noted on Resident #1's shirt sleeves. RN #3 stated that RN #1 was pulling eggs out of Resident #1's mouth using finger sweeps. She stated Resident #1 slumped over and became unresponsive. Suction was set up and RN #1 suctioned pieces of food out of his mouth, mainly eggs. She stated Resident #1 remained unresponsive. RN #3 revealed the MD pronounced Resident #1 at that time. RN #3 also confirmed Resident #1 had a history of [REDACTED].#3 stated Resident #1 should have always been supervised during meals because he shoved large amounts of food into his mouth. She revealed Resident #1 had an incident on [DATE] where a roll was stuck in his throat. RN #3 stated Resident #1 was able to cough up the roll with assistance. RN #3 further stated the doctor ordered an x-ray, Speech Therapy was consulted, and antibiotics ordered. An interview, on [DATE] at 10:00 AM, with the Medical Director (MD), revealed, Resident #1 had a history of [REDACTED].#1 was impulsive and had several other behaviors. He stated Resident #1 should have had one on one supervision, 24 hours a day due to his behaviors. The MD further stated he was called to the Memory Care Unit on [DATE] and was at the bedside while the staff suctioned the food particles from the resident's mouth. The MD said Resident #1 became unresponsive, stopped breathing, and was pronounced at 7:28 AM. The MD confirmed the cause of death was [MEDICAL CONDITION] due to choking and aspirating his breakfast. The MS further stated he was involved in the Quality Assurance (QA) meetings after the incident in which everything was discussed, and he approved the facility's plan of action. During an interview, on [DATE] at 5:00 PM, the Director of Nursing (DON) confirmed, Resident #1 had a history of [REDACTED]. The DON stated she did not know the Speech Therapist had requested a special spoon to prevent choking until [DATE], when it was discussed in a meeting. The DON stated the staff informed her the resident was not getting the spoon with all meals because the facility only had one. The DON revealed she told the Dietary Manager to order more spoons. The DON stated she was not aware the Speech Therapist recommended one on one supervision, serving Resident #1 last, and to offer sips of water in between bites until after the resident's death. The DON stated she did not know the Speech Therapist had in-serviced the CNAs on [DATE] with behavior modifications to Resident #1. The DON said she discussed with the Administrator and the Owner of the facility, that the Memory Care Unit should have a nurse during meals. She stated the Administrator and Owner refused. Review of the facility's Removal Plan, revealed, the facility took the following actions to remove the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC): 1. Sixty-three (63) residents were assessed by the Licensed Social Worker and the Social Services Director for behaviors that may lead to self-injury or harm on [DATE] completed at 12:30 PM. Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on [DATE] at 12:30 PM. 2. Sixty-three (63) residents were assessed by the Speech Therapist for swallowing difficulties and choking. Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on [DATE] at 2:30 PM. 3. Eight (8) of eight (8) Registered Nurses(RN), seven (7) of 13 Licensed Practical Nurses(LPN), 30 of 38 Certified Nursing Assistants (CNA), four (4) of 12 Dietary Aides, five (5) of seven (7) Housekeepers, five (5) of seven (7) Activity Personnel, two (2) of three (3) Laundry Personnel, one (1) of three (3) Therapist, four (4) of four (4) Administrative Staff were in-serviced on [DATE] by the Assistant Director of Nursing (ADON) from 2:30 PM until 3:00 PM on supervising and monitoring risk for aspiration and choking hazards. 4. A total of 64 residents' charts were reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/ Quality Assurance Nurse. All 64 residents' charts were reviewed and assessed based on their prescribed diets and [DIAGNOSES REDACTED]. A total of 64 residents care plans were reviewed at this time with 100% accuracy. The chart reviews were completed on [DATE] at 5:30 PM. 5. Eight (8) of eight (8) RN's, 22 of 38 CNA's, eight (8) of 13 LPN's, two (2) of seven (7) Housekeeper's, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on [DATE]-3, 2020 by the Social Services Director and the ADON from 6:00 PM until 10:00 AM on Meal Supervision and Assistance Policy. 6. Eight (8) of eight (8) RN's, 22 of 38 CNA's, eight (8) of 13 LPNs, two (2) of seven (7) Housekeeper's, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in- serviced on [DATE] by the Owner of the facility from 2:30 PM until 3:00 PM on the accessibility of care plans and nutritional systems location. 7. Eight (8) of eight (8) RN's, 22 of 38 CNA's, eight (8) of 13 LPN's, two (2) of seven (7) Housekeeper's, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when, and how to report to the State Agency. 8. The Quality Assurance Committee (QA) comprised of the Medical Director, Administrator, Director of Nursing, Infection Control Preventionist, Quality Assurance, Owner of facility, Certified Recreational Therapist, Certified Dietary Manager, Assistant Director of Nursing, Licensed Social Worker, Social Services Director, Admissions Nurse, Minimum Data Set Nurse, Medical Records Nurse and Care Plan Nurse met on [DATE] at 1:00 PM. A plan of action was implemented at this time to ensure that all staff is in-serviced on supervising and monitoring risk for aspiration and choking hazards, Meal Supervision and Assistance Policy, systematic communication within the facility related to residents that are deemed to be at risk for aspiration or a choking hazard, implementation of the nursing/therapy communication form, accessibility of care plans and nutritional systems location. If a resident is identified as being a choking or aspiration risk, the resident will be assessed by a Speech Therapist to determine the adequate level of supervision needed. This determination will be based on the individual needs of the resident and identified hazards. A nursing/therapy communication form was implemented at this time to ensure all residents that are deemed at risk for aspiration or choking will be reviewed and discussed by the Interdisciplinary Team (IDT) and reviewed by the Quality Assurance Committee. The Care Plan Nurse will review all charts and diet orders of the resident who is at risk for aspiration or choking and refer to the Quality Assurance Committee for review and implementation of any negative outcomes. All residents' charts that were identified according to their prescribed diet and aspiration risk have been reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/Quality Assurance Nurse. A total of 64 residents care plans were updated on [DATE] at 5:30 PM by the Care Plan Nurse. The IDT reviewed all policy and procedures related to the adverse event and deemed all policies and procedures do not require any revision at this time. QA reviewed the state and federal regulation and facility guideline requirements for reporting incidents to the State Agency and the Attorney General's office. All reported incidents will be reviewed in the monthly QA meeting. 9. The QA Committee met on [DATE] at 8:00 AM for review and implementation to have all 63 residents assessed for behaviors that may lead to self-injury or harm, to identify anyone who is at risk and implement person centered interventions, and to in-service all staff members on recognizing behaviors and potential for self-harm and injury and whom to report to. The findings were as followed: Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on [DATE] at 12:30 PM. The QA Committee determined all 63 residents will be assessed by the Speech Therapist for difficulty swallowing and choking and to review and implement a plan of care to prevent any adverse reactions related to findings by the Speech Therapist. The findings were as followed Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. All residents that have a diet order or diet changes will be reviewed during the weekly care plan meeting by the IDT to prevent any further adverse events. All residents that are reported on the Nurse/Therapy documentation form will be immediately reviewed by the IDT, recommendations discussed, and a plan of care will be put into effect. The Nurse/Therapy documentation forms will be reviewed weekly during the care plan meeting with the IDT to prevent any further adverse events. No staff will be allowed to work until they are in-serviced. The facility alleges the IJ and SQC was removed on [DATE]. The State Agency (SA) validated the facility's Corrective Actions through observation, interview, record review, and review of sign-in sheets. 1. The SA validated through interviews and record review of all residents were assessed by the licensed Social Worker and the director of Social Services for behaviors that may lead to self-injury or harm. 2. The SA validated through interviews and record review of all residents were assessed by the speech therapist for swallowing difficulties and choking aspiration. 3. The SA validated through interviews and were in-serviced on supervising and monitoring risk for aspiration and choking hazards. 4. The SA validated through record review that all residents in the facility charts were reviewed by the care plan nurse for accuracy of all Residents diets. 5. The SA validated through interviews and in-services by the Social Worker on meal Supervision. 6. The SA validated through interview and in-services on the accessibility of care plans and nutritional systems location. 7. The SA validated through interview and in-services on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when and how to report to the state agency. 8. The SA validated a Quality Assessment and Assurance Committee meeting was held on [DATE] and [DATE] by interview and review of the sign-in sheet. 9. The SA validated that all corrective actions listed were accomplished by [DATE]. 10. The SA validated through interviews and record review that staff were not allowed to work until in-serviced. 11. The SA validated that all corrective actions were completed as of [DATE], and the IJ was removed prior to exit on [DATE].

Based on interviews, record review, and facility policy review, the facility failed to revise the Comprehensive Care Plan to include recommendations made by the Speech Therapist, related to safe food consumption, for one (1) of four (4) residents reviewed, Resident #1. The facility's failure to revise the care plan for Resident #1 caused serious harm, injury, and death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 05/15/2020, when the facility left Resident #1, who was known for choking and aspirating, unattended with food in the dining room. The facility's Administrator was notified of the IJ on 09/02/2020. The State Agency (SA) received an acceptable, credible Removal Plan on 09/05/2020, in which the facility alleged that all corrective actions were completed as of 09/04/2020, and the IJ was removed on 09/05/2020. The SA determined the IJ to be removed as of 09/05/2020, prior to exit. Therefore, the scope and severity for IJ at 42 CFR (s): 483.21(b) (1) - Comprehensive Care Plan, (F657) was lowered to a D, while the facility revised a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's, Care Plan Policy, dated January 2020, revealed, the Comprehensive Care Plan will be reviewed and revised as necessary, when a resident experience a status change. The nurse will notify the Minimum Data Set (MDS) Coordinator, the Physician, and the Resident's Representative. The MDS Coordinator and Interdisciplinary Team will discuss the resident's condition and collaborate on intervention options. The team meeting discussion will be documented in the nursing progress notes. The care plan will be updated with the new or modified interventions. Care plans will be modified as needed by the MDS Coordinator or other designated staff member. The Unit manager or other designated staff member will communicate care plan interventions to all staff involved in the resident's care. The Unit Manager or other designated staff member will conduct an audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident's needs. A review of Resident #1's Comprehensive Care Plan , dated 04/17/2020, revealed, it was not revised to include the Speech Therapist recommendations dated 05/01/2020, for one on one supervision due to impulsive behavior, hand over hand intervention to prevent resident from shoveling large amounts of food in his mouth, and sips of water in between each bite. A review of the facility's Nurses Notes for Resident #1, dated 11/05/2019, revealed a nurse was called to the Memory Care Unit. The Certified Nursing Assistant (CNA) reported Resident #1 shoved a roll into his mouth and choked. The Nurses' Notes revealed, the CNA further stated she had to dig the roll out of his mouth. The Nurses' Notes also revealed, the CNA stated the resident choked yesterday on green beans because eats so fast. Review of the facility's Nurses' Notes for Resident #1, dated 12/31/2019, revealed, the resident feeds self with cueing and supervision. Resident #1 gulps food unless monitored. A review of Resident #1's Nurses' Notes, dated 05/15/2020, documented by Registered Nurse (RN) #1, revealed, she entered the Memory Care Unit and observed Resident #1 standing up with a bluish-gray, pale tint to his face and around his lips. Resident #1 appeared to be choking. Resident #1 was unable to cough to clear his airway. The [MEDICATION NAME] maneuver was performed two times. Resident #1 became weak and collapsed to the floor. Mouth sweeps were performed with food particles removed. Resident #1 was transferred to his room. The Medical Doctor (MD) was at bedside, oxygen administered as well as suctioning. Food particles were removed from Resident #1's airway. The staff was unable to clear airway. The Medical Doctor pronounced Resident #1 at 7:28 AM. Record review of the facility's Physicians Notes, dated 05/15/2020 at 7:45 AM, revealed, Resident #1 was eating breakfast without swallowing, aspirated with collapse. The [MEDICATION NAME] and mouth sweeps performed by the nursing code team. Large chunks of scrambled eggs removed from air way before he arrived from down the hall. Resident #1 was awake, eyes open sitting up, no coughing but spontaneous respirations. Within a minute Resident #1 collapsed again, transferred to bed the staff yanker suctioned more food debris. Resident #1 noted to be DNR, no spontaneous respiration effort, no gag reflex, oxygen added, ambulance in route, agonal heartbeat but no pulse, no heartbeat, eyes fixed and dilated. Ambulance canceled. Resident #1 pronounced at 7:28 AM. During an interview, on 09/03/2020 at 1:30 PM, with the Speech Therapist (ST), she revealed, Resident #1 had a history of [REDACTED].#1 was impulsive and shoveled food in his mouth. The ST stated she had put several things in place for Resident #1 behavior medication and safety. She stated the facility had a Utilization Review (UR) Meeting every Friday, where the MD, Administrator (ADM), Director of Nursing (DON), Minimum Data Set (MDS), Care Plan Nurse, Assistant Director of Nursing (ADON), Therapy, and Quality Assurance (QA) Nurse to discuss the care of all the residents receiving skilled care. She revealed the Therapist gives a copy of all their notes to the UR team. She stated the Therapy notes has all the goals, recommendations, and updates for each resident. An interview, on 09/04/2020 at 9:00 AM, with RN #2, revealed, he stated that he wasn't aware of the Speech Therapist recommendation for Resident #1 to have one on one supervision during meals. RN #2 further stated he did not know about the recommendations for sips of water after each bite. RN #2 revealed he receives the therapy updates during stand up and at the care plan meetings. RN #2 stated he did not have access to the therapy notes. He stated that he was just given the therapy tab on his computer. RN #2 also said he only looked at the seven (7) day look back of nurses notes when he updates the care plan. During an interview, on 09/04/2020 at 9:15 AM, the Administrator confirmed, the facility had communication problems between Therapy and Nursing. The Administrator stated the facility had created a communication form to start using as of today to communicate between nursing and therapy. Review of the facility's Removal Plan, revealed, the facility took the following actions to remove the Immediate Jeopardy: 1. Sixty-three (63) residents were assessed by the Licensed Social Worker and the Social Services Director for behaviors that may lead to self-injury or harm on September 4, 2020 completed at 12:30 PM. Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. 2. Sixty-three (63) residents were assessed by the Speech Therapist for swallowing difficulties and choking. Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 2:30 PM. 3. Eight (8) of eight (8) Registered Nurses (RN), seven (7) of 13 Licensed Practical Nurses(LPN), 30 of 38 Certified Nursing Assistants (CNA), four (4) of 12 Dietary Aides, five (5) of seven (7) Housekeepers, five (5) of seven (7) Activity Personnel, two (2) of three (3) Laundry Personnel, one (1) of three (3) Therapist, four (4) of four (4) Administrative Staff were in-serviced on September 2, 2020 by the Assistant Director of Nursing (ADON) from 2:30 PM until 3:00 PM on supervising and monitoring risk for aspiration and choking hazards. 4. A total of 64 residents' charts were reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/ Quality Assurance Nurse. All 64 residents' charts were reviewed and assessed based on their prescribed diets and [DIAGNOSES REDACTED]. A total of 64 residents care plans were reviewed at this time with 100% accuracy. The chart reviews were completed on September 2, 2020 at 5:30 PM. 5. Eight (8) of eight (8) RN's, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeeper's, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on September 2-3, 2020 by the Social Services Director and the ADON from 6:00 PM until 10:00 AM on Meal Supervision and Assistance Policy. 6. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in- serviced on September 2, 2020 by the Owner of the facility from 2:30 PM until 3:00 PM on the accessibility of care plans and nutritional systems location. 7. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when, and how to report to the State Agency. 8. The Quality Assurance Committee (QA) comprised of the Medical Director, Administrator, Director of Nursing, Infection Control Preventionist, Quality Assurance, Owner of facility, Certified Recreational Therapist, Certified Dietary Manager, Assistant Director of Nursing, Licensed Social Worker, Social Services Director, Admissions Nurse, Minimum Data Set Nurse, Medical Records Nurse and Care Plan Nurse met on September 2, 2020 at 1:00 PM. A plan of action was implemented at this time to ensure that all staff is in-serviced on supervising and monitoring risk for aspiration and choking hazards, Meal Supervision and Assistance Policy, systematic communication within the facility related to residents that are deemed to be at risk for aspiration or a choking hazard, implementation of the nursing/therapy communication form, accessibility of care plans and nutritional systems location. If a resident is identified as being a choking or aspiration risk, the resident will be assessed by a Speech Therapist to determine the adequate level of supervision needed. This determination will be based on the individual needs of the resident and identified hazards. A nursing/therapy communication form was implemented at this time to ensure all residents that are deemed at risk for aspiration or choking will be reviewed and discussed by the Interdisciplinary Team (IDT) and reviewed by the Quality Assurance Committee. The Care Plan Nurse will review all charts and diet orders of the resident who is at risk for aspiration or choking and refer to the Quality Assurance Committee for review and implementation of any negative outcomes. All residents' charts that were identified according to their prescribed diet and aspiration risk have been reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/Quality Assurance Nurse. A total of 64 residents care plans were updated on September 2, 2020 at 5:30 PM by the Care Plan Nurse. The IDT reviewed all policy and procedures related to the adverse event and deemed all policies and procedures do not require any revision at this time. QA reviewed the state and federal regulation and facility guideline requirements for reporting incidents to the State Agency and the Attorney General's office. All reported incidents will be reviewed in the monthly QA meeting. 9. The QA Committee met on September 4, 2020 at 8:00 AM for review and implementation to have all 63 residents assessed for behaviors that may lead to self-injury or harm, to identify anyone who is at risk and implement person centered interventions, and to in-service all staff members on recognizing behaviors and potential for self-harm and injury and whom to report to. The findings were as followed: Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. The QA Committee determined all 63 residents will be assessed by the Speech Therapist for difficulty swallowing and choking and to review and implement a plan of care to prevent any adverse reactions related to findings by the Speech Therapist. The findings were as followed Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. All residents that have a diet order or diet changes will be reviewed during the weekly care plan meeting by the IDT to prevent any further adverse events. All residents that are reported on the Nurse/Therapy documentation form will be immediately reviewed by the IDT, recommendations discussed, and a plan of care will be put into effect. The Nurse/Therapy documentation forms will be reviewed weekly during the care plan meeting with the IDT to prevent any further adverse events. No staff will be allowed to work until they are in-serviced. The facility alleges the immediate jeopardy be removed on September 5, 2020. The State Agency (SA) validated the facility's Corrective Actions through observation, interview, record review, and review of sign-in sheets. 1. The SA validated through interviews and record review of all residents were assessed by the licensed Social Worker and the director of Social Services for behaviors that may lead to self-injury or harm. 2. The SA validated through interviews and record review of all residents were assessed by the speech therapist for swallowing difficulties and choking aspiration. 3. The SA validated through interviews and were in-serviced on supervising and monitoring risk for aspiration and choking hazards. 4. The SA validated through record review that all residents in the facility charts were reviewed by the care plan nurse for accuracy of all Residents diets. 5. The SA validated through interviews and in-services by the Social Worker on meal Supervision. 6. The SA validated through interview and in-services on the accessibility of care plans and nutritional systems location. 7. The SA validated through interview and in-services on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when and how to report to the State Agency. 8. The SA validated a Quality Assessment and Assurance Committee meeting was held on September 2, 2020 and September 4, 2020 by interview and review of the sign-in sheet. 9. The SA validated that all corrective actions listed were accomplished by 09/05/2020. 10. The SA validated through interviews and record review that staff were not allowed to work until in-serviced. 11. The SA validated that all corrective actions were completed as of 09/05/2020, and the IJ was removed prior to exit on 09/05/2020.

Based on interviews, record review and facility policy review, the facility failed to implement an appropriate plan of action to monitor identified issues related to Resident #1's high risk for choking and/or aspirating, which resulted in the resident choking to death. This affected one (1) of four (4) residents identified as being high risk for choking/aspirating. The facility's failure to ensure an effective Quality Assurance and Performance Improvement (QAPI) process to implement measures to care for Resident #1's needs placed this resident and other residents, who required supervision due to their risk for choking/aspirating, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 05/15/2020 when Resident #1, who required supervision due to being high risk for choking, was left unattended during the breakfast meal. Resident #1 shoveled food into his mouth and choked, which resulted in him choking to death. The facility failed to have a system in place for monitoring and communicating with Speech Therapy related to dietary recommendations initiated for residents who were at high risk for choking. This resulted in staff having inaccurate and inconsistent information to use to prevent Resident #1 and other residents, who were high risk, from choking or aspirating. A Quality Assurance and Assessment (QAA) review, revealed, the QAA Committee was not aware of this systemic issue, and the QAA committee was not monitoring facility practices related to accurate and consistent communication of Resident #1's behavior and or food modifications. The facility's Administrator was notified of the Immediate Jeopardy (IJ) on 09/02/2020. The State Agency (SA) received an acceptable, credible Removal Plan on 09/05/2020, in which the facility alleged that all corrective actions were completed as of 09/04/2020, and the IJ was removed on 09/05/2020. The SA determined the IJ to be removed as of 09/05/2020, prior to exit. Therefore, the scope and severity for the IJ at 42 CFR(s): 483.75(g)(2)(ii) - QAPI/QAA Improvement Activities (F867) was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Quality Assessment and Assurance (QAA) policy, dated 01/2019, revealed: It is this facility's policy to develop, implement, and maintain an effective, comprehensive, data-driven QAA program that focuses on outcomes of care, promotes individual choice and the improvement in quality of life. The QAA Committee shall be interdisciplinary and shall consist at a minimum of: The Administrator, the Medical Director, the Director of Nursing, the Infection Control Prevention Officer, two other members of the facility's staff. The QAA Committee will: -Conduct scheduled monthly meetings. -Develop and implement appropriate plans of action to correct identified quality concerns and deficiencies. -Participate in development, implementation and monitoring of the facilities written QAPI Plan. -Regularly review and analyze performance data, including data collected under the QAPI program, Infection Reports, Pharmacy, Psychological Reports, and recommendations. -Identify issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program are necessary. -Act on available data to make corrections or improvements. -Review and evaluate all filed and completed grievances. -Adverse events will be monitored in accordance with established procedures based on the type of adverse event. The data related to adverse events will be used to develop activities to prevent them. Review of the facility's Quality Assessment and Assurance (QAA) sign-in sheet and meeting minutes, dated 05/15/2020, revealed, the Medical Director, Facility Owner, Administrator, Director of Nursing, QAA Coordinator, Infection Preventionist, Minimum Data Set Nurse, Therapist, and others attended the QA meeting. A review of the minutes, revealed: IDT (Interdisciplinary Team) discussed (Name of Resident) Resident #1's incident that occurred, all statements and summary was reviewed, the medical chart was reviewed, discussed adverse event related to choking incident. IDT discussed increase monitoring at meal times for Daylily Memory Care. Recommendations: Increase monitoring at meal times for Daylily Memory Care. Record review of the facility's Speech Therapy (ST) Plan of Care, dated 11/06/2019, revealed, Resident #1 was referred to Speech Therapy due to new onset of decreased safety during oral intake, coughing/choking during oral intake, risk for aspiration, decreased safety awareness, increased behaviors, decreased verbal communication, increased need for assistance from others, decreased ability to use compensatory strategies and cognitive-communicative deficits placing patient at risk for aspiration, weight loss and further decline in functions and falls. The ST Plan of Care also indicated precautions for Resident #1 included, an aspiration risk, had impulsive tendencies, to restrict the resident's performance in unsupervised tasks, reduce background noise, stand directly in front of the resident and speak in a deep voice when communicating. Review of the ST's Plan of Care, dated 05/01/2020, revealed, Resident #1 was referred to ST after a new onset of decreased safety during a meal, which was evidenced by, Resident #1 severely choking during a meal when food was stuck in the resident's throat. As a result, nursing monitored Resident #1 and took Pneumonia precautions with X-ray after the resident's temperature spiked two days later. The Plan of Care revealed the Bedside Dysphagia evaluation was given to Resident #1, found and the resident to have both oral and pharyngeal dysphagia, which put him at risk for aspiration. The Plan of Care further indicated Resident #1 was impulsive and puts large spoons/bites in mouth and sometimes two (2) or more spoons/bites in his mouth causing severe choking episodes. Resident #1 was found to be a candidate for skilled dysphagia therapy to implement training strategies for both the resident and caregivers to decrease choking risk. A record review instructions for Resident #1, dated 05/01/2020, given as an in-service to the Certified Nursing Assistants (CNA), by the Speech Therapist, revealed, CNA #1 and CNA #2 was in-serviced on: Purpose of a small spoon, to encourage liquids between swallows during meal time, strategies to recognize impulsive behavior during meal time also have the ability to recognize mood of patient and determine level of assistance needed that day. Then, implement use of compensatory strategies (i.e. Hand over Hand, diet modifications not giving roll, removing tray from patient and calming patient down, giving meal tray last, and being one-on-one, handing patient something to drink in between bites and ultimately removing tray from patient and feeding patient) to decrease impulsive behavior and to ensure meal time safety. During an interview, on 09/03/2020 at 12:30 PM. CNA #1 stated she was assisting Resident #1 with his breakfast on 05/15/2020 (day of incident). CNA #1 stated another resident had came into the dining room. CNA #1 confirmed she left Resident #1 at the table to assist the other resident by unwrapping her food and setting up her tray. CNA #1 stated when she turned around to check on Resident #1, she noticed Resident #1 was stuffing food from his tray and another resident's tray into his mouth. She revealed, Resident #1 was turning gray and that she tried to get Resident #1 to open his mouth but he clenched his teeth together. CNA #1 stated she tried to assist Resident #1 to the bathroom to clean his mouth, but he started turning blue and fell to the ground in the day area by the nurses' station. CNA #1 stated CNA #2 called for a nurse. There were no nurses on the unit. CNA #1 stated the nurses were not on the unit during meals. CNA #1 revealed she was in-serviced by the Speech Therapist to give Resident #1 meals last, and to assist him with his meals because he stuffed food in his mouth that would choke him. CNA #1 confirmed Resident #1 should not have been left unattended because he was impulsive and had a history of [REDACTED]. Interview on 09/04/2020 at 9:15 AM, with the Administrator, revealed, the Quality Assurance (QA)/Infection Nurse set up the QA meetings monthly and as needed. The Administrator stated the facility had a QA meeting on 05/15/2020 and Resident #1's death was discussed. The Administrator revealed, the QA team reviewed all the staff's statements, Resident #1's chart, and adverse event related to choking incident. The QA team recommended increase monitoring of all meals on the memory care unit. The Administrator stated the facility didn't do any disciplinary action towards the CNA that left Resident #1 unattended with food in the Memory Care dining room and the policies were not changed or updated. An interview with RN #3, on 09/04/2020 at 9:45 AM, confirmed the facility had a QA meeting on 05/15/2020. RN #3 revealed the QA committee discussed Resident #1's death and received statements from everybody involved. RN #3 revealed the committee recommended to increase monitoring at mealtimes for the Memory Care Unit. RN #3 stated the policies were not updated or changed and no disciplinary action was done. Review of the facility's Removal Plan, revealed the facility took the following actions to remove the Immediate Jeopardy: 1. Sixty-three (63) residents were assessed by the Licensed Social Worker and the Social Services Director for behaviors that may lead to self-injury or harm on September 4th, 2020 completed at 12:30 PM. Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. 2. Sixty-three (63) residents were assessed by the Speech Therapist for swallowing difficulties and choking. Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 2:30 PM. 3. Eight (8) of eight (8) Registered Nurses(RN), seven (7) of 13 Licensed Practical Nurses(LPN), 30 of 38 Certified Nursing Assistants (CNA), four (4) of 12 Dietary Aides, five (5) of seven (7) Housekeepers, five (5) of seven (7) Activity Personnel, two (2) of three (3) Laundry Personnel, one (1) of three (3) Therapist, four (4) of four (4) Administrative Staff were in-serviced on September 2, 2020 by the Assistant Director of Nursing (ADON) from 2:30 PM until 3:00 PM on supervising and monitoring risk for aspiration and choking hazards. 4. A total of 64 residents' charts were reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/ Quality Assurance Nurse. All 64 residents' charts were reviewed and assessed based on their prescribed diets and [DIAGNOSES REDACTED]. A total of 64 residents care plans were reviewed at this time with 100% accuracy. The chart reviews were completed on September 2, 2020 at 5:30 PM. 5. Eight (8) of eight (8) RNs, 22 of 38 CNA's, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on September 2-3, 2020 by the Social Services Director and the ADON from 6:00 PM until 10:00 AM on Meal Supervision and Assistance Policy. 6. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in- serviced on September 2, 2020 by the Owner of the facility from 2:30 PM until 3:00 PM on the accessibility of care plans and nutritional systems location. 7. Eight (8) of eight (8) RNs, 22 of 38 CNAs, eight (8) of 13 LPNs, two (2) of seven (7) Housekeepers, one(1) of three (3) Laundry, one (1) of 12 Dietary, three (3) of five (5) Activity Personnel, four (4) of four (4) Administrative Staff were in-serviced on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when, and how to report to the State Agency. 8. The Quality Assurance Committee (QA) comprised of the Medical Director, Administrator, Director of Nursing, Infection Control Preventionist, Quality Assurance, Owner of facility, Certified Recreational Therapist, Certified Dietary Manager, Assistant Director of Nursing, Licensed Social Worker, Social Services Director, Admissions Nurse, Minimum Data Set Nurse, Medical Records Nurse and Care Plan Nurse met on September 2, 2020 at 1:00 PM. A plan of action was implemented at this time to ensure that all staff is in-serviced on supervising and monitoring risk for aspiration and choking hazards, Meal Supervision and Assistance Policy, systematic communication within the facility related to residents that are deemed to be at risk for aspiration or a choking hazard, implementation of the nursing/therapy communication form, accessibility of care plans and nutritional systems location. If a resident is identified as being a choking or aspiration risk, the resident will be assessed by a Speech Therapist to determine the adequate level of supervision needed. This determination will be based on the individual needs of the resident and identified hazards. A nursing/therapy communication form was implemented at this time to ensure all residents that are deemed at risk for aspiration or choking will be reviewed and discussed by the Interdisciplinary Team (IDT) and reviewed by the Quality Assurance Committee. The Care Plan Nurse will review all charts and diet orders of the resident who is at risk for aspiration or choking and refer to the Quality Assurance Committee for review and implementation of any negative outcomes. All residents' charts that were identified according to their prescribed diet and aspiration risk have been reviewed by the Care Plan Nurse, the Admissions Nurse, and the Infection Control Preventionist/Quality Assurance Nurse. A total of 64 residents care plans were updated on September 2, 2020 at 5:30 PM by the Care Plan Nurse. The IDT reviewed all policy and procedures related to the adverse event and deemed all policies and procedures do not require any revision at this time. QA reviewed the state and federal regulation and facility guideline requirements for reporting incidents to the State Agency and the Attorney General's office. All reported incidents will be reviewed in the monthly QA meeting. 9. The QA Committee met on September 4, 2020 at 8:00 AM for review and implementation to have all 63 residents assessed for behaviors that may lead to self-injury or harm, to identify anyone who is at risk and implement person centered interventions, and to in-service all staff members on recognizing behaviors and potential for self-harm and injury and whom to report to. The findings were as followed: Six (6) of the 63 residents that were assessed were found to be at risk for self-injury or harm to themselves. Person-centered interventions were identified for each resident and reviewed by the Medical Director and the Psychiatric Nurse Practitioner, who is in agreement with the course of action and no further recommendations were made at this time. Six (6) of the 63 residents care plans were reviewed and updated on September 4, 2020 at 12:30 PM. The QA Committee determined all 63 residents will be assessed by the Speech Therapist for difficulty swallowing and choking and to review and implement a plan of care to prevent any adverse reactions related to findings by the Speech Therapist. The findings were as followed Six (6) of 63 residents that were assessed were found to be at risk for difficulty swallowing and choking at this time. Person-centered interventions and care plans were identified for each resident and reviewed by the Medical Director, Interdisciplinary Team (IDT), and the Dietician. No further recommendations were made at this time. All residents that have a diet order or diet changes will be reviewed during the weekly care plan meeting by the IDT to prevent any further adverse events. All residents that are reported on the Nurse/Therapy documentation form will be immediately reviewed by the IDT, recommendations discussed, and a plan of care will be put into effect. The Nurse/Therapy documentation forms will be reviewed weekly during the care plan meeting with the IDT to prevent any further adverse events. No staff will be allowed to work until they are in-serviced. The facility alleges the immediate jeopardy be removed on September 5, 2020. The State Agency validated the facility's Corrective Actions through observation, interview, record review, and review of sign-in sheets. 1. The SA validated through interviews and record review of all residents were assessed by the licensed Social Worker and the director of Social Services for behaviors that may lead to self-injury or harm. 2. The SA validated through interviews and record review of all residents were assessed by the speech therapist for swallowing difficulties and choking aspiration. 3. The SA validated through interviews and were in-serviced on supervising and monitoring risk for aspiration and choking hazards. 4. The SA validated through record review that all residents in the facility charts were reviewed by the care plan nurse for accuracy of all Residents diets. 5. The SA validated through interviews and in-services by the Social Worker on meal Supervision. 6. The SA validated through interview and in-services on the accessibility of care plans and nutritional systems location. 7. The SA validated through interview and in-services on the facilities Abuse, Neglect, and exploitation policy to include information regarding who, when and how to report to the State Agency. 8. The SA validated a Quality Assessment and Assurance Committee meeting was held on September 2, 2020 and September 4, 2020 by interview and review of the sign-in sheet. 9. The SA validated that all corrective actions listed were accomplished by 09/05/2020. 10. The SA validated through interviews and record review that staff were not allowed to work until in-serviced. 11. The SA validated that all corrective actions were completed as of 09/5/2020, and the IJ was removed prior to exit on 09/05/2020.

Based on interview, record review and facility policy review, the facility failed to report an allegation of Quality of Care/Supervision, related to an incident which resulted in Resident #1 choking/aspirating and death, within the two (2) hour required timeframe for one (1) of six (6) residents reviewed, Resident #1. Review of the facility's, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation Policy, dated [DATE], revealed: It is the policy of this facility to report all allegations of abuse, neglecr, exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. All alleged violation involving abuse, neglect, exploitation or mistreatment must be reported immediately. This includes injury of unknown source and misappropriation of resident property. If the alleged violation involves abuse/neglect or results serious bodily injury it must be reported immediately but no later than two (2) hours after allegation is made. If the alleged violation does not involve abuse or does not involve serious bodily injury it must be reported no later than 24 hours after allegation is made. The definition of neglect is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Injuries of unknown source includes circumstances when the injury is suspicious because of the extent of injury as soon as possible, but not to exceed 24 hours after discovery of the incident. Record review of the facility's Nurses' Notes, dated [DATE], by RN #1, revealed she was called to the Memory Care Unit where she observed Resident #1 standing up with a bluish gray pale tint to his face and around his lips. Resident #1 appeared to be choking. Resident #1 was unable to cough to clear his airway. The [MEDICATION NAME] maneuver was performed twice. Resident #1 became weak and collapsed to the floor. Mouth sweeps were performed with food particles removed. Resident #1 was placed in a wheelchair and taken to his room. The Medical Doctor was at bedside, Oxygen administered as well as suctioning. Food particles were removed from Resident #1's airway. The staff was unable to clear airway. The Medical Doctor pronounced Resident #1 dead at 7:28 AM. An interview, on [DATE] at 10:00 AM, with the Medical Director (MD), revealed, Resident #1 had a history of [REDACTED].#1 was impulsive and had several other behaviors. He stated Resident #1 should have had one on one supervision 24 hours a day due to his behaviors. The MD also stated he was called to the Memory Care Unit on [DATE], and was at Resident #1's bedside while the staff attempted to suction the food particles from the resident's mouth. The MD stated Resident #1 became unresponsive and stopped breathing. He revealed that he pronounced the resident at 7:28 AM. The MD said the cause of death was [MEDICAL CONDITION] due to choking and aspirating his breakfast. The MD also stated he was involved in the Quality Assurance (QA) meetings after the incident, in which everything was discussed, and he approved the facility's plan of action. A review of Resident #'s1 Death Certificate, dated [DATE], revealed, the cause of death was [MEDICAL CONDITION] due to airway obstruction and aspiration of food. During an interview, on [DATE] at 9:15 AM, with the Administrator, she confirmed the facility had communication problems between Therapy and Nursing. The Administrator stated she was aware of Resident #1's death. The Administrator stated she did not report the incident to the State Agency because the facility knew what happened to the resident. She stated Resident #1 aspirated and died . The Administrator stated that she did not feel the resident was neglected. The Administrator said she did not know Resident #1 had a choking history and was not aware of the Speech Therapist recommendation. The Administrator stated the facility did everything to care for Resident #1.

Based on record review, facility policy review, and interviews, the facility failed to comply with Resident #74's right to refuse or accept treatment regarding her wishes for no Cardiopulmonary Resuscitation (CPR) in the event if her heart stops beating or she stops breathing, no other medical treatment would be started or continued. Resident #74 had an elective Advanced Directive for a Do Not Resuscitate (DNR) code status and a Physician's Order for a DNR, dated [DATE]. On [DATE], the facility staff did not verify Resident #74's code status, before initiating Cardiopulmonary Resuscitation (CPR) when staff discovered the resident unresponsive with no evidence of a pulse or respirations. An Immediate Jeopardy (IJ) was determined to exist, on [DATE] at 7:28 PM, when facility staff found Resident #74 unresponsive, without a pulse or respirations. The facility's staff initiated Cardio-Pulmonary Resuscitation (CPR) on Resident #74 and continued to provide CPR for five (5) minutes until the Emergency Medical Services (EMS) was notified and the local Fire Department arrived and reviewed Resident #74's medical record and found Resident #74 was a Do Not Resuscitate (DNR) resident. The CPR was stopped, and Resident #74 was pronounced deceased at 7:42 PM. Resident #74 was never revived during the CPR. The facility's failure to identify Resident #74 as a DNR resident prior to initiating CPR resulted in the resident's decision for a DNR status not being honored or followed by the facility. The facility's failure to identify Resident #74's rights and Advance Directive for a DNR, placed Resident #74 and other DNR residents in a situation that was likely to cause serious injury, harm, impairment, or death. On [DATE] at 12:05 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an Acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed on [DATE]. The SA validated the facility's Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit. Findings include: Review of the facility's policy titled, Advance Directives Policy, dated ,d+[DATE], revealed the Advance Directive definition was a written instruction, such as a living will or durable power of attorney for health care, recognized by State law, relating to the provisions of health care when the individual was incapacitated. The Do Not Resuscitate (DNR) definition indicated that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Further review of the policy revealed information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. Review of the facility's policy titled, Resident Rights, dated ,d+[DATE], revealed: The facility will protect and promote the rights of the resident. A resident has the right to exercise his or her rights as a resident of the facility. Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR) Policy, dated ,d+[DATE], revealed, it is the policy of this facility to adhere to resident's rights to formulate advance directives, and the facility will implement guidelines regarding cardiopulmonary Resuscitation (CPR). If a resident experiences a cardiac arrest, the facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in accordance with the resident's advance directive. Review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The Fire Department arrived at 7:35 PM and the resident's chart was reviewed to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival. An interview, on [DATE] at 3:24 PM, with Registered Nurse (RN) #1/Supervisor, revealed she confirmed she did not ask anybody to get the chart until the Fire Department personnel asked for it. RN #1 said they received a call from the lab reporting a critically high Potassium level. RN #1 stated the Medical Doctor (MD) instructed them to send Resident #74 to the emergency room (ER) for evaluation and treatment. Resident #74 was left alone in the room with the Certified Nursing Assistant (CNA). RN #1 could not remember who the CNA was. RN #1 stated the CNA came to the door saying, I don't think she's breathing. RN #1 stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR. RN #1 said she entered the room and instructed another CNA to call 911. RN #1 said the next thing she knew was when she looked up and the Fire Department was at the facility, and that was when Resident #74's DNR status was identified. RN #1 said she did not know what happened, it happened so quick. RN #1 did say she had been in-serviced several times on where to look for a resident's code status to ensure it was identified and provided per the resident's request. Review of the Progress Notes-Nurses Notes, dated [DATE] at 7:17 PM, revealed a call was received from (Name of Hospital) lab reporting a critically high Potassium level of 8.7. Relayed to (Name of MD) who instructed to send resident to (Name of Hospital) to be evaluated and treated. (Names of Contact Persons) were notified and verbalized understanding. An interview, on [DATE] at 3:30 PM, revealed RN #5/Charge Nurse confirmed she did not ask anybody to get the chart to review Resident #74's code status. RN #5 said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. RN #5 said she provided chest compressions and LPN #2 provided mouth to mouth breathing. During an interview, on [DATE] at 3:59 PM, LPN #2 revealed she assisted RN #5 with resuscitating Resident #74. LPN #2 confirmed she did not ask anybody to get the chart. LPN #2 stated she has been trained where the code status was located in the chart. LPN #2 also stated she thought the supervisor had checked the chart for Resident #74's code status. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's Admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. During an interview, on [DATE] at 4:44 PM, Firefighter #1, revealed on [DATE], upon responding to the 911 call, the Chief obtained Resident #74's chart and discovered that Resident #74 was a DNR code status. Firefighter #1 stated that CPR was ceased at that time. An interview, on [DATE] at 12:22 PM, an interview with the Assistant Director of Nurses (ADON) revealed she was responsible for checking the residents code status and making sure there's a written order that is in the electronic record and on the Medication Administration Record (MAR). The ADON stated Resident #74's DNR order was in the chart Physician's Orders, and on the MAR. Resident #74's DNR code status was not honored due to the nurse's failure to check the Physician's Orders and MAR. During an interview, on [DATE] at 5:52 PM, the Director of Nursing (DON) confirmed Resident #74's code status was a Do Not Resuscitate (DNR), and when the resident was found unresponsive, on [DATE], the Charge Nurse initiated CPR. The DON stated after they found out the resident was a DNR, CPR was stopped. As a result, Resident #74's DNR code status choice was not honored. During an interview, on [DATE] at 4:46 PM, the Deputy Coroner stated the fire department had already pronounced the resident by the time he arrived. The Deputy Coroner said he was told the staff had performed CPR and the resident was never revived. An interview with the Medical Director, on [DATE] at 11:53 AM, revealed he was made aware of the staff initiating CPR after the EMS staff left the building. The Medical Director stated he was told the staff found the resident unresponsive and initiated CPR until the Fire Chief pulled the resident's chart and noted she was a DNR, and the Fire Chief stopped the CPR at that moment. The Medical Director stated the resident could have had a negative outcome of surviving with broken ribs or being placed on a ventilator. Review of the Admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Based on staff interview, record review and facility policy review, the facility failed to ensure Resident #74's Care Plan was implemented for a Do Not Resuscitate (DNR) code status, and to develop/implement Resident #22's Care Plan for pain medication administration as needed during wound care. These concerns were identified for two (2) of 30 care plans reviewed. Resident #74 had a Care Plan initiated and revised, on [DATE], for a DNR code status. The SA identified an Immediate Jeopardy (IJ) on [DATE] at 7:28 PM, when Resident #74 was found unresponsive and without a pulse or respirations by the facility staff. The facility staff failed to verify Resident #74's code status. Cardiopulmonary Resuscitation (CPR) was initiated by the facility staff until the local Fire Department arrived at 7:35 PM, and reviewed Resident #74's chart where the DNR code status was documented. The CPR was stopped after five (5) minutes, and Resident #74 was pronounced deceased at 7:42 PM. The facility staff did not follow Resident #74's Care Plan regarding her DNR code status. The facility's failure to follow Resident #74's Comprehensive Care Plan regarding her DNR code status placed Resident #74 and other residents with a DNR code status in situations that was likely to cause serious harm, injury, impairment or death. On, [DATE] at 12:05 PM, the State Agency (SA) notified the facility's Administrator of the Immediate Jeopardy (IJ). The facility submitted an Acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged all corrective actions were completed on [DATE], and the IJ was removed on [DATE]. The SA validated the facility's Immediate Jeopardy Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit. Findings Include: Record Review of the facility's policy titled, Comprehensive Care Plans, dated ,d+[DATE], revealed it is the policy of this facility to develop and implement a comprehensive person centered Care Plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #74 Review of Resident #74's Care Plan revealed the facility failed to follow the care plan regarding the resident's Do Not Resuscitate (DNR) code status. The Care Plan was initiated, on [DATE], for Resident #74's DNR code status. The goal was to honor the resident and family wishes. The interventions included: Ensure comfort measures are achieved without heroics. Ensure resident/family understands meaning of code status. Label the chart, Medication Administration Record (MAR) and Treatment Administration Record (TAR) to inform staff of DNR code status, obtain signed consent and Medical Doctors orders for DNR. Review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and reviewed Resident #22's chart to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival. During an interview, on [DATE] at 5:25 PM, RN #4/Care Plan Nurse revealed he looks at the residents advance directives to determine whether the resident is a full code or a DNR. LPN #4 said he normally does a care plan for the resident with a DNR code status and he expected the staff to follow the care plan. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's Admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. Review of the Admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #22 Review of Resident #22's Care Plan revealed the Care Plan did not address pain assessment/management for wound care. Further review of the Care Plan revealed the Focus for risk for skin breakdown secondary to decreased mobility and history (hx) of occasional urinary incontinence was initiated, on [DATE]. The Goal stated the resident would be free of skin breakdown with a Target Date of [DATE]. Further review of the care plan revealed an Intervention, dated [DATE], to cleanse the unstageable wound to the left heel with Normal Saline (NS), pat dry, apply Santyl to wound bed, apply sureprep to wound edges, apply adhesive dressing (dsy), wrap with kerlix, daily (dly) and as needed (PRN) until healed. The Interventions also included: Administer Ultram 50 milligrams (mg) by mouth (po) every (q) six (6) hours as needed (prn) for pain. Monitor effectiveness of prn medication and document. Notify Medical Doctor (MD) if medication not effective in helping relieve and/or control pain. An observation, on [DATE] at 9:00 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse, did not follow Resident #22's Care Plan due to she did not assess the residents gestures and verbalization of pain/discomfort during the wound care observation, or administer pain medication. Registered Nurse (RN) #3/Wound Care Nurse, was assisted by Certified Nursing Assistant (CNA) #1. Resident #22 was observed lying comfortably in bed on her right side. When RN #3 began to clean the wound with NS, Resident #22 cried out OWWW and drew her left leg upward toward her chest, during the wound care. RN #3 confirmed Resident #22 did not receive pain medication prior to wound care. RN #3 continued to clean Resident #22's wound with NS. RN #3 measured the wound, washed her hands, applied gloves and cleaned the wound again. Resident #22 cried out OWWW a second time. RN #3 continued to preform the wound care until complete without assessing Resident #22's pain or providing pain medication. Resident #22's left heel wound measured 1.4 centimeter (cm) by 1.2 cm, with 50% slough, mild clear drainage, and no odor. An interview, on [DATE] at 11:00 AM, with RN #3/Wound Care Nurse, revealed Resident #22 did not receive pain medication prior to the wound care to the left heel. RN #3/Wound Care Nurse stated Resident #22 usually does not complain of pain. RN #3/Wound Care Nurse stated she should have stopped the treatment when the resident complained of pain. Review of Resident #22's Order Review Report revealed an order, dated [DATE], to cleanse the unstageable left heel wound with NS, pat dry, apply santyl to wound bed. Apply sureprep to wound edges. Apply adhesive foam dressing. Wrap with kerlix daily and PRN until healed, every day shift and as needed. Further review of the report revealed an order, dated [DATE], for Ultram Tablet 50 milligrams (mg), give one (1) tablet by mouth every six (6) hours as needed for pain. There also was an order, dated [DATE], to administer Tylenol tablet, give 1000 mg by mouth daily for pain. During an interview, on [DATE] at 5:33 PM, RN #4/Care Plan Nurse confirmed the facility failed to develop a care plan related to pain regarding Resident #22's left heel wound care. RN #4/Care Plan Nurse said he developed a care plan today, and he notified the doctor of Resident #22's wound care pain and received an order for pain medication routinely and as needed. An interview, on [DATE] at 5:58 PM, revealed the Director of Nurses (DON) stated, I would have stopped as soon as the resident cried out in pain during the wound care treatment and got her some pain medication. Review of the Face Sheet revealed Resident #22 was admitted by the facility, on [DATE], with the included diagnoses of Chronic Kidney Disease, Urinary Retention and Vascular Dementia with behavioral Disturbance. A review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the presence of an unstageable pressure ulcer suspected of deep tissue injury evolution. Review of the resident's pain assessment revealed she received routine pain medication, but no as needed pain medication. The pain interview was not done. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy be removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ was removed on [DATE], prior to exit.

Based on interviews, record review and facility policy review, the facility failed to honor Resident #74's Do Not Resuscitate (DNR) code status by initiating Cardio-Pulmonary Resuscitation (CPR) when the resident was found by the facility staff unresponsive and with no pulse or respirations, for one (1) of four (4) residents reviewed who had expired in the facility within the past six (6) months. The State Agency identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Resident #74 had a Physician's Order and Advance Directive for a Do Not Resuscitate (DNR) code status dated [DATE] and was found by staff, on [DATE] at 7:28 PM, without a pulse or respirations. CPR was initiated by the facility's staff for five (5) minutes until the local Fire Department arrived. CPR was stopped due to the Fire Department staff reviewed the resident's chart and discovered the DNR code status. Resident #74 was never revived and was pronounced deceased at the facility. The facility's failure to honor Resident #74's DNR code status, placed this resident and other residents with a DNR code status, in a situation that was likely to cause serious harm, injury, impairment or death. The facility Administrator was notified of the IJ and SQC on [DATE]. The State Agency (SA) received an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA determined the IJ was removed on [DATE] prior to the SA's exit on [DATE]. Findings Include: Review of the facility's policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed it is the policy of the facility to adhere to resident's rights to formulate the advance directives. In accordance to these rights, the facility will implement guidelines regarding Cardio-pulmonary Resuscitation (CPR). The facility will follow current American Heart Association (AHA) guidelines regarding CPR. If a resident experience a cardiac arrest, facility staff will provide basic life support, including CPR, prior to the arrival of emergency medical services, and in accordance with the resident's advance directives, or in the absence of advance directives, or Do Not Resuscitate order and/ or if the resident does not show obvious signs of clinical death (e.g. rigor mortis, decapitation, transection, or decomposition). Review of the facility's policy titled, Advance Directives dated [DATE], revealed the Advance Directives will be respected in accordance with state law and facility policy. The policy guidelines stated that upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an Advance Directive if he or she chooses to do so. Information about whether the resident has executed an Advance Directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established Advance Directives, the facility staff should offer assistance in establishing advance directives. The resident has the right to refuse treatment, whether he or she has an Advance Directive. A resident will not be treated against his or her own wishes. The facility states the Advance Directive policy is a written instruction such as a living will or durable power of attorney for health care, recognized by state law, relating to the provisions of health care when the individual is incapacitated. The facility's Do Not Resuscitate (DNR) definition indicated, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used. Review of the facility's Resident Rights policy, dated [DATE], revealed the facility will inform the residents both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Prior to or upon admission the social service designee, or another designated staff member, will inform the resident and or the resident's representative of the resident's rights and responsibilities. The facility will protect and promote the rights of the resident. Review of the Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM stated the Charge Nurse, Medication (Med) cart nurse, Registered Nurse (RN) and three (3) Certified Nursing Assistants (CNAs) entered the room and Resident #74 was found unresponsive and no pulse. The resident was assisted to the floor via a sheet and Cardiopulmonary Resuscitation (CPR) was initiated per the American Heart Association protocol and 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and the resident's chart was reviewed to discover the resident was a DNR. CPR was ceased at that time. Resident was pronounced deceased at 7:42 PM. The Coroner arrived at 8:11 PM, and the resident's body was released to the funeral home at 8:32 PM. The Nurses Notes revealed CPR was performed for five (5) minutes, prior to the fire department's arrival. Registered Nurse (RN) #1/Supervisor was interviewed on [DATE] at 3:24 PM. RN #1/Supervisor confirmed she did not ask anybody to get Resident #74's chart until the Fire Department personnel asked for it. RN #1/Supervisor said she did not know what happened, it happened so quick. RN #1/Supervisor stated RN #1 and LPN #5 initiated the CPR, and when she looked up the Fire Department was already there, and that's when they checked the chart for the code status. RN #1/Supervisor said they had received a call from the lab reporting a critically high Potassium level, and the Medical Doctor (MD) instructed them to send Resident #74 to the emergency room (ER) for evaluation and treatment. Resident #74 was left alone in the room with the Certified Nursing Assistant (CNA). RN #1/Supervisor said she could not remember who the CNA was. RN #1/Supervisor reported the CNA came to the door saying, I don't think she's breathing. RN #1/Supervisor stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR, and when she entered the room she instructed another CNA to call 911. RN #1/Supervisor said when she looked up the Fire Department was at the facility, and that was when Resident #74's DNR status was identified. RN #1 did say she had been in-serviced several times on where to look for a resident's code status. Review of the Progress Notes-Nurses Notes, dated [DATE] at 7:17 PM, confirmed a call was received from (Name of Hospital) lab reporting a critically high Potassium level of 8.7, which was reported to (Name of MD) who instructed to send resident to (Name of Hospital) to be evaluated and treated. (Names of Contact Persons) were notified and verbalized understanding. RN #5/Charge Nurse was interviewed, on [DATE] at 3:30 PM. RN #5/Charge Nurse said she did not ask anybody to get the chart to identify Resident #74's code status. RN #5/Charge Nurse said she provided chest compressions and LPN #2 provided mouth to mouth breathing. RN #5/Charge Nurse said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. An interview, on [DATE] at 3:59 PM, with LPN #2 revealed she had been trained where the code status was located in the resident's chart. LPN #2 confirmed she did not ask anybody to get the chart because she thought RN #5/Charge Nurse checked Resident #74's chart for the code status. LPN #2 said she did assist RN #5/Charge Nurse with resuscitating Resident #74. The Medical Director was interviewed, on [DATE] at 11:53 AM. The Medical Director stated Resident #74 could have had a negative outcome if she had survived with broken ribs or being placed on a ventilator. The Medical Director stated he was told the staff found Resident #74 unresponsive and initiated CPR. The Medical Director said CPR was performed until the Fire Chief pulled the resident's chart and noted she was a DNR, and the Fire Chief stopped the CPR at that moment. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's Admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. An interview, on [DATE] at 4:44 PM, revealed Firefighter #1 stated he responded to the call on [DATE] when Resident #74 was found pulseless. Fire Fighter #1 stated the Chief reviewed Resident #74's medical records and found Resident #74 was a DNR. CPR was stopped at that time once they identified Resident #74 as a DNR. Fire Fighter #1 also stated that the Resident #74 was pronounced by the Fire Department and the coroner was notified. An interview, on [DATE] at 12:22 PM, with the Assistant Director of Nurses (ADON) revealed Resident #74's DNR order was in the chart's Physician's Orders, and on the Medication Administration Record (MAR). The ADON stated she was responsible for checking the residents code status and making sure there's a written order that is in the electronic record and on the Medication Administration Record (MAR). The ADON revealed the orders for a DNR code status, and the resident's choice for a DNR code status was not followed by the nurses. An interview, on [DATE] at 5:52 PM, revealed the Director of Nursing (DON) confirmed Resident #74 was found unresponsive on [DATE], and Registered Nurse #5/Charge Nurse and Licensed Practical Nurse (LPN) #2 initiated CPR. The DON stated CPR ceased after Resident #74 was identified as a DNR by the local Fire Department when the chart was reviewed by them. The DON reported the nurses did not check the resident's code status, and as a result, Resident #74's DNR code status was not honored by the nurses who initiated the CPR. An interview, on [DATE] at 4:46 PM, with the Deputy Coroner revealed he was informed by the facility staff Resident #74 was never revived, and the fire department had already pronounced the resident by the time he arrived. Review of the Admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. Review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Based on interviews, record review and facility policy review, the facility failed to ensure Resident #74's choice for a Do Not Resuscitate (DNR) code status was honored. This was identified for one of four (1 of 4) residents reviewed who expired in the facility over the past six (6) months. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE]. Resident #74 had a Physician's Order and an Advanced Directive, dated [DATE], for a DNR code status. On [DATE] at 7:38 PM, Resident #74 was found unresponsive, and without a pulse or respirations by the facility's staff. Cardiopulmonary Resuscitation (CPR) was initiated by the facility's staff and the Emergency Medical System (EMS) was notified. The local Fire Department was dispatched to the facility. Resident #74's chart was checked by the Fire Chief on arrival to the facility and it was discovered at that time Resident #74 was a DNR. CPR had been in progress five (5) minutes and was stopped by the Fire Chief at that time. Resident #74 was not revived during the CPR and was pronounced deceased at the facility. The facility's staff did not check Resident #74's chart to verify her choice of code status was a DNR, and CPR should not have been initiated. The facility's failure to honor Resident #74's choice for a DNR code status, placed Resident #74 and other residents with a DNR code status, in a situation that was likely to cause serious harm, injury, impairment or death. The SA notified the facility's Administrator of the IJ and SQC on [DATE]. Findings Include: Review of the facility's, Advance Directives Policy, dated ,d+[DATE], revealed the Advance Directives will be respected in accordance with state law and facility policy. Information about whether the resident has executed an Advance Directive shall be displayed prominently in the medical record. A resident will not be treated against his or her own wishes. The facility's Do Not Resuscitate (DNR) definition indicated that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life sustaining treatments or methods are to be used. Review of the Progress Notes - Nurses Notes, revealed, on [DATE] at 7:28 PM, Resident #74 was found unresponsive and without a pulse. Resident #74 was assisted to the floor, and CPR was initiated by LPN #2 and RN #5. The Nurse's Notes stated 911 was called at 7:30 PM. The local Fire Department arrived at 7:35 PM and CPR was stopped at that time when the Fire Department staff checked Resident #74's code status on the medical record. Resident #74 was pronounced dead at 7:42 PM. The Nurse's Notes revealed Resident #74 was resuscitated for five (5) minutes, prior to the Fire Department's arrival. An interview with RN #1/Supervisor, on [DATE] at 3:24 PM, revealed she failed to follow the facility's policy for Resident #74's DNR code status. RN #1 confirmed she did not ask anybody to get the chart until the Fire Department requested it, which resulted in Resident #74's DNR code status not being recognized. RN #1 stated she didn't know what happened, everything happened so quick. During an interview on [DATE] at 3:30 PM, Registered Nurse (RN) #5 revealed she provided chest compressions and Licensed Practical Nurse (LPN) #2 provided the mouth to mouth breathing on [DATE] when Resident #74 was found unresponsive and with no pulse or respirations. RN #5 stated she did not ask anybody to get the resident's chart to verify the code status because she thought RN #1/Supervisor had done that. RN #5 revealed she was called into Resident #74's room by a Certified Nursing Assistant (CNA). RN #1/Supervisor was present at this time of the interview and stated she was in the room and they relieved each other until the Fire Department got there. Failure of the facility's staff to verify Resident #74's code status prior to initiating CPR resulted in the resident's Advance Directive choice for a DNR code status not being honored. Review of the facility's Advanced Care Planning form revealed Resident #74's printed name and her daughter's printed and signed name, dated [DATE], for an elected DNR code status. Resident #74's Admission Record revealed the resident's daughters were the first and second contact persons. The resident's Advanced Directive was a Do Not Resuscitate. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. During an interview, on [DATE] at 3:59 PM, LPN #2, stated she did assist RN #5 with resuscitating Resident #74 on [DATE]. LPN #2 also confirmed she did not ask anybody to get the chart to review Resident #74's code status. LPN #2 also stated she thought the supervisor had checked the chart for Resident #74's code status. LPN #2 stated she has been trained several times on where the code status was located. Review of Resident #74's Care Plan, dated [DATE], revealed Resident #74's code status was Do Not Resuscitate (DNR). The goal is to honor the resident and family wishes. The interventions are to ensure comfort measures are achieved without heroics, ensure resident/family understands meaning of code status, label the chart, Medication Administration Record (MAR) and Treatment Administration Record (TAR) to inform staff of DNR code status, obtain signed consent and Medical Doctors order's for DNR. Fire Fighter #1's interview, on [DATE] at 4:44 PM, revealed he responded to the call the night Resident #74 died . Firefighter #1 revealed CPR was in process by the facility staff on arrival, and the Fire Chief reviewed the medical records and confirmed Resident #74 was a DNR code status and CPR was discontinued. The Director of Nurse's (DONs) interview, on [DATE] at 5:52 PM, confirmed RN #5/Charge Nurse found Resident #74 unresponsive, without a pulse and initiated CPR. The DON stated that CPR was stopped after the Fire Department found Resident #74 was a DNR code status on review of the resident's medical records. The DON confirmed Resident #74 was a DNR code status, and the CPR should not have been initiated. The DNR code status was located on the resident's medical record. The Medical Director's interview, on [DATE] at 11:53 AM, revealed he was informed staff found Resident #74 unresponsive and CPR was initiated. The Medical Director stated Resident #74 could have had a negative outcome of surviving with broken ribs or being placed on a ventilator. Review of the Admissions Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses of Cardiomyopathy, Heart Failure, Cardiomegaly, Tachycardia, Pulmonary Disease and Chronic Atrial Fibrillation. A review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE] revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy be removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit.

Based on interviews, record review, and facility policy review, the facility failed to monitor, review, and evaluate their Quality Assessment and Assurance (QAA) plan to identify and document the resident's Advance Directive choice for code status. During the initial recertification survey on [DATE] to [DATE], the State Agency (SA) identified the facility's failure to honor Resident #74's Do No Resuscitate (DNR) code status, on [DATE], when the resident was found unresponsive, and without a pulse and respirations. The facility staff initiated Cardiopulmonary Resuscitation (CPR), which continued for five (5) minutes until the Fire Department arrived and reviewed the resident's medical record which revealed the DNR code status. Resident #74 was never revived and announced deceased at the facility. The SA also identified inaccurate code status documented for Resident #31 and #64 on re-entrance on [DATE] to extend the survey to [DATE]. This concern was identified for three (3) of 78 (facility's census at time the SA re-entrance) resident code statuses reviewed. The SA identified an Immediate Jeopardy (IJ) on [DATE], due to the facility's failure to ensure accurate and consistent information regarding resident code status to use in emergency situations. The QAA review showed the QAA committee was not aware of this systemic issue, and the QAA committee was not monitoring facility practices related to accurate and consistent communication of resident's Advance Directives regarding code statuses. The facility's QAA met on [DATE] to discuss the facility's policy and procedure related to the code status for each resident. A plan of action was implemented to ensure all licensed nurses were in-serviced on honoring Resident's Rights and the right to choose a code status. The Director of Nurses (DON) provided an in-service, on [DATE], to all licensed nurses on honoring resident's rights, the right to choose a code status, and CPR policies. On, [DATE], the Assistant Director of Nurses (ADON) reviewed all resident code status records in each resident's paper chart and compared that review to all of the resident's electronic health records, for a total of 77 records. The result was 55 residents were DNRs, and 22 were full code status. On [DATE], the SA identified inaccurate code statuses for Resident's #31 and #64. The facility's failure to monitor the QAA's corrective plan to ensure the residents' Advance Directive regarding code status was accurate, placed Resident #74, #31, #64 and other residents with a DNR code status at risk for serious injury, harm, impairment or death. The facility Administrator was notified of the IJ on [DATE] at 12:05 PM. The State Agency (SA) received an acceptable Immediate Jeopardy Removal Plan on [DATE], in which the facility alleged that all corrective actions were completed as of [DATE], and the Immediate Jeopardy was removed on [DATE]. The SA determined the IJ was removed on [DATE], prior to the SA's exit on [DATE]. Findings include: Review of the facility's Quality Assessment & Assurance (QAA) policy, dated ,d+[DATE], revealed it is this facility's policy to develop, implement, and maintain an effective, comprehensive, data-driven QAA program that focuses on outcomes of care, promotes individual choice and the improvement in quality of life. The QAA Committee shall be interdisciplinary and shall consist at a minimum of: The Administrator, The Medical Director, The Director of Nursing, Infection Control Prevention Officer, two facility staff. The QAA Committee will: Conduct scheduled monthly meeting. Develop and implement appropriate plans of action to correct identified quality concerns and deficiencies. Participate in development, implementation and monitoring of the facilities written QAPI Plan. Regularly review and analyze performance data, including data collected under the QAPI (Quality Assurance and Performance Improvement) program, Infection Reports, Pharmacy, Psychological Reports, and recommendations. Identify issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program are necessary. Act on available data to make corrections or improvements. Review and evaluate all filed and completed grievances. Adverse events will be monitored in accordance with established procedures based on the type of adverse event. The data related to adverse events will be used to develop activities to prevent them. On [DATE] at 2:39 PM, an interview with the Administrator revealed the facility held monthly QAA meetings. The Administrator stated new areas of concern are identified and a plan of correction is established. The Administrator stated the plan of correction included goals for resolutions. The Administrator stated old concerns are discussed for current status and if changes are needed. The Administrator revealed the concerns are identified from complaints/grievances, nursing reports, and general reporting by families, staff, and/or residents. Resident #74 The facility failed to monitor a plan of correction established by the facility's QAA regarding the resident's Advanced Directives regarding their code status was honored and documented correctly in the medical record. As a result per review of Resident #74's Progress Notes-Nursing Notes, dated [DATE] at 9:18 PM, revealed a note at 7:28 PM documented Resident #74 was found by staff unresponsive and without a pulse or respirations. The staff initiated CPR. (Resident #74 was a Do Not Resuscitate (DNR) code status). The Emergency Medical System (EMS) was notified at 7:30 PM. The Fire Department arrived at 7:35 PM and checked the resident's chart and it was discovered at that time the resident was a DNR. The CPR was performed for five (5) minutes, until the Fire Department instructed the CPR to be stopped. Resident #74 was not revived and was pronounced deceased at 7:42 PM. The facility staff failed to check Resident #74's code status prior to initiating CPR. Review of Resident #74's Care Plan, dated [DATE], revealed the resident was a DNR code status. Review of Resident #74's Physician's Orders revealed an order, dated [DATE], for a DNR code status. Review of Resident #74's Advance Directive, dated [DATE], revealed the resident and her daughter had elected a DNR code status. An interview with Registered Nurse (RN) #1/Supervisor, on [DATE] at 3:24 PM, revealed she did not ask anyone to get Resident #74's chart to check the code status. RN #1/Supervisor confirmed the code status was not identified until the Fire Department personnel asked for the chart. RN #1 said she had been in-serviced regarding the location of the residents' code status, but everything happened so fast, and before she knew it the Fire Department was there. RN #1/Supervisor stated RN #5 and Licensed Practical Nurse (LPN) #2 initiated CPR, and when she entered the room, she instructed another Certified Nursing Assistant (CNA) to call 911. An interview with RN #5/Charge Nurse, on [DATE] at 3:30 PM, revealed she did not ask anybody to get the chart to identify Resident #74's code status. RN #5/Charge Nurse said she did not ask anybody to get the chart because she thought RN #1/Supervisor had checked the chart for the code status. RN #5 said she was called into the room by a CNA. RN #5/Charge Nurse said she provided chest compressions and LPN #2 provided mouth to mouth breathing. Licensed Practical Nurse (LPN) #2 was interviewed on [DATE] at 3:59 PM. LPN #2 revealed she did not ask anybody to get the chart because she thought RN #5/Charge Nurse checked Resident #74's chart for the code status. LPN #2 confirmed she did assist RN #5/Charge Nurse with resuscitating Resident #74. LPN #2 revealed she had been trained where the code status was located in the resident's chart. On [DATE] at 5:52 PM, an interview with the Director of Nursing (DON), confirmed, on [DATE], Resident #74 was found unresponsive and with no pulse or respirations. The DON confirmed Resident #74 was a DNR, and CPR was initiated by the facility staff until the Fire Department arrived and discovered the resident was a DNR. The DON revealed CPR was performed for five (5) minutes until the Fire Department's discovery of the DNR code status. The facility staff did not check the resident's chart to ensure the code status was identified and honored. Review of the facility's Quality Assessment and Assurance (QAA) sign in sheets dated [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] revealed the Medical Director, Administrator, Director of Nurses, Quality Assurance Nurse, Activity Director, Dietary Manager, Infection Preventionist, Social Worker, Minimum Data Set and Assistant Director of Nursing attended the QA meetings. The meeting on [DATE] had a typed note attached stating, Discussed policy and procedure related to code status. Discussed implementation and in-serving staff on policy and procedure related to code status. The [DATE] notes addressed the discussion of (citation tag number), in-services conducted on resident code status, mock code drill with no issues identified. Discussed policy and procedure related to communication of code status, with no changes made. Discussed the facility's action plan to include audits of residents' code status, and all findings will be reported to QAPI. Review of the facility's In-Service Attendance Record, dated [DATE], revealed the staff was trained on honoring Resident/family right to choose CPR and code status. Further review of the facility's In-Service Attendance Records revealed the facility provided a training titled, Initiating CPR/Code Status to the licensed nurses, on [DATE]. An interview, on [DATE] at 11:53 AM, revealed the Administrator confirmed the QAA committee failed to monitor their corrective actions to make sure all the resident's code status was correct. The Administrator also stated the system failed because their checks and balances did not work. The Administrator confirmed the system the QAA interdisciplinary team put in place was not successful. The Administrator stated the facility had a QAA meeting, on [DATE], and discussed Resident #74's DNR code status. The Administrator stated the QAA committee considered this as a high risk situation and should be taken care of immediately. The Administrator stated the only thing the disciplinary team implemented during the meeting was to in-service the supervisors on where to locate the resident's code status and to perform a mock code. The Administrator stated the Quality Assurance (QA)/Infection Nurse schedules the QAA meetings monthly and as needed. The Administrator also stated the RN supervisors were in-serviced immediately on all shifts on how to locate the resident's code status in the chart, computer and Kiosk. The Administrator reported the RNs involved in the incident with Resident #74 did not receive any disciplinary actions from the facility. The Administrator stated the Assistant Director of Nursing (ADON) was responsible for checking the Physician's Orders, Quick Reference Sheet and the Medication Administration Records (MARS) to make sure the code statuses matched. The ADON was also responsible for monitoring all resident's code status. The Administrator said LPN #5 was the acting QA/Infection Control Nurse, and was responsible for checking behind the ADON to make sure the resident's code status was updated. Review of the facility's In-Service Attendance Record, dated [DATE], revealed the signatures of RN #1 and #5, regarding Code Status Simulation. On [DATE] at 12:22 PM, an interview with the ADON revealed Resident #74's DNR status was not honored due to the nurses did not check her code status which was on the chart, the physician's orders, and the Medication Administration Record (MAR). Review of the Admission Record revealed Resident #74 was admitted by the facility, on [DATE], with the included diagnoses of Cardiomyopathy, Cardiomegaly, Tachycardia, Pulmonary Disease, Heart Failure, and Chronic Atrial Fibrillation. A review of Resident #74's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Resident #31 Review of Resident #31 Quick Reference Sheet revealed Resident #31 was a Full Code. Review of the chart and current Electronic Physician's Orders revealed Resident #31 had elected to have a DNR code status. On [DATE] at 12:16 PM, an interview with LPN #5/Interim QA Nurse, revealed she did not know what happened with Resident #31's DNR code status not being on the Quick Reference Sheet. LPN #5 confirmed Resident #31 was a DNR, and should have been identified as such. LPN #5 stated she had only checked the new admissions since the last survey because all of the other charts had been checked. Resident #64 Review of Resident #64's Quick Reference Guide report sheet, revealed Resident #64 was listed as a DNR code status. Review of the current Physician's Orders revealed there was no code status order for a DNR. Further review revealed there was no code status on the Medication Administration Record (MAR). This is an additional check for code status for the facility. The MAR did not indicate a DNR because the nurse deleted it on the Physician's Orders which could have resulted in CPR being initiated instead of a DNR. An interview, on [DATE] at 11:53 AM, revealed the Administrator confirmed Resident #64's DNR code status was deleted from the electronic record by mistake. The Administrator stated LPN #1 deleted the DNR order instead of a medication. The Administrator confirmed this was not found until the SA discovered it and reported the finding to them on [DATE]. The Administrator reported the facility ran a report of discontinued orders and found that LPN #1 discontinued the DNR order for Resident #64 on [DATE]. A medication order should have been discontinued instead of Resident #64's code status. An interview, on [DATE] at 11:45 AM, with LPN #1, revealed she clicked on the wrong thing in the computer. LPN #1 confirmed she clicked on DNR instead of a medication she was trying to delete. LPN #1 did not realize the mistake until LPN #4 revealed it to her. On [DATE] at 12:16 PM, an interview with Licensed Practical Nurse (LPN) #5 revealed she didn't know what happened with Resident #64's code status being incorrect. LPN #5 stated she missed it. Resident #64's DNR code status was deleted on the Electronic Record. During an interview, on [DATE] at 4:20 PM, LPN #6 revealed the nurses were trained to find the resident's code status on their Quick Reference Sheet, on the MARs, the bright red sheet at the nurse's station and crash cart. LPN #6 also said the ADON updates them monthly and with new admits or changes in the resident's code status. During an interview with LPN #7, on [DATE] at 4:45 PM, she revealed the nurses are trained to find the resident's code status on top of the MARs, Quick Reference Sheet, the red sheet at the nurses' station and crash cart. LPN #7 also said she thought the ADON updated them. LPN #7 stated the nurses write changes on their report sheet and turn it in at the end of the shift. An interview, on [DATE] at 12:22 PM, revealed the ADON said she was responsible for checking the resident's code status and making sure there's a written order in the Electronic Record and on the MAR. The ADON also confirmed the facility was not aware of the nurse deleting the resident's Code status until the SA discovered it. The ADON also stated if Resident #31 and Resident #64 conditions would have changed, both residents potentially could have had Cardiopulmonary Resuscitation (CPR) done, which could possibly cause pain from broken ribs and or resident being placed on a ventilator. This is the facility's accepted Immediate Jeopardy Removal Plan: Summary of events: The State Agency notified [NAME] Gardens Nursing Center on [DATE]th, 2020 at 12:05 P.M. of the immediate jeopardy and substandard quality of care for Residents #74, #31, and #64. The Facility failed to honor Resident #74's advance directive for a do not resuscitate (DNR) code status, failed to honor the Resident's Rights for Advance Directive, failed to follow the care plan for a DNR code status and failed to prevent a potential negative outcome by initiating Cardiopulmonary Resuscitation (CPR). Resident #74 was found pulseless on [DATE]th, 2019 at 7:28 PM by RN #1 who initiated Cardiopulmonary Resuscitation (CPR) for a total of five minutes. CPR was discontinued when emergency services arrived and notified RN #1 of Resident#74's DNR code status. RN #1 failed to follow the policy and procedures in place to identify Resident #74's code status. The State Agency notified the facility on [DATE]th, 2020 at 3:30 PM that Resident #31's code status was documented incorrectly on the Report Sheet and Resident #64's code status was not in the Electronic Health Record, according to their wishes which could have likely caused harm for Residents #31 and #64. The facility failed to follow policy and procedure to identify the correct code status for Residents #74, #31, and #64. Facility action plan: 1. The Director of Nursing (DON) conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with Registered Nurse (RN) #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. On [DATE]th, 2019 Care Plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. On [DATE]th, 2019 at 1:30 PM the Director of Nursing in serviced all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. On [DATE]th and 30th, 2020 the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. On [DATE] the Assistant Director of Nursing (ADON) reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. On [DATE]th, 2020 at 12:05PM, the State Agency identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. Care Plan Nurse found that Resident #64's order had been discontinued by Licensed Practical Nurse (LPN) #1 and the order was reentered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. No staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The facility alleges the immediate jeopardy was removed on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, review of in-service sign-in sheets, and review of documents across all disciplines. The SA verified the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review of the sign-in sheets and interview with the Director of Nursing (DON) that the facility conducted an in service on [DATE]th, 2019 at 2:30 PM to include return demonstration of a mock code drill, communication of code status policy and review of CPR policy with RN #1 and RN #2. No concerns were identified. No disciplinary action for RN #1 or RN #2 occurred. 2. The SA validated through record review of the in-service sign-in sheets and interview with the Care Plan Nurse that on [DATE]th, 2019 Care plan Nurse conducted in services from 7:30 AM to 5:30 PM on initiating CPR and how to identify resident code status. 3. The SA validated through record review of the sign-in sheets and interview with the DON that the facility conducted an in-service on [DATE]th, 2019 at 1:30 PM, by the Director of Nursing, to all licensed nurses on honoring residents' rights, the right to choose code status and CPR policies. 4. The SA validated through record review of the in-service sign-in sheets and interview with the facility owner that on [DATE]th and 30th, 2020, the owner of the facility conducted an in service starting at 1:30 PM on [DATE] and ending at 3 PM on [DATE]th, 2020 to discuss the advance directive protocol for determining code status, location of code status, policy and procedure related to communication of code status with all licensed nurses. 5. The SA validated by interview of the ADON that on [DATE] the ADON reviewed all code status records in each resident's paper chart and compared all resident's electronic health record to ensure all code status orders were being followed to prevent any adverse events. A total of 77 records were reviewed with no discrepancies. The findings were 55 DNR and 22 full code status. 6. The SA validated by record review and staff interviews, on [DATE]th, 2020 at 12:05 PM, the SA identified concerns for code status on Resident #64 which was not in the Electronic Health Record orders and Resident #31 which was incorrectly listed on the Report Sheet. The Care Plan Nurse found that Resident #64's order had been discontinued by LPN #1 and the order was re-entered into the Electronic Record. Resident #31's order was recorded incorrectly on the Report Sheet. The Report Sheets with code status were immediately removed from the nursing station. The audit completed on [DATE] by the Care Plan Nurse, ADON and Restorative Nurse found all paper charts and Electronic Health Records were 100% in compliance. to prevent any future adverse events or outcomes. 7. The SA validated by interviews the Quality Assurance team met on [DATE]th, 2019 at 8 A.M. to discuss the policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist (ICP), Quality Assurance (QA), Licensed Social Worker, Certified Recreational Therapist, Medical Records Nurse, Certified Dietary Manager, ADON, and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on honoring Residents' Rights and the right to choose a code status. 8. The SA validated through interviews with the Facility Administrator and the DON the Quality Assurance team met on [DATE]th, 2020 at 1:40 P.M. to discuss the negative outcome and failure to implement and follow policy and procedure related to the code status of each resident. The Quality Assurance team that met was the Director of Nursing, Medical Director, Administrator, Infection Control Preventionist, Quality Assurance, Owner of facility, Nurse Practitioner Clinician, Certified Recreational Therapist, Certified Dietary Manager, Dietitian, Assistant Director of Nursing, Licensed Social Worker, Restorative Nurse, Minimum Data Set Nurse, Clinical Liaison Nurse, Medical Records Nurse and Care Plan Nurse. A plan of action was implemented at this time to ensure that all licensed nurses were in serviced on the advance directive protocol for determining code status. All resident charts were audited to ensure no discrepancies between the electronic health record, orders, and the paper chart. The Quality Assurance team reviewed the audit and found the charts were 100% compliant. The Policies of Communication of Code Status and Cardiopulmonary Resuscitation Procedure policies was reviewed, and no revisions were required. A Quality Assurance Performance Improvement plan was discussed, developed and implemented. The Communication of Code Status Policy states that the nurse who notes the physician order is responsible for communicating the directions in all relevant sections of the medical record. The SA validated through interviews with the Administrator and the DON that no staff will be allowed to work at the facility prior to receiving in service training on facility policy and procedure on identifying code status with understanding expressed by staff member. The SA validated that all corrective actions to remove the IJ had been completed as of [DATE], and the IJ removed on [DATE], prior to exit. 37415

Based on observation, interviews, record review and facility policy review, the facility failed to assess or administer pain medication for Resident #22's gestures and verbalization of pain/comfort during wound care. Resident #22's wound care was observed, 11/26/2019 at 9:00 AM. Resident #22 exhibited gestures and verbalization of pain, such a pulling her left leg up and saying Owww twice during the treatment. The wound was located on the left heel. Resident #22 was not assessed by the Treatment Nurse neither time, and therefore no pain medication was offered or administered. Resident #22 had orders for a pain medication every (6) six hours as needed. As a result, the nurse's failure to assess and administer Resident #22's pain medication during the wound care observation, raised this concern to a harm level. This concern was identified for one of eight (1 of 8) residents reviewed for pain. Findings include: Review of the facility's policy titled, Pain Management, dated 11/2018, revealed the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. The facility utilizes a systematic approach for recognition, assessment, treatment and monitoring of pain. In order to help a resident, attain or maintain their highest practicable level of well-being and to prevent or manage pain, the facility should: a. Recognize when the resident's experiencing pain and identifies circumstances when the pain is anticipated; b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and with change in condition or status (e.g., after a fall with change in behavior or mental status). c. Manages or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. An observation, on 11/26/2019 at 9:00 AM, revealed Registered Nurse (RN) #3/Wound Care Nurse, failed to assess Resident #22's gestures and verbalization of pain/discomfort during the wound care. Registered Nurse (RN) #3/Wound Care Nurse, was assisted by Certified Nursing Assistant (CNA) #1. Resident #22 was initially observed lying comfortably in bed on her right side. When RN #3 began to clean the wound with NS, Resident #22 cried out OWWW and drew her left leg upward toward her chest, during the wound care. RN #3 confirmed Resident #22 did not receive pain medication prior to wound care. RN #3 continued to clean Resident #22's wound with NS. RN #3 measured the wound, washed her hands, applied gloves and cleaned the wound again. Resident #22 cried out OWWW a second time. RN #3 continued to preform the wound care until complete without assessing Resident #22's pain or providing pain medication. Resident #22's left heel wound measured 1.4 centimeter (cm) by 1.2 cm, with 50% slough, mild clear drainage, and no odor. During an interview, on 11/26/2019 at 11:00 AM, RN #3 confirmed she did not stop to assess Resident #22's pain level during the wound care. RN #3 stated Resident #22 did not receive any pain medication prior to the wound care treatment. RN #3 stated Resident #22 normally does not complain of pain. RN #3 confirmed she should have stopped the treatment when Resident #22 complained of pain to assess her pain and administer pain medication. RN #3 said she thought the State Agency (SA) would have a problem with her stopping the treatment. During an interview, on 11/26/2019 at 10:00 AM, CNA #1 stated Resident #22 only complains of pain when the nurses does the wound care. Review of Resident #22's Order Review Report revealed an order, dated 10/24/2019, to cleanse the unstageable left heel wound with NS, pat dry, apply santyl to wound bed. Apply sureprep to wound edges. Apply adhesive foam dressing. Wrap with kerlix daily and PRN until healed, every day shift and as needed. Further review of the report revealed an order, dated 9/16/2019, for Ultram Tablet 50 milligrams (mg), give one (1) tablet by mouth every six (6) hours as needed for pain. There also was an order, dated 6/28/2019, to administer Tylenol tablet, give 1000 mg by mouth daily for pain. During an interview, on 11/26/2019 at 5:58 PM, the Director of Nursing (DON) stated residents are assessed prior to wound care treatments. The DON stated, I would have stopped as soon as the resident cried out in pain during the wound treatment and got her some pain medication. Review of Resident #22's Medical Record revealed she was hospitalized [DATE] to 6/15/2019 after a fall. Resident #22 returned to the facility on [DATE] status post a left hip replacement and was identified with soft heels. Sureprep was ordered to both heels as well as off loading. Further review of Resident #22's wound/skin assessments revealed: On 6/29/2019, the left heel was staged a Deep Tissue Injury (DTI) measuring 3.7 cm x 3.2 cm dark purple area with treatment continued. On 7/25/2019 the left heel measured 2.2 cm x 2.7 cm, black and firm. On 8/29/2019, the left heel measured 1.8 cm x 1.7 cm. On 9/26/2019 the left heel measured 1.5 cm x 1.5 cm with treatment continuing. On 10/31/2019 the left heel measured 1.5 cm x 2.0 cm. On 11/21/2019 the left heel measured 1.4 cm x 1.2 cm with continued treatment. Gradual slow healing. An interview, on 11/26/2019 at 9:45 AM, revealed the Director of Nurses (DON) stated Resident #22's heels were soft on return to the facility from the hospital on 6/15/2019 due to a left hip replacement. The DON stated the Wound Care Nurse put treatments into place. The DON stated we are seeing improvement, but it is a slow gradual healing. Review of the Admission Record revealed the facility admitted Resident #22, on 4/30/2012, with the included diagnoses of Unstagable Left Heel Wound, Alzheimer's Disease, Osteoarthritis, Chronic Kidney Disease and Atherosclerotic Heart Disease. Review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/19, revealed Resident #22 had a Brief Interview of Mental Status (BIMS) score 3, which indicated the resident was severely cognitively impaired. Further review of the MDS revealed the presence of an unstageable pressure ulcer suspected of deep tissue injury evolution. Review of the resident's pain assessment revealed she received routine pain medication, but no as needed pain medication. The pain interview was not done.

Based on record review, staff interview and facility policy review, the facility failed to develop/implement the care plan for pain medication as needed, during wound care, for Resident #22; and failed to implement the care plan for Resident #74, regarding the code status for two (2) of 20 care plans reviewed. Findings include: Review of the facility's Comprehensive Care Plans policy, dated ,[DATE], revealed, it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #22 Review of Resident #22's comprehensive care plan, initiated [DATE], revealed the resident had interventions for [MEDICATION NAME] 50 milligrams (mg) every six (6) hours as needed for pain. Observation of wound care, on [DATE] at 9:00 AM, and interview with Registered Nurse (RN) #1, revealed, Resident #22 cried out OWWW and drew her left leg upward toward her chest, during wound care. RN #1 confirmed Resident #22 did not receive pain medication prior to wound care. RN #1 continued to clean Resident #22's wound care with normal saline. RN #1 measured the wound, washed her hands, applied gloves and cleaned the wound again. Resident #22 cried out OWWW a second time. RN #1 applied Sure Prep to the wound edges, Santyl to the wound bed, covered the wound with foam dressing and wrapped the left heel with Kerlix. During an interview, on [DATE] at 5:33 PM, RN #2/Care Plan Nurse confirmed he did not develop a care plan related to pain, for Resident #22's left heel pressure ulcer. RN #2 stated he notified the doctor and received an order, for pain medication routinely and as needed. Resident #74 Review of the Comprehensive Care Plan, initiated [DATE], revealed, Resident #74 had a DNR code status. Review of the nurses notes, dated [DATE] at 9:18 PM, revealed Resident #74 was found unresponsive and Cardiopulmonary Resuscitation (CPR) was initiated by staff. During an interview, on [DATE] at 5:25 PM, RN #2/Care Plan Nurse revealed he expects the staff to follow the care plan.

Based on observation, staff interview, record review, and facility policy review, the facility failed to assist the resident for pain at time of treatment for one (1) of three (3) pressure ulcers observed, Resident #22. Resident #22 cried out in pain during wound care treatment, without the nurse assessing and/or providing pain management prior to continuing the wound care. Findings include: Review of the facility's Wound Treatment Management Policy, dated 11/18, revealed: the policy is to promote wound healing of various types of wound, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Characteristics of the wound, includes the pressure ulcer stage, size, and presence of pain. During an observation of Resident #22's wound care, and interview with Registered Nurse (RN) #1, on 11/26/2019 at 9:00 AM, revealed the resident lying in bed on her right side, with no obvious signs of pain or distress. Resident #22 cried out OWWW, and drawed her left leg up towards her chest, during the wound care performed by RN #1. RN #1 stated she had not given Resident #22 pain medication prior to wound care. RN #1 continued to clean Resident #22's wound with normal saline, measured the wound, washed her hands, applied gloves, and cleaned the wound again. Resident #22 cried out OWWW a second time. RN #1 applied Sure Prep to the wound edges, Santyl to the wound bed, covered the wound with foam dressing, and wrapped it with Kerlix. At no time during the wound care process, was Resident #22 offered pain medication, nor did the nurse discontinue treatment when the resident cried out. Review of Resident #22's physicians orders, dated 9/16/19, revealed an order for [REDACTED]. During an interview, on 11/26/19 at 10:00 AM, Certified Nursing Assistant (CNA) #1 confirmed Resident #22 only complains of pain when the nurses do her wound care. During an interview, on 11/26/19 at 11:00 AM, RN #1 confirmed Resident #22 did not receive pain medication, prior to wound care to the left heel. RN #1 stated Resident #22 normally does not complain of pain. RN #1 confirmed she should have stopped the treatment when the resident complained of pain. RN #1 stated she thought the State Agency (SA) would have a problem with her stopping the treatment. During an interview, on 11/26/19 at 5:58 PM, the Director of Nursing (DON) stated residents are assessed prior to wound care treatments. The DON stated, I would have stopped as soon as the resident cried out in pain during the wound treatment and got her some pain medication. A review of Resident #22's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/22/19, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident is cognitively impaired.

Based on interview, record review and facility policy review, the facility failed to have a system in place to transcribe lab orders to meet professional standards of practice as evidenced by failure to obtain an ordered [MEDICATION NAME] Time (PT)/International Normalized Ratio (INR) on [DATE] for one (1) of three (3) residents receiving anticoagulant therapy, from a total of 19 residents reviewed (Resident #14), resulting in an Immediate Jeopardy. The facility was unaware of this system failure prior to notification by the survey team on [DATE]. Resident #14 was admitted to the facility on [DATE] with a PT/INR ordered to be obtained on [DATE]. The order was not transcribed to the lab log and the facility failed to obtain the lab as ordered. Resident #14's condition declined and the resident was sent to the local hospital on [DATE]. The PT/INR results obtained in the hospital were high critical on [DATE], which resulted in Resident #14 receiving Vitamin K (used to counteract [MEDICATION NAME] Toxicity) and two units of Packed Red Blood Cells while in the hospital. The Resident #14 expired in the hospital on [DATE] due to [MEDICAL CONDITION]. Findings include: Resident #14 Nursing 2013 Drug Handbook, 33rd Edition, indicated that [MEDICATION NAME] ([MEDICATION NAME]) had a black box warning that stated [MEDICATION NAME] can cause major or fatal bleeding. Regular monitoring of the INR in all patients was recommended by this standard. This standard of practice also pointed out that elderly patients are especially sensitive to this drug's effect. Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of a PT/INR obtained on [DATE] at 6:25 a.m. at the local hospital prior to Resident #14's admission to the nursing facility on [DATE], revealed a PT of "56.0 H (High) with a reference range of 9.1 to 12.0 seconds and an INR of 4.8 HC (High Critical) with a reference range of 1.5 to 3.0 Ratio." Record review of Resident #14's closed record revealed local hospital discharge orders, dated [DATE], with an order for [REDACTED]. [REDACTED]. Record review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Record review of the facility's "lab log" revealed no entry for [DATE] for Resident #14. Resident #14 was transferred to the local hospital emergency room (ER) on [DATE] due to a decline in condition. This was evidenced by the nurses notes on [DATE] at 7:15 p.m., which contained documentation that food was falling out of the resident's mouth. The nurses notes, then documented again on [DATE] at 9:00 p.m., that Resident #14 was found in bed with a low heart rate and with hands and fingers cold to touch via the nurse. Record review of the local hospital's ER Physician's report on [DATE] at 10:20 p.m., revealed multiple bruising to Resident #14's skin. Review of the acute hospital stay physician's orders [REDACTED].#14's [MEDICATION NAME], give Vitamin K 10 mg intramuscular (IM), and obtain a PT/INR. Record review of the local hospital's Laboratory Comparative Report for Resident #14, after the resident was transferred from the facility, revealed on [DATE] at 10:33 p.m. a [MEDICATION NAME] (coagulation study) was attempted in the local hospital emergency room (ER). The hospital lab was unable to obtain a valid result, and the specimen was sent to the reference lab. On [DATE] at 10:35 a.m. the hospital attempted another [MEDICATION NAME] but was unable to get a valid result, and again sent the specimen to the reference lab. On [DATE] at 1:22 a.m. the hospital was able to obtain the first coagulation results. The results were: PT 157.0 H (High) with a reference range of 9XXX,[DATE].0; INR 13.4 HC (High Critical) with a reference range of 1XXX,[DATE].0 ratio; Partial [MEDICATION NAME] Time (PTT) of 91.6 H (High) with a reference range of 25XXX,[DATE].4. Interview with the facility Director of Nursing (DON) on [DATE] at 10:30 a.m. revealed that Resident #14 was transferred to the local hospital Emergency Department for an evaluation, was admitted to the hospital and stayed there until her death on [DATE]. The DON stated that the ordered lab for PT/INR on [DATE] was not collected due to the facility "missed it". The DON also stated that the Medical Director, Physician and Responsible Party were not notified due to the lack of facility's knowledge of missing lab prior to survey. A statement received from the facility's Administrator on [DATE] at 11:25 a.m. stated a PT/INR was not drawn for Resident #14 on [DATE]. Interview on [DATE] at 3:30 p.m. with the facility's Medical Director, which was also Resident #14's primary physician, revealed that he "was not sure what happened" or why the lab ordered was not drawn. He also stated he was not sure how to prevent lab from being missed again. Interview with Registered Nurse (RN) #1 on [DATE] at 1:36 p.m. revealed that she was taught in orientation that the nurse receiving the lab order is the person responsible for noting off the order, and the nurse writing the orders is responsible when the order is for a new admission. RN #1 was the admitting nurse for Resident #14 on [DATE] and wrote the admission orders At that time when she (Resident #14) came in, I thought if it (order for [DATE]) was not a 'now' lab that it (the lab) went with the original admission orders [REDACTED]." RN #1 stated she thought admission orders [REDACTED]. RN #1 stated she spent "a couple of hours here and there" with a nurse during orientation, and thought she understood the process as it was explained to her on hire. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on [DATE] at 4:05 p.m. A review of the facility's Credible Allegation of Compliance revealed: "This serves as our Credible Allegation for the Incident Involving Resident #14 on [DATE]. On [DATE] Resident #14 was admitted to the facility with orders for [MEDICATION NAME] 2.5 mg daily and a PT INR to be drawn on [DATE]. The PT INR was not drawn on [DATE] for Resident #14. Physician #1 was notified that the lab was not done on [DATE] at 3:15 pm by the owner of the facility. On [DATE] the Administrative Supervisor reviewed Resident #14's medical record and determined RN #1 had written orders for admission to include an order for [REDACTED]. This order for PT INR was not noted by RN #1 on [DATE] when Resident #14 was admitted to the facility on [DATE]. The Quality Assurance Nurse began in servicing all RNs and LPNs on [DATE] at 3:00 pm on the lab order policy to include: the nurse receiving the order will note the lab order, place the order on the lab calendar for the appropriate date, complete a lab slip, then place the slip in the lab book, the charge nurse will check the lab calendar daily, obtain the labs for that day, and the nurse receiving the lab results will notify the physician and the document the response in the nurses notes. No RN or LPN will be allowed to return to work before receiving in service on policies and procedures for labs as indicated in the above paragraph. On [DATE] at 4:00 pm a Quality Assurance Meeting was conducted with the Administrative Supervisor, Administrator, Director of Nursing, Quality Assurance Nurse, Infection Control Nurse, Registered Dietician, the owner of the facility, and MDS Nurse. It was discussed during the Quality Assurance Meeting that the lab was not drawn for Resident #14 and measures to prevent reoccurrence. Measures to be taken to prevent reoccurrence as discussed are: in servicing all RNs and LPNs on procedures for noting lab orders on [DATE], revising of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses' to schedule labs when ordered, reviewing all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], auditing lab orders twice weekly beginning [DATE] by the Quality Assurance nurse to ensure labs have been completed and results are placed in the medical record by the Quality Assurance Nurse for the next 90 days, and the Quality Assurance Nurse will report findings from lab audits at the monthly Quality Assurance Meeting. On [DATE] at 5:00 pm the Restorative Nurse started a lab calendar and placed it at one of the two nursing stations which is centrally located in the facility. On [DATE] at 5:00 pm the administrative nursing staff began review of all resident medical records for accuracy of physicians' orders, care plans and labs. Seventy-five of seventy five medical records were reviewed. Residents #10 and #16 are identified as receiving [MEDICATION NAME]. There were no negative outcomes noted for Residents #10 and #16. No further discrepancies were identified. On [DATE] the facility Administrator contacted the Medical director at 6:00 pm to discuss the minutes from the Quality Assurance Meeting held on [DATE] at 4:00 pm. The Medical Director agreed with measures to prevent reoccurrence and made no further recommendations. On [DATE] at 6:30 pm a formal investigation was conducted by the Administrative Supervisor. During this formal investigation on [DATE] at 6:30 pm the following were also present- administrator, Director of Nursing, Data Entry Nurse, Quality Assurance Nurse, owner of facility and RN #1. RN #1 stated she had checked the admission orders [REDACTED]. RN #1 stated that her understanding is any lab not ordered STAT is scheduled by the data entry nurse. During the formal investigation RN #1 was educated by the Administrative Supervisor on proper procedures for noting physician orders [REDACTED]. RN #1 verbalized her understanding of procedure for noting lab orders. RN#1 was counseled by the Director of Nursing on [DATE] at 7 pm for failure to note orders for Resident #14 on [DATE]. On [DATE] at 7:00 pm the Consulting Pharmacist arrived at the facility. The Director of Nursing discussed the incident concerning Resident #14 with the Consulting Pharmacist. The Consulting Pharmacist reviewed Resident #14, #10 and #16 medical records and made no further recommendations. Quality Assurance nurse will audit lab orders twice weekly beginning [DATE] to ensure labs have been completed and the results have been placed in the medical record. The findings will be presented at the monthly QA meetings. The QA committee will make recommendations for changes and corrective actions as needed. This deficient practice has the potential to affect all residents. The facility feels this immediate jeopardy was removed on [DATE] at 11:35 pm." The surveyor validated the corrective actions taken by the facility as follows: The inservices held records beginning on [DATE] were validated by review of the sign in sheets and interviews with staff members. The content of the meeting was validated which included the lab order policy to include the procedure the nursing staff are to follow when labs are ordered by the physician. Information that was given to all RNs and LPNs at in-services beginning on [DATE] was reviewed for validation of in-service content. The survey team validated the QA meeting sign in sheet dated [DATE] at 4:00 p.m. showing the Administrative Supervisor, Administrator, DON, QA Nurse, and the Registered Dietician attended. The facility owner and the MDS nurse validated this meeting by indicating it was discussed during the QA Meeting that the lab was not drawn for Resident #14. The measures to prevent reoccurrence were discussed which included: in-service of all RNs and LPNs on procedures for noting lab orders on [DATE], revision of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses to schedule labs when ordered. A review of all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff to begin on [DATE], and audit all lab orders twice weekly beginning [DATE] by the QA nurse for the next 90 days. The QA nurse to report findings from lab audits at the monthly QA meeting. The survey team reviewed a signed statement from the facility administrator validated and documented a discussion with the Medical Director at [DATE] at 6:00 p.m. regarding the Quality Assurance Meeting that was held on [DATE] at 4:00 p.m. This document contained documentation of the following discussions: the revision of the current lab policy; measures the facility would take in order to prevent reoccurrence; the placing of all labs on a calendar with the QA nurse to audit the lab orders twice weekly to ensure labs were completed; and QA to monitor to ensure lab results were placed in the medical record for the next 90 days. The QA Nurse would report findings at the next monthly QA meeting. This document also noted that the Medical Director had no further recommendations. The lab calendar on the "400 unit" nurses station with labs to be drawn was validated on [DATE] at 4:30 p.m. On [DATE] the surveyor validated the pharmacy consultant's visit by review of the pharmacist documentation on Resident #14's, #10's and #16's medical record. Review of a signed statement by the facility DON on [DATE] noted that the Consulting Pharmacist arrived at the facility on [DATE] at 7:00 p.m. and reviewed the charts of Resident #14, Resident #10 and Resident #16 for residents receiving or had received [MEDICATION NAME] Therapy with no further recommendations made. Interviews with all RNs/LPNs were completed [DATE] at 6:15 p.m. and validated that all nursing staff had been in-serviced on procedures for noting lab orders and the revision of the lab order policy. An acceptable Allegation of Compliance (AoC) was received on [DATE] at 4:05 p.m., which alleged removal of the Immediate Jeopardy on [DATE] at 11:35 p.m. The State Agency confirmed on [DATE] that the facility removed the Immediate Jeopardy on [DATE] at 11:35 p.m., as stated in the facility's AOC. Therefore, the Immediate Jeopardy was lowered to the scope and severity of "D" at 42 CFR 483.20 Resident Assessment (F-281), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

Based on staff interview, record review and facility policy review, the facility failed to follow the admission plan of care as evidenced by failure to obtain [MEDICATION NAME] Time (PT)/International Normalized Ratio (INR) on [DATE], as ordered, for one (1) of three (3) residents receiving anticoagulant therapy, from a total of 19 residents reviewed (Resident #14), resulting in an Immediate Jeopardy. The facility did not update the care plan due to the lack of knowledge of the PT/INR being missed until it was identified by the survey team. Resident #14 was admitted to the facility on [DATE] with a PT/INR to be obtained on [DATE] and was placed on the admission care plan to be done. The facility failed to follow the plan of care to obtain the PT/INR as ordered by the physician. Resident #14's condition declined and the resident was sent to the local hospital on [DATE]. The PT/INR results obtained in the hospital were high critical on [DATE], which resulted in Resident #14 receiving Vitamin K (used to counteract [MEDICATION NAME] Toxicity) and two units of Packed Red Blood Cells while in the hospital. The Resident #14 expired in the hospital on [DATE] due to [MEDICAL CONDITION]. Findings include: Resident #14 The facility's policy entitled "Interim Care Plan Policy", dated ,[DATE], noted: The interim care plan is utilized to provide guidance to facility staff concerning the resident and his/her care needs. Record review of Resident #14's admission care plan indicated the resident was on anticoagulant therapy and listed [MEDICATION NAME] 2.5 mg by mouth (po) daily with a listed goal of no complications with interventions. Care plan review revealed an intervention to monitor labs as ordered, monitor for signs and symptoms of bleeding and protect from injury. Record review of the physician's admission orders [REDACTED]. The facility failed to obtain any PT/INR's for Resident #14 while in the facility between [DATE] through [DATE]. Interview with Director of Nursing (DON) on [DATE] at 4:50 p.m. confirmed that the PT/INR order was present on the admission care plan; however, the care plan was not followed. The DON stated that the facility will continue to place ordered labs on the care plan and update as necessary. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on [DATE] at 4:05 p.m. A review of the facility's Credible Allegation of Compliance revealed: "This serves as our Credible Allegation for the Incident Involving Resident #14 on [DATE] On [DATE] Resident #14 was admitted to the facility with orders for [MEDICATION NAME] 2.5 mg daily and a PT INR to be drawn on [DATE]. The PT INR was not drawn on [DATE] for Resident #14. Physician #1 was notified that the lab was not done on [DATE] at 3:15 p.m. by the owner of the facility. On [DATE] the Administrative Supervisor reviewed Resident #14's medical record and determined RN #1 had written orders for admission to include an order for [REDACTED]. This order for PT INR was not noted by RN #1 on [DATE] when Resident #14 was admitted to the facility on [DATE]. The Quality Assurance Nurse began in servicing all RNs and LPNs on [DATE] at 3:00 pm on the lab order policy to include: the nurse receiving the order will note the lab order, place the order on the lab calendar for the appropriate date, complete a lab slip, then place the slip in the lab book, the charge nurse will check the lab calendar daily, obtain the labs for that day, and the nurse receiving the lab results will notify the physician and the document the response in the nurses notes. No RN or LPN will be allowed to return to work before receiving in service on policies and procedures for labs as indicated in the above paragraph. On [DATE] at 4:00 pm a Quality Assurance Meeting was conducted with the Administrative Supervisor, Administrator, Director of Nursing, Quality Assurance Nurse, Infection Control Nurse, Registered Dietician, the owner of the facility, and MDS Nurse. It was discussed during the Quality Assurance Meeting that the lab was not drawn for Resident #14 and measures to prevent reoccurrence. Measures to be taken to prevent reoccurrence as discussed are: in servicing all RNs and LPNs on procedures for noting lab orders on [DATE], revising of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses ' to schedule labs when ordered, reviewing all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], auditing lab orders twice weekly beginning [DATE] by the Quality Assurance nurse to ensure labs have been completed and results are placed in the medical record by the Quality Assurance Nurse for the next 90 days, and the Quality Assurance Nurse will report findings from lab audits at the monthly Quality Assurance Meeting. On [DATE] at 5:00 pm the Restorative Nurse started a lab calendar and placed it at one of the two nursing stations which is centrally located in the facility. On [DATE] at 5:00 pm the administrative nursing staff began review of all resident medical records for accuracy of physicians ' orders, care plans and labs. Seventy-five of seventy five medical records were reviewed. Residents #10 and #16 are identified as receiving [MEDICATION NAME]. There were no negative outcomes noted for Residents #10 and #16. No further discrepancies were identified. On [DATE] the facility Administrator contacted the Medical director at 6:00 pm to discuss the minutes from the Quality Assurance Meeting held on [DATE] at 4:00 pm. The Medical Director agreed with measures to prevent reoccurrence and made no further recommendations. On [DATE] at 6:30 pm a formal investigation was conducted by the Administrative Supervisor. During this formal investigation on [DATE] at 6:30 pm the following were also present- administrator, Director of Nursing, Data Entry Nurse, Quality Assurance Nurse, owner of facility and RN #1. RN #1 stated she had checked the admission orders [REDACTED]. RN #1 stated that her understanding is any lab not ordered STAT is scheduled by the data entry nurse. During the formal investigation RN #1 was educated by the Administrative Supervisor on proper procedures for noting physician orders [REDACTED]. RN #1 verbalized her understanding of procedure for noting lab orders. RN#1 was counseled by the Director of Nursing on [DATE] at 7 pm for failure to note orders for Resident #14 on [DATE]. On [DATE] at 7:00 pm the Consulting Pharmacist arrived at the facility. The Director of Nursing discussed the incident concerning Resident #14 with the Consulting Pharmacist. The Consulting Pharmacist reviewed Resident #14, #10 and #16 medical records and made no further recommendations. Quality Assurance nurse will audit lab orders twice weekly beginning [DATE] to ensure labs have been completed and the results have been placed in the medical record. The findings will be presented at the monthly QA meetings. The QA committee will make recommendations for changes and corrective actions as needed. This deficient practice has the potential to affect all residents. The facility feels this immediate jeopardy was removed on [DATE] at 11:35 pm." The surveyor validated the corrective actions taken by the facility as follows: During random interviews with staff, the survey team validated the inservice training and implementation of the care plans as indicated by the QA committee. A review of in-service records and review of the sign in sheets of the inservice conducted beginning on [DATE] validated the attendance of staff and the content of the meeting which included the lab order policy to include the procedure the nursing staff are to follow the plan of care when labs are ordered by the physician. Information given to all RNs and LPNs at inservices beginning on [DATE] was reviewed for validation of in-service content. The survey team validated the QA meeting sign in sheet dated [DATE] at 4:00 p.m. with the Administrative Supervisor, Administrator, DON, QA Nurse, Registered Dietician. The facility owner and the MDS nurse who were in the QA meeting confirmed the discussion of the lab not being drawn for Resident #14 and the measures to prevent the reoccurrence which included: in-service of all RNs and LPNs on procedures for noting lab orders on [DATE], revision of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses to schedule labs when ordered, review of all medical records including care plans to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], audit all lab orders twice weekly beginning [DATE] by the QA nurse for the next 90 days, and the QA nurse to report findings from lab audits at the monthly QA meeting. Review of a signed statement from the facility administrator validated and documented a discussion with the Medical Director at [DATE] at 6:00 p.m. regarding the Quality Assurance Meeting that was held on [DATE] at 4:00 p.m. This document noted the discussion of the revision of the current lab policy and measures the facility would take in order to prevent reoccurrence. This document also noted the facility would place all labs on a calendar and the QA nurse would audit the lab orders twice weekly to ensure labs were completed, and the results were placed in the medical record for the next 90 days. The QA Nurse would report findings at the next monthly QA meeting. This document noted that the Medical Director had no further recommendations. Interviews with all RNs/LPNs were completed [DATE] at 6:15 p.m. and validated that all nursing staff had been in-serviced on procedures for noting lab orders and the revision of the lab order policy and following the plan of care. An acceptable Allegation of Compliance (AoC) was received on [DATE] at 4:05 p.m., which alleged removal of the Immediate Jeopardy on [DATE] at 11:35 p.m. The State Agency confirmed on [DATE] that the facility removed the Immediate Jeopardy on [DATE] at 11:35 p.m., as stated in the facility's AOC. Therefore, the Immediate Jeopardy was lowered to the scope and severity of "D" at 42 CFR 483.20 Resident Assessment (F-282), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

Based on staff interview, record review and facility policy review, the facility failed to ensure that a resident received services to maintain their highest possible well-being for one (1) of three (3) residents receiving anticoagulant therapy, from a total of 19 residents reviewed (Resident #14), resulting in an Immediate Jeopardy and Substandard Quality of Care. The facility was made aware of the missing lab during the survey by the survey team. The facility had no knowledge of the missing lab until notified by the surveyor. Resident #14 was transferred to the hospital on [DATE] due to a decline in condition. On [DATE] Resident #14's [MEDICATION NAME] Time (PT)/International Normalized Ratio (INR) obtained at the hospital was high critical. On [DATE], Resident #14 was administered Vitamin K (used to counteract [MEDICATION NAME] Toxicity) intramuscularly. On [DATE] Resident #14's Hemoglobin was 7.4 and Hematocrit was 22. On [DATE], Resident #14 was given two units of Packed Red Blood Cells (PRBC). Resident #14 died on [DATE] at the local hospital due to [MEDICAL CONDITION]. Findings include: Resident #14 Record Review of the facility's admission document (undated) entitled "Quality of Life" revealed, the facility's policy "is one of promoting the highest of quality of life for its residents. The environment of the facility is one that promotes maintenance or enhancement of the individual resident's quality of life." On [DATE], Resident #14 was admitted to the facility. [DIAGNOSES REDACTED]. A Brief Interview for Mental Status was unable to be completed prior to the resident being transferred to the hospital on [DATE]. Record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #14 obtained a PT/INR on [DATE] at 6:25 a.m. at the local hospital prior to admission to the nursing facility with abnormal results of PT 56.0 H (High) (PT reference range was 9.1 to 12.0 seconds) and INR 4.8 HC (High Critical) (INR a reference range of 1.5 to 3.0 ratio). Record review of Resident #14's closed record revealed local hospital transfer orders for resident's admission to the nursing facility, dated [DATE], with a physician's orders [REDACTED]. Record Review of Resident #14's closed record from the nursing facility revealed an admission physician's orders [REDACTED]. Record review of the facility's "lab log" revealed no entry for [DATE] for Resident #14. There was no documented PT/INR results dated [DATE] on Resident #14's record. Record review revealed Resident #14 was transferred to the local hospital on [DATE] due to a decline in the resident's condition. This was documented in the nurse's notes on [DATE] at 7:15 p.m., which read "food falling out of resident's mouth". Then documentation again in the nurse's notes on [DATE] at 9:00 p.m., which read "found in bed with a low heart rate with hands and fingers cold to touch." Resident #14 was transferred to the local emergency room . Review of the local hospital's ER Physician's report on [DATE] at 10:20 p.m., revealed Resident #14 had multiple bruising to the skin. Record review of the acute hospital stay physician's orders [REDACTED]. Record review of the laboratory reports from the local hospital for Resident #14, after transfer from the facility, revealed after two invalid results, the hospital was able to obtain the first coagulation results on [DATE] at 1:22 a.m. The results were as follows: PT: 157.0, High (reference range of 9.1 to 12.0); INR: 13.4, High Critical (reference range of 1.5 to 3.0); and Partial [MEDICATION NAME] Time (PTT): 91.6 High (reference range of 25.4 to 38.4). Review of the Complete Blood Count (CBC) results for the following revealed: On [DATE] at 10:33 p.m., revealed a Red Blood Cell count of 3.70 (reference range: 4.20 to 5.40), a Hemoglobin result of 10.3 (reference range: 11.50 to 16.50), and a Hematocrit result of 32 (reference range: 37 to 47). On [DATE] at 4:30 a.m., revealed a Red Blood Cell count of 3.11, Hemoglobin result of 8.6, and a Hematocrit result of 27. On [DATE] at 12:40 a.m., revealed a Red Blood Cell count of 2.82, Hemoglobin result of 7.8, and a Hematocrit result of 24. On [DATE] at 9:54 a.m., revealed a Red Blood Cell count of 2.59 , a Hemoglobin result of 7.4, and a Hematocrit result of 22. Record review revealed a physician order [REDACTED]." Record review of the latest hospital record revealed a death certificate which confirmed that Resident #14 expired at the local hospital on [DATE] due to [MEDICAL CONDITION]. Interview with the facility Director of Nursing (DON) on [DATE] at 10:30 a.m. revealed that Resident #14 was transferred on [DATE] to the local hospital emergency room for evaluation where she was admitted , and stayed until her death on [DATE]. Interview on [DATE] at 10:30 a.m. with the DON revealed that the ordered lab for PT/INR on [DATE] was not collected by the nursing facility. During this interview the DON confirmed that the facility was not aware the lab had been missed until the results were requested by the survey team. The DON stated that she had looked but could not find the results. On [DATE] at 11:25 a.m., a statement was received from the facility's Administrator which stated the PT/INR was not drawn on [DATE] for Resident #14. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on [DATE] at 4:05 p.m. A review of the facility's Credible Allegation of Compliance revealed: "This serves as our Credible Allegation for the Incident Involving Resident #14 on [DATE] On [DATE] Resident #14 was admitted to the facility with orders for [MEDICATION NAME] 2.5 mg daily and a PT INR to be drawn on [DATE]. The PT INR was not drawn on [DATE] for Resident #14. Physician #1 was notified that the lab was not done on [DATE] at 3:15 p.m. by the owner of the facility. On [DATE] the Administrative Supervisor reviewed Resident #14's medical record and determined RN #1 had written orders for admission to include an order for [REDACTED]. This order for PT INR was not noted by RN #1 on [DATE] when Resident #14 was admitted to the facility on [DATE]. The Quality Assurance Nurse began in servicing all RNs and LPNs on [DATE] at 3:00 pm on the lab order policy to include: the nurse receiving the order will note the lab order, place the order on the lab calendar for the appropriate date, complete a lab slip, then place the slip in the lab book, the charge nurse will check the lab calendar daily, obtain the labs for that day, and the nurse receiving the lab results will notify the physician and the document the response in the nurses notes. No RN or LPN will be allowed to return to work before receiving in service on policies and procedures for labs as indicated in the above paragraph. On [DATE] at 4:00 pm a Quality Assurance Meeting was conducted with the Administrative Supervisor, Administrator, Director of Nursing, Quality Assurance Nurse, Infection Control Nurse, Registered Dietician, the owner of the facility, and MDS Nurse. It was discussed during the Quality Assurance Meeting that the lab was not drawn for Resident #14 and measures to prevent reoccurrence. Measures to be taken to prevent reoccurrence as discussed are: in servicing all RNs and LPNs on procedures for noting lab orders on [DATE], revising of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses' to schedule labs when ordered, reviewing all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], auditing lab orders twice weekly beginning [DATE] by the Quality Assurance nurse to ensure labs have been completed and results are placed in the medical record by the Quality Assurance Nurse for the next 90 days, and the Quality Assurance Nurse will report findings from lab audits at the monthly Quality Assurance Meeting. On [DATE] at 5:00 pm the Restorative Nurse started a lab calendar and placed it at one of the two nursing stations which is centrally located in the facility. On [DATE] at 5:00 pm the administrative nursing staff began review of all resident medical records for accuracy of physicians' orders, care plans and labs. Seventy-five of seventy five medical records were reviewed. Residents #10 and #16 are identified as receiving [MEDICATION NAME]. There were no negative outcomes noted for Residents #10 and #16. No further discrepancies were identified. On [DATE] the facility Administrator contacted the Medical director at 6:00 pm to discuss the minutes from the Quality Assurance Meeting held on [DATE] at 4:00 pm. The Medical Director agreed with measures to prevent reoccurrence and made no further recommendations. On [DATE] at 6:30 pm a formal investigation was conducted by the Administrative Supervisor. During this formal investigation on [DATE] at 6:30 pm the following were also present- administrator, Director of Nursing, Data Entry Nurse, Quality Assurance Nurse, owner of facility and RN #1. RN #1 stated she had checked the admission orders [REDACTED]. RN #1 stated that her understanding is any lab not ordered STAT is scheduled by the data entry nurse. During the formal investigation RN #1 was educated by the Administrative Supervisor on proper procedures for noting physician orders [REDACTED]. RN #1 verbalized her understanding of procedure for noting lab orders. RN#1 was counseled by the Director of Nursing on [DATE] at 7 pm for failure to note orders for Resident #14 on [DATE]. On [DATE] at 7:00 pm the Consulting Pharmacist arrived at the facility. The Director of Nursing discussed the incident concerning Resident #14 with the Consulting Pharmacist. The Consulting Pharmacist reviewed Resident #14, #10 and #16 medical records and made no further recommendations. Quality Assurance nurse will audit lab orders twice weekly beginning [DATE] to ensure labs have been completed and the results have been placed in the medical record. The findings will be presented at the monthly QA meetings. The QA committee will make recommendations for changes and corrective actions as needed. This deficient practice has the potential to affect all residents. The facility feels this immediate jeopardy was removed on [DATE] at 11:35 pm." The surveyor validated the corrective actions taken by the facility as follows: A review of in-service records and sign-in sheets validated in-services held beginning on [DATE] and interviews with staff members further validated their attendance and content of the meeting which included the lab order policy to include the procedure the nursing staff are to follow when labs are ordered by the physician. Information that was given to all RNs and LPNs at in-services beginning on [DATE] was reviewed for validation of in-service content. Review of the QA meeting sign in sheet dated [DATE] at 4:00 p.m. confirmed the attendance of the Administrative Supervisor, Administrator, DON, QA Nurse, Registered Dietician. The facility owner and the MDS nurse validated this meeting and indicated it was discussed during the QA Meeting that the lab was not drawn for Resident #14 and measures to prevent reoccurrence. Measures to be taken to prevent reoccurrence as discussed were: in-service of all RNs and LPNs on procedures for noting lab orders on [DATE], revision of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses to schedule labs when ordered, review of all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], audit all lab orders twice weekly beginning [DATE] by the QA nurse for the next 90 days, and the QA nurse to report findings from lab audits at the monthly QA meeting. Review of a signed statement from the facility administrator validated and documented a discussion with the Medical Director at [DATE] at 6:00 p.m. regarding the Quality Assurance Meeting that was held on [DATE] at 4:00 p.m. This document noted the discussion of the revision of the current lab policy and measures the facility would take in order to prevent reoccurrence. This document also noted the facility would place all labs on a calendar and the QA nurse would audit the lab orders twice weekly to ensure labs were completed, and the results were placed in the medical record for the next 90 days. The QA Nurse would report findings at the next monthly QA meeting. This document noted that the Medical Director had no further recommendations. The lab calendar on the "400 unit" nurses station with labs to be drawn was validated on [DATE] at 4:30 p.m. The surveyor validated the pharmacy consultant's visit on [DATE] by review of the pharmacist documentation on Resident #14's, #10's and #16's medical record. Review of a signed statement by the facility DON on [DATE] noted that the Consulting Pharmacist arrived at the facility on [DATE] at 7:00 p.m. and reviewed the charts of Resident #14, Resident #10 and Resident #16 for residents receiving or had received [MEDICATION NAME] Therapy with no further recommendations made. Interviews with all RNs/LPNs were completed [DATE] at 6:15 p.m. and validated that all nursing staff had been in-serviced on procedures for noting lab orders and the revision of the lab order policy. An acceptable Allegation of Compliance (AoC) was received on [DATE] at 4:05 p.m., which alleged removal of the Immediate Jeopardy on [DATE] at 11:35 p.m. The State Agency confirmed on [DATE] that the facility removed the Immediate Jeopardy on [DATE] at 11:35 p.m., as stated in the facility's AOC. Therefore, the Immediate Jeopardy was lowered to the scope and severity of "D" 42 CFR 483.25 Quality of Care (F-309), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

Based on interview, record review and facility policy review, the facility failed to obtain a [MEDICATION NAME] Time (PT)/International Normalized Ratio (INR) for one (1) of three (3) residents receiving anticoagulant therapy, from a total of 19 residents reviewed (Resident #14), resulting in an Immediate Jeopardy. The facility was made aware of this deficient practice by the survey team during the survey process. The facility denied knowledge of the missed PT/INR prior to the survey. Resident #14 was admitted to the facility on [DATE] with a PT/INR ordered to be obtained on [DATE]. The order was not transcribed to the lab log and the facility failed to obtain the lab as ordered. Resident #14's condition declined and the resident was sent to the local hospital on [DATE]. The PT/INR results obtained in the hospital were high critical on [DATE], which resulted in Resident #14 receiving Vitamin K (used to counteract [MEDICATION NAME] Toxicity) and two units of Packed Red Blood Cells while in the hospital. The Resident #14 expired in the hospital on [DATE] due to [MEDICAL CONDITION]. Findings include: Resident #14 Review of the facility's policy entitled "Laboratory Monitoring Policy", dated ,[DATE], documented "All labs will be completed as ordered by the physician and results obtained and reported to the attending physician or Medical Director. Procedure: (1). Each nursing station will maintain a monthly lab log. The lab log will be divided by days. (2). When an order is received for lab work, the nurse noting the order will record the lab work that was ordered and complete lab slip and put it under correct day. (3). The night shift will check the lab log each night and compare it with orders for that day to make sure all ordered labs were recorded properly for the labs to be drawn the next day. " Record review of Resident #14's closed record revealed local hospital discharge orders, dated [DATE], with an order for [REDACTED]. [REDACTED]. Record review of Resident #14's "lab log" revealed ordered lab for [DATE] was not documented. There was no documented PT/INR results dated [DATE] for Resident #14. Record review of the [DATE] Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] for nine (9) days as ordered by the physician on ,[DATE]-,[DATE]. Record review of the local hospital's lab report for Resident #14 after being transferred to the hospital due to unresponsiveness, revealed a PT of 157.0 High and an INR of 13.4 High Critical on [DATE] after two (2) invalid readings. Interview with the facility Director of Nursing (DON) on [DATE] at 10:30 a.m. revealed that the ordered lab for PT/INR on [DATE] was not collected. The DON stated, " We missed it." The DON stated the facility had looked for the results but could not find it. A statement received from the facility's Administrator on letterhead on [DATE] at 11:25 a.m. stated a PT/INR was not drawn for Resident #14 on [DATE]. Interview with the facility's Medical Director and Resident #14's primary physician on [DATE] at 3:30 p.m. he stated that he "was not sure what happened" or why the lab ordered was not drawn. Interview with Registered Nurse (RN) #1 on [DATE] at 1:36 p.m. revealed the nurse receiving the lab order is the person responsible for noting off the order and placing on lab log. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on [DATE] at 4:05 p.m. A review of the facility's Credible Allegation of Compliance revealed: "This serves as our Credible Allegation for the Incident Involving Resident #14 on [DATE] On [DATE] Resident #14 was admitted to the facility with orders for [MEDICATION NAME] 2.5 mg daily and a PT INR to be drawn on [DATE]. The PT INR was not drawn on [DATE] for Resident #14. Physician #1 was notified that the lab was not done on [DATE] at 3:15 p.m. by the owner of the facility. On [DATE] the Administrative Supervisor reviewed Resident #14's medical record and determined RN #1 had written orders for admission to include an order for [REDACTED]. This order for PT INR was not noted by RN #1 on [DATE] when Resident #14 was admitted to the facility on [DATE]. The Quality Assurance Nurse began in servicing all RNs and LPNs on [DATE] at 3:00 pm on the lab order policy to include: the nurse receiving the order will note the lab order, place the order on the lab calendar for the appropriate date, complete a lab slip, then place the slip in the lab book, the charge nurse will check the lab calendar daily, obtain the labs for that day, and the nurse receiving the lab results will notify the physician and the document the response in the nurses notes. No RN or LPN will be allowed to return to work before receiving in service on policies and procedures for labs as indicated in the above paragraph. On [DATE] at 4:00 pm a Quality Assurance Meeting was conducted with the Administrative Supervisor, Administrator, Director of Nursing, Quality Assurance Nurse, Infection Control Nurse, Registered Dietician, the owner of the facility, and MDS Nurse. It was discussed during the Quality Assurance Meeting that the lab was not drawn for Resident #14 and measures to prevent reoccurrence. Measures to be taken to prevent reoccurrence as discussed are: in servicing all RNs and LPNs on procedures for noting lab orders on [DATE], revising of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses to schedule labs when ordered, reviewing all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], auditing lab orders twice weekly beginning [DATE] by the Quality Assurance nurse to ensure labs have been completed and results are placed in the medical record by the Quality Assurance Nurse for the next 90 days, and the Quality Assurance Nurse will report findings from lab audits at the monthly Quality Assurance Meeting. On [DATE] at 5:00 pm the Restorative Nurse started a lab calendar and placed it at one of the two nursing stations which is centrally located in the facility. On [DATE] at 5:00 pm the administrative nursing staff began review of all resident medical records for accuracy of physicians' orders, care plans and labs. Seventy-five of seventy five medical records were reviewed. Residents #10 and #16 are identified as receiving [MEDICATION NAME]. There were no negative outcomes noted for Residents #10 and #16. No further discrepancies were identified. On [DATE] the facility Administrator contacted the Medical director at 6:00 pm to discuss the minutes from the Quality Assurance Meeting held on [DATE] at 4:00 pm. The Medical Director agreed with measures to prevent reoccurrence and made no further recommendations. On [DATE] at 6:30 pm a formal investigation was conducted by the Administrative Supervisor. During this formal investigation on [DATE] at 6:30 pm the following were also present- administrator, Director of Nursing, Data Entry Nurse, Quality Assurance Nurse, owner of facility and RN #1. RN #1 stated she had checked the admission orders [REDACTED]. RN #1 stated that her understanding is any lab not ordered STAT is scheduled by the data entry nurse. During the formal investigation RN #1 was educated by the Administrative Supervisor on proper procedures for noting physician orders [REDACTED]. RN #1 verbalized her understanding of procedure for noting lab orders. RN#1 was counseled by the Director of Nursing on [DATE] at 7 pm for failure to note orders for Resident #14 on [DATE]. On [DATE] at 7:00 pm the Consulting Pharmacist arrived at the facility. The Director of Nursing discussed the incident concerning Resident #14 with the Consulting Pharmacist. The Consulting Pharmacist reviewed Resident #14, #10 and #16 medical records and made no further recommendations. Quality Assurance nurse will audit lab orders twice weekly beginning [DATE] to ensure labs have been completed and the results have been placed in the medical record. The findings will be presented at the monthly QA meetings. The QA committee will make recommendations for changes and corrective actions as needed. This deficient practice has the potential to affect all residents. The facility feels this immediate jeopardy was removed on [DATE] at 11:35 pm." The surveyor validated the corrective actions taken by the facility as follows: The survey team validated the inservice information that was given to all RNs and LPNs at in-services beginning on [DATE] was reviewed for content regarding policy and procedure for obtaining lab. The QA meeting sign in sheet dated [DATE] at 4:00 p.m. were validated by review. It was confirmed that the Administrative Supervisor, Administrator, DON, QA Nurse, Registered Dietician, the facility owner and the MDS nurse attended the meeting. Validation was made of the discussion during the QA Meeting related to the lab not being drawn for Resident #14 and measures to prevent reoccurrence were also discussed. Action plan discussed to prevent reoccurrence as discussed included: in-service of all RNs and LPNs on procedures for noting lab orders on [DATE], revision of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses to schedule labs when ordered, review of all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], audit all lab orders twice weekly beginning [DATE] by the QA nurse for the next 90 days, and the QA nurse to report findings from lab audits at the monthly QA meeting. The survey team validated the corrective action taken by QA. In a review of a signed statement from the facility administrator it was validated by the survey team that a discussion with the Medical Director at [DATE] at 6:00 p.m. regarding the Quality Assurance Meeting that was held on [DATE] at 4:00 p.m. This document addressed the discussion of the revision of the current lab policy and measures the facility would take in order to prevent reoccurrence. This document also noted the facility would place all labs on a calendar and the QA nurse would audit the lab orders twice weekly to ensure labs were completed, and the results were placed in the medical record for the next 90 days. The QA Nurse would report findings at the next monthly QA meeting. This document noted that the Medical Director had no further recommendations. The lab calendar on the "400 unit" nurses station with labs to be drawn was validated on [DATE] at 4:30 p.m. This is noted to be at a central location within the facility. The surveyor validated the pharmacy consultant's visit on [DATE] by review of the pharmacist documentation on Resident #14's, #10's and #16's medical record. Review of a signed statement by the facility DON on [DATE] noted that the Consulting Pharmacist arrived at the facility on [DATE] at 7:00 p.m. and reviewed the charts of Resident #14, Resident #10 and Resident #16 for residents receiving or had received [MEDICATION NAME] Therapy with no further recommendations made. The survey team conducted interviews with all RNs/LPNs on [DATE] at 6:15 p.m. and validated that all nursing staff had been in-serviced on procedures for noting lab orders and the revision of the lab order policy. An acceptable Allegation of Compliance (AoC) was received on [DATE] at 4:05 p.m., which alleged removal of the Immediate Jeopardy on [DATE] at 11:35 p.m. The State Agency confirmed on [DATE] that the facility removed the Immediate Jeopardy on [DATE] at 11:35 p.m., as stated in the facility's AOC. Therefore, the Immediate Jeopardy was lowered to the scope and severity of "D" at 42 CFR 483.75 Administration (F-502), while the facility monitors the effectiveness of systemic changes and quality assurance activities.

Based on observation, interview, record review and facility policy review, (A) The facility failed to maintain accurate medical records for one (1) of three (3) residents receiving anticoagulant therapy, from a total of 19 residents reviewed (Resident #14), resulting in an Immediate Jeopardy. The facility was not aware of the deficient practice until notified by the surveyor. On [DATE], Resident #14's [MEDICATION NAME] Time (PT)/International Normalized Ratio (INR) obtained at the hospital was high critical at PT: 157 and INR: 13. On [DATE], Resident #14 was administered Vitamin K (used to counteract [MEDICATION NAME] Toxicity) intramuscularly. On [DATE] Resident #14's Hemoglobin was 7.4 and Hematocrit was 22. On [DATE], Resident #14 was given two units of Packed Red Blood Cells (PRBC). Resident #14 died on [DATE] at the local hospital due to [MEDICAL CONDITION]. (B) The facility also failed to maintain accurate medical records related to inaccurate physician orders for two (2) of 19 records reviewed. (Resident # 6 and Resident # 10) Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status was unable to be completed. The resident was transferred to the hospital on [DATE]. Record review of Resident #14's closed record revealed an admission physician's order, dated [DATE], received by Registered Nurse (RN) #1 for a PT/INR to be obtained on [DATE]. Record review of the facility's "lab log" revealed no entry for [DATE] for Resident #14's PT/INR to be obtained. Record review revealed no lab for PT/INR was obtained for Resident #14 on [DATE] as ordered on admission to the facility. Review of the [DATE] cumulative (monthly) physician's orders failed to document the order for a PT/INR for [DATE] for Resident #14. Interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m. confirmed the lab order was not transcribed onto the lab log for Resident #14's PT/INR to be obtained on [DATE] and that the PT/INR was "missed". Interview with RN #1 on [DATE] at 1:36 p.m. revealed, "At that time when she (Resident #14) came in, I thought if it (order for [DATE]) was not a now lab that it (the lab) went with the original admission orders [REDACTED]." The facility's Physician Orders Policy, dated ,[DATE], read: Orders should be place on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility submitted an acceptable Allegation of Compliance related to the Immediate Jeopardy (IJ) on [DATE] at 4:05 p.m. A review of the facility's Credible Allegation of Compliance revealed: "This serves as our Credible Allegation for the Incident Involving Resident #14 on [DATE] On [DATE] Resident #14 was admitted to the facility with orders for [MEDICATION NAME] 2.5 mg daily and a PT INR to be drawn on [DATE]. The PT INR was not drawn on [DATE] for Resident #14. Physician #1 was notified that the lab was not done on [DATE] at 3:15 p.m. by the owner of the facility. On [DATE] the Administrative Supervisor reviewed Resident #14's medical record and determined RN #1 had written orders for admission to include an order for [REDACTED]. This order for PT INR was not noted by RN #1 on [DATE] when Resident #14 was admitted to the facility on [DATE]. The Quality Assurance Nurse began in servicing all RNs and LPNs on [DATE] at 3:00 pm on the lab order policy to include: the nurse receiving the order will note the lab order, place the order on the lab calendar for the appropriate date, complete a lab slip, then place the slip in the lab book, the charge nurse will check the lab calendar daily, obtain the labs for that day, and the nurse receiving the lab results will notify the physician and the document the response in the nurses notes. No RN or LPN will be allowed to return to work before receiving in service on policies and procedures for labs as indicated in the above paragraph. On [DATE] at 4:00 pm a Quality Assurance Meeting was conducted with the Administrative Supervisor, Administrator, Director of Nursing, Quality Assurance Nurse, Infection Control Nurse, Registered Dietician, the owner of the facility, and MDS Nurse. It was discussed during the Quality Assurance Meeting that the lab was not drawn for Resident #14 and measures to prevent reoccurrence. Measures to be taken to prevent reoccurrence as discussed are: in servicing all RNs and LPNs on procedures for noting lab orders on [DATE], revising of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses' to schedule labs when ordered, reviewing all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], auditing lab orders twice weekly beginning [DATE] by the Quality Assurance nurse to ensure labs have been completed and results are placed in the medical record by the Quality Assurance Nurse for the next 90 days, and the Quality Assurance Nurse will report findings from lab audits at the monthly Quality Assurance Meeting. On [DATE] at 5:00 pm the Restorative Nurse started a lab calendar and placed it at one of the two nursing stations which is centrally located in the facility. On [DATE] at 5:00 pm the administrative nursing staff began review of all resident medical records for accuracy of physicians' orders, care plans and labs. Seventy-five of seventy five medical records were reviewed. Residents #10 and #16 are identified as receiving [MEDICATION NAME]. There were no negative outcomes noted for Residents #10 and #16. No further discrepancies were identified. On [DATE] the facility Administrator contacted the Medical director at 6:00 pm to discuss the minutes from the Quality Assurance Meeting held on [DATE] at 4:00 pm. The Medical Director agreed with measures to prevent reoccurrence and made no further recommendations. On [DATE] at 6:30 pm a formal investigation was conducted by the Administrative Supervisor. During this formal investigation on [DATE] at 6:30 pm the following were also present- administrator, Director of Nursing, Data Entry Nurse, Quality Assurance Nurse, owner of facility and RN #1. RN #1 stated she had checked the admission orders [REDACTED]. RN #1 stated that her understanding is any lab not ordered STAT is scheduled by the data entry nurse. During the formal investigation RN #1 was educated by the Administrative Supervisor on proper procedures for noting physician orders to include: placing lab orders on the calendar, completing the lab slip and placing the lab slip in the lab book for the date scheduled. RN #1 verbalized her understanding of procedure for noting lab orders. RN#1 was counseled by the Director of Nursing on [DATE] at 7 pm for failure to note orders for Resident #14 on [DATE]. On [DATE] at 7:00 pm the Consulting Pharmacist arrived at the facility. The Director of Nursing discussed the incident concerning Resident #14 with the Consulting Pharmacist. The Consulting Pharmacist reviewed Resident #14, #10 and #16 medical records and made no further recommendations. Quality Assurance nurse will audit lab orders twice weekly beginning [DATE] to ensure labs have been completed and the results have been placed in the medical record. The findings will be presented at the monthly QA meetings. The QA committee will make recommendations for changes and corrective actions as needed. This deficient practice has the potential to affect all residents. The facility feels this immediate jeopardy was removed on [DATE] at 11:35 pm." The surveyor validated the corrective actions taken by the facility as follows: The surveyor validated the inservice and reviewed the sign in sheets for the inservice beginning on [DATE] and validated the content of the meeting which included the lab order policy to include the procedure for accuracy of medical records when labs are ordered by the physician. The survey team validated the information given to all RNs and LPNs at in-services beginning on [DATE]. The QA meeting was validated by review of the QA meeting sign in sheet dated [DATE] at 4:00 p.m. with the Administrative Supervisor, Administrator, DON, QA Nurse, Registered Dietician in attendance. The facility owner and the MDS nurse confirmed it was discussed during the QA Meeting that the lab was not drawn for Resident #14 and measures to prevent reoccurrence of this incident such as: in-service of all RNs and LPNs on procedures for noting lab orders on [DATE], revision of lab order policy with effective date of [DATE] to include initiating a lab calendar for nurses to schedule labs when ordered, review of all medical records to ensure all labs have been completed as ordered to include but not limited to therapeutic drug levels by administrative nursing staff on [DATE], audit all lab orders twice weekly beginning [DATE] by the QA nurse for the next 90 days, and the QA nurse to report findings from lab audits at the monthly QA meeting. Review by the surveyor of a signed statement from the facility Administrator validated documentation of a discussion with the Medical Director at [DATE] at 6:00 p.m. regarding the Quality Assurance Meeting which was held on [DATE] at 4:00 p.m. This document discussed the revision of the current lab policy and measures the facility would take to prevent reoccurrence. This document revealed the facility would place all labs on a calendar and the QA nurse would audit the lab orders twice weekly to ensure labs were completed, and the results were to be placed in the medical record for the next 90 days. The QA Nurse would report findings at the next monthly QA meeting according to the documentation validated. This document noted no further recommendations by the Medical Director. The surveyor validated on [DATE] that the consultant pharmacist's review of documentation on Resident #14's, 10's, and #16's medical record. Interviews with all RNs/LPNs were completed [DATE] at 6:15 p.m. These interviews validated that all nursing staff had been in-serviced on procedures for noting lab orders and the revision of the lab order policy. An acceptable Allegation of Compliance (AoC) was received on [DATE] at 4:05 p.m., which alleged removal of the Immediate Jeopardy on [DATE] at 11:35 p.m. The State Agency confirmed on [DATE] that the facility removed the Immediate Jeopardy on [DATE] at 11:35 p.m., as stated in the facility's AOC. Therefore, the Immediate Jeopardy was lowered to the scope and severity of "D" at 42 CFR 483.75 Administration (F-514), while the facility monitors the effectiveness of systemic changes and quality assurance activities. Resident #6 Record review of Resident #6's printed Physician Orders for [DATE] did not accurately reflect the prescribed dosage amount for [MEDICATION NAME]. Resident #6's printed Physician Orders for [DATE] revealed an order for [REDACTED]. The printed order stated 0.5 mg as the dosage, not the correct dosage of [MEDICATION NAME] 5 mg. Interview on [DATE] at 11:35 a.m. with the Director of Nursing (DON) revealed that she thought the [MEDICATION NAME] order was transcribed wrong. Record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #6's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating Resident #6 was moderately cognitively impaired. Resident #10 Review of "Physician's Orders for Admission", dated [DATE], read: "Lab: CBC (complete blood count) Q (every) Year, CMP (Comprehensive Metabolic Profile) Q year, BMP (Basic Metabolic Profile) Q 6 months, HgbA1C (Glycated Hemoglobin) Q 3 months, PT-INR ([MEDICATION NAME] Time-International Normalized Ratio) Q month, H & H (Hemoglobin and Hematocrit) Q 6 months and Mg (Magnesium) level Q 6 months." Review of cumulative, printed "Physician Orders for the month of [DATE]" did not include any lab orders. There were no physician orders to discontinue the labs that were ordered on admission to the facility. Interview on [DATE] at 4:25 p.m. with Licensed Practical Nurse (LPN) #2, stated, "I put those orders for lab in the computer but I don't know why the lab didn't show up; everything else is on the printed sheet; see, the diet, side rails, everything but lab." Interview on [DATE] at 10:05 a.m. with LPN #1 stated, " I can promise that her PT/INR would not have been missed." LPN #1 explained the lab log procedure. Review of the facility's policy entitled "Medical Records Policy" dated ,[DATE] read: "A Medical Record must be treated as a legal document. All charting must be factual. All entries must be signed by person making entry. The following points are important: 2. Orders are transferred to Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]." Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's cognitive status on the Initial Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed that Resident #10's Brief Interview for Mental Status (BIMS) score was 15 that indicated Resident #10 was cognitively intact.

CI MS #8947 Based on observation, record review, policy review and staff interview the facility failed to ensure that facility was administered in a manner to ensure that one (1) of six (6) residents reviewed did not leave the facility on 12/26/10 without staff knowledge or supervision (Resident #1). Resident #1 had a history of [REDACTED]. Resident #1 left the facility without staff knowledge and supervision on 12/26/10. The last time Resident #1 was seen in the facility by Registered Nurse (RN) #1 was a little after 9:00 a.m. Resident #1 was found off the facility premises at the hospital. The route from the facility to the hospital was measured as 1.8 miles on Highway 26 E / Central Ave. Resident #1 was returned to the facility around 10:00 a.m. by Deputy #1. The facility's failure to adequately supervise Resident #1 who was identified to be at risk for wandering put Resident #1 at risk for harm, impairment, serious injury and/or death. These actions were deemed as Substandard Quality of Care and an Immediate Jeopardy (IJ) on 1/7/11 at 12:18 p.m. to begin on 12/26/10 through 12/29/10 when Resident #1 left the building without staff supervision or staff knowledge. The Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 12/30/10 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's QA to evaluate the corrective actions. Findings Include: Cross refer findings to F-323 for the facility's failure to ensure that Resident #1 did not remove his wanderguard and leave the facility without staff knowledge and supervision. The facility provided the following Credible Allegation of Compliance on 01/07/11: "Resident #1 was returned at 10 am on December 26, 2010 by county deputy #1. Resident #1 was fully assessed by RN #1 who took vital signs and checked resident #1's condition and noted no signs of distress. RN #1 asked Resident #1 where wanderguard was and resident #1 stated, "I pulled it off and threw it in trash." DON was notified December 26, 2010 at 9:58 am and was told by LPN #1 of resident #1 returned from hospital. DON notified administrator #1 of occurrence December 26, 2010. DON instructed LPN #1 to locate wanderguard. LPN #4 instructed housekeeper #1 to look in trash. The wanderguard was located in trash in resident #1's room and turned in to LPN #4, who verified it was the armband resident #1 had been wearing. The armband was still functional, but band had been stretched. RN #1 verified all doors were operational and locked December 26, 2010. No malfunctions were found. LPN #4 replaced the wanderguard on left ankle making it more difficult to be removed by resident #1 December 26, 2010 at 10 am. Resident #1 has chronic back pain due to [MEDICAL CONDITION] disk disease and has difficulty bending down. LPN #1 and LPN #4 talked to spouse (responsible party) in resident #1's room December 26, 2010 around 11 am and explained what they knew about the situation. On December 26, 2010, medical director was notified about elopement at approximately 10:50 a.m. On Monday, December 27, 2010, investigation of incident began by DON. DON talked to spouse (responsible party) that morning with administrator #2. Spouse (responsible party) said that resident 31 left the facility to go to Biloxi VA. DON began interviewing staff and taking statements from the aforementioned nurses. On December 28, another wanderguard was placed on resident #1 with a double band per recommendation of wanderguard manual. On December 28, the administrator #1 called sheriff department and requested to speak to deputy on duty the morning of December 26. Administrator #1 left message for deputy to return the call. Administrator #1 left name and telephone number. On December 28, 2010, Deputy #1 called and stated would meet later in afternoon as was not on duty. Deputy #1 arrived to facility at approximately 4 p.m.. Deputy #1 explained that he was familiar with resident #1 and had received several calls from resident #1's residence. Deputy #1 stated that he verified home and hospital to see if he had come from those locations. Deputy #1 stated that the hospital called facility and determined that was a resident at Azalea Gardens Nursing Center. The statements from deputy #1 verify that resident removed wanderguard of own violation and that resident #1 was not physically harmed and condition was good. All facility staff including nursing staff, housekeeping, laundry, dietary and office, on duty December 29 and December 30 was in-serviced at 2:15 p.m. by administrator #1 and DON on elopement policies, wanderguard door policies, monitoring of all residents with wanderguards, visual monitoring, and Abuse and Neglect and Exploitation Policies. The notebooks on elopement risks, which are kept at both nurses stations, were reviewed and staff discussed the residents deemed at risk. There were 15 other wandering risk residents who were assessed with [REDACTED]. If missing resident is not found, local authorities are notified and grounds are searched. In-services on abuse, neglect, resident rights, and dementia was conducted by LPN #3 on December 26, 2010 to all facility staff. No staff was allowed to work until he or she was in-serviced. The elopement book and policies were updated and monitored by QA nurse when assessments on all residents at risk and/or there is a significant change. Mock elopement drills have been conducted several times on the three shifts. Elopement drills were conducted on November 21, 2010 at 1:30 p.m. and December 26, 2010. These drills were conducted by QA nurse, administrators, and/or charge nurses. All exit doors are monitored by nurses q (every) shift to ensure all are working correctly. The log is checked by administrators and QA nurses for completion. Wanderguards are monitored on MAR q shift by nurses for placement and expiration date. Resident's that are at risk of elopement are monitored by QA and RN's on elopement risk sheets. Residents are monitored every 30 minutes if there is an expressed behavior of elopement and every 15 minutes if a resident makes an attempt to elope. If a resident elopes then one on one may be initiated based on resident assessment and needs. Quality Assurance committee met on December 30, 2010 and discussed resident #1, investigation of elopement, policies and procedures of elopement, wanderguard, in-services held, missing persons, and abuse and neglect." The Allegation of Compliance was signed by the Administrator. Based on verification of the implementation of corrective actions by record review, staff interview, inservice review and policy review, the Immediate Jeopardy was removed and the scope and severity was lowered on 12/30/10 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's QA to evaluate the corrective actions.

CI MS #8947 Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of six (6) residents reviewed did not leave the facility on 12/26/10 without staff knowledge or supervision (Resident #1). Resident #1 had a history of [REDACTED]. Resident #1 left the facility without staff knowledge and supervision on 12/26/10. The last time Resident #1 was seen in the facility by Registered Nurse (RN) #1 was a little after 9:00 a.m. Resident #1 was found off the facility premises at the hospital. The route from the facility to the hospital was measured as 1.8 miles on Highway 26 E / Central Ave. Resident #1 was returned to the facility around 10:00 a.m. by Deputy #1. The facility's failure to adequately supervise Resident #1 who was identified to be at risk for wandering put Resident #1 at risk for harm, impairment, serious injury and/or death. These actions were deemed as Substandard Quality of Care and an Immediate Jeopardy (IJ) on 1/7/11 at 12:18 p.m. to begin on 12/26/10 through 12/29/10 when Resident #1 left the building without staff supervision or staff knowledge. The Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on 12/30/10 to a "D" level, which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor the effectiveness of the interventions and to allow the facility's QA to evaluate the corrective actions. Findings Include: On 12/29/10, a complaint call was received by the State Agency alleging a new resident (Resident #1) at Azalea Gardens Nursing Center eloped on Sunday, 12/26/10, and that it was reported in the local county newspaper. Resident #1 got out of the facility and made it all the way down to local county hospital. The police brought Resident #1 back to Azalea Gardens Nursing Center. Review of the article posted in the local county hospital on [DATE], confirmed an article "Patient walks away from nursing center". The article printed that a patient at Azalea Gardens Nursing Center walked away from the facility Sunday after removing a device meant to trigger an alarm (wanderguard). The patient made it to a local hospital, and personnel there contacted the local county Sheriff Department. Review of the Sheriff's Department Incident Report dated 12/29/10 revealed: "Incident type as missing person on hospital premise. Deputy #1 was dispatched to (Name of local County Hospital). The nurse at the hospital called Azalea Garden to see if (Resident #1) might have come from there, and it was determined that he did." Resident #1 told Deputy #1 that he tore his wanderguad off his arm and walked all the way to the hospital. At about 8:45 a.m., Deputy #1 noted that he patrolled through that same area from West 26 to East 26 and did not see anyone walking. Reported that it was very cold that morning and if he would have seen anybody walking that he would have offered them a ride. Deputy #1 returned Resident #1 to Azalea Garden Nursing Center. Phone interview with Deputy #1 on 1/6/11 at 3:13 p.m., confirmed that he picked Resident #1 up around 9:00 a.m. at the hospital. Deputy #1 believes Resident #1 may have gotten a ride, because it was very cold that morning. Deputy #1 stated that it was just too cold for anybody to be walking. Deputy #1 stated that he patrolled through that area a few minutes earlier and did not see anybody. Deputy #1 said that Resident #1 had on sweat pants, some type of undergarment and a flannel shirt. Deputy #1 expressed that Resident #1 was not dressed appropriately for the weather. Deputy #1 returned Resident #1 to the nursing home from the hospital. Observation on 1/7/11 at 9:25 a.m. revealed that from the facility to the hospital was 1.8 miles on Highway 26 E / Central Avenue. Highway 26 is a two (2) lane highway with curves, hills, sharp drop off from the shoulders, railroad track, cemetery, middle school, Catholic Church, business and residential areas on route. The traffic was fairly heavy with cars, motorcycles, and trucks. The weather on 12/26/10 was 40 degrees Fahrenheit (F) as the high. and the low was 27 degrees (F). On 1/4/11, a written report was received by the facility concerning a self reporting of an unusual occurrence involving Resident #1. The written report was submitted by the the Director of Nursing (DON), signed, and dated 12/30/10, which stated the following: "This report is written to comply with the state and federal regulations concerning self reporting of unusual occurrence. (Resident #1) is a [AGE] year old white male admitted to Azalea Gardens Nursing Center on 12/23/10. He was admitted from home by his wife. She selected long term care for him due to his dementia and rapid decline in cognitive abilities, yet he is still able to assist her with many of his ADL's. She reported having to call 911 three times to find him as he had wondered off into the woods and they lived in the rural wooded terrain east of Wiggins. Due to this history (Resident #1) was placed on the Wander Guard alarm bracelet system. Also his picture was taken and placed in the elopement book and upon admission; he was started on the initial 36 hour, every 15 minute monitoring system. After 36 hours he was placed on the thirty minute monitoring system, because he had shown no attempt to leave the building and was adjusting without evidence of problems. His admission [DIAGNOSES REDACTED]. (Resident #1) was very new to us when the following was reported. On 12/26/10 at about 9:50 a.m. someone for (Name of the local county Hospital) telephoned (RN #1) and asked if (Resident #1) was a resident of ours. (RN #1) confirmed he is. They told her that there is a deputy here at the hospital and he will bring (Resident #1) back to Azalea Gardens. Upon his return (RN #1) completed an exam and vital signs; reported resident was without physical signs of a problem or appearance of having been out in the elements. He did not have on the wander guard bracelet. On questioning him about the bracelet, he reported that he had taken it off and put it in the trash. His wander guard bracelet was located by housekeeping in the trash can in his room. On examination it was apparent the bracelet had been stretched out of shape and was then able to be removed. (RN #1) reported that she checked all the doors with the wander guard door check system and that all doors were functional and locked when checked. That there were no alarms going off and there was no indication that any one wearing a Wander Guard bracelet had exited the building. Per reported documentation (RN #1) and his CNA both reported seeing him at 9:30 a.m. the morning of 12/26/10 in his room. Per reported statements he was looking for an attorney to get his wife out of jail, resident experienced delusional thinking. As a process of the investigation (Administrator #1) contacted the Sheriff's Department and requested to speak to Deputy returning resident, who was (Deputy #1). He came in and gave her a report. He reported he had picked up the patient at the hospital and brought him back to facility. Resident was placed on every 15 minute visual monitoring. The Wander Guard bracelet was placed on his ankle to reduce his visual reminder of it. A double band was applied with visual monitoring every 15 minutes, staff monitors the band and the resident. Staff has been in-served on facility policies of Abuse and Neglect and on Elopement and the Wander-Guard System. Wife was notified of incident when she came in facility right after he was returned. Director of Nursing was notified and Administrator was notified by DON; physician was notified and MSDH was notified." Resident #1 Record review revealed that Resident #1, date of birth 4/27/44, was admitted to the facility on [DATE]. Resident #1 had [DIAGNOSES REDACTED]. Resident #1 medications included: Omeprazole (Prilosex) 20 mg EC Cap two (2) po (by mouth) BID (twice a day), Sorbito 70% solution 30 ML (2 TBS) po QOD (every other day), Morphine S04 15 MG IR one (1) tab po Q (every) 8 hr (hours) PRN (as needed), Gabapentn (Neurontin) 300 mg po TID (three times a day), Galantamine Hydrobromide (Razadyne) 8 ms SA 1 po QD (every day), and Paroxetine HCL (Paxil) 40 mg 1 1/2 tabs po QD. Review of the "Progress Notes" printed at another hospital on [DATE] by provider clinic, revealed: "Alzheimer's Disease, increasingly confused and threatening to wife." A note on 12/2/10 by the Mental Health (MH) Nurse Practitioner, revealed: "Resident #1 is here with wife. Wife is fighting back tears as she tells things are worse. Resident #1 is hardly sleeping at all. Hardly knows wife and does not know anyone else. Resident #1 is demanding. Wife has locked all the firearms away because she found him with a loaded 12 gauge shotgun last month. Resident #1 believed there was an intruder and, for an instant, seemed to think she was the intruder. Frightened her greatly." Observation and interview with Resident #1 on 1/6/11 at 1:35 p.m., revealed that Resident #1 is an elderly white, male sitting on bed in the room. Height: 5 ft 6 in; weight is 182 lbs. Resident #1 was ambulatory with a cane, gait unsteady. Resident #1's hearing was poor. Resident #1 wears bifocals. Resident #1 recalled the incident on 12/26/10 and stated he walked all the way to the hospital. Resident #1 stated that it was pretty cold that night. "I don't know why, just something in my head told me to." Resident #1 described that he stretched, stretched, stretched, twisted, twisted, twisted his wanderguard. Resident #1 stated: "I just kept doing it till it came off. It took maybe 8 minutes. I hurt my fingers while doing it too. I don't remember what door I went out of, I think it was one of the side doors." Resident #1 recalled that he was wearing a pair of blue jeans, fleece lined shirt, and house shoes. Resident #1 said that the Sheriff brought him home because he was lost and couldn't find his way home. Review of the Interim Care Plan (12/23/10) for Resident #1 revealed the following: "(11). Falls/Safety Risk/Elopement Risk. Goal: Resident will remain free of injuries and falls. Wander alarm / Wanderguard bracelet." Review of the Care Plan for Resident #1 revealed a Problem Onset date of 12/23/10; "Risk for elopement related to disease process, and new admit." Approaches included: "Wanderguard bracelet for safety, check every shift for presence and expiration date. Alert all staff of wander risk. Reassess every 90 days. Place picture in "At Risk for Wandering Book". Review of the Physician's Telephone Orders revealed: On 12/23/10 "(1) Wanderguard bracelet on. (2) Check on wanderguard every shift." Review of the "Wanderguard System Approval/Refusal" form signed and dated 12/23/10 revealed that Resident #1 agrees/consents to the wanderguard system to monitor for my safety and protection. Review of the "Elopement Risk Screening" form dated 12/23/10, identified Resident #1 as confused, disoriented, and wanders. admitted today. Resident #1 has a history of wandering away from home. Wanderguard put on." Review of the "Pain Evaluation" form dated 12/23/10, profiled Resident #1 taking Morphine in the morning and at night for arthritis, pain in back, and right arm. Origin of pain is arthritis and [DIAGNOSES REDACTED]. Review of the "Fall Risk Evaluation" form dated 12/30/10, scored Resident #1 as a "9" for falls. A resident who scores a "10" or higher is at risk. Consider environmental risk factors in resident's interventions. Review of the Nurse's Notes (NN) for Resident #1 revealed: On 12/25/10 (Christmas Day), "Resident #1 is confused. States, "I need a lawyer. My wife is in jail and they are wanting me too." " Resident #1 complained all day of needing to check out and get a lawyer. Staff members have tried to reorient Resident #1 without results." Interview with Licensed Practical Nurse (LPN) #2 on 1/7/11 at 11:48 a.m., revealed that LPN #2 was Resident #1's nurse on the day of the incident on 12/26/10. LPN #2 arrived to work about 7:00 a.m., and fed residents in the dining room for breakfast. At 8:00 a.m. that morning, Resident #1 was sitting in the sunroom sitting on the couch. LPN #2 stated that on 12/25/10, Resident #1 was wanting to get a lawyer because his wife was in jail. LPN #2 stated that she tried to talk to Resident #1 and inform him that everything was closed on Christmas. Resident #1 told LPN #2 "You're right, I'll wait." LPN #2 stated that Resident #1's wife did not visit that day (12/25/10), while LPN #2 was working. On 12/26/10 at 9:50 a.m. the nursing note written by Registered Nurse (RN) #1, revealed that a hospital staff called the nursing home to inquire if they had Resident #1. The hospital staff stated that Resident #1 was in their lobby. The hospital staff said that Deputy #1 was at the hospital and would bring Resident #1 back to the nursing home. The hospital staff stated that he had a name tag on but did not have a wanderguard on. On 12/26/10 at 10:00 a.m., RN #1 wrote in the nursing notes: "rechecked all the doors with wanderguard checks. The doors were all working. Resident #1 returned to the nursing home at 10:15 a.m., accompanied by Deputy #1. Resident #1 was alert and oriented to person. Resident #1 told RN #1 that he was at the VA hospital and walked back because he had no car. Resident #1 did not have a wanderguard on. The Resident #1 said he took it off and threw it in the garbage. Resident #1 denies any pain or discomfort. Skin is warm, dry, no bruising or red area on his skin. Vital Signs (VS) T-97.3, P-80, and BP-130/80." Nursing notes on 12/26/10 at 10:00 a.m. (on a separate Nurse's Note by LPN #4), documented that Resident #1 removed wanderguard bracelet and threw it in the trash can in his room. Replaced wanderguard on left ankle. Interview with LPN #4 on 1/6/11 at 4:15 p.m., revealed that LPN #3 was the Weekend Charge Nurse on 12/26/10. LPN #4 notified the DON, the physician, and the RP. LPN #4 stated that RN #1 received a phone call from the hospital about a quarter to 10:00 a.m. wanting to know if Resident #1 was a resident of the facility. Around 10:00 a.m. on 12/26/10, the Deputy #1 brought Resident #1 back to the facility. A wanderguard was replaced on Resident #1's left ankle. Another nursing note on 12/26/10 at approximately 10:00 a.m. by LPN #1, documented that staff called the Director of Nursing (DON) and informed her of the situation. LPN #1 saw Resident #1 at approximately 8:15 a.m. Wangerguard was intact. Resident #1 was sitting on couch in sunporch. Interview with LPN #1 on 1/6/11 at 4:00 p.m., revealed that LPN #1 was the Medication Nurse on the day of the incident on 12/26/10 stationed on Medication Cart A. LPN #1 stated that she was giving medicines up by the sunporch around 8:00 a.m. - 8:15 a.m. LPN #1 saw Resident #1 on the couch with his legs crossed and he had his walking cane. LPN #1 finished the medication pass on the 200 Hall, came back around, and was informed that Resident #1 was missing about 9:45 a.m. The first thing LPN #1 did was looked in the monitoring book and noted Resident #1 was signed off as being seen at 9:30 a.m. by RN #1. LPN #1 notified the DON. Interview with the DON on 1/7/11 at 3:05 p.m., revealed that on 12/26/10 the DON received a call from LPN #1 saying that the hospital called and said they were bringing Resident #1 back. The DON asked, Why was Resident #1 sent out. LPN #1 explained that the facility did not send Resident #1 out to the hospital. LPN #1 reported that Resident #1 was last seen at 9:30 a.m. The DON notified Administrator #1 with instructions to find out what happened. The DON went around and checked all the doors and noted that all the doors were working properly. Resident #1's wanderguard was found in the trash in his room with the band all stretched out of shape. The facility applied a double band on Resident #1's ankle because he could not get it off as easily due to his back problems. A verbal contract was made by Resident #1 to his wife that he would not leave the premises again. Staff will occasionally remind Resident #1 that he made that promise to his wife. The DON stated that she did not report the occurrence to the State Agency nor the Attorney General's Office with in 24 hours of discovery. The DON was trying to get the 72 hour report in. The DON stated that she just let it slip through the cracks. Review of the "30 Minute Visual Monitoring", "Resident, Visual Monitoring Record", and "Maintenance Log for Door Alarms" were signed off on the designated dates with staff initials. Interview with RN #1 on 1/6/11 at 3:42 p.m. confirmed that the nurses on the med cart usually keep the paperwork. It is not assigned to a particular designated person. Everybody is a back up. The paper work is at the station and you just mark it down. Review of the Social Services Progress Notes for Resident #1 revealed: On 12/29/10 around 1:30 p.m., the Social Worker (SW) asked Resident #1 if he remembered what happened Sunday (12/26/10). Resident #1 had a puzzled expression and said "No". Resident #1 said sometimes he does things he does not understand. Told the SW voices told him to do things he doesn't know why. Review of the Initial Social Service History dated 12/23/10 for Resident #1 revealed: "Resident #1 only has interaction with his wife. Resident #1 has no hobbies or interest. Resident #1 likes to watch TV." Resident #1 was returned at 10:00 a.m. on 12/26/10 by local county Deputy #1. Resident #1 was fully assessed by RN #1 who took vital signs and checked Resident #1's condition and noted no signs of distress. RN #1 asked Resident #1 where the wanderguard was and Resident #1 stated, "I pulled it off and threw it in trash." Interview with RN #1 on 1/6/11 at 3:42 p.m., revealed that she saw Resident #1 a little after 9:00 a.m. RN #1 went to go do some paper work and received a call from the hospital about five (5) to 10 minutes before 10:00 a.m. that they had Resident #1 there. Resident #1 was returned to the facility by Deputy #1 around 10:15 a.m. RN #1 stated that she believed that Resident #1 got a ride. The last time RN #1 says she saw him was at 9:25 a.m. No one else remembers seeing him. RN #1 stated that Resident #1 was dressed in a heavy sweater, medium size coat, and that he had his cane with him. RN #1 stated that morning the weather was very cold. The DON was notified 12/26/10 at 9:58 a.m. and was told by LPN #1 of Resident #1 being returned from hospital. The DON notified Administrator #1 of the occurrence on 12/26/10. The DON instructed LPN #4 to locate the wanderguard. LPN #4 instructed Housekeeper #1 to look in the trash. The wanderguard was located in the trash in Resident #1's room and turned in to LPN #4, who verified it was the armband Resident #1 had been wearing. The armband was still functional, but the band had been stretched. RN #1 verified all doors were operational and locked on 12/26/10. No malfunctions were found. LPN #4 replaced wanderguard on Resident #1's left ankle on 12/26/10 at 10:00 a.m., making it more difficult to be removed. RN #1 stated that Resident #1 has chronic back pain due to Degenerative Disk Disease and has difficulty bending down. LPN #1 and LPN #4 talked to the spouse (Responsible Party) in Resident #1's room on 12/26/10 around 11:00 a.m. and explained what they knew about the situation. Interview with the Medical Director on 1/7/11 at 3:32 p.m., validated that the Medical Director was notified about the elopement on 12/26/10 at approximately 10:50 a.m. On Monday, 12/27/10, an investigation of the incident was initiated by the DON. The DON talked to the spouse (Responsible Party) that morning with Administrator #2. The spouse (Responsible Party) said that Resident #1 left the facility to go to local VA. The DON began interviewing staff and taking statements from the aforementioned nurses. On 12/28/10, another wanderguard was placed on Resident #1 with a double band per recommendation of the wanderguard manual. Interview with the Responsible Party (RP) on 1/6/11 at 3:24 p.m., revealed that she was not initially notified by the facility staff of the incident on 12/26/10 by Resident #1. The RP stated that she went to visit Resident #1 on Sunday. Resident #1 stated telling her that he walked all the way to the VA. The RP asked Resident #1 when did this happen; Resident #1 said, "This morning". The RP asked the nurse on duty and the nurse confirmed the occurrence. The RP stated that Resident #1 has a history of wandering. She had to call 911 three (3) times where they lived prior to Resident being admitted to the nursing home, and the police had to locate Resident #1. The RP stated that the facility has applied the wanderguard bracelet to Resident #1's ankle because he can not bend and twist due to four (4) ruptured disc in his back. At the time of the elopement, the wanderguard bracelet was on Resident #1's left wrist. Resident #1 kept working the vinyl till he got it off of his wrist. Resident #1 is a Marine and he has always protected the RP. The RP stated that Resident #1 thought she was in some type of trouble because she did not visit that day on 12/25/10. On 12/28/10, Administrator #1 called the Sheriff's Department and requested to speak to the deputy on duty the morning of 12/26/10. Administrator #1 left message for Deputy to return the call. Administrator #1 left name and telephone number. On 12/28/10, Deputy #1 called and stated that he would meet later in afternoon because he was not on duty. Deputy #1 arrived to facility at approximately 4:00 p.m. Deputy #1 explained that he was familiar with Resident #1 and had received several calls from Resident #1's residence. Deputy #1 stated that he verified home and hospital to see if he had come from those locations. Deputy #1 stated the hospital called facility and determined that he was a resident at Azalea Gardens Nursing Center. The statements from Deputy #1 verified that Resident #1 removed the wanderguard of own volition and the Resident #1 was not physically harmed and condition was good. All facility staff including nursing staff, housekeeping, laundry, dietary and office, on duty on 12/29/10 and 12/30/10 were in-serviced at 2:15 p.m. by Administrator #1 and the DON on elopement policies, wanderguard door policies, monitoring of all residents with wanderguards, visual monitoring, and Abuse, Neglect, and Exploitation Policies. The notebooks on elopement risks, which are kept at both nurses stations, were reviewed and staff discussed the residents deemed at risk. There were 15 other wandering risk residents who were assessed with [REDACTED]. If missing resident is not found, local authorities are notified and grounds are searched. In-services on abuse, neglect, resident rights, and dementia were conducted by LPN #3 on 12/26/10 to all facility staff. No staff were allowed to work until he or she was in-serviced. The elopement book and policies were updated and monitored by QA Nurse when there is a change in status of resident or there is a new assessment. QA Nurse does quarterly assessments on all residents at risk and/or there is a significant change. Mock elopement drills have been conducted several times on three (3) shifts. Elopements drills were conducted on 11/21/10 at 1:30 p.m. and 12/26/10. These drills were conducted by QA Nurse, Administrators, and/or Charge Nurses. All exit doors are monitored by nurses every shift to ensure all are working correctly. The logs are checked by Administrators and QA Nurses for completion. Wanderquards are monitored on the MAR every shift by nurses for placement and expiration date. Resident's that are at risk of elopement are monitored by QA and RN's on elopement risk sheets. Residents are monitored every 30 minutes if there is an expressed behavior of elopement and every 15 minutes if a resident makes an attempt to elope. If a resident elopes, then one (1) on one (1) may be initiated based on resident assessment and needs. The Quality Assurance Committee met on 12/30/10 and discussed Resident #1, investigation of elopement, policies and procedures of elopement, wanderguard, in-services held, missing persons, and abuse and neglect. Review of the "Wander-guard Policy Process for Initiation", effective 5/11/10. revealed: "If the resident presents as a risk for elopement a wander-guard will be placed on his/her wrist or ankle. Explanation of the wander-guard is explained to responsible party upon admission. At that time permission is obtained to use the wander-guard. physician's orders [REDACTED]. Family is notified of order and of the placement of wander-guard. Order is placed on the MAR. Wander-guard will be added to Plan of Care and CNA Care Plan. Wander-guard is checked by staff every shift for placement on resident. Placement and monitoring of expiration date is verified by nursing and signed on MAR every shift. Resident photo will be placed in Elopement Risks and Policies notebook located at Nurse's station." Review of the "Wander Guard Utilization" effective 5/11/10, revealed: "Placement of Bracelet - Each resident monitored by the Wander Guard system will have a bracelet. Place the bracelet on resident's wrist, preferably or ankle, leaving enough room for two fingers to fit between bracelet and wrist. use scissors to cut off excess bracelet. Do not place on wrist with jewelry. This could affect signaling device (alarm). The doors alarmed with the Wander Guard system can be locked or unlocked by pressing the code." Review of the "Elopement Risk Screening Policy", effective 5/27/10, revealed: "It is the facility's policy that the elopement risk screening form will be utilized as follows: Completed on all residents upon admission. Residents identified at risk will be care planned for potential elopement. Updated quarterly and with any significant change. Completed by a licensed nurse." Review of the "Elopement Policy", effective 5/10, revealed: "Elopement is considered to be when a resident (confused or alert) attempts to leave the facility and is successful in his/her attempt. Facts to consider: An injury may or may not occur with elopement. Anytime the resident is successful in getting off the facility premises, this is considered to be an elopement. If a resident leaves the facility and remains off the premises, but is in a potentially dangerous situation such as: In the maintenance shop, by a busy road... this should be investigated and reported due to the safety factor involved. Reporting: Elopement is considered to be an occurrence which should be reported to the Physician, Family, State Department of Health, and Attorney General." Review of the "Potential Elopement Risk and Resident Visual Monitoring Record Policy", effective 5/10, revealed: "To monitor the whereabouts of wandering, disoriented residents visually monitor every 2 hours. If an elopement is attempted Visual Monitoring Record is initiated. Initialed every 15 minutes on residents who attempt or achieve elopement. Monitor until resident makes no attempt to elope in 36 hours. Every hour for additional 24 hours. Completed by Licensed nurses on Visual Monitoring Record. Maintained at the nurses desk until completion. Placed in the resident' medical record. Reminders: Report all attempts of elopement to the Director of Nursing and the Administrator. Document on 24 hour report, office and nursing logs." Review of the 24 hour report, validated that Resident #1's elopement incident was documented on 12/26/10 (Sunday) on the 7-3 shift. The report documented that Resident #1 was on every 15 minutes monitoring related to the elopement. Resident #1 removed the wanderguard bracelet. He went to the hospital. Returned by Deputy #1 with no distress. The wanderguard was found in the trash can in his room. The facility staff placed a new wanderguard on Resident #1's left ankle with every 15 minute visual monitoring. Review of the "Residents' Free From Abuse Policy", effective 1/1/07, revealed: "It is the facility's policy that all resident will be free from physical, mental and/or verbal abuse. If an actual incident occurs, the occurrence should be reported to the State Department of Health and the Attorney General's Office." Review of the "Abuse, Neglect, or Exploitation Policy", effective 1/1/07, revealed: "The complaint must be reported to the State Department of Health, to the Medicaid Fraud Control Unit (Attorney General), By phone: 1. Within 24 hours of discovery. 2. Excluding Saturdays, Sundays and Holidays. In writing: 1. Within 72 hours of discovery." The facility's failure to adequately supervise Resident #1 who was identified to be at risk for wandering put Resident #1 at risk for harm, impairment, serious injury and/or death. These actions were deemed as Substandard Quality of Care and an Immediate Jeopardy on 1/7/11 at 12:18 p.m. to begin on 12/26/10 through 12/29/10 when Resident #1 left the building without staff supervision or staff knowledge. The facility provided the following Credible Allegation of Compliance on 01/07/11: "Resident #1 was returned at 10 am on December 26, 2010 by county deputy #1. Resident #1 was fully assessed by RN #1 who took vital signs and checked resident #1's condition and noted no signs of distress. RN #1 asked Resident #1 where wanderguard was and resident #1 stated, "I pulled it off and threw it in trash." DON was notified December 26, 2010 at 9:58 am and was told by LPN #1 of resident #1 returned from hospital. DON notified administrator #1 of occurrence December 26, 2010. DON instructed LPN #1 to locate wanderguard. LPN #4 instructed housekeeper #1 to look in trash. The wanderguard was located in trash in resident #1's room and turned in to LPN #4, who verified it was the armband resident #1 had been wearing. The armband was still functional, but band had been stretched. RN #1 verified all doors were operational and locked December 26, 2010. No malfunctions were found. LPN #4 replaced the wanderguard on left ankle making it more difficult to be removed by resident #1 December 26, 2010 at 10 am. Resident #1 has chronic back pain due to degenerative disk disease and has difficulty bending down. LPN #1 and LPN #4 talked to spouse (responsible party) in resident #1's room December 26, 2010 around 11 am and explained what they knew about the situation. On December 26, 2010, medical director was notified about elopement at approximately 10:50 a.m. On Monday, December 27, 2010, investigation of incident began by DON. DON talked to spouse (responsible party) that morning with administrator #2. Spouse (responsible party) said that resident 31 left the facility to go to Biloxi VA. DON began interviewing staff and taking statements from the aforementioned nurses. On December 28, another wanderguard was placed on resident #1 with a double band per recommendation of wanderguard manual. On December 28, the administrator #1 called sheriff department and requested to speak to deputy on duty the morning of December 26. Administrator #1 left message for deputy to return the call. Administrator #1 left name and telephone number. On December 28, 2010, Deputy #1 called and stated would meet later in afternoon as was not on duty. Deputy #1 arrived to facility at approximately 4 p.m.. Deputy #1 explained that he was familiar with resident #1 and had received several calls from resident #1's residence. Deputy #1 stated that he verified home and hospital to see if he had come from those locations. Deputy #1 stated that the hospital called facility and determined that was a resident at Azalea Gardens Nursing Center. The statements from deputy #1 verify that resident removed wanderguard of own violation and that resident #1 was not physically harmed and condition was good. All facility staff including nursing staff, housekee