Every finding on record at Creekwood Nursing & Rehabilitation

Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 85 of the facility's 86 residents who consumed food from the kitchen. Observation of the walk-in freezer revealed multiple food items in their original containers but were not sealed or dated when opened. The findings include: Review of facility's undated policy titled, Food Receiving and Storage, revealed foods should be received and stored in a manner that complies with safe food handling practices. Further review revealed all foods stored in the refrigerator or freezer would be covered, labeled, and dated (use-by date). Continued review revealed wrappers of frozen foods must remain intact until thawing. Observation of the kitchen, on 10/29/2024 at 11:20 AM, with the Dietary Manager (DM) of the walk-in freezer revealed the food items were in the original boxes and packaged inside large plastic bags. However, the boxes and packages had been opened but were not sealed or dated when opened. These opened items included bulk foods of cookie dough, broccoli, western style beef patties, and mixed vegetables (which had a scoop lying inside the box on top of the vegetables). Further observation revealed multiple bags of tater tots in its original container with one package that had been opened and half of the bag used, but was not sealed or dated when opened replaced into the original container. During an interview on 10/29/2024 at 11:50 AM, the DM stated he was aware that food items were to be labeled, dated, and sealed to ensure there was no contamination. He further stated that residents could get sick from exposed food items and could be worse for residents who had compromised immune systems. The DM stated he would use the situation as a teachable moment for all dietary staff to ensure they were educated on the facility's policy and procedure related to proper food storage and how resident's health could be affected if those policies were not followed. During an interview on 10/31/2024 at 11:30 AM with [NAME] (C) 2, she stated she worked in the facility in the dietary department for eight years. She stated when foods were stored in the freezer and the open boxes should include the opened date and use-by-date. C2 stated if the box contained individually sealed packages. those opened packages were resealed and dated when opened as well as sealing the box. She further stated when bulk items were opened and stored back in the freezer, the plastic bag and the box were both resealed. Per C2, she was aware that if staff were not following the facility's policy on food storage that resident's could get sick. She further stated food could be freezer burned and residents had complained before about food not tasting good. She stated she did not want to provide food that the residents did not like. In an interview on 10/31/2024 at 11:40 AM, C3 stated she had been a cook at the facility for four years. She stated all open boxes should be sealed and dated when the boxes/packages were opened. She stated the staff had used scoops to get the amount needed but staff should never leave a scoop in with the food to prevent potential cross contamination. She stated all food items were to be rotated which was why the dates were important to ensure they were serving quality meals. She stated resident could get sick if staff had not followed the facility's policy and procedures related to food storage and the resident would be unhappy with food that had been freezer burned. She stated the facility had wanted to serve residents the best food and ensure any concerns with their meals were resolved because it was all about the residents receiving the best quality care. During a second interview with DM, on 10/31/2024 at 11:50 AM, he stated his expectations was for staff to ensure the boxes that were opened had been properly sealed and dated when opened. He further stated that moving forward he would ensure the staff understood the importance of residents receiving quality food service. In an interview with the Administrator, on 10/31/2024 at 4:05 PM, she stated her expectations for dietary staff would be to follow the protocols the facility had established for food safety.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one of one residents (Resident (R) 81) reviewed who received tube feeding. Observation and interview on 10/30/2024 at 3:02 PM revealed Certified Nurse Aide (CNA) 2 had detached and placed R81's feeding pump on hold while she gave resident care which was not within her job description. The findings include: Review of the facility policy, Care and Treatment of Feeding Tubes, revised 05/31/2023, revealed It was a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Review of the Certified Nursing Assistant Job Description, dated 2018 revealed a commitment to promoting wellness, healing, and independence for all the lives a CNA touches. The summary included to perform direct resident care duties under the supervision of licensed nursing personnel. Review of essential duties and responsibilities revealed the CNA was to assist nursing staff with the basics of aseptic and sterile techniques to avoid infection of residents. Further review revealed the CNA's responsibilities did not include detaching and/or placing on hold a resident's feeding tube/pump. Review of the CNA 2's current learning/education list revealed no education on the use of feeding tube pumps or with resident tube feedings. Review of R81's medical record revealed the facility admitted the resident on 08/28/2024 with diagnoses which included cerebral ischemia (stroke), acute respiratory failure, persistent vegetative state after a traumatic brain injury from a motor vehicle accident, and gastrostomy (feeding tube) status. Review of the Admission Minimum Data Set (MDS) with Assessment Reference Date of 09/01/2024 revealed the resident was of a persistent vegetative state. On 10/30/2024 at 3:02 PM, CNA2 and CNA12 were observed performing incontinent care for R81. The resident was in a supine position with the head of bed flat. The resident's gastrostomy tube (G-tube) was detached from the resident. Observation revealed the tubing was coiled on top the feeding tube pump with no cap in place at the end of the tubing and the pump was set on hold. CNA2 stated the nurse had unhooked the feeding tube. As the pump started to alarm, CNA2 stated it would alarm until the nurse hooked the pump tubing back up to the resident. During an interview on 10/30/2024 at 3:06 PM with Registered Nurse (RN) 1 at the nurses station, she stated she did not detach R81's gastrostomy tube and she was the only nurse working this unit. She also stated when she detaches a gastrostomy tube, she caps the end of the tubing so it stays clean. During an interview 10/30/2024 at 3:12 PM, CNA2 stated she had unhooked R81's feeding tube. CNA2 stated she knew the nurse was busy and did not want to bother her so she unhooked it herself. She further stated she had not been educated on unhooking the tube feeding or on the use of the feeding tube. CNA2 stated she knew she was not supposed to detach the tube or place the pump on hold. During an interview on 10/31/24 at 12:30 PM, Licensed Practical Nurse (LPN) Staff Development Coordinator (SDC) stated she had been working as the SDC since the end of August 2024. She stated the orientation packet for CNAs did not include anything about gastrostomy tube care because CNAs are unable to care for the gastrostomy tubes. LPN/SDC further stated she verbally told them during orientation that residents with G-Tubes (Gastrostomy tubes) were to have their head of bed (HOB) elevated 30 to 45 degrees and if there was any concern about the tube to tell their nurse. She stated her expectations was for the CNA to keep the resident's HOB elevated and to watch for any complications of the tube; however, CNAs are not to touch the tube. During an interview with the Director of Nursing (DON) on 10/31/2024 at 2:48 PM, she stated she expected the CNAs to follow the facility policy and the CNA job description which does not include the care of gastrostomy tubes. She further stated only nurses could change, continue, or terminate feedings. Per the DON, staff receive inservices and orientation regarding management of feeding tubes. The DON stated CNAs were educated to not touch the tube or turn it off/on. During an interview on 10/31/24 at 3:57 PM, the Administrator stated CNAs should not touch or turn off a feeding tube per the facility policy.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure an account of all controlled drugs was maintained and reconciled for two of 14 residents (Residents (R) 3 and R41) who received narcotic medications in the facility. The findings include: Review of the facility policy, Medication Administration revised 02/20/2024, revealed medications were administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy further revealed that if the medication were a controlled substance, staff were to sign the narcotic book. Per the policy, staff were to correct any discrepancies and report to the nurse manager. Review of the facility policy, Disposal of Medications and Medication-Related Supplies revealed Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal and state laws and regulations. The Director of Nursing, in collaboration with the consultant pharmacist is responsible for the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. When a dose of a controlled medication was removed from the container for administration but refused by the resident or not given for any reason, it was not placed back in the container. The medication would be destroyed in the presence of a licensed nurse and disposal was documented on the accountability record/book on the line representing that dose. Review of R41's facility face sheet revealed the resident was admitted on [DATE] with diagnoses which included, chronic obstructive pulmonary disease, rheumatoid arthritis and traumatic subdural hemorrhage. Review of the physician order with a start date of 08/27/2024 revealed an order for Tramadol 50 milligrams (a schedule IV narcotic) to be taken every six hours as needed for pain. Review of the Medication Administration Record (MAR) for R41 revealed the Tramadol 50 milligrams was administered to R41 at 9:00 PM on 10/29/2024. On 10/30/2024 at 3:18 PM an observation with Kentucky Medical Assistant (KMA) 4 with medication cart 300 B (the 300 unit had 2 medication carts. A and B) revealed a discrepancy with the narcotic count for R41. The count of the Tramadol 50 milligrams was twenty-two tablets; however, the count sheet or sign out record showed there were twenty-three available. KMA4 stated she must have overlooked that count at 2:00 PM today when she and KMA1 counted. During further interview, KMA4 stated when she did the count at 2:00 PM on 10/30/2024 with KMA1, she should have noted the discrepancy. She stated she was looking at the medications and KMA1 was reviewing the sign out records for the narcotics. She stated it was hard to see the tablets in the medication card especially when the medication was the same color as the card and when the tablets were small. During an interview on 10/31/2024 at 9:40 AM, KMA1 stated she counted narcotics with RN2 at 6:00 AM on 10/30/2024; however, she did not notice the discrepancy at that time. She further revealed she counted with KMA6 at 2:00 PM when she left the facility and neither of them noted the discrepancy. Review of R3's medical record revealed the facility admitted the resident on 04/25/2022 with diagnoses which included, schizophrenia, osteoarthritis, and lumbosacral pain. Further review revealed the resident was presently receiving palliative care. Review of R3's physician orders revealed an order for Ativan (lorazepam a Schedule IV drug) 0.5 milligrams per tablet, one tablet three times a day for anxiety. During the observation of Medication cart 300 B with KMA4, the lorazepam 0.5 milligram tablet count was incorrect. The count of tablets were four (4); however, the narcotic count sheet showed there were five (5) tablets available. KMA4 stated, Oh, I wasted one earlier when I dropped it on the floor, headed to the resident's room and I haven't signed it out yet. The surveyor asked whom she wasted it with, she stated, I just picked it up and automatically threw it in the sharps box. She stated she was supposed to waste it with a licensed nurse; however, she just planned to have one sign it later. During an interview on 10/30/2024 at 3:24 PM, the Director of Nursing (DON) stated she expected the staff administering the medication to sign out the medication as the medication was given. She also stated during the narcotic counts, she expected staff to ensure the count and the medication monitoring/control record have the same count. The DON further stated she expected all nursing staff giving narcotic medications to follow the narcotic waste policy as written and to ensure a licensed nurse was used to waste and cosign the narcotic count sheet. During an interview with the Administrator on 10/31/2024 at 3:24 PM, she stated she expected all nursing personnel counting narcotics to ensure the counts match the sign out sheets and if there is a discrepancy, to notify the DON immediately. She further stated she expected nursing staff administering narcotics to follow the facility policy for wasting narcotics as written.

Based on observation, interview, record review and review of the facility policy, it was determined the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of infections for one of 18 sampled residents (Resident (R) 81). Observation and interview on 10/30/2024 revealed Certified Nurse Aide (CNA) 2 detached R81's tube feeding and placed the uncovered/uncapped end on top of the feeding tube pump. The findings include: Review of the facility policy titled Infection Prevention and Control Program, revised on 02/21/2024, revealed the facility had established and maintained 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. The policy explanations and compliance guidelines revealed all staff were responsible for following all policies and procedures related to the program. Staff included employees. All staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Per the policy, all staff shall 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. Review of the Certified Nursing Assistant Job Description, dated 2018 revealed a commitment to promoting wellness, healing, and independence for all lives touched. The summary included that the CNA will perform direct resident care duties under the supervision of licensed nursing personnel. Review of essential duties and responsibilities revealed the CNA was to assist nursing staff with the basics of aseptic and sterile techniques to avoid infection of residents. Review of R81's medical record the facility admitted the resident on 08/28/2024 with diagnoses which included cerebral ischemia (stroke), acute respiratory failure, persistent vegetative state after a traumatic brain injury from a motor vehicle accident, gastrostomy (feeding tube) status. Review of R81's Admission Minimum Data Set (MDS) with Assessment Reference Date of 09/01/2024 revealed the resident was in a persistent vegetative state. On 10/30/2024 at 3:02 PM, CNA2 and CNA12 were observed performing incontinent care for R81. The resident was in a supine position with the head of bed flat. The resident's gastrostomy tube (G-tube) was detached from the resident. The tubing was coiled on top the feeding tube pump with no cap in place at the end of the tubing and the pump was set on hold. CNA2 stated the nurse had unhooked the feeding tube. During an interview on 10/30/2024 at 3:06 PM with Registered Nurse (RN) 1 at the nurses station, she stated she did not detach R81's gastrostomy tube and she was the only nurse working this unit. She also stated when she detaches a gastrostomy tube, she caps the end of the tubing so it stays clean. During a second interview on 10/30/2024 at 3:12 PM, CNA2 stated she had unhooked R81's feeding tube. She stated she knew the nurse was busy and didn't want to bother her so she did it herself. Per CNA2, she had not been educated on use of the feeding tube. She further stated she did not know the tube was to be capped when detached. In an interview on 10/31/24 at 12:30 PM with Licensed Practical Nurse (LPN) Staff Development Coordinator (SDC) she stated she had been working as the SDC since the end of August 2024. She stated the orientation packet for CNAs did not include anything about gastrostomy tube care because CNAs are unable to care for the gastrostomy tubes. She stated she verbally told them during orientation that residents with G-Tubes were to have their head of bed (HOB) elevated 30 to 45 degrees and if there was any concern about the tube to tell their nurse. She stated her expectations was for the CNA to keep the resident's HOB elevated and to watch for any complications of the tube; however, CNAs are not to touch the tube. During an interview on 10/31/2024 at 2:48 PM, the Director of Nursing (DON) stated she expected the CNAs to follow the facility policy and the CNA job description which does not include the care of gastrostomy tubes. She also stated only nurses could change, continue, or terminate feedings. She further stated staff were provided in-services and orientation regarding management of feeding tubes. Per the DON, CNAs are educated to not touch the tube or turn it off and on. The DON stated she expected all nursing staff to cap the end of a gastrostomy tube when temporarily detaching the tubing. She stated this would ensure no contamination of the tubing. On 10/31/24 at 3:57 PM, an interview with the Administrator revealed CNAs should not touch or turn off a feeding tube per the facility policy and should follow the infection control policy as written.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to have an effective system to ensure three (3) of eighty-three (83) sampled residents were free from abuse (Residents #1, #2 and #3). Interviews and review of witness statements, revealed the facility failed to protect Residents #1, #2 and #3 from physical and verbal abuse. Licensed Practical Nurse (LPN) #1 yelled, screamed, and hit Resident #1. She also yelled, taunted and pulled Resident #2's hair and yelled, hit and scolded Resident #3. On 06/24/2021, Resident #3 was in the common area getting something to drink when LPN #1 slapped his/her hand and scolded him/her like a child. On 07/17/2021, Resident #2 was in the common area waiting on breakfast. He/She had a baggie with salt pepper and sugar. LPN #1 saw the bag and grabbed it from Resident #2's hand thinking it was her bag. She argued with Resident #2 and held the bag behind her back and over her head, so the resident could not reach the bag. As Resident #2 was rolling away in his/her wheelchair LPN #1 called him/her a fat cow. The facility allowed LPN #1 to complete her shift on 06/24/2021 and worked the next day. On 07/17/2021, LPN #1 was removed from resident care and suspended. LPN #1 resigned on 07/19/2021. The facility's failure to have an effective system in place to ensure residents were free from abuse, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 09/02/2021, and was determined to exist on 06/24/2021, at 42 CFR 483.12 Freedom from Abuse (F600, F609 and F610). The facility was notified of Immediate Jeopardy on 09/02/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 09/09/2021, with the facility alleging removal of the Immediate Jeopardy, on 09/01/2021. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 09/01/2021. The facility's remaining non-compliance was at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised on 10/2020, revealed it was the policy of the facility to provide protections for the health, welfare and rights of each resident. This included prohibiting and preventing abuse, neglect exploitation, and misappropriation of resident property. 1. Closed record review revealed the facility admitted Resident #1 on 06/01/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Admission assessment dated [DATE], revealed the facility assessed the resident's cognition with the Brief Interview for Mental Status (BIMS) examination. Resident #1 scored six (6) indicating severe cognitive impairment. Resident #1 was discharged from the facility on 07/02/2021. Interviews with Nurse Aides (NA) #3 and #10, on 06/24/2021, at 6:30 PM, revealed they were providing care to Resident #1, who was yelling out and being combative with care. NA #3 and NA #10 stated Licensed Practical Nurse (LPN) #1 came in Resident #1's room yelling and screaming, telling the resident to stop it. The Nursing Assistants stated LPN #1 then smacked Resident #1 on the hand two-three (2-3) times. Review of the facility's investigation summary, dated 06/24/2021 but not signed, revealed that two (2) Nurse Aide Students, NA #3 and NA #10, had witnessed and reported verbal and physical abuse by LPN #1. The Director of Nursing (DON) and the former Administrator had phone interviews with NA #3 and NA #10 to discuss the situation and the NA students stated it was not abuse, but was not appropriate. Interview with NA #3, on 08/25/2021 at 3:25 PM, revealed she and NA #10 were providing care for Resident #1 and he/she was being combative and yelling out. She revealed LPN #1 came in and said, Sometimes you just got to be mean to them. She stated Resident #1 grabbed LPN #1's hand and the LPN started smacking the top of Resident #1's hand and yelling at him/her to let go and stop. NA #3 stated LPN #1 slapped Resident #1's hand two to three (2-3) times. She further stated that Certified Nurse Aide (CNA) #9 came in the room and told LPN #1 to be a littler nicer. NA #3 stated she reported the concern to the Staff Development Coordinator and the Staffing Coordinator. She stated interviews were done by phone with the DON and former Administrator and they wrote out a statement. Review of Nurse Aide #10's witness statement, dated 06/24/2021, revealed NA #10 witnessed LPN #1 yelling at Resident #1 before entering the room. She stated LPN #1 continued yelling and slapped Resident #1's hand. Interview with NA #10, on 08/26/2021 at 10:40 AM, revealed she had asked NA #3 to assist her with Resident #1. NA #10 stated Resident #1 was yelling out before she went into his/her room. She stated LPN #1 slapped the resident's hand before he/she grabbed NA #3's hand and she slapped his/her hand again after he/she grabbed NA #3's hand. She stated the slaps were hard, not taps. NA #10 stated LPN #1's yelling at Resident #1 made him/her more agitated. The NA stated she called the DON and made her aware that LPN #1 had slapped Resident #1's hand. Continued interview on 08/26/2021 at 10:40 AM with NA #10 revealed she witnessed LPN #1 yell at and slap Resident #1's hand when he/she was trying to get something to drink from the drink cart. The NA stated she had a phone interview with the DON and former Administrator, Registered Nurse (RN) #1, NA #3 and CNA #9. She stated she wrote a statement. NA #10 stated she did not see Resident #1 hit LPN #1. She stated LPN #1 was threatening to call the resident's family and tell them how bad he/she was acting. She further revealed that LPN #1 was not removed from resident care or suspended. Review of Certified Nursing Assistant (CNA) #9's witness statement revealed she witnessed LPN #1 yell at Resident #1, using a loud, hateful tone. Further review revealed LPN #1 slapped Resident #1's hand when he/she grabbed LPN #1's wrist. Interview with CNA #9, on 08/27/2021 at 7:28 AM, revealed she had just clocked in for her shift around 6:30 PM. She stated she was walking down the hall and heard someone yelling and realized it was coming from Resident #1's room. She stated she went in and saw NA #3 and NA #10 providing care and LPN #1 was yelling. CNA #9 stated LPN #1's tone was loud and hateful. She further revealed that LPN #1 slapped Resident #1's hand when he/she grabbed LPN #1's wrist. CNA #9 stated LPN #1 wasn't even trying to talk to the resident. CNA #9 reported the incident to RN #1 and she (RN #1) called the DON and Administrator. The CNA stated she had a phone interview and wrote out statements. Interview with Registered Nurse (RN) #1, on 08/31/2021 at 10:27 AM, revealed NA #3, NA #10 and CNA #9 had witnessed and reported to her that LPN #1 had slapped Resident #1's hand. She stated they were providing care when LPN #1 came in the room yelling because Resident #1 was yelling out and being combative. She stated she immediately called the DON. Interview with the Advanced Practice Registered Nurse (APRN), on 08/25/2021 at 9:50 AM, revealed she was made aware of an incident involving Resident #1 and LPN #1. The APRN stated she assessed Resident #1 and saw no bruising or concerns with the resident's hands. She stated she spoke to the DON and was told that LPN #1 had been suspended until the investigation was completed. Interview with the Director of Nursing (DON), on 08/30/2021 at 12:08 PM, revealed that on 06/24/2021 she received a phone call from RN #1 and the Staffing Coordinator about NA #3, NA #10 and CNA #9 having concerns about LPN #1 popping Resident #1's hand. Continued interview revealed NA #10 also had concerns about LPN #1 slapping Resident #3's hand. She stated she had RN #1 gather the witnesses for a phone interview with her and the former Administrator. The DON stated the former Administrator asked the staff if they thought LPN #1 was intentionally hurting Resident #1 and they said no, but it was not appropriate. She stated the NA's said LPN #1 was correcting Resident #1 like a child. The DON stated NA #3 and NA #10 had said it was not abuse so an investigation was not done. She stated she had NA #3, NA #10 and CNA #9 do written statements. The DON stated she did not read the statements, but placed them in a folder. She further revealed an investigation was not completed as it was not an allegation of abuse. Interview with Regional Director of Operations (RDO) and former Administrator, on 08/27/2021 at 8:46 AM, revealed she received a call from the DON; however, she could not recall the time or the date. She stated it had been reported that LPN #1 had smacked Resident #1 on the arm and was loud with him/her. The RDO stated all reportable events were reported directly to her. She stated she did a phone interview with the DON, RN #1, NA #3 and NA #10. Continued interview revealed she specifically asked them if they felt like it was abuse and they said no. The RDO stated the students were told to report everything because they were new and in training. She stated she thought LPN #1 was removed from care and sent home. The RDO stated that when the NA students said it was not abuse, the facility did not investigate or do a reportable event. However, follow-up interview with NA #3 on 08/31/2021 at 10:12 AM, revealed she thought LPN #1 was abusive to Resident #1 on 06/24/2021. Interview with NA #10 on 08/31/2021 at 11:54 AM, revealed she felt like LPN #1 had verbally and physically abused Resident #1 on 06/24/2021. 2. Record review revealed the facility admitted Resident #2 on 09/26/2018 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/20/2021, revealed a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated moderate cognitive impairment. Review of the facility's investigation summary, dated 07/17/2021, but not signed, revealed the DON was notified by a CNA (Staffing Coordinator), that LPN #1 and Resident #2 had gotten into an argument and LPN #1 had pulled Resident #2's hair. The DON contacted RN #1, who was on duty and instructed her to send LPN #1 home. She then had a phone interview with Resident #2, who stated that LPN #1 had pulled his/her hair. The DON asked him/her if he/she thought this was abuse and Resident #2 stated no, that he/she did not think she did it on purpose. The investigation was completed as the resident felt it was not abuse. Interview with Resident #2, on 08/26/2021 at 10:18 AM, revealed he/she was waiting on breakfast and had a bag with salt, pepper and sugar in it. Resident #2 stated LPN #1 must have thought the bag was hers. He/she stated LPN #1 was yelling and grabbed the bag from his/her hand. Resident #2 stated he/she had told LPN #1 that it was his/her bag. Continued interview revealed LPN #1 put the bag behind her back when Resident #2 tried to get it. Resident #2 then stated, for no reason, LPN #1 pulled the hair on the back of his/her head. Resident #2 stated he/she did take a swing at LPN #1 and that LPN #1 swung back at him/her, but he/she was rolling away in the wheelchair. Resident #2 stated LPN #1 also called him/her a name because of his/her weight. Review of NA #4's witness statement, dated 08/26/2021, revealed she witnessed LPN #1 yelling and screaming at Resident #2 while smacking his/her hand away. She stated she also pulled his/her hair and called the resident a name. Interview with NA #4, on 08/25/2021 at 3:00 PM, revealed the incident occurred on a weekend. NA #4 stated Resident #2 always sat at the back table. She stated LPN #1 had put her lunch box on the table (where the resident sat) and Resident #2 pushed it out of the way. LPN #1 started yelling and screaming at the resident to not touch her stuff. Continued interview revealed LPN #1 took the baggie from the resident (salt/pepper/sugar). When the resident reached to get it, LPN #1 put it behind her back. NA #4 stated when Resident #2 reached for it again, she smacked the resident's hand away then she grabbed a handful of the resident's hair and pulled it. NA #4 stated Resident #2 did take a swing at LPN #1 and that LPN #1 swung back at the resident. She stated LPN #1 then walked away. Resident #2 was backing up and he/she may have ran over LPN #1's foot. NA #4 stated LPN #1 then called Resident #2 a name like fat cow or fat [NAME]. Review of the witness statement from CNA #8, dated 07/17/2021, revealed she witnessed LPN #1 hollering and swatting at Resident #2. She also witnessed LPN #1 throw the resident's baggie at him/her and called him/her porky. Interview with CNA #8, on 08/26/2021 at 2:36 PM, revealed LPN #11 thought Resident #2 was getting into her bag/lunch box. She stated LPN #1 yelled at Resident #2 and took his/her baggie away from him/her. CNA #8 stated LPN #1 was arguing with Resident #2 and the resident tried to hit her and LPN #1 swatted back at him/her. She stated LPN #1 threw the baggie at him/her and called the resident porky. 3. Record review revealed the facility admitted Resident #3 on 05/26/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated severe cognitive impairment. Interview with NA #10, on 08/26/2021 at 10:40 AM, revealed Resident #3 was getting something to drink from the drink cart like always. The NA stated LPN #1 ran over to Resident #3 and yelled at the resident, slapped the resident on the hand and scolded him/her like a child. An acceptable Allegation of Compliance/Removal Plan (AoC) was received on 09/09/2021. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 09/01/2021, as alleged. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #2 was assessed by Licensed Practical Nurse for injuries. a. Resident #1 was discharged from the facility on 07/02/2021. b. Resident #3 was assessed for injury, by a Licensed Practical Nurse, and for changes in mood and behaviors and psychosocial well-being. 2. All residents with a Brief Interview for Mental Status (BIMS) score of eight (8) and above were interviewed about any type of abuse. a. Residents with a BIMS' score of seven (7) and below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. b. All residents with a BIMS Score of seven (7) and below were assessed by Social Services Director, LPN and RN for changes in mood, behavior or psychosocial changes. c. All staff were interviewed by the Director of Nursing, Assistant Director of Nursing, Business Office Manager, Dietary Manager and Housekeeping Supervisor for abuse that had not been reported. 3. Education was provided to all staff by the DON, ADON, Dietary Manager and Housekeeping Supervisor on abuse including all types and to whom and when to report abuse. Education was also provided on reporting abuse to the Administrator or DON immediately. a. All concerns will be investigated immediately per the Administrator/DON or designee. This was discussed in the daily clinical meeting by the Administrator, DON or designee and the IDT team. A log will be kept by the Administrator/DON. b. Administrative Staff, Administrator, DON, ADON, UM, SSD, MDS, SDC and Medical records will monitor residents at risk by monitoring residents off shift. c. Interviews and observations of five (5) employees by the Administrative team will be done weekly for four (4) weeks, monthly for three (3) months then quarterly. 4. Abuse reporting will be discussed in the monthly QAPI meeting by the Administrator, DON or designee to discuss any trends or concerns. QAPI committee consist of LNHA, DON, ADON, UM, SSD, BOM, Advanced Registered Nurse Practitioner (ARNP), MDS, Dietary Manager, BOM, SDC and Medical Director a. All abuse reporting will be documented on the Abuse Investigation Log which tracks trends, concerns and outcomes. Weekly review will be conducted by the DON. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Resident #2 was assessed by the Assistant Director of Nursing for injuries. No concerns were identified. Interview with the ADON on 09/16/2021 at 9:40 AM revealed she assessed Resident #2 and Resident #3 for injury on 08/31/2021. The Skin Monitoring sheet was used for documentation. a. Review of Nursing Progress Note dated 07/02/2021 revealed Resident #1 was discharged from the facility on 07/02/2021. b. Resident #3 was assessed for injury by the ADON for changes in mood and behaviors and psychosocial well-being with no concerns identified. Interview with the ADON, on 09/16/2021 at 9:40 AM, revealed she assessed Resident #2 and Resident #3 for injuries on 08/31/2021. The Skin Monitoring sheet was used for documentation. 2. Review of the interview sheets titled, Resident Interview Questions: Abuse/Neglect, revealed the Social Services Director interviewed all interviewable residents related to care and abuse with no concerns. This was completed on 09/01/2021. a. Review of the Skin Monitoring: Comprehensive CNA Shower Review, revealed skin assessments were completed by Licensed Practical Nurses #2 and #5 and Registered Nurse #1 for residents that were not interviewable. This was completed on 08/31/2021. b. All residents with a BIMS' Score of seven (7) and below were assessed by the ADON for changes in mood, behavior or psychosocial changes. This was completed on 08/31/2021 and documented on the Skin Monitoring form. Interview with the ADON, on 09/16/2021 at 9:40 AM, revealed she assessed residents that were not interviewable for changes in mood, behaviors and/or psychosocial changes and documented on the Skin Monitoring from. c. Review of the Staff Abuse Questionnaire revealed the DON, ADON, Business Office Manager, Dietary Manager and Housekeeping Supervisor interviewed all staff for any abuse that had not been reported. This was completed on 08/31/2021. No concerns identified. 3. Review of in-service education and sign-in sheets revealed education was provided by the Director of Nursing, Assistant Director of Nursing, Dietary Manager and Housekeeping Supervisor to all employees related to abuse, including all types and who and when to report abuse. This included reporting to the Administrator or DON immediately. This was completed on 08/26/2021 thru 08/31/2021. Interviews with the DON, on 09/16/2021 at 11:06 AM, and the Administrator, on 09/16/2021 at 11:16 AM, revealed they had received education on 08/30/2021 from the RDO (Regional Director of Operations) on the abuse policy, the types of abuse, and the investigation and reporting process. Review of the email revealed the Assistant Director of Clinical Services (ADCS) educated the Regional Director of Operations on 08/30/2021, on the types of abuse, investigating and reporting of abuse allegations. Interview with the ADCS on 09/16/2021 at 10:31 AM, revealed she educated the RDO on 08/29/2021 and completed the education on 08/30/2021 on the policy for Abuse Neglect and Exploitation, the types of abuse, completing a thorough investigation and reporting to the appropriate agencies. Interviews on 09/15/2021 with CNA #17 at 1:52 PM, NA #3 at 3:26 PM, and CNA #5 at 3:46 PM, LPN #4 at 1:57 PM, LPN #2 at 2:03 PM and LPN #5 at 2:09 PM, revealed they received education from the DON on abuse, types of abuse, when to report abuse and whom to report abuse to. a. Review of the Concern Log, dated 08/30/2021 thru 09/03/2021, revealed three (3) allegations of verbal abuse had been reported to the DON. No concerns were identified. b. Administrative Staff, Administrator, DON, ADON, UM, SSD, MDS, SDC and Medical Records monitored residents at risk by interviews and observations off shift. Review of the interview sheets titled, Resident Interview Questions: Abuse/Neglect, revealed the SSD interviewed all interviewable residents related to care and abuse. This was completed on 09/01/2021. No concerns were identified. c. Review of the facility's audit titled, Staff Abuse Questionnaire, revealed five (5) employees had been interviewed on 09/05/2021 and 09/11/2021 by a member of the Administrative team which consist of LNHA, DON, ADON, UM, SDC MDS and/or Medical Records. No concerns were identified. 4. The Administrator and DON and or designee reported all findings to QAPI on 08/31/2021 and on 09/05/2021 gave a weekly update. The initial meeting on 08/31/2021 included: The Abuse QAPI Tool and the Reportable Events Log, weekly Audits for four (4) weeks, monthly for three (3) months then quarterly with any concerns documented, corrected immediately and staff will be educated accordingly. The QAPI committee consist of the Administrator, DON, ADON, UM, SSD, BOM, Advanced Registered Nurse Practitioner (ARNP), MDS, Dietary Manager, Staff Development Coordinator and the Medical Director. No concerns identified. The next QAPI meeting will be held 09/16/2021. a. Review of the Abuse Investigation Log revealed three (3) allegations had been investigated and reported with no concerns identified.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to have an effective system in place to ensure allegations of abuse were reported to state agencies for three (3) of eighty-three (83) sampled residents (Residents #1, #2 and #3). Interviews and review of witness statements, revealed the facility failed to report allegations of abuse. Staff reported the allegations to the nurse, who reported to the Director of Nursing (DON). However, the facility failed to report the allegations to the State agencies. Staff witnessed physical and verbal abuse by Licensed Practical Nurse (LPN) #1 who yelled, screamed, and hit Resident #1. LPN #1 also yelled, taunted and pulled Resident #2's hair; and yelled, hit and scolded Resident #3. On 06/24/2021, Resident #1 was being combative and yelling out with direct care staff. Licensed Practical Nurse (LPN) #1 entered the room yelling and screaming at Resident #1 while staff were performing direct care. She proceeded to slap Resident #1's hand three (3) times and threatened to call his/her family. On 06/24/2021, Resident #3 was in the common area getting something to drink when LPN #1 slapped his/her hand and scolded him/her like a child. On 07/17/2021, Resident #2 was in the common area waiting on breakfast. He/She had a baggie with salt pepper and sugar. LPN #1 saw the bag and grabbed it from Resident #2's hand thinking it belonged to her. She argued with Resident #2 and held the bag behind her back and over her head. As Resident #2 was rolling away in his/her wheelchair LPN #1 called him/her a fat cow. The facility's failure to have an effective system in place to ensure the reporting abuse allegations to State Agencies has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 09/02/2021, and was determined to exist on 06/24/2021, at 42 CFR 483.12 Freedom from Abuse (F600, F609 and F610). The facility was notified of Immediate Jeopardy on 09/02/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 09/09/2021, with the facility alleging removal of the Immediate Jeopardy, on 09/01/2021. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 09/01/2021. The facility's remaining non-compliance was at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation dated 10/2020, revealed that reporting of all alleged violations to the Administrator, State Agency, Adult Protective Services and to all other required agencies within the specified timeframes: Immediately, but not later than two (2) hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury. 1. Closed record review revealed the facility admitted Resident #1 on 06/01/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of six (6) indicating severe cognitive impairment. The resident was discharged from the facility on 07/02/2021. Review of witness statements, dated 06/24/2021, revealed on 06/24/2021 at 6:30 PM, Nurse Aide (NA) #3 and NA #10 were providing care to Resident #1. The resident was yelling out and being combative with care. NA #3 and NA #10 stated LPN #1 came into Resident #1's room yelling and screaming telling the resident to stop it. NA #3 and #10 stated LPN #1 then smacked the resident on the hand two-three (2-3) times. Interview with NA #3 on 08/25/2021 at 3:25 PM revealed she and NA #10 were providing care for Resident #1 and he/she was being combative and yelling out. She stated LPN #1 came in and said, Sometimes you just got to be mean to them. NA #3 stated Resident #1 grabbed her hand and LPN #1 started smacking the top of Resident #1's hand and yelling at him/her to let go and stop. She stated LPN #1 slapped Resident #1's hand two to three (2-3) times. The NA further stated CNA #9 came in the room and told LPN #1 to be a littler nicer. NA #3 revealed she reported the concern to the Staff Development Coordinator and the Staffing Coordinator. She stated interviews were done by phone with the DON and former Administrator and they wrote out a statement. Interview with NA #10, on 08/26/2021 at 10:40 AM, revealed she had asked NA #3 to assist her with Resident #1. She stated Resident #1 was yelling out. NA #10 stated LPN #1 was yelling at the resident before she even came in the room. She stated LPN #1 slapped the resident's hand before he/she grabbed NA #3's hand and she slapped Resident #1's hand again after he/she grabbed NA #3. NA #10 stated the slaps were hard, not taps. She revealed she called the DON and made her aware of LPN #1 slapping Resident #1's hand. NA #10 stated there was a phone interview with the DON and former Administrator, Registered Nurse (RN) #1, herself, NA #3 and CNA #9. 2. Record review revealed the facility admitted Resident #2 on 09/26/2018 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident's cognition was moderately impaired. Review of a note, dated 07/17/2021, revealed the Director of Nursing (DON) was notified by the Certified Nursing Assistant (CNA) of the incident with Resident #2. The note was not signed. Interview with Resident #2, on 08/26/2021 at 10:18 AM, revealed the resident was waiting on breakfast and had a bag with salt, pepper and sugar in it. Resident #2 revealed LPN #1 must have thought the bag was hers as LPN #1 was yelling and grabbed the bag from the resident's hand. Resident #2 stated he/she had told LPN #1 that it was his/her bag. Resident #2 stated that LPN #1 put the baggie behind her back when he/she tried to get it. Continued interview revealed LPN #1 pulled the hair on the back of his/her head for no reason. Resident #2 stated he/she did take a swing at LPN #1 and that LPN #1 swung back, but he/she was rolling away in the wheelchair. Resident #2 stated LPN #1 also called him/her a name because of the resident's weight. 3. Record review revealed the facility admitted Resident #3 on 05/26/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a BIMS score of three (3) indicating severe cognitive impairment. Interview with NA #10, on 08/26/2021 at 10:40 AM, revealed Resident #3 was getting something to drink from the drink cart as the resident always did. Resident #3 revealed LPN #1 ran over to the resident and yelled at him/her, slapped his/her hand and scolded the resident like a child. She further stated that LPN #1 could have handled it differently. Interview with the Director of Nursing (DON), on 08/30/2021 at 12:08 PM, revealed that on 06/24/2021 she received a phone call from RN #1 about an allegation of abuse. She revealed NAs #3, #10 and CNA #9 had concerns about LPN #1 popping Resident #1's hand and NA #10 having concerns about LPN #1 slapping Resident #3's hand. The DON stated she had RN #1 gather the witnesses for a phone interview with her and the former Administrator. She stated the former Administrator asked the staff if they thought LPN #1 was intentionally hurting Resident #1 and they said no, but it was not appropriate. She stated the NA's said LPN #1 was correcting Resident #1 like a child. Continued interview revealed NA #3 and NA #10 had said it was not abuse so an investigation was not done. She stated she had NA #3, NA #10 and CNA #9 do written statements. The DON stated she did not read the statement but placed them in a folder. She further revealed an investigation was not completed as it was not an allegation of abuse. However, interview with NA #3 on 08/31/2021 at 10:12 AM, and NA #10 at 11:54 AM, revealed they thought LPN #1 was verbally and physically abusive to Resident #1 on 06/24/2021. Interview with the Regional Director of Operations (RDO), former Administrator on 08/27/2021 at 8:46 AM, revealed she received a call from the DON. However, she could not recall the time or the date. She stated it had been reported that LPN #1 had smacked Resident #1 on the arm and was loud with him/her. The RDO stated all reportable events were reported directly to her. She revealed she did a phone interview with the DON, RN #1, NA #3 and NA #10. She stated she specifically asked them if they felt like it was abuse and they said no. The RDO stated the students were told to report everything because they were new and in training. She further stated that when the NA students said it was not abuse the facility did not do a reportable event. An acceptable Allegation of Compliance (AoC) was received on 09/09/2021. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 09/01/2021. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #2 was assessed by Licensed Practical Nurse for injuries. a. Resident #1 was discharged from the facility on 07/02/2021. b. Resident #3 was assessed for injury by Licensed Practical Nurse (no date) and for changes in mood and behaviors and psychosocial well-being. 2. All residents with a Brief Interview Mental Status (BIMS) of eight (8) and above were interviewed by the SSD about any type of abuse. a. Residents with a BIMS score of seven (7) and below had skin assessments completed by a Licensed Practical Nurse or Registered Nurse. b. All residents with a BIMS Score of seven (7) and below were assessed by Social Services Director, LPN and RN for changes in mood, behavior or psychosocial changes. c. All staff were interviewed by the Director of Nursing, Assistant Director of Nursing, Business Office Manager, and Dietary Manager for abuse that had not been reported. 3. Identified allegations will be reported to the Administrator/DON immediately. Admin/DON will immediately report and protect the identified residents prior to initiating an investigation. 4. The Assistant Director of Clinical Services educated the Regional Director of Operations on 08/30/2021, on the types of abuse, investigating and reporting of abuse allegations. a. The Administrator, DON, ADON, MDS, Unit Managers, Business Office, Activities, Payroll , Maintenance, Therapy and Scheduling received education from the RDO on, the definition of abuse, how to prevent abuse and neglect, when to report abuse and neglect and to report all abuse to the Administrator/DON immediately. b. The Administrator/DON will make the initial report to the Office of Inspector General (State Survey Agency), Department of Community Based Services, the State and local Ombudsman, the responsible parties and the physician or Nurse Practitioner within two (2) hours. Investigation of events will begin immediately. 5. The facility will monitor the alleged victim and monitor the other residents at risk by conducting management visits at different times and shifts. a. The facility will use the Investigation Tool, starting 08/31/2021 to investigate all allegations of abuse. b. The reportable Events Log will be reviewed weekly by the Regional Director of Clinical Services. (RDCS) c. Education was provided to all staff by the DON, Administrator or designee on identifying types of abuse and neglect, when to report suspected abuse and neglect and reporting of abuse and neglect to the Administrator immediately. d. New hires, including agency staff, will be in serviced on abuse in the facility's orientation process prior to being assigned to a clinical area. e. A list of all staff was developed and no persons will be allowed to work without having completed the education prior to assuming to a clinical area. f. The Administrator and DON and or designee reported all findings to QAPI on 08/31/2021. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Resident #2 was assessed for injuries by the Assistant Director of Nursing. No concerns were identified. Interview with the ADON on 09/16/2021 at 9:40 AM revealed she assessed Resident #2 and Resident #3 for injury on 08/31/2021. The Skin Monitoring sheet was used for documentation with no concerns identified. a. Review of Nursing Progress Notes revealed Resident #1 was discharged from the facility on 07/02/2021. b. Resident #3 was assessed for injury by the ADON, and for changes in mood and behaviors and psychosocial well-being. No concerns were identified. Interview with the ADON on 09/16/2021 at 9:40 AM, revealed she assessed Resident #2 and Resident #3 for injury on 08/31/2021. The Skin Monitoring sheet was used for documentation with no concerns identified. 2. Review of the interview sheets titled, Resident Interview Questions: Abuse/Neglect, revealed the Social Services Director interviewed all interviewable residents related to care and abuse with no concerns. This was completed on 09/01/2021. No concerns were identified. a. Review of Skin Monitoring: Comprehensive CNA Shower Review, revealed Skin Assessments were completed by Licensed Practical Nurses #2 and #5 and Registered Nurse #1, for residents that were not interviewable. This was completed on 08/31/2021. b. All residents with a BIMS score of seven (7) and below were assessed by the ADON for changes in mood, behavior or psychosocial changes. This was completed on 08/31/2021 and documented on the Skin Monitoring: Comprehensive CNA Shower Review. No concerns identified. Interview with the ADON, on 09/16/2021 at 9:40 AM, revealed she assessed residents that were not interviewable for changes in mood, behaviors and/or psychosocial changes and documented on the Skin Assessment form. c. Review of the Staff Abuse Questionnaire revealed the DON, ADON, Business Office Manager, Dietary Manager and Housekeeping Supervisor interviewed all staff for any abuse that had not been reported. This was completed on 08/31/2021 with no concerns identified. 3. Review of the investigations from three (3) allegations that revealed the allegations were reported to the Administrator or DON immediately and reported to the appropriate agencies. No concerns were identified. 4. Review of the email revealed the Assistant Director of Clinical Services (ADCS) educated the Regional Director of Operations on 08/30/2021, on the types of abuse, investigating and reporting of abuse allegations. Interview with ADCS on 09/16/2021 at 10:31 AM, revealed she educated the RDO on 08/29/2021 and completed the education on 08/30/2021 on the policy for Abuse Neglect and Exploitation, the types of abuse, completing a thorough investigation and reporting to appropriate agencies. a. Reviewed the In-service sign-in sheet indicating the RDO provided education to the Administrator, DON, ADON, MDS, Unit Managers, Business Office, Activities, Payroll, Maintenance, Therapy and Scheduling. The in service included: the definition of abuse, how to prevent abuse and neglect, when to report abuse and neglect and to report all abuse to the Administrator/DON immediately. Interviews on 09/15/2021 at 1:32 PM, with the Maintenance Director, the Admissions Liaison at 4:10 PM, the Business Office Manager at 4:12 PM and the Rehab Manager on 09/16/2021 at 10:00 AM, revealed they received education from the DON and the RDO on abuse, reporting and to whom to report abuse. Interviews with the DON, on 09/16/2021 at 11:06 AM, and the Administrator, on 09/16/2021 at 11:16 AM, revealed they had received education on 08/30/2021 from the RDO on the abuse policy, the types of abuse, investigation and reporting process. b. Reviewed three (3) reportable allegations that indicated the DON made the initial report to the Office of Inspector General (State Survey Agency), Department of Community Based Services, the State and local Ombudsman, the responsible parties and the physician or Nurse Practitioner within two (2) hours and the investigations of events were initiated immediately. 5. Review of the interview sheets titled, Resident Interview Questions: Abuse/Neglect, dated 09/01/2021 revealed the SSD interviewed all interviewable residents related to care and abuse with no concerns. Administrative Staff, Administrator, DON, ADON, UM, SSD, MDS, SDC and Medical Records monitored residents at risk by conducting interviews and making observations at different times and shifts. No concerns identified. a. Review of the Investigation Tool revealed the tools had been implemented on 08/31/2021 thru 09/03/2021 for three (3) allegations of verbal abuse. No concerns were identified. b. Review of the reportable events log completed by the DON revealed the weekly review was signed by the Regional Director of Clinical Services (RDCS). No concerns were identified. c. Reviewed the in-service and sign in sheets of all staff that education was provided by the DON, Administrator and designee on identifying types of abuse and neglect, when to report suspected abuse and neglect and reporting of abuse and neglect to the Administrator immediately. No concerns were identified. Interviews on 09/15/2021 with CNA #17 at 1:52 PM, NA #3 at 3:26 PM, and CNA #5 at 3:46 PM, LPN #4 at 1:57 PM, LPN #2 at 2:03 PM and LPN #5 at 2:09 PM, revealed they received education from the DON on abuse, types of abuse, when to report abuse and whom to report abuse. d. New hires, including agency staff, will be in serviced on abuse in the facility's orientation process prior to being assigned to a clinical area. Interviews with newly hired employees on 09/15/2021, Kentucky Medication Aide (KMA (15) at 12:55 PM, Certified Nursing Assistant (CNA) #19 at 3:02 PM, CNA #18 at 3:07 PM and CNA #16 at 4:00 PM, revealed they had received education on Abuse and Neglect, including the types of abuse, and to whom to report abuse to during the orientation process. e. Review of check off list of employees revealed all employees had been educated in person or via phone call. Interviews on 09/15/2021 with Licensed Practical Nurse (LPN) #4 at 1:57 PM, LPN #2 at 2:03 PM and LPN #5 at 2:09 PM revealed they had received education from the DON about abuse, the types of abuse, when to report and to whom to report abuse to beginning 08/27/2021 thru 09/01/2021. Interviews, on 09/15/2021 with NA #3 at 3:26 PM, and CNA #5 at 3:46 PM, revealed they received education from the DON about abuse, the types of abuse, when to report and to whom to report abuse to beginning on 08/27/2021 thru 09/01/2021. Further interviews on 09/15/2021 with the Admission Liaison at 4:10 PM, the Business Office Manager at 4:26 PM revealed they received education from the RDO about abuse, the types of abuse, when to report and to whom to report abuse to on 08/30/2021. f. The Administrator and DON and or designee reported all findings to QAPI on 08/31/2021 and on 09/05/2021 gave a weekly update. The initial meeting on 08/31/2021 included: The Abuse QAPI Tool and the Reportable Events Log, weekly Audits for four (4) weeks, monthly for three (3) months then quarterly with any concerns documented, corrected immediately and staff will be educated accordingly. The QAPI committee consist of the Administrator, DON, ADON, UM, SSD, BOM, Advanced Registered Nurse Practitioner (ARNP), MDS, Dietary Manager, Staff Development Coordinator and the Medical Director. No concerns identified. The next QAPI meeting will be held 09/16/2021.

Based on observation, interview, record review and review of the facility's policy it was determined the facility failed to conduct thorough abuse investigations for three (3) of eighty-three (83) sampled residents (Residents #1, #2 and #3). On 06/24/2021, the former Administrator and the Director of Nursing (DON) were made aware that three (3) staff members had witnessed verbal and physical abuse by Licensed Practical Nurse (LPN) #1 related to Residents #1 and #3. However, the DON and former Administrator failed to identify it as an allegation of abuse, and failed to thoroughly investigate the allegation. Again on 07/17/2021, the DON and Administrator were made aware that two (2) staff had witnessed verbal and physical abuse by LPN #1 related to Resident #2. However, the DON and the Administrator failed to identify it as an allegation of abuse, and failed to thoroughly investigate the allegation. Interviews and review of witness statement revealed the facility failed to investigate allegations of abuse related to Residents #1, #2 and #3. Licensed Practical Nurse (LPN) #1 yelled, screamed, and hit Resident #1; yelled, taunted and pulled Resident #2's hair; and yelled, hit and scolded Resident #3. The facility's failure to have an effective system in place to ensure allegations of abuse were thoroughly investigated has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 09/02/2021, and was determined to exist on 06/24/2021, at 42 CFR 483.12 Freedom from Abuse (F600, F609 and F610). The facility was notified of Immediate Jeopardy on 09/02/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan on 09/09/2021, with the facility alleging removal of the Immediate Jeopardy, on 09/01/2021. The State Survey Agency validated removal of the Immediate Jeopardy, as alleged on 09/01/2021. The facility's remaining non-compliance was at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 10/2020, revealed an immediate investigation would be warranted when suspicion of abuse, neglect or exploitation or reports of abuse, neglect or exploitation occurred. The investigation would include: identifying and interviewing all involved persons, providing a complete and thorough documentation of the investigation Interview with NA (Nurse Aide) #3, on 08/25/2021 at 3:25 PM, revealed she witnessed LPN (Licensed Practical Nurse) #1 yell and scream at Resident #1 and smack the top of his/her hand. Interview with NA #10, on 08/26/ at 10:40 AM, revealed she witnessed LPN #1 slap Resident #1's hand two to three (2-3) times while yelling and screaming at the resident. Interview with CNA #9, on 08/27/2021 at 7:28 AM, revealed when NA #3 and NA #10 were providing care for Resident #1 LPN #1 came in the room yelling at the resident. She stated LPN #1's tone was loud and hateful. She further revealed that LPN #1 slapped Resident #1's hand and when he/she grabbed LPN #1's wrist, she slapped the resident's hand again. She revealed LPN #1 didn't even try to talk to the resident. The LPN just yelled and screamed at the resident causing the resident to become more agitated. CNA #9 reported the incident to Registered Nurse (RN) #1. RN #1 called the Director of Nursing (DON) and Administrator. Interview with the Director of Nursing (DON), on 08/30/2021 at 12:08 PM, revealed that on 06/24/2021 she received a phone call from Registered Nurse (RN) #1 about an allegation of abuse. She stated Nurse Aides (NA) #3, #10 and CNA #9 had concerns about LPN #1 popping Resident #1's hand. She stated NA #10 had concerns about LPN #1 slapping Resident #3's hand. She stated she had RN #1 gather the witnesses for a phone interview with her and the former Administrator. She stated the former Administrator asked the staff if they thought LPN #1 was intentionally hurting Resident #1 and they said no, but it was not appropriate. Continued interview revealed the NA's said LPN #1 was correcting Resident #3 like a child. The DON stated NA #3 and NA #10 had said it was not abuse so an investigation was not done. She stated she had NA #3, NA #10 and CNA #9 do written statements. She stated she did not read the statements, but placed them in a folder. She further revealed an investigation was not completed as it was not an allegation of abuse. However, interview with NA #3 on 08/31/2021 at 10:12 AM, and NA #10 at 11:54 AM, revealed they thought LPN #1 was verbally and physically abusive to Resident #1 on 06/24/2021. Interview with Regional Director of Operations (RDO), the former Administrator on 08/27/2021 at 8:46 AM, revealed she received a call from the DON, but she could not recall the time or the date. She revealed it had been reported that LPN #1 had smacked Resident #1 on the arm and was loud with him/her. The RDO revealed all reportable events were reported directly to her. Continued interview revealed she did a phone interview with the DON, RN #1, NA #3 and NA #10. She stated she specifically asked them if they felt like it was abuse and they said no. She stated she thought LPN #1 was removed from care and sent home. She further revealed that when the NA students said it was not abuse the facility did not investigate or do a reportable event. An acceptable Allegation of Compliance/Removal Plan (AOC) was received on 09/09/2021, which alleged removal of the Immediate Jeopardy on 09/01/2021. The State Survey Agency validated the Immediate Jeopardy had been removed on 09/01/2021, as alleged. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #2 was assessed by Licensed Practical Nurse for injuries. a. Resident #1 was discharged from the facility on 07/02/2021. b. Resident #3 was assessed for injury by Licensed Practical Nurse, for changes in mood and behaviors and psychosocial well-being with no concerns identified. 2. On 09/01/2021, all residents with a Brief Interview Mental Status (BIMS) of eight (8) and above were interviewed about any type of abuse. a. Residents with a BIMS Score of seven (7) and below had skin assessments completed by a LPN or RN. b. Residents with a BIMS score of 7 and below were assessed by Social Services Director, LPN and RN for any changes in mood, behaviors or psychosocial changes. c. All facility staff were interviewed by one of the following: the Director of Nursing (DON), Assistant Director of Nursing (ADON), Business Office Manager (BOM), Dietary Manager and Housekeeping Supervisor for any abuse that had not been reported with concerns addressed immediately and reported to appropriate agencies by the DON. 3. One hundred percent (100%) of staff were educated by the DON, ADON, Dietary Manager and Housekeeping Supervisor on abuse including all types and who and when to report abuse. Education was completed on 08/31/2021. a. Education was presented to all staff that all allegations of abuse were to be reported to the Administrator and/or the DON immediately. b. Education was presented to licensed staff that, The Investigation of Events, would include observation of the resident, the location of the event, interviews with the victim, alleged perpetrator, witnesses, practitioner and family. 4. Education on abuse, including the types of abuse, when to report and who to report to was provided to the Regional Director of Operations (RDO) by the Assistant Director of Clinical Services (ADCS) on 08/30/2021. a. The Administrator and DON were educated on 8/31/2021 by the RDO on reporting and investigation which included that all concerns would be reported immediately. b. The facility implemented a Concerns Log, to track concerns, trends and outcomes. The DON will send to the Regional Director of Clinical Services (RDCS) weekly for review. 5. The facility will monitor all alleged victims and monitor the other residents at risk which included conducting management visits at different times and shifts. a. Interviews and observations of five (5) staff members will be done weekly for four (4) weeks, monthly for three (3) months, and then quarterly. b. All administrative staff, (DON, ADON, UM, MDS, Dietary Manager, Housekeeping Supervisor, BOM, SSD, HIM, and the Rehab Director) were educated by the RDO on Abuse and Neglect as well as the investigative process. c. Identified alleged violations are to be reported to the Administrator/DON immediately. The Administrator/DON makes the initial report to the Office of Inspector General (State Survey Agency), Department of Community Based Services, the State and local Ombudsman, the responsible party and the physician/ARNP within two (2) hours. d. All education was completed by 08/31/2021. No persons will be allowed to work without having completed the education prior to returning to work on the unit. 6. Abuse reporting tool will be completed monthly by the Administrator with Audits done weekly for three (3) months, then quarterly for twelve (12) months to ensure investigations are completed and in place. All findings will be reported to the monthly QAPI team by the DON for a minimum of six (6) months. Trends will be monitored by the RDCS. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Resident #2 was assessed for injuries by the Assistant Director of Nursing, with no injury noted. a. Review of a Nursing Progress note, dated 07/02/2021, revealed Resident #1 was discharged from the facility on 07/02/2021. b. Resident #3 was assessed for injury by the Assistant Director of Nursing, for changes in mood and behaviors and psychosocial well-being. No concerns were identified. 2. Review of the interview sheets titled, Resident Interview Questions: Abuse/Neglect, dated 09/01/2021, revealed the Social Services Director interviewed all interviewable residents related to care and abuse with no concerns. a. Review of Skin Monitoring: Comprehensive CNA Shower Review, revealed skin assessments were completed by Licensed Practical Nurse #2 and #5 and Registered Nurse #1 on 08/31/2021 for residents that were not interviewable. No concerns were identified. b. Review of Skin Monitoring: Comprehensive CNA Shower Review revealed the Assistant Director of Nursing documented no change in mood, behavior or psychosocial on residents that were not interviewable. This was completed on 08/31/2021. No concerns were identified. Interview with the ADON on 09/16/2021 at 9:40 AM revealed she assessed residents that were not interviewable for changes in mood, behaviors and/or psychosocial changes and documented on the Skin Assessment form. c. Review of the form, Staff Abuse Questionnaire revealed the DON, ADON, Dietary Manager and Housekeeping Supervisor interviewed all staff for any abuse that had not been reported. This was completed on 08/31/2021. No concerns were identified. 3. Review of in-service education and sign-in sheets revealed education was provided by the Director of Nursing, Assistant Director of Nursing, Dietary Manager and Housekeeping Supervisor to all employees on abuse, including all types of abuse, and who and when to report abuse. This was completed on 08/26/2021 thru 08/31/2021. Interviews on 09/15/2021 with CNA #17 at 1:52 PM, NA #3 at 3:26 PM, CNA #5 at 3:46 PM, LPN #4 at 1:57 PM, LPN #2 at 2:03 PM and LPN #5 at 2:09 PM, revealed they received education from the DON on abuse, types, of abuse, when to report abuse and to whom to report abuse. a. Review of in-service education and sign-in sheets revealed the Director of Nursing, Assistant Director of Nursing, Dietary Manager and Housekeeping Supervisor provided education to all employees that abuse was to be reported to the Administrator or Director of Nursing immediately. This was completed 08/26/2021 thru 08/31/2021. b. Review of in-service-education to licensed staff revealed that, The Investigation of Events, would include observation of the resident, the location of the event, interviews with the victim, alleged perpetrator, witnesses, practitioner and family. This was completed 08/31/2021. No concerns were identified. 4. Education on abuse, including the types of abuse, when to report and to whom to report abuse was provided to the Regional Director of Operations (RDO) by the Assistant Director of Clinical Services (ADCS) on 08/30/2021. Interview with the ADCS on 09/16/2021 at 10:31 AM, revealed she educated the RDO on 08/29/2021 and completed the education on 08/30/2021 on the policy for Abuse Neglect and Exploitation, the types of abuse, completing a thorough investigation and reporting to the appropriate agencies. a. Review of signed education sheets revealed the Administrator and DON were educated by the RDO on reporting and investigating all concerns immediately on 08/31/2021. No concerns were identified. b. Review of the Concern Log dated 08/30/2021 thru 09/03/2021 revealed three (3) allegations of verbal abuse had been investigated with no concerns identified. 5. Review of the interview sheets titled, Resident Interview Questions: Abuse/Neglect, revealed the SSD interviewed all interviewable residents related to care and abuse. This was completed on 09/01/2021. No concerns were identified. a. Review of the facility's audit titled, Staff Abuse Questionnaire, revealed five (5) employees had been interviewed on 09/05/2021 and 09/11/2021 by a member of the Administrative team which included: the Administrator, DON, ADON, UM, SDC MDS and Medical Records. No concerns were identified. b. Review of an in-service education sign in sheet revealed all Administrative staff, (DON, ADON, UM, MDS, Dietary Manager, Housekeeping Supervisor, BOM, SSD, HIM, and the Rehab Director) were educated by the RDO on Abuse and Neglect as well as the investigative process. This was completed on 08/31/2021. No concerns were identified. c. Review of the Concern Log dated 08/30/2021 thru 09/03/2021 revealed three (3) allegations of verbal abuse had been investigated and reported by the DON with no concerns identified. d. Review of check off list of employees revealed all employees had been educated in person or via phone call. Interviews on 09/15/2021 with Licensed Practical Nurse (LPN) #4 at 1:57 PM, LPN #2 at 2:03 PM and LPN #5 at 2:09 PM revealed they had received education from the DON about abuse, the types of abuse, when to report and to whom to report abuse to beginning 08/27/2021 thru 09/01/2021. Interviews, on 09/15/2021 with NA #3 at 3:26 PM, and CNA #5 at 3:46 PM, revealed they received education from the DON about abuse, the types of abuse, when to report and who to report abuse to beginning on 08/27/2021 thru 09/01/2021. Further interviews on 09/15/2021 with the Admission Liaison at 4:10 PM, the Business Office Manager at 4:26 PM revealed they received education from the RDO about abuse, the types of abuse, when to report and to whom to report abuse to on 08/30/2021. 6. Review of the QAPI (Quality Assurance Performance Improvement) attendance record revealed they met on 08/31/2021 and 09/08/2021. The QAPI Committee included: the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, Social Services Director, MDS, Advanced Registered Nurse Practitioner, Dietary Manager, Staff Development Coordinator, Business Office Manager, and the Medical Director. The Committee will review investigations with concerns addressed immediately by the Administrator or DON and will be discussed in the daily clinical meeting with the IDT team (Administrator, DON, ADON, SDC and Unit Managers).

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to treat each resident with respect, dignity, and care in a manner that promotes maintenance or enhancement of his/her quality of life, recognizing each resident's individuality, for one (1) of four (4) sampled residents (Resident #4). Staff failed to maintain Resident #4's individuality, respect, and dignity while providing care during a shower. The findings include: Review of the facility's policy titled, Rights and Responsibilities of Residents, dated August 2009, revealed each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Staff shall promote, maintain and protect resident privacy, including body privacy during assistance with personal care and during treatment procedures. Record review revealed the facility admitted Resident #4 on 08/11/17, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment, dated 02/11/2020, revealed the facility assessed Resident #4's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Observation, on 02/18/2020 at 9:15 AM, revealed Resident #4 was in the shower room waiting for State Registered Nursing Assistant (SRNA) #2 to assist him/her with a shower. Observation revealed another resident was in the shower room waiting for a whirlpool bath. Interview with Resident #4, on 02/18/2020 at 9:18 AM, revealed he/she did not want to be showered at the same time another resident was in the shower room. Interview revealed Resident #4 stated bath time is my private time. I should not have to share my bath time with anyone else. I don't blame the nurse aide, she is doing all she can, they just don't have enough staff for us (residents). Further interview revealed staff used privacy curtains when providing care; however, Resident #4 preferred not to share the shower room at the same time as another resident. Interview with SRNA #2, on 02/18/2020 at 1:50 PM, revealed she had two (2) residents in the shower room for bathing. Interview revealed SRNA #2 failed to ask each resident's permission to bath while another resident was bathing. Interview revealed Resident #4 received a shower and the other resident received a whirlpool bath. Interview revealed the privacy curtain separated each resident and neither resident could view the other. SRNA #2 stated to ensure the resident's get their bath, I took 2 at a time. Interview with Registered Nurse (RN) #1, on 02/18/2020 at 10:00 AM, revealed she was aware two (2) residents were showered during the same time. Further interview revealed she would expect the staff to ask the resident's permission and to make sure to use the privacy curtain. Interview revealed RN #1 was not aware Resident #4 did not like to bathe when another resident was in the shower room; however, RN #1 did know if Resident #4 had been assessed regarding his/her shower preference. Interview with the Interim/Assistant Director of Nursing (ADON), on 02/19/2020 at 2:40 PM, revealed the shower room was equipped to accommodate more than one (1) resident at a time. Interview revealed the Interim/ADON did not have a concern with two (2) residents using the shower room at the same time as long as the privacy curtain was pulled. Further interview revealed she was not aware Resident #4 did not like to use the shower room with another resident, and was not aware if staff assessed Resident #4 on his/her shower preference.

Based on observation, interview, record review, and facility policy review, it was determine the facility failed to provide a sanitary environment to help prevent the development of infection one (1) of twenty-five (25) sampled residents (Resident #50). Observation revealed Certified Nurse Aide #1 used poor technique with incontinent care which contaminated an open area to the sacral area. The findings include: Review of the facility policy titled, Infection Prevention, Infection Prevention and Control, last revised 01/04/18 revealed it is the policy of this facility to provide a safe, sanitary, and comfortable environment. This facility will attempt to prevent the development and transmission of infections. The facility will provide precautionary measures to prevent the spread of potential infection, while monitoring resident's progress. Review of the facility's Incontinence Care check sheet, not dated, revealed to turn resident on side and clean the buttocks/rectal area from front to back. Record review revealed the facility admitted Resident #50 on 06/01/17 with [DIAGNOSES REDACTED]. Review of the a Quarterly Minimum Data Set (MDS) assessment, dated 08/16/19 revealed the facility assessed Resident #50's cognition as intact with a Brief Interview for Mental Status (BIMS) score of seven (7) which indicated the resident was not interviewable. Further review of the MDS revealed the resident was assessed at risk for developing pressure ulcers/injuries and had a Stage II pressure ulcer. Observation of Resident #50's incontinent care provided by Certified Nurse Aide (CNA) #1 on 09/25/19 at 10:10 AM revealed she contaminated an open area to the right buttock when doing incontinent care. She wiped the soiled cloth with a smear of feces from the rectum over the open area while cleaning. She then patted the area dry from the rectum to the open area. Observation of the buttock revealed there was a small amount of bloody discharge (dime size) on the brief and the area was approximately a quarter size circular area with open area. The tissue around the wound was pink and blanchable. Certified Nurse Aide (CNA) #1 placed barrier cream to the area. Interview with CNA #1 on 09/25/19 at 10:25 AM revealed she realized she had contaminated the wound after she completed the care. She stated she did not usually work with this resident and was unaware of the wound. The CNA stated she would inform the charge nurse of the wound. Interview with the Charge Nurse on 09/25/19 at 10:28 AM, revealed CNA #2 noted the wound during the resident's shower this AM. She stated she was aware of the wound but had not yet assessed the wound. Interview with CNA #2, on 09/25/19 at 10:55 AM revealed she noted the wound to right buttock this morning around 6:00 AM during the resident's shower. When asked the size of the wound she held up her hand and made a circle with her thumb and pointer finger that was approximately quarter size and stated, it was about that size. She further revealed the resident would frequently have wounds to buttocks that would open and close depending on if the resident would lay on bottom. She stated the resident was non-compliant related to turning onto sides and wanted to lay on his/her back most of time. CNA #2 stated she would clean the peri area from front to back making sure not to contaminate the open area. Interview with CNA #3 on 09/25/19 at 2:45 PM revealed when cleaning a resident that is soiled with a wound, she would make sure to clean in the appropriate direction and not wipe across the wound when cleaning so that contamination does not occur. Interview with Administrator and Director of Nursing, on 09/25/19 at 2:00 PM revealed the Nurse Practitioner had evaluated the wound earlier and it was not open. The Administrator requested that this surveyor go and look at the wound again with the DON. Observation of Resident #50's wound with DON, Administrator, and Survey Team Leader, on 09/25/19 at 2:08 PM revealed the wound on the right buttock was open with red bloody drainage noted on the brief. During the assessment, the resident complained of pain when gloved hand touched the open area. Interview with the DON on 09/25/19 at 2:21 PM revealed she expected staff to not go over a wound with a soiled cloth which would contaminate the wound.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to maintain professional standards of quality for one (1) of three (3) sampled residents (Resident #1). On Resident #1 received five milliliters (5 ml) of influenza vaccine instead of the ordered dose of zero point five milliliters (0.5 ml). The findings include: Review of the facility policy titled, General Dose Preparation and Medication Administration last revised [DATE], revealed facility staff should verify that the medication name and dose are correct. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Further review of the record revealed Resident #1 expired in the facility on [DATE]. Review of the Resident #1's Physician's Order, dated [DATE], revealed the resident may have flu vaccine per policy. Review of the Nurse Notes dated [DATE] at 3:00 PM as a late entry revealed, Resident received flu shot to right deltoid at this time. MD notified with new orders to monitor site and for adverse drug side effects (ADSE). Family aware. Site without redness, [MEDICAL CONDITION] or tenderness noted. Per Advanced Registered Nurse Practitioner (ARNP), only a local ADSE could occur. Review of the facility Influenza vaccination box, revealed to administer zero point five (0.5) ml. for ages five (5) years and older; however, interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 2:55 PM, revealed she administered five (5) ml. to Resident #1, instead of 0.5 ml. She stated when she realized the mistake she immediately notified the Administrator, the resident's daughter, and ARNP. She revealed the physician was also consulted by the ARNP and poison control was contacted as well. She revealed Poison Control advised the staff to monitor the site of the injection for redness, irritation or swelling. She stated the ARNP ordered for the staff to monitor the resident for seventy-two (72) hours for the appearance of the site, vital signs, and lethargy. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 11:26 AM, revealed there was no policy specifically for influenza vaccinations. She stated she expected the nurse to administer the dosage listed on the Influenza box. Interview with the ARNP, on [DATE] at 1:10 PM, revealed she expected the appropriate dose be given. She stated she was made aware of the incident and discussed it with the Physician as well as Poison Control and it was determined there would be no long-term reactions.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to review and revise the plan of care and Nurse Aide Data Sheet (NADS) for one (1) of three (3) sampled residents, (Resident #1). Resident #1 was assessed per Therapy recommendations to be transferred from the bed to the chair utilizing a mechanical lift; however, review of the Comprehensive Care Plan and Nurse NADS revealed the facility failed to revise the care plan. On 10/11/18, Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 from his/her bed to the chair without the use of the mechanical lift which resulted in the resident having to be lowered to the floor with not injury. The findings include: Review of the facility's policy and procedures, Care Plan, dated 11/20/17, revealed it is the facility policy that residents will have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives, and addresses their assessed needs. Care plan approaches will be communicated to staff for use in providing direction for care. The plan of care will be reviewed and revised when requested by the resident and/or indicated, based on resident's response to plan of care. Review of the facility's procedures, Therapy Communication to Nursing Instructions for Completion, dated 06/07/11, revealed the Therapy Communication To Nursing form shall be used to communicate therapy identified resident needs, changes, discharges, or necessary nursing follow-up and to in-service nursing staff. The form shall be initiated by the treating therapist/assistant and will be given to the Unit Manager (UM) or in his/her absence, the charge nurse. The contents will be reviewed to verify clear understanding. The nurse receiving the communication will sign at the bottom of the form, acknowledging receipt of the form. The communication will be processed in the same manner as orders received, in example {i.e}, update the Interdisciplinary Care Plan and update the Nurse Aide Data Sheet. Record review revealed the facility admitted Resident #1 on 10/03/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 10/10/18, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of the Resident #1's Therapy Communication to Nursing form, dated 10/05/18, revealed Physical Therapy communicated for the resident to complete bed to wheelchair transfers with a mechanical lift; however, review of the Comprehensive Care Plan and NADS revealed the facility failed to revise the care plan to use a mechanical lift for transfer from bed to wheelchair. Review of the facility's Event Report for Resident #1, dated 10/11/18 at 10:40 AM, revealed CNA #1 and CNA #2 were assisting the resident in a transfer from bed to the wheelchair without the use of a mechanical lift, when Resident #1's knees buckled resulting in him/her being assisted to the floor in a seated position. Interview with CNA #1, on 10/23/18 at 2:30 PM, and CNA #2 on 10/24/18 at 4:24 PM revealed the CNA's were transferring Resident #1 from the bed to the wheelchair when the resident's knees buckled which resulted in the resident being assisted to the floor. The CNA's stated the NADS for Resident #1 indicated transfers were physical assist of two (2) staff. Interview with LPN #1, on 10/24/18 at 9:35 AM, revealed she received a Therapy Communication to Nursing for Resident #1 on 10/05/18. LPN #1 stated she was responsible to implement the Therapy recommendations; however, failed to do so by adding to Resident #1's NADS and Care Plan. Interview with the Director of Nursing (DON) and Administrator, on 10/24/18 at 3:20 PM, revealed LPN #1 received Therapy recommendations on 10/05/18 for Resident #1's transferring care needs; however, LPN #1 failed to implement the recommendations and/or communicate with Therapy, and the recommendations were not carried out. Additionally, the DON and Administrator revealed therapy recommendations for Resident #1 to transfer with the use of a mechanical lift should have either been reviewed and revised and added the resident's care plan and NADS or discussed to explore other option for transfers to meet the resident care needs that would prepare him/her in transition to home.

Based on interview, record review, and review of the facility's policies and procedures, it was determined the facility failed to ensure assistive devices were utilized to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Resident #1 was assessed per Therapy recommendations to be transferred from the bed to the chair utilizing a mechanical lift; however, on 10/11/18, Certified Nurse Aide (CNA) #1 and CNA #2 transferred Resident #1 from his/her bed to the chair without the use of the mechanical lift. The findings include: Review of the facility's policy and procedures tiled, Incident/Accident, dated 11/28/16, revealed it is the facility's policy to provide a safe and hazard free environment as is possible. An incident/accident is defined as an unexpected, unintended event that can cause a resident or visitor bodily injury. Residents are reviewed through routine analysis and a care planning process for factors that may place them at risk for incidents or accidents. Interventions will be implemented based on the analysis findings. Review of the facility's procedures, Therapy Communication to Nursing Instructions for Completion, dated 06/07/11, revealed the Therapy Communication To Nursing form shall be used to communicate therapy identified resident needs, changes, discharges, or necessary nursing follow-up and to in-service nursing staff. The form shall be initiated by the treating therapist/assistant and will be given to the Unit Manager (UM) or in his/her absence, the charge nurse. The contents will be reviewed to verify clear understanding. The nurse receiving the communication will sign at the bottom of the form, acknowledging receipt of the form. The communication will be processed in the same manner as orders received, in example {i.e}, update the Interdisciplinary Care Plan and update the Nurse Aide Data Sheet. Record review revealed the facility admitted Resident #1 on 10/03/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 10/10/18, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of the Resident #1's Therapy Communication to Nursing, dated 10/05/18, revealed Physical Therapy communicated for the resident to complete bed to wheelchair transfers with a mechanical lift. Review revealed mechanical lift was indicated for Resident #1 regarding needed assistance for left upper extremity (LUE) and left lower extremity (LLE) placement. Review of the facility's Event Report for Resident #1, dated 10/11/18 at 10:40 AM, revealed CNA #1 and CNA #2 were assisting the resident in a transfer from bed to the wheelchair without the use of a mechanical lift, when Resident #1's knees buckled resulting in him/her being assisted to the floor in a seated position. Interview with CNA #1, on 10/23/18 at 2:30 PM, revealed she and CNA #2 were transferring Resident #1 from the bed to the wheelchair when the resident's knees buckled which resulted in the resident being assisted to the floor. CNA #1 stated she was was not aware the resident was to be transferred using a mechanical lift. CNA #1 further stated, it was my first time caring for the resident. The other CNA and I used our Nurse Aide Data Sheet (NADS) to provide the resident's care and use of a mechanical lift for transfers was not listed on the NADS; transfer was listed as physical assist of two (2). Interview with CNA #2, on 10/24/18 at 4:24 PM, revealed on 10/11/18, she and CNA #1 were transferring Resident #1 from the bed to chair when the resident knees buckled and the resident was assisted to the floor. CNA #2 stated the NADS for Resident #1 indicated transfers were physical assist of 2 staff. She further stated after the fall, Resident #1 NADS was changed to use mechanical lift with assistance of 2 staff. Interview with the Doctor of Physical Therapy (DPT), on 10/24/18 at 10:11 AM, revealed Resident #1 was assessed on 10/04/18 and it was determined Physical Therapy would treat for bed mobility, balance, and transferring from bed to chair. The DPT stated Resident #1 was admitted from the hospital and therapy services were implemented; and, the resident's goal was to regain strength to return home. Further interview with the DPT revealed a Therapy Communication to Nursing recommendation was given to Licensed Practical Nurse (LPN) #1 for Resident #1 to transfer from bed to chair with mechanical lift and 2 staff assistance. Interview with LPN #1, on 10/24/18 at 9:35 AM, revealed she received a Therapy Communication to Nursing for Resident #1 on 10/05/18. LPN #1 stated she was responsible to implement the Therapy recommendations; however, failed to do so by adding to Resident #1's NADS and Care Plan. LPN #1 revealed was the nurse assigned to Resident #1 on 10/11/18 and she was summoned to Resident #1's room because the resident was on the floor. LPN #1 stated, I assessed the resident, there were no injury, and myself along with the nurse aides physically transferred the resident back to bed. Interview with the Director of Nursing (DON) and Administrator, on 10/24/18 at 3:20 PM, revealed they would not have expected Resident #1 to be transferred with a mechanical lift because she was at the facility to receive Therapy services to prepare to transition home. They stated LPN #1 received Therapy recommendations on 10/05/18 for Resident #1's transferring care needs; however, LPN #1 failed to implement the recommendations and/or communicate with Therapy, and the recommendations were not carried out. They further revealed LPN #1 admitted Resident #1 to the facility on [DATE] and was aware of the resident care needs. They stated Resident #1 was not assessed as a Fall Risk; therefore, they would not have expected Resident #1 to be transferred with a mechanical lift despite therapy services recommendation.

Based on observation interview, record review, and facility policy review, it was determined the facility failed to notify the resident's representative of a significant change in condition and treatment for one (1) of three (3) sampled residents (Resident #1). The facility failed to notify Resident #1's spouse that Resident #1 was receiving treatment for scabies as of 06/28/18. The findings include: Review of the facility policy titled, Notification Requirements, dated 08/22/17, revealed it is the policy of this facility to notify the resident, his or her attending physician, and representative consistent with his or her authority, of changes in the resident's condition. The facility should notify the resident's attending physician and representative when there is a need to alter the resident's treatment significantly; and, when there is a significant change in the resident's physical, mental, or psychological status. All notifications will be documented in the resident's medical record. 1. Record review revealed the facility readmitted Resident #1 on 04/06/18 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 06/07/18, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Review of Resident #1's (MONTH) (YEAR) Physician's Orders revealed to apply [MEDICATION NAME] ([MEDICATION NAME]) cream (treatment of scabies or head lice) tonight (06/28/18) and repeat in five (5) days. Review of a Medication Regimen Review revealed the resident received the Elimiite on 06/28/18. However, review of the Nursing Progress Note, dated 06/28/18, revealed there was no documented evidence the resident's representative was notified. Interview with Physician for Resident #1 on 07/18/18 at 3:00 PM revealed he thought Resident # 1 might' have Scabies and stated that was why he started the resident on [MEDICATION NAME]. He stated the nurse (Registered Nurse {RN} #1) making rounds with him was aware. Interview with RN #1 on 07/19/18 at 10:34 AM revealed she thought Resident #1 was being treated for contact [MEDICAL CONDITION]. She stated Resident #1 called and told his/her spouse that the staff were going to start putting some cream on his/her rash, then handed her the phone. RN #1 stated she told spouse they were going to put [MEDICATION NAME] cream on the resident and leave on for twelve (12) hours and then shower off. RN #1 revealed she did not tell the spouse what the cream was for and the spouse did not ask. She stated she was aware [MEDICATION NAME] was only given for scabies. Interview with the Director of Nursing (DON) on 07/19/18 at 4:18 PM revealed the licensed nurse should have notified the resident's spouse that the resident was being treated for scabies,

Based on observation, interview, record review and facility policy review, it was determined the facility failed to update/revise the Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #1). The facility failed to update/revise a Care Plan for Resident #1 to include the [DIAGNOSES REDACTED]. The findings inlcude: Review of the facility policy titled, Care Plan, dated (MONTH) 2007, revealed it is the facility policy that residents will have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives, and addresses their assessed needs. Care plan approaches will be communicated to staff for use in providing direction for care. The plan of care will be reviewed and revised when requested by ther resident and/or indicated, based on resident response to the plan of care. The plan of care will be stated clearly and will identify the resident problem, measurable goals to be achieved, which include timetables to meet resident's needs, and the interventions to be followed by staff in providing the care. The care plan should be revised as conditions develop, change or improve requiring a change in plan. Record review revealed the facility readmitted Resident #1 on 04/06/18 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 06/07/18, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Review of the (MONTH) (YEAR) Physician's Orders revealed an order for [REDACTED]. However, review of a Comprehensive Care Plan for Resident #1, dated 06/19/18, revealed there was no care plan to address the possibility of the resident having scabies or what care to provide. Observation of Resident # 1 on 07/18/18 at 8:53 AM revealed some red rash like pin point areas on the resident's back and chest. Interview with the resident on this date at 9:00 AM revealed the resident denied any itching and no scratching observed. Interview with Physician for Resident # 1 on 07/19/18 at 10:30 AM revealed he thought Resident #1 might' have Scabies and stated that was why he started the resident on [MEDICATION NAME] and the nurse (Registered Nurse {RN} #1) making rounds with him was aware he thought the resident might have Scabies as he had told her. Interview with RN #1 on 07/19/18 at 10:34 AM revealed she thought Resident #1 was being treated for [REDACTED]. Inerview with Director of Nursing (DON) and MDS Coordinator on 07/19/18 at 4:18 PM revealed the Care Plan should have been updated to include the [DIAGNOSES REDACTED].

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents received the appropriate care and services related to changing of a urinary catheter as per physician's orders [REDACTED]. Resident #1 was care planned and had a physician's orders [REDACTED].#1's catheter in (MONTH) (YEAR). The findings include: Review of facility policy titled, Urinary Indwelling Catheter, dated 11/20/17, revealed a physician's orders [REDACTED]. Interventions should be implemented to minimize the risks associated with indwelling catheter use. Such interventions may include but are not limited to catheter care each shift, monitor for signs and symptoms of infection. Record review revealed the facility readmitted Resident #1 on 04/06/18 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 06/07/18, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Further review revealed the resident was also assessed to have a Urinary Catheter. Observation of Resident #1 on 07/18/18 at 8:53 AM revealed the resident lying in bed with a urinary catheter to bedside drainage with yellow urine in drainage tubing, covered with dignity bag. Review of (MONTH) (YEAR) physician's orders [REDACTED]. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL) Self Care Deficit dated 06/19/18 revealed interventions to change catheter every month and as needed. Review of the May, (MONTH) and (MONTH) (YEAR) Treatment Administration Records (TARS) revealed Resident #1's urinary catheter was changed on 05/11/18 and 07/17/18. However, there was no documented evidence the catheter was changed in (MONTH) (YEAR). Review of hospital records revealed a urinalysis was conducted on 07/03/18 at 10:39 AM and showed too numerous to count white blood cell count (indicating infection) and three plus (3+) bacteria. Final report showed probable contamination of urine specimen. However, review of Progress Notes from the hospital revealed the resident had signs/symptoms (s/s) of a Urinary Tract Infection such as altered mental status, complaints of pain at catheter site and purulent urine drainage upon admission to the hospital. White Blood Cell count (WBC) was elevated at 11.47 (4.8-10.8 normal range) on 07/03/18. Interview with the Director of Nursing (DON) on 07/19/18 at 4:18 PM revealed they could not find any proof the catheter was changed in (MONTH) (YEAR) and stated if there was no documentation to prove it was changed, then it was not changed. She stated she expected staff to change the catheter as ordered and document appropriately.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety. Observation of the kitchen, on 07/01/18 and on 07/02/18, revealed food being stored in the walk-in refrigerator which had passed their used by dates; foods being stored in the walk-in refrigerator and in the Cook's refrigerator with no dates present on them; and opened and unsealed foods being stored in the walk-in freezer. In addition, there was dirty kitchen equipment. Review of the Census and Condition, dated 07/01/18, revealed eighty-eight (88) of eighty-nine (89) residents received their food from the kitchen. The findings include: Review of facility policy titled, Dietary Sanitation, last revised 11/20/17, revealed the facility will store, prepare and distribute and serve food in accordance with professional standards for food service safety. It further states food service staff are to follow procedures that reduce potential for food borne pathogens, in storing, preparing and serving food. Review of the facility policy titled, Dietary Sanitation-Clinical Practice Guidelines, dated 11/20/17, revealed when food products are delivered to the facility, the facility staff must inspect the items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard all perishable foods and covering, labeling and dating all potentially hazardous food and time/temperature control for safety foods and storing in the refrigerator or freezer as indicated. The policy also states, the dry food storage room is maintained in a clean, dry and orderly manner, free from contaminants and all food is in sealed packaging or containers with tight fitting lids. Further review of this policy, revealed opened food packages and left over foods stored in the refrigerators are sealed and dated and left over foods should be used within three (3) days or discarded. Continued review of the policy, revealed fixed equipment - when cleaning items like mixers, slicer's and other equipment that can't be immersed in water, the removable parts are to be washed and sanitized and the non-removable parts to be cleaned per manufacturer guidelines. 1. Observation of the kitchen in the walk-in refrigerator, on 07/01/18 at 9:32 AM, revealed there was a container of low fat cottage cheese with no use by date; a plastic container of small curd cottage cheese with no dates present on the container as to when the use by date was, and a container of chocolate syrup with an expiration date of 06/30/18. 2. Observation of the walk-in freezer on 07/01/18 at 9:39 AM, revealed a box of beef steak fritters open to air and not sealed; a box of ground beef patties open to air and not sealed; and a box of peas and carrots in a box open to air and not sealed. 3. Observation of the dried storage/pantry room on 07/01/18 at 9:42 AM, revealed a package of lemon cake mix that was split open and the package was being stored in a open canister with the cake mix package sitting on top of some of the cake mix in the canister. Further observation revealed the cake mix was visibly spilled all over floor and boxes beside the canister the cake mix package was being stored in. In addition, there was a canister of corn flakes with a used by date of 09/25/17 being stored next to the other breakfast cereal. 4. Observation of the Cook's refrigerator on 07/01/18 at 9:45 AM, revealed a bowl of boiled eggs, a bowl of salad, and a small bowl of cottage cheese with no dates on them when they were placed in the bowls or when their use by date was. In addition, there was a canister of small curd cottage cheese with no date of when opened or when the used by date was. 5. Observation of the kitchen on 07/01/18 at 9:53 AM, revealed the can opener was visibly soiled and dirty with a build up of black and brown material on the cutting edge, all over the handle, and the holder the manual can opener was in. In addition, the meat slicer had a visible build up a dry, crusty and yellowish material all over the cutting blade area. Interview with the Dietary Manager on 07/01/18 at 11:10 AM, revealed she expected all foods in the refrigerators and freezers to be sealed completely and labeled with open dates, delivery date and best by/used by date. She stated she expected staff to clean the can opener as they go and run it through the dishwasher at least every shift. She revealed the meat slicer should be cleaned after each use and taken apart and washed. Interview with the facility Registered Dietician on 07/02/18 at 02:04 PM, revealed she expected all foods to be labeled with an open on date and a used by date. She stated anything that is put in different containers are to be labeled, dated and sealed in a air tight container. She revealed she expected the meat slicer and manual can opener to be cleaned after each use.

Based on observation, interview, record review and facility policy review, it was determined the facility failed to provide care for two (2) of eighteen (18) sampled residents (Residents #10 and #46)). Observations on 07/01/18 revealed Residents #10's urinary catheter bag was not in a dignity bag. In addition, observations on 07/01/18 and 07/02/18 revealed Resident #46's blue bunny boots were soiled and stained, The findings include: Review of the facility's policy, Rights of Nursing Home Residents, dated 08/15/17, revealed the facility promotes and protects the rights of each resident and the residents have the right to be treated with respect and dignity and to make choices about how they want to live their lives and receive care. Further review revealed the nursing home must provide its residents with the necessary care and services to attain their highest practicable level of physical, mental, and social well-being. 1. Record review revealed the facility admitted Resident #10 on 10/14/16 with [DIAGNOSES REDACTED]. Review of a Quarterly MDS assessment, dated 04/01/18, revealed the facility coded Resident #10's BIMS score as 99, which indicated the resident was severely cognitively impaired and not interviewable. Observation of Resident #10 on 07/01/18 at 10:23 AM, 11:42 AM and 12:00 noon, revealed the resident's catheter bag was no in a dignity bag and was facing the doorway, visible to any residents, staff or visitors passing by the door. Interview with Certified Nursing Assistants (CNA's) #11 and #12 on 07/03/18 at 1:55 PM revealed the catheter dignity bag covers for Residents #10 was overlooked but, should have been on the catheter bags. Interview with Assistant Director of Nursing (ADON) on 07/03/18 at 2:40 PM revealed she expected staff to have catheter bags in dignity bags. Interview with Director of Nursing (DON) on 07/03/18 at 2:52 PM revealed she expected staff to keep dignity bag covers over all urinary catheters bags. 2. Record review revealed the facility admitted Resident #46 on 09/16/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 05/22/18, revealed the facility assessed Resident #46's cognition as severely impaired with a BIMS score of seven (7), which indicated the resident was not interviewable. Observations on 07/01/18 at 12:44 PM and 3:26 PM, revealed Resident #46 was up in a chair wearing blue bunny boots with brown, dried stains on them. Observation on 07/02/18 at 9:13 AM, revealed Resident #46 was up in chair and was wearing the blue bunny boots that were visibly stained with a brown, dry substance. Interview with CNA #1 on 07/03/18 at 2:03 PM, revealed the soiled bunny boots should have been washed prior to placing on Resident #46. She stated there are extra pairs located in the supply closet accessible to staff. Interview with Licensed Practical Nurse (LPN) #1 on 07/02/18 at 11:06 AM, revealed she would not have expected the aides to use the soiled boots because they were dirty and should have been sent to be washed. She stated the boots were currently being washed and she was not sure if the resident had a back-up pair. Interview with the DON on 07/03/18 at 2:51 PM, revealed she would have expected the soiled boots to be replaced on Resident #46. She stated clean pairs of boots are located in the supply closet assessable to staff.

Based on interview and facility policy review it was determined the facility failed to ensure each resident is offered an influenza immunization from (MONTH) 1 through (MONTH) 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period and/or a pneumoccocal immunization to four (4) of eighteen (18) sampled residents (Residents #32, #37, #11, and #10). The findings include: Review of facility policy titled, Immunizations, dated 11/20/17, revealed it is the policy of the facility that residents are encouraged to accept immunizations and/or vaccinations that help to prevent infectious diseases, unless medically contraindicated. Further, residents are encouraged to accept influenza and pneumonia vaccines in accordance with current accepted clinical practice standards. Residents should be offered a pneumonia vaccine upon admission unless otherwise ordered by his/her physician, declined by the resident, or his/her resident representative, or has already been immunized. The following guidelines should be utilized for which residents are candidates for the Pneumococcal Vaccines: Age nineteen (19) to sixty-four (64) with chronic or immuno-suppressed medical condition, including asthma, and those residents in this age group that smoke cigarettes. All residents who are sixty-five (65) years of age who have never received the vaccine or at least five (5) years have past since they received the vaccine if it was given prior to [AGE] years of age. 1. Record review revealed the facility admitted Resident #10 on 10/14/16 with [DIAGNOSES REDACTED]. Further record review revealed there was no documented evidence the resident had received a pneumoccocal immunization. In addition, there was documentation the resident received a flu immunization on 10/04/16, but no evidence it was provided for (YEAR). 2. Record review revealed the facility admitted Resident #11 on 11/03/17 with [DIAGNOSES REDACTED]. Further record review revealed there was no documented evidence the resident received a pneumoccocal immunization. Interview with Administrator on 07/03/18 at 2:55 PM revealed they could not find the documentation Resident #10 and #11 had received their Pneumococcal immunizations on admission or Flu immunizations for (YEAR). 3. Record review revealed the facility admitted Resident #32 on 04/28/15 with [DIAGNOSES REDACTED]. Resident was a former smoker. Further review of the Quarterly Minimum Data Set (MDS) assessment, dated 05/09/18 revealed the facility assessed Resident #32's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Resident's Immunization Record revealed the date of last known pneumonia vaccine was 09/17/12. 4. Record review revealed the facility admitted Resident #37 on 07/01/16 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 05/06/18 revealed the facility assessed Resident #37's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. Review of the Resident's Immunization Record revealed Resident #37 had received a Pneumonia vaccine, but it was over five (5) years ago. Interview on 07/03/18 at 1:40 PM with the Assistant Director of Nursing (ADON) revealed he/she expected pneumonia vaccines to be offered to all residents on admission, especially if it has been over five (5) years since the resident received the last vaccine. Interview on 07/03/18 at 1:55 PM with the Director of Nursing (DON) revealed he/she expected all residents to be up to date on their immunizations.

Based on interview, record review, and facility policy review, it was determined the facility failed to consult with the resident's physician; for a significant change in the resident's physical, mental, or psychosocial status for two (2) of eighteen (18) sampled residents (Resident #37 and #54). On spproximately 04/18/18 through 04/22/18, Resident #37 had a significant change in condition with him/her becoming lethargic, having a decline in intake, and refusing medication; however, the facility failed to call the physician until 04/23/18 when the resident was identified as having an Oxygen Saturation (O2 sat) level of seventy-eight percent (78%) on room air; blood pressure was unattainable with any electronic equipment; manual blood pressure was faint at 60/40 (resident's baseline blood pressure 153/69); and resident was lethargic. The resident was transferred to the hospital and admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. On 04/18/18, Resident #54 weight 139 pounds and on 05/18/18 the resident weighed 124.2 pounds which was a 14.8 pound weight loss (10.65 percent) in one month; however, the Physician was not notified of the significant weight loss until 05/23/18 (five {5} days later). The findings include: 1. Review of the facility policy, Nursing Weight and Height Monitoring, dated (MONTH) 2007, revealed weights will be reviewed to identify weight changes, trends, or significant changes. The policy further revealed the physician will be notified of significant changes in weight and residents will be referred to the Nutritionally At Risk (NAR) for further review, as indicated. Record review revealed the facility readmitted Resident #54 on 04/09/18, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/04/18, revealed the facility assessed Resident #46's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. Review of Resident #54's Weight Record revealed the resident weighed 139.0 pounds on 04/18/18 and weighed 124.2 pounds on 05/18/18, which was a significant weight loss of 10.65 percent in one (1) month. However, review of the Registered Dietician's Notes, dated 06/01/18, revealed the Physician was not notified of the significant weight loss until 05/23/18. Interview with the Registered Dietitian (RD) on 07/03/18 at 1:08 PM, revealed Resident #54's current weight was 126.4 pounds. She stated the physician should be notified timely of significant weight changes. Interview with the Assistant Director of Nursing (ADON) on 07/03/18 at 1:40 PM, revealed she would have expected the physician to be notified in a more timely manner and if the resident has a significant weight loss they should be placed on weekly weights. Interview with the Director of Nursing (DON) on 07/03/18 at 1:55 PM, revealed she would have expected the Physician to be notified sooner than five days of a significant weight loss. 2. Review of the facility policy titled, Notification Requirements, last revised 8/22/17, revealed it is the policy of the facility to notify the resident's attending physician of changes in the resident's condition. The facility should notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status. All notifications will be documented in the resident's medical record. Record review revealed the facility admitted Resident #37 on 07/01/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #37's cognition as severely impaired with a BIMS score of four (4) which indicated the resident was not interviewable. In addition, the resident was always incontinent of bowel and bladder; required extensive assistance of two (2) staff with toileting and extensive assist of one (1) staff for personal hygiene. Review of the Nurse's Notes dated 04/20/18 at 9:35 PM, revealed Resident #37 was lethargic for the past few days. Review of the twenty-four (24) hour Condition Report Summaries on 04/20/18 during day shift and night shift, Resident #37 was lethargic. On 04/21/18, documentation indicated the resident was lethargic on night shift. On 04/22/18, documentation indicated the resident was lethargic with decreased oral intake on night shift, and on day shift the resident was lethargic, had decreased oral intake and refused his/her medications. However, further review of the Nurse's Notes 04/20/18-04/22/18 nightshift revealed there was no documented evidence the Physician was notified of the resident's continuing lethargy, decreased intake, and refusal of medication. Review of a Nursing Note, dated 04/23/18 at 2:00 PM revealed Resident #37's Oxygen Saturation (O2 sat) level was seventy-eight (78) percent on room air; blood pressure was unattainable with any electronic equipment; manual blood pressure was faint at 60/40 (resident's baseline blood pressure 153/69); and resident was lethargic. Review of the hospital History and Physical dated 04/23/18 revealed Resident #37 was admitted to the Intensive Care Unit with [DIAGNOSES REDACTED]. The resident was treated with fluids and antibiotics. Interview with Licensed Practical Nurse (LPN) #2 on 07/03/18 at 10:30 AM revealed he/she called the hospital for a status update on the resident after he/she was sent to the hospital. The LPN stated he/she did not recognize a change in the resident before being sent to the hospital. The LPN further stated he/she remembered charting on the 24 Hour Report that resident was lethargic. Interview with Registered Nurse (RN) #3 on 07/03/18 at 10:54 AM revealed Resident #37's lethargy had been going on for a while. When asked how long is a while she replied, Oh I don't know, a while. The RN further stated this is a change that she would normally notify the physician for, however, I thought the previous day shift had notified the doctor of the change. Interview with Assistant Director of Nursing (ADON) on 07/03/18 at 1:40 PM revealed staff should have notified the physician regarding resident's change in condition. She stated if there was an immediate change in condition, she would expect immediate notification. Interview with the Director of Nursing (DON) on 07/03/18 at 1:55 PM revealed the physician should be notified immediately of significant change in status. The DON further stated this is unacceptable.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure the resident environment was comfortable and homelike to the extent possible for the maintenance of comfortable sound levels related to excessive loud, frequent overhead paging. The findings include: Review of the facility policy, Rights of Nursing Home Residents, revealed residents have the right to a safe, clean, comfortable, and homelike environment, to include the maintenance of comfortable sound levels. Observations on 07/01/18 at 3:22 PM, 3:43 PM, 3:57 PM, 3:58 PM and 4:22 PM revealed multiple pages for staff over the load speaker related to phone calls. Further observation on 07/02/18 at 9:19 AM and 10:34 AM, revealed staff paging over the facility load speaker for related to phone calls. Interview with Assistant Director of Nursing (ADON) on 07/03/18 at 2:43 PM, revealed she expected staff to only page in emergencies, otherwise they can walk to find the person. She stated with the previous phone system staff could page through the phones and with this new system they we are still monitoring the pages and the need to educate staff. Interview with the Director of Nursing (DON) on 07/03/18 at 2:51 PM, revealed she would expect staff to keep the paging to a minimum. Interview with the Administrator on 07/03/18 at 2:54 PM, revealed the facility normally does not page that much but they recently obtained a new phone system and was working on an alternate method to keep the volume down and through the phones instead of the loud speaker.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop a comprehensive person-centered care plan for one (1) of nine (9) sampled residents (Resident #1). Resident #1 chose to be a Full Code (staff to provide Cardiopulmonary Resuscitation (CPR) if found with no respirations and no heart beat). However, the facility failed to develop a person-centered plan of care that supported the resident in making their own choices, per facility policy. On [DATE], Resident #1 was found unresponsive, no pulse, not breathing and his/her eyes were fixed and dilated. The licensed staff failed to provide the resident CPR. The licensed staff pronounced Resident #1 as expired and did not call Emergency Medical Services (EMS). The facility's failure to develop a comprehensive care plan related to a resident's choice to have CPR, has caused or is likely to cause serious injury, harm, impairment, or death to residents. The facility was made aware of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], alleging removal of the Immediate Jeopardy and substantial compliance on [DATE]. The State Survey Agency validated the facility had corrected the deficient practice on [DATE], prior to the State Survey Agency entering the building on [DATE]. Therefore, the State Survey Agency determined the facility had past non-compliance. The findings include: Review of the facility's policy titled, Care Plan, last revised [DATE] revealed, Residents will have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives, and addresses their assessed needs. The facility's definition of Person-Centered Care is to focus on the resident as the locus of control and support the resident in making their own choices; and, having control over their daily lives. The resident has the right to be informed of and participate in his or her treatment and development of the plan of care. The resident is encouraged to participate in establishing expected goals of care, the type, amount, and frequency of care and other factors that may impact the plan of care. Care plan approaches will be communicated to staff for use in providing direction for care. The facility will honor the resident's rights regarding the development and implementation of the plan of care. Closed record review revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Further review of the record revealed there was a Green Full Code sheet, which indicated the resident chose to receive CPR. Review of the (MONTH) (YEAR) Physician order [REDACTED]. However, review of the Baseline Nursing Care Plan, dated [DATE], and the Comprehensive Care Plan dated [DATE], revealed there was no care plan developed to address Resident #1's choice of Full Code status. Per facility policy, the facility was to develop a person centered care plan that addressed resident's choices. Review of a Nurses' Note dated [DATE], with no time noted, and interviews on [DATE] with Registered Nurse (RN) #1 at 12:38 PM, and a Laundry Worker at 1:05 PM, revealed Resident #1 was found by the laundry person to be unresponsive and called RN #1. RN #1 immediately proceeded to the room where she noted the resident to be pulseless, not breathing and with his/her eyes fixed and dilated. The RN pronounced the resident as expired on [DATE] at 6:05 AM. The RN failed to initiate CPR per the resident's chose and physician's orders [REDACTED]. Interview with RN #1, on [DATE] at 12:38 PM, revealed she did not look at the record or the Care Plans for Resident #1's CPR status after finding the resident to be unresponsive, pulseless, breathless and with his/her eyes fixed and dilated. She stated she should have followed the policy and initiated CPR and called 911. Interview (Post Survey) with the MDS staff, on [DATE] at 11:42 AM, revealed the care plans were the ultimate responsibility of the MDS staff. She stated prior to this incident the facility did not add the Code Status information into the Care Plan. Interview with the former Director of Nursing (DON), now Assistant Director of Nursing (ADON) on [DATE] at 12:46 PM, revealed staff should update the Care Plan, as needed. She further stated that when the MDS Coordinator was not in the building, staff should update the care plan as new orders were received. Interview with the Administrator on [DATE] at 2:29 PM, revealed prior to the incident on [DATE], the facility did not require a resident's Code Status to be documented on the Care Plan. However, review of the facility's policy revealed Residents will have a person-centered plan of care that supports the resident in making their own choices. Further interview with the Administrator, on [DATE] at 9:20 AM, revealed the MDS staff were responsible to write the Care Plans when they were in the building and if new orders were received, the nurse taking the order was responsible for updating the Care Plan. **The facility implemented the following actions to correct the deficient practice: 1. The resident involved in the Immediate Jeopardy expired on [DATE]. 2. An audit was conducted by the Director of Nursing on [DATE] of all code blue situations since [DATE] to ensure that CPR was performed on full code residents. No issues were identified. 3. The Licensed Nurse that failed to provide CPR to Resident #1 was given 1:1 education on [DATE], prior to being allowed to return to work. This education was presented by the Director of Nursing and covered following physician orders [REDACTED]. Education also included to always clarify the physician orders [REDACTED]. 4. The Licensed Nurse that failed to provide CPR to Resident #1 was also given a final written Performance Correction on [DATE], prior to returning to work by the Director of Nursing, after consultation with the Regional Human Resources Director. 5. An Emergent Quality Assurance Meeting was conducted on [DATE], the date this incident occurred, to discuss the failure of the Licensed Nurse to provide CPR to the resident. The Emergent Quality Assurance Meeting was held with the Regional Quality Management Specialist, Director of Nursing, and Assistant Director of Nursing to discuss actions that needed to be implemented to prevent this situation from happening again. The Medical Director was made aware of the situation on [DATE], by the Regional Director. 6. An investigation was initiated by the Regional Quality Management Specialist on [DATE], the date this incident occurred. The investigation determined this to be an isolated incident caused by a decision made by one nurse. 7. Education was started on [DATE], with all nursing staff regarding the Cardiopulmonary Resuscitation policy and the Visitor Cardiopulmonary Resuscitation policy and CPR initiation. Education included designation of Red and Green paper for DNR and Full Code. The education was completed with all nursing staff on [DATE]. This education was presented by the Director of Nursing. In addition, education was provided to licensed nurses on [DATE] by the Assistant Director of Nursing and the MDS Coordinators; and, on [DATE] by the Quality Management Specialist of the need to have every resident's code status listed on their care plan. 8. Nursing Staff hired since this incident occurred on [DATE], have been educated on CPR initiation by the Director of Nursing. 9. The facility has ensured there has been nursing staff present in the facility, on all shifts, that are CPR certified, since [DATE]. The facility brought in an outside entity, a Certified CPR instructor through the American Heart Association to teach CPR classes for staff needing certification or re-certification. 10. An audit was conducted by the Director of Nursing, Assistant Director of Nursing, and Unit Manager beginning on [DATE] to ensure that every resident with DNR orders had their purple DNR bracelet on. On-going audits will be conducted weekly times eight (8) weeks to ensure all residents with DNR orders were wearing their DNR bracelets. 11. An audit was conducted by the Medical Records Coordinator on [DATE], to ensure each resident's chart had the Red DNR paper or Green Full Code paper in their charts. All new admission charts were brought to the next Abbreviated Quality Assurance Meeting to ensure the Red DNR paper or Green Full Code paper was present in the front of the chart. On weekends and holidays, the Administrative Nurse on call will verify the presence of the Red DNR paper or Green Full Code paper in the front of the charts for new admissions. 12. All DNR residents had their chart audited by the Business Office Manager (formal Social Services Director) on [DATE] to ensure all DNR paperwork was up to date and had all signatures needed. The audit also included ensuring that residents with Advance Directives had a copy of the Advance Directive in the chart. 13. An audit was conducted on [DATE] by the Payroll Coordinator and Assistant Director of Nursing to check all nursing staff to determine what staff needed CPR certification. CPR classes were held on [DATE], [DATE], and [DATE]. Another CPR class is also scheduled for (MONTH) (YEAR). 14. Every resident death will be discussed during the Abbreviated Quality Assurance Meeting held Monday - Friday to ensure the resident's code status was honored by the staff present. Resident deaths occurring on the weekends or holidays will be reviewed by the Administrative Nurse on call to ensure the resident's code status was honored by the staff present. Monitoring will continue for three (3) months and results will be discussed during monthly QA meetings to determine ongoing monitoring. 15. All residents on palliative care had their care plans audited by the MDS Coordinators on [DATE], to ensure these residents had an Advanced Directive Care Plan in place. 16. All resident care plans were audited on [DATE] by the MDS Coordinators to ensure that each resident had their code status listed on their care plan. 17. All residents' care plans were audited for DNR/Full Code status on [DATE] by the Quality Management Specialist; and, on [DATE]-[DATE] by the Regional Resource Nurse. Auditing of resident care plans for DNR/Full code status will continue monthly for six (6) months to include all residents at least quarterly. Audits will be completed by designated members of the quality Assurance Committee. ** The State Survey Agency validated the following actions to correct the deficiency: 1. Review of the Provisional Report of Death, dated [DATE], revealed Resident #1 expired at 6:05 AM. 2. Review of an audit completed by the DON on [DATE], revealed that the facility has had no Code Blues since [DATE]. This was confirmed by interview. 3. Review of the content of the Education/Training Attendance Record revealed RN #1 received education from the DON on [DATE] at 6:10 PM, regarding the importance to always follow the Physician Order, and if there was something you were unsure or uncertain about, always clarify the order. This education was confirmed by interview with RN #1 on [DATE] at 12:38 PM. 4. Review of the Performance Correction Notice revealed the DON gave RN #1 a final written warning. The RN confirmed this information during a telephone interview on [DATE] at 12:38 PM. 5. Review of Action Plan and Follow up Record and interview with the Quality Management Specialist on [DATE] at 12:09 PM, revealed and Emergency Quality Assurance Management meeting was held on [DATE] with herself, the DON and the ADON to discuss the failure to initiate CPR on a resident that was determined to be a Full Code. Interview with the facility's Medical Director, on [DATE] at 9:50 AM, revealed he was notified of the incident and was involved in the CQI process. 6. Interview with the QMS and Interim Administrator, on [DATE] at 12:09 PM revealed an investigation was conducted of the incident and it was determined this was an isolated incident. 7. Review of the Education Attendance Records revealed all staff were educated on CPR initiation. This was done by lecture by the DON. This education included the Red paper for DNR status and Green paper for Full Code status. This education was completed by [DATE]. Interviews with RN #1 on [DATE] at 12:38 PM, RN #2 on [DATE] at 10:07 AM, RN #3 on [DATE] at 9:58 AM, RN #4 on [DATE] at 10:00 AM, RN #5 on [DATE] at 10:05 AM, RN #6 on [DATE] at 8:01 AM, LPN #1 on [DATE] at 11:02 AM, LPN #2 on [DATE] at 11:25 AM, LPN #3 on [DATE] at 8:05 AM, SRNA #5 on [DATE] at 2:13 PM, SRNA #4 on [DATE] at 11:35 AM, SRNA #3 on [DATE] at 2:00 PM, SRNA #2 on [DATE] at 2:47 PM, Med Tech on [DATE] at 3:57 PM and SRNA #1 on [DATE] at 1:00 PM revealed they were re-educated on the CPR initiation policy, Code policy, the purple bands, the Red DNR and Green CPR papers in the charts. They were also aware of the on-going audits related to the incident on [DATE]. The licensed staff stated they were also educated on updating the care plan to reflect the residents' Code Status. 8. Interview with the ADON (former DON), on [DATE] at 12:46 AM, revealed all staff hired since the incident have received inservice training and have been educated on CPR initiation. 9. Interview with the QMS, on [DATE] at 12:09 PM, and review of the investigation book revealed the facility now ensures there is a CPR certified staff person in the building at all times. 10. Review of the audit tool dated [DATE], used by the DON, ADON and Unit Managers revealed all residents with DNR orders had on a purple bracelet. Further review of the audits tools revealed the audits continued weekly for eight (8) weeks. No concerns were identified. 11. Review of an Audit tool dated [DATE] revealed the Medical Records Coordinator audited all residents' charts to ensure each resident chart had a Red DNR paper or a Green Full Code paper in the front of their charts. Review of Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9's charts revealed the papers were in the resident charts based on their code status. 12. Review of an audit conducted by the Business Office Manager on [DATE] and interview with the QMS on [DATE] at 12:09 PM, revealed all DNR residents had their charts audited to ensure that all DNR paperwork was up to date and they had all the signatures needed. The audit also included ensuring that residents with Advance Directives had a copy of the Advance Directive in the chart. 13. Review of an audit conducted on [DATE] by the Payroll Coordinator and ADON revealed they checked all nursing staff to determine what staff needed CPR certification. CPR classes were held on [DATE], [DATE] and [DATE] and another CPR class is scheduled for (MONTH) (YEAR). 14. Interview with the QMS/ Interim Administrator on [DATE] at 12:09 PM revealed they will discuss residents' deaths at the facility during the Abbreviated Quality Assurance meeting held Monday - Friday to ensure that the resident's code status was honored by the staff present. She stated resident deaths that occur on the weekends or on a holiday will be review by the Administrative Nurse on call to ensure the resident's code status was honored by the staff present. Further interview revealed monitoring will continue for three (3) months and the results will be discussed during the monthly QA meeting to determine ongoing monitoring. 15. Review of an audit tool dated [DATE], revealed all residents on palliative care had their care plans audited by the MDS Coordinators on [DATE], to ensure these residents had an Advanced Directive Care Plan in place. 16. Review of facility audits tools dated [DATE], revealed the ADON and MDS Coordinators audited each resident's care plan to ensure their code status was listed on their care plan. 17. Review of audit tools dated [DATE] and ,[DATE]-,[DATE] revealed the Quality Management Specialist and Regional Resource Nurse audited resident records to ensure a DNR/Full Code status was on the care plan.

Based on interview, record review, review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, and facility policy review, it was determined the facility failed to meet professional standards of quality by not following the physician order [REDACTED]. Resident #1 had a physician's orders [REDACTED].{CPR} if needed). However, Registered Nurse (RN) #1 failed to provide CPR; and, did not call Emergency Medical Services (EMS) when Resident #1 was found unresponsive, with no pulse, not breathing and his/her eyes were fixed and dilated on [DATE]. The RN proceeded to pronounce the resident as expired. The facility's failure to follow the physician's orders [REDACTED]. The facility was made aware of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], alleging removal of the Immediate Jeopardy and substantial compliance on [DATE]. The State Survey Agency validated the facility had corrected the deficient practice on [DATE], prior to the State Survey Agency entering the building on [DATE]. Therefore, the State Survey Agency determined the facility had past non-compliance. The findings include: Review of the KBN AOS #14 last revised [DATE], revealed nurses are held responsible and accountable for their decisions regarding the receipt and implementation of patient care orders based upon the individuals' education preparation and clinical competence in nursing. The nurse's practice should be consistent with the State Nursing Laws and be evidence based. Review of the facility's policy titled, Cardiopulmonary Resuscitation, last revised [DATE], revealed it is the policy of the facility to provide an efficient and organized team approach in response to a medical emergency requiring Cardiopulmonary Resuscitation (CPR). The facility recognized that the use of an Automated External Defibrillator (AED) along with Cardiopulmonary Resuscitation (CPR) methods may increase the resident's change for survival. If a resident experiences a cardiac or respiratory arrest, CPR will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status is not IMMEDIATELY known. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of a Nurse's Note, dated [DATE]; and, interview with Registered Nurse (RN) #1 on [DATE] at 12:38 PM, revealed Resident #1 was found by the laundry person. The resident was unresponsive. The laundry person immediately called for RN #1. RN #1 proceeded to the room where she noted the resident had no pulse, was not breathing and his/her eyes were fixed and dilated. The RN proceeded to pronounce the resident as expired at 6:05 PM. The RN failed to initiate CPR, per the physician's orders [REDACTED]. Interview with RN #1, on [DATE] at 12:38 PM, revealed she didn't think to look at the resident's record for the code status and she did not check to see if the resident was wearing a purple bracelet which would have indicated DNR status. RN #1 stated she should have looked at the chart to provide care as ordered. She stated she was aware of the facility's policy to provide CPR, but the situation was chaotic at the time. Interview, on [DATE] at 12:46 PM, with the former Director of Nursing (DON), now the Assistant Director of Nursing (ADON), revealed she was at home when RN #1 called her related to Resident #1. She stated when she spoke to RN #1 she determined that the RN had failed to initiate CPR. The ADON stated she expected all staff to follow physician's orders [REDACTED]. Interview with the Interim Administrator and the Quality Management Specialist (QMS), on [DATE] at 12:09 PM, revealed staff were aware of the resident's code status by looking in the chart for a Red DNR page or a Green CPR page. They could also check the physician's orders [REDACTED]. their status was DNR. Interview with the facility's Medical Director, on [DATE] at 9:50 AM, revealed he expected CPR to be started on a resident that was listed as a Full Code and 911 called for Emergency Medical Services. **The facility implemented the following actions to correct the deficient practice: 1. The resident involved in the Immediate Jeopardy expired on [DATE]. 2. An audit was conducted by the Director of Nursing on [DATE] of all code blue situations since [DATE] to ensure that CPR was performed on full code residents. No issues were identified. 3. The Licensed Nurse that failed to provide CPR to Resident #1 was given 1:1 education on [DATE], prior to being allowed to return to work. This education was presented by the Director of Nursing and covered following physician orders [REDACTED]. Education also included to always clarify the physician orders [REDACTED]. 4. The Licensed Nurse that failed to provide CPR to Resident #1 was also given a final written Performance Correction on [DATE], prior to returning to work by the Director of Nursing, after consultation with the Regional Human Resources Director. 5. An Emergent Quality Assurance Meeting was conducted on [DATE], the date this incident occurred, to discuss the failure of the Licensed Nurse to provide CPR to the resident. The Emergent Quality Assurance Meeting was held with the Regional Quality Management Specialist, Director of Nursing, and Assistant Director of Nursing to discuss actions that needed to be implemented to prevent this situation from happening again. The Medical Director was made aware of the situation on [DATE], by the Regional Director. 6. An investigation was initiated by the Regional Quality Management Specialist on [DATE], the date this incident occurred. The investigation determined this to be an isolated incident caused by a decision made by one nurse. 7. Education was started on [DATE], with all nursing staff regarding the Cardiopulmonary Resuscitation policy and the Visitor Cardiopulmonary Resuscitation policy and CPR initiation. Education included designation of Red and Green paper for DNR and Full Code. The education was completed with all nursing staff on [DATE]. This education was presented by the Director of Nursing. In addition, education was provided to licensed nurses on [DATE] by the Assistant Director of Nursing and the MDS Coordinators; and, on [DATE] by the Quality Management Specialist of the need to have every resident's code status listed on their care plan. 8. Nursing Staff hired since this incident occurred on [DATE], have been educated on CPR initiation by the Director of Nursing. 9. The facility has ensured there has been nursing staff present in the facility, on all shifts, that are CPR certified, since [DATE]. The facility brought in an outside entity, a Certified CPR instructor through the American Heart Association to teach CPR classes for staff needing certification or re-certification. 10. An audit was conducted by the Director of Nursing, Assistant Director of Nursing, and Unit Manager beginning on [DATE] to ensure that every resident with DNR orders had their purple DNR bracelet on. On-going audits will be conducted weekly times eight (8) weeks to ensure all residents with DNR orders were wearing their DNR bracelets. 11. An audit was conducted by the Medical Records Coordinator on [DATE], to ensure each resident's chart had the Red DNR paper or Green Full Code paper in their charts. All new admission charts were brought to the next Abbreviated Quality Assurance Meeting to ensure the Red DNR paper or Green Full Code paper was present in the front of the chart. On weekends and holidays, the Administrative Nurse on call will verify the presence of the Red DNR paper or Green Full Code paper in the front of the charts for new admissions. 12. All DNR residents had their chart audited by the Business Office Manager (formal Social Services Director) on [DATE] to ensure all DNR paperwork was up to date and had all signatures needed. The audit also included ensuring that residents with Advance Directives had a copy of the Advance Directive in the chart. 13. An audit was conducted on [DATE] by the Payroll Coordinator and Assistant Director of Nursing to check all nursing staff to determine what staff needed CPR certification. CPR classes were held on [DATE], [DATE], and [DATE]. Another CPR class is also scheduled for (MONTH) (YEAR). 14. Every resident death will be discussed during the Abbreviated Quality Assurance Meeting held Monday - Friday to ensure the resident's code status was honored by the staff present. Resident deaths occurring on the weekends or holidays will be reviewed by the Administrative Nurse on call to ensure the resident's code status was honored by the staff present. Monitoring will continue for three (3) months and results will be discussed during monthly QA meetings to determine ongoing monitoring. 15. All residents on palliative care had their care plans audited by the MDS Coordinators on [DATE], to ensure these residents had an Advanced Directive Care Plan in place. 16. All resident care plans were audited on [DATE] by the MDS Coordinators to ensure that each resident had their code status listed on their care plan. 17. All residents' care plans were audited for DNR/Full Code status on [DATE] by the Quality Management Specialist; and, on [DATE]-[DATE] by the Regional Resource Nurse. Auditing of resident care plans for DNR/Full code status will continue monthly for six (6) months to include all residents at least quarterly. Audits will be completed by designated members of the quality Assurance Committee. ** The State Survey Agency validated the following actions to correct the deficiency: 1. Review of the Provisional Report of Death, dated [DATE], revealed Resident #1 expired at 6:05 AM. 2. Review of an audit completed by the DON on [DATE], revealed that the facility has had no Code Blues since [DATE]. This was confirmed by interview. 3. Review of the content of the Education/Training Attendance Record revealed RN #1 received education from the DON on [DATE] at 6:10 PM, regarding the importance to always follow the Physician Order, and if there was something you were unsure or uncertain about, always clarify the order. This education was confirmed by interview with RN #1 on [DATE] at 12:38 PM. 4. Review of the Performance Correction Notice revealed the DON gave RN #1 a final written warning. The RN confirmed this information during a telephone interview on [DATE] at 12:38 PM. 5. Review of Action Plan and Follow up Record and interview with the Quality Management Specialist on [DATE] at 12:09 PM, revealed and Emergency Quality Assurance Management meeting was held on [DATE] with herself, the DON and the ADON to discuss the failure to initiate CPR on a resident that was determined to be a Full Code. Interview with the facility's Medical Director, on [DATE] at 9:50 AM, revealed he was notified of the incident and was involved in the CQI process. 6. Interview with the QMS and Interim Administrator, on [DATE] at 12:09 PM revealed an investigation was conducted of the incident and it was determined this was an isolated incident. 7. Review of the Education Attendance Records revealed all staff were educated on CPR initiation. This was done by lecture by the DON. This education included the Red paper for DNR status and Green paper for Full Code status. This education was completed by [DATE]. Interviews with RN #1 on [DATE] at 12:38 PM, RN #2 on [DATE] at 10:07 AM, RN #3 on [DATE] at 9:58 AM, RN #4 on [DATE] at 10:00 AM, RN #5 on [DATE] at 10:05 AM, RN #6 on [DATE] at 8:01 AM, LPN #1 on [DATE] at 11:02 AM, LPN #2 on [DATE] at 11:25 AM, LPN #3 on [DATE] at 8:05 AM, SRNA #5 on [DATE] at 2:13 PM, SRNA #4 on [DATE] at 11:35 AM, SRNA #3 on [DATE] at 2:00 PM, SRNA #2 on [DATE] at 2:47 PM, Med Tech on [DATE] at 3:57 PM and SRNA #1 on [DATE] at 1:00 PM revealed they were re-educated on the CPR initiation policy, Code policy, the purple bands, the Red DNR and Green CPR papers in the charts. They were also aware of the on-going audits related to the incident on [DATE]. The licensed staff stated they were also educated on updating the care plan to reflect the residents' Code Status. 8. Interview with the ADON (former DON), on [DATE] at 12:46 AM, revealed all staff hired since the incident have received inservice training and have been educated on CPR initiation. 9. Interview with the QMS, on [DATE] at 12:09 PM, and review of the investigation book revealed the facility now ensures there is a CPR certified staff person in the building at all times. 10. Review of the audit tool dated [DATE], used by the DON, ADON and Unit Managers revealed all residents with DNR orders had on a purple bracelet. Further review of the audits tools revealed the audits continued weekly for eight (8) weeks. No concerns were identified. 11. Review of an Audit tool dated [DATE] revealed the Medical Records Coordinator audited all residents' charts to ensure each resident chart had a Red DNR paper or a Green Full Code paper in the front of their charts. Review of Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9's charts revealed the papers were in the resident charts based on their code status. 12. Review of an audit conducted by the Business Office Manager on [DATE] and interview with the QMS on [DATE] at 12:09 PM, revealed all DNR residents had their charts audited to ensure that all DNR paperwork was up to date and they had all the signatures needed. The audit also included ensuring that residents with Advance Directives had a copy of the Advance Directive in the chart. 13. Review of an audit conducted on [DATE] by the Payroll Coordinator and ADON revealed they checked all nursing staff to determine what staff needed CPR certification. CPR classes were held on [DATE], [DATE] and [DATE] and another CPR class is scheduled for (MONTH) (YEAR). 14. Interview with the QMS/ Interim Administrator on [DATE] at 12:09 PM revealed they will discuss residents' deaths at the facility during the Abbreviated Quality Assurance meeting held Monday - Friday to ensure that the resident's code status was honored by the staff present. She stated resident deaths that occur on the weekends or on a holiday will be review by the Administrative Nurse on call to ensure the resident's code status was honored by the staff present. Further interview revealed monitoring will continue for three (3) months and the results will be discussed during the monthly QA meeting to determine ongoing monitoring. 15. Review of an audit tool dated [DATE], revealed all residents on palliative care had their care plans audited by the MDS Coordinators on [DATE], to ensure these residents had an Advanced Directive Care Plan in place. 16. Review of facility audits tools dated [DATE], revealed the ADON and MDS Coordinators audited each resident's care plan to ensure their code status was listed on their care plan. 17. Review of audit tools dated [DATE] and ,[DATE]-,[DATE] revealed the Quality Management Specialist and Regional Resource Nurse audited resident records to ensure a DNR/Full Code status was on the care plan.

Based on interview, record review, and facility policy review, it was determined the facility failed to have an effective system in place to ensure residents who chose to be a full code (receive Cardiopulmonary Resuscitation) was honored for one (1) of three (3) expired residents in the selected sample of nine (9) residents (Resident #1). Resident #1 chose to receive Cardiopulmonary Resuscitation (CPR) and had a physician's orders [REDACTED]. However, on [DATE], the licensed staff (Registered Nurse {RN})failed to provide Resident #1 CPR when he/she was found unresponsive, with no pulse, not breathing and his/her eyes were fixed and dilated. The RN proceeded to pronounce the resident as expired at 6:05 PM. In addition, there was no Advance Directive in Resident #1's chart. The facility's failure to ensure their system for ensuring a resident's choice to be a full code status was honored has caused or is likely to cause serious injury, harm, impairment, or death to residents. The facility was made aware of the Immediate Jeopardy on [DATE]. The Immediate Jeopardy was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (A[NAME]) on [DATE], alleging removal of the Immediate Jeopardy and substantial compliance on [DATE]. The State Survey Agency validated the facility had corrected the deficient practice on [DATE], prior to the State Survey Agency entering the building on [DATE]. Therefore, the State Survey Agency determined the facility had past non-compliance. The findings include: Review of the facility's policy titled, Cardiopulmonary Resuscitation, last revised [DATE], revealed it is the policy of the facility to provide an efficient and organized team approach in response to a medical emergency requiring Cardiopulmonary Resuscitation (CPR). The facility recognizes that the use of an Automated External Defibrillator (AED) along with CPR methods may increase the resident's chance for survival. Licensed Nurses, Certified Medication Aides, and Certified Nursing Assistants will be responsible to maintain a current certification in CPR according to the American Heart Association (AHA) Basic Life Support Health Care Provider Course (BLS). Licensed nurses, certified medication aides and certified nursing assistants will be trained to safely use an AED for use when CPR is being performed. If a resident experiences cardiac or respiratory arrest, CPR will be initiated if a purple colored Do Not Resuscitate (DNR) wristband is NOT present and if the code status is not IMMEDIATELY known. Wrist band will be facility designated type and material and will not include colored jewelry such as leather or metal wristlets, wrist straps or bracelets. Facilities shall notify local emergency medical services as applicable by state/local requirements of the existence, location and type of AED required. Review of the Wipedia Dictionary revealed Cardiopulmonary Resuscitation (CPR) is an emergency procedure that combines chest compressions often with artificial ventilation in an effort to manually preserve intact brain function until further measures are taken to restore spontaneous blood circulation and breathing in a person who is in [MEDICAL CONDITION]. Review of the facility's policy titled, Advance Directives/Do Not Resuscitate, last revised [DATE], revealed it is the policy of the facility to inform the residents of their right to formulate an advance directive, and/or living will/advanced directive, assist them in exercising that right, and to ascertain that their directive is honored. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. Resident #1 expired on [DATE]. Further review revealed there was no Advanced Directive in Resident #1's chart, but there was a green sheet with FULL CODE in the front of the record with the resident's name and physician's name handwritten at the bottom of the page. Interview with the Administrator, on [DATE] at 9:15 AM, revealed that since the resident was listed as a full code, Advanced Directive paperwork would not apply, therefore, the resident did not have this paperwork in the chart. Review of the Admission Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14), which indicated the resident was interviewable. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the late entry Nurse's Note, dated [DATE], no time noted, written by Registered Nurse (RN) #1, revealed she was called to Resident #1's room. Further review revealed when she entered the resident's room, the resident was in bed, eyes opened, pupils fixed and dilated, and no carotid pulse was found on palpation. The Note stated the resident . was last seen awake between 3:00 AM-4:00 AM eating chips and drinking 'Gatorade'. Time of death 6:05 AM. Provisional death certification completed, Kentucky Organ Donation Affiliates (KODA) called, and physician, family and DON notified. Interview with a Laundry Aide, on [DATE] at 1:05 PM, revealed she had already clocked in and was a family friend, so she stopped by Resident #1's room to check on the resident. She stated when she called the resident's name, there was no response so she touched the resident and he/she was warm to touch. The Laundry Aide stated she then yelled for the nurse, at the same time she was attempting to notify the resident's family. She stated the staff did not start CPR and she was not CPR certified. Interview with RN #1, on [DATE] at 12:38 PM, revealed the Laundry Aide had entered Resident #1's room then called out for her to come. She stated when she entered the room the resident was not breathing and when she checked for peripheral and carotid pulses, there were none. RN #1 stated according to the facility's policy, she should have started CPR. She stated, It was totally my fault. The RN stated she did not look for the presence of a purple bracelet which would have indicated the resident was a DNR. She stated the State Registered Nurse Aides (SRNA's) told her they had last seen the resident around 2:00 AM-3:00 AM, had provided incontinent care, and the resident was eating chips and drinking Gatorade. The RN stated she was rushed through orientation and that she had been an emergency room nurse and and Long Term Care (LTC) was really different. She stated that she felt she was thrown to the wolves. Review of the personnel file for RN #1, revealed she had received the facility required education during orientation for CPR. In addition, she was CPR and Advanced Cardiac Life Support (ACLS) certified with copies of the current cards in the file. Interview, on [DATE] at 12:46 PM, with the former Director of Nursing (DON), now the Assistant Director of Nursing (ADON), revealed she was at home when RN #1 called her to find out where the Provisional Death Reports were kept. She stated RN #1 reported that Resident #1 had expired. She stated she asked RN #1 if they had been expecting the resident to pass, and she was told by the RN that the resident was a pretty sick (man/woman). She revealed after hanging up the phone, she called the facility back to ask what the resident's code status was and was informed the resident was a Full Code. She stated she told the nurse that she should always initiate CPR and the RN stated, I know. Interview with the Interim Administrator and the Quality Management Specialist, on [DATE] at 12:09 PM, revealed staff were educated to look to determine the resident's code status by looking in the chart for a red DNR page or a green CPR page, physician's orders [REDACTED]. Interview with the facility's Medical Director, on [DATE] at 9:50 AM, revealed he expected CPR to be started on a resident that was listed as a Full Code and 911 called for Emergency Medical Services. **The facility implemented the following actions to correct the deficient practice: 1. The resident involved in the Immediate Jeopardy expired on [DATE]. 2. An audit was conducted by the Director of Nursing on [DATE] of all code blue situations since [DATE] to ensure that CPR was performed on full code residents. No issues were identified. 3. The Licensed Nurse that failed to provide CPR to Resident #1 was given 1:1 education on [DATE], prior to being allowed to return to work. This education was presented by the Director of Nursing and covered following physician orders [REDACTED]. Education also included to always clarify the physician orders [REDACTED]. 4. The Licensed Nurse that failed to provide CPR to Resident #1 was also given a final written Performance Correction on [DATE], prior to returning to work by the Director of Nursing, after consultation with the Regional Human Resources Director. 5. An Emergent Quality Assurance Meeting was conducted on [DATE], the date this incident occurred, to discuss the failure of the Licensed Nurse to provide CPR to the resident. The Emergent Quality Assurance Meeting was held with the Regional Quality Management Specialist, Director of Nursing, and Assistant Director of Nursing to discuss actions that needed to be implemented to prevent this situation from happening again. The Medical Director was made aware of the situation on [DATE], by the Regional Director. 6. An investigation was initiated by the Regional Quality Management Specialist on [DATE], the date this incident occurred. The investigation determined this to be an isolated incident caused by a decision made by one nurse. 7. Education was started on [DATE], with all nursing staff regarding the Cardiopulmonary Resuscitation policy and the Visitor Cardiopulmonary Resuscitation policy and CPR initiation. Education included designation of Red and Green paper for DNR and Full Code. The education was completed with all nursing staff on [DATE]. This education was presented by the Director of Nursing. In addition, education was provided to licensed nurses on [DATE] by the Assistant Director of Nursing and the MDS Coordinators; and, on [DATE] by the Quality Management Specialist of the need to have every resident's code status listed on their care plan. 8. Nursing Staff hired since this incident occurred on [DATE], have been educated on CPR initiation by the Director of Nursing. 9. The facility has ensured there has been nursing staff present in the facility, on all shifts, that are CPR certified, since [DATE]. The facility brought in an outside entity, a Certified CPR instructor through the American Heart Association to teach CPR classes for staff needing certification or re-certification. 10. An audit was conducted by the Director of Nursing, Assistant Director of Nursing, and Unit Manager beginning on [DATE] to ensure that every resident with DNR orders had their purple DNR bracelet on. On-going audits will be conducted weekly times eight (8) weeks to ensure all residents with DNR orders were wearing their DNR bracelets. 11. An audit was conducted by the Medical Records Coordinator on [DATE], to ensure each resident's chart had the Red DNR paper or Green Full Code paper in their charts. All new admission charts were brought to the next Abbreviated Quality Assurance Meeting to ensure the Red DNR paper or Green Full Code paper was present in the front of the chart. On weekends and holidays, the Administrative Nurse on call will verify the presence of the Red DNR paper or Green Full Code paper in the front of the charts for new admissions. 12. All DNR residents had their chart audited by the Business Office Manager (formal Social Services Director) on [DATE] to ensure all DNR paperwork was up to date and had all signatures needed. The audit also included ensuring that residents with Advance Directives had a copy of the Advance Directive in the chart. 13. An audit was conducted on [DATE] by the Payroll Coordinator and Assistant Director of Nursing to check all nursing staff to determine what staff needed CPR certification. CPR classes were held on [DATE], [DATE], and [DATE]. Another CPR class is also scheduled for (MONTH) (YEAR). 14. Every resident death will be discussed during the Abbreviated Quality Assurance Meeting held Monday - Friday to ensure the resident's code status was honored by the staff present. Resident deaths occurring on the weekends or holidays will be reviewed by the Administrative Nurse on call to ensure the resident's code status was honored by the staff present. Monitoring will continue for three (3) months and results will be discussed during monthly QA meetings to determine ongoing monitoring. 15. All residents on palliative care had their care plans audited by the MDS Coordinators on [DATE], to ensure these residents had an Advanced Directive Care Plan in place. 16. All resident care plans were audited on [DATE] by the MDS Coordinators to ensure that each resident had their code status listed on their care plan. 17. All residents' care plans were audited for DNR/Full Code status on [DATE] by the Quality Management Specialist; and, on [DATE]-[DATE] by the Regional Resource Nurse. Auditing of resident care plans for DNR/Full code status will continue monthly for six (6) months to include all residents at least quarterly. Audits will be completed by designated members of the quality Assurance Committee. ** The State Survey Agency validated the following actions to correct the deficiency: 1. Review of the Provisional Report of Death, dated [DATE], revealed Resident #1 expired at 6:05 AM. 2. Review of an audit completed by the DON on [DATE], revealed that the facility has had no Code Blues since [DATE]. This was confirmed by interview. 3. Review of the content of the Education/Training Attendance Record revealed RN #1 received education from the DON on [DATE] at 6:10 PM, regarding the importance to always follow the Physician Order, and if there was something you were unsure or uncertain about, always clarify the order. This education was confirmed by interview with RN #1 on [DATE] at 12:38 PM. 4. Review of the Performance Correction Notice revealed the DON gave RN #1 a final written warning. The RN confirmed this information during a telephone interview on [DATE] at 12:38 PM. 5. Review of Action Plan and Follow up Record and interview with the Quality Management Specialist on [DATE] at 12:09 PM, revealed and Emergency Quality Assurance Management meeting was held on [DATE] with herself, the DON and the ADON to discuss the failure to initiate CPR on a resident that was determined to be a Full Code. Interview with the facility's Medical Director, on [DATE] at 9:50 AM, revealed he was notified of the incident and was involved in the CQI process. 6. Interview with the QMS and Interim Administrator, on [DATE] at 12:09 PM revealed an investigation was conducted of the incident and it was determined this was an isolated incident. 7. Review of the Education Attendance Records revealed all staff were educated on CPR initiation. This was done by lecture by the DON. This education included the Red paper for DNR status and Green paper for Full Code status. This education was completed by [DATE]. Interviews with RN #1 on [DATE] at 12:38 PM, RN #2 on [DATE] at 10:07 AM, RN #3 on [DATE] at 9:58 AM, RN #4 on [DATE] at 10:00 AM, RN #5 on [DATE] at 10:05 AM, RN #6 on [DATE] at 8:01 AM, LPN #1 on [DATE] at 11:02 AM, LPN #2 on [DATE] at 11:25 AM, LPN #3 on [DATE] at 8:05 AM, SRNA #5 on [DATE] at 2:13 PM, SRNA #4 on [DATE] at 11:35 AM, SRNA #3 on [DATE] at 2:00 PM, SRNA #2 on [DATE] at 2:47 PM, Med Tech on [DATE] at 3:57 PM and SRNA #1 on [DATE] at 1:00 PM revealed they were re-educated on the CPR initiation policy, Code policy, the purple bands, the Red DNR and Green CPR papers in the charts. They were also aware of the on-going audits related to the incident on [DATE]. The licensed staff stated they were also educated on updating the care plan to reflect the residents' Code Status. 8. Interview with the ADON (former DON), on [DATE] at 12:46 AM, revealed all staff hired since the incident have received inservice training and have been educated on CPR initiation. 9. Interview with the QMS, on [DATE] at 12:09 PM, and review of the investigation book revealed the facility now ensures there is a CPR certified staff person in the building at all times. 10. Review of the audit tool dated [DATE], used by the DON, ADON and Unit Managers revealed all residents with DNR orders had on a purple bracelet. Further review of the audits tools revealed the audits continued weekly for eight (8) weeks. No concerns were identified. 11. Review of an Audit tool dated [DATE] revealed the Medical Records Coordinator audited all residents' charts to ensure each resident chart had a Red DNR paper or a Green Full Code paper in the front of their charts. Review of Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9's charts revealed the papers were in the resident charts based on their code status. 12. Review of an audit conducted by the Business Office Manager on [DATE] and interview with the QMS on [DATE] at 12:09 PM, revealed all DNR residents had their charts audited to ensure that all DNR paperwork was up to date and they had all the signatures needed. The audit also included ensuring that residents with Advance Directives had a copy of the Advance Directive in the chart. 13. Review of an audit conducted on [DATE] by the Payroll Coordinator and ADON revealed they checked all nursing staff to determine what staff needed CPR certification. CPR classes were held on [DATE], [DATE] and [DATE] and another CPR class is scheduled for (MONTH) (YEAR). 14. Interview with the QMS/ Interim Administrator on [DATE] at 12:09 PM revealed they will discuss residents' deaths at the facility during the Abbreviated Quality Assurance meeting held Monday - Friday to ensure that the resident's code status was honored by the staff present. She stated resident deaths that occur on the weekends or on a holiday will be review by the Administrative Nurse on call to ensure the resident's code status was honored by the staff present. Further interview revealed monitoring will continue for three (3) months and the results will be discussed during the monthly QA meeting to determine ongoing monitoring. 15. Review of an audit tool dated [DATE], revealed all residents on palliative care had their care plans audited by the MDS Coordinators on [DATE], to ensure these residents had an Advanced Directive Care Plan in place. 16. Review of facility audits tools dated [DATE], revealed the ADON and MDS Coordinators audited each resident's care plan to ensure their code status was listed on their care plan. 17. Review of audit tools dated [DATE] and ,[DATE]-,[DATE] revealed the Quality Management Specialist and Regional Resource Nurse audited resident records to ensure a DNR/Full Code status was on the care plan.

Based on interview, record review and facility policy review, it was determined the facility failed to provide services in accordance with one (1) of three (3) sampled residents (Resident #1), written plan of care related to transfers. Resident #1 was care planned to be transferred by a Hoyer Lift with the assistance of two (2) staff; however, on 12/28/16, State Registered Nurse Aide (SRNA) #4 transferred Resident #1 from the bed to the wheelchair without the Hoyer lift and the assistance of another staff member. Resident #1 sustained a Right Distal Femur Fracture that required surgery. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, last revised 11/28/16, revealed it is the policy of the facility that residents will have a person-centered plan of care that supports the resident in making their own choices, having control of their daily lives, and addresses their assessed needs. Specific descriptions of care planned interventions may be included in other areas of the record. Care plan approaches will be communicated to staff for use in providing directions for care. Closed record review revealed the facility admitted Resident #1 on 01/06/11 with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Care Plan for self-care deficit dated 02/22/16, and the Nurse Aide Data Sheet (NADS)revealed two (2) staff should transfer Resident #1 via Hoyer Lift. However, review of the facility's Final Investigation Report, undated, revealed on 12/28/16, SRNA #4 had transferred Resident #1 from the bed to the wheelchair by assisting the resident to stand and pivot around to the wheelchair without using the lift and the assistance of another staff member. Review of a faxed communication, Physician order [REDACTED]. An X-ray was ordered and revealed a periprosthetic fracture about the distal femur component with anterior angulation and posterior displacement. The resident was transferred to the hospital for evaluation and treatment of [REDACTED]. Review of the Hospital Operative Note, dated 01/06/17, revealed Resident #1 had surgery to repair the right knee fracture. Interview with SRNA #4, on 01/19/17 at 2:40 PM, revealed on 12/28/16 the lift batteries were dead and the resident wanted to get up to go to church. She stated the CNA working with her was pregnant and she did not want her to get hurt so she and the resident had their arms around each other and she pulled the resident up to a standing position then pivoted him/her around to the chair. She revealed the resident stated, you hurt my leg after she was positioned in the wheelchair. SRNA #4 stated she was going to tell the nurse but she got busy and she forgot to report the incident to the nurse. The SRNA revealed she was aware the NADS called for Resident #1 to be transferred using a mechanical lift with two (2) staff. Interviews with the facility Administrator, on 01/19/17 at 2:00 PM and on 01/23/17 at 4:10 PM, revealed she expected staff to follow the residents care plan. **The facility implemented the following actions to correct the deficient practice: 1. SRNA #4 was suspended on 12/29/16, and ultimately terminated on 01/02/17 by the DON. 2. On 01/03/17, staff was educated by who on checking the lifts and batteries prior to shift change and the batteries are to be placed on the charger when removed from the lift. All nursing staff were educated by the DON and ADON on 01/05/17. The education included the need to check and follow the resident's NADS. Violation of planned care especially related to transfers and Hoyer lifts will not be tolerated. Violations will be investigated with disciplinary action. If they are care planned for Hoyer use, you must use the Hoyer and two (2) staff. A Post test was conducted related to follow NADS ad use of lifts and the charging of lifts. Staff who were not present for the education will be educated prior to working. On 01/17/17, all clinical staff were re-educated by the Director of Nurses (DON), Assistant Director of Nursing (ADON) & Quality Management Specialist (QMS) on the facility's Zero Tolerance policy regarding using the Nurse Aide Data Sheets and were required to sign the aknowledgement form. 3. On 01/02/17, an audit was performed by the DON and ADON to verify that additional batteries for the Hoyer lifts were available. 4. On 01/02/17, the Maintenance Department was responsible to check all batteries to verify that chargers are charging appropriately and batteries are charging. All batteries were checked for voltage output to ensure it was adequate by the Maintenance Director. 5. On 01/02/17, all residents who required the use of a lift for transfers Nurse Aide Data Sheets were reviewed by the Unit Nurses to verify it was reflected the the NADS and Care Plans. 6. On 01/03/17, nursing expanded the audit to include the mode of transfer for all residents to ensure that the NADS and Care Plan were accurate. 7. Batteries are checked at shift change by the nurse and SRNA's on walking rounds and reported to QA. The mechanical lift batteries and chargers are audited/inspected quarterly by the Director of Maintenance or appointed staff member. A log will be kept of inspections. Results of the Inspection will be reported to the Administrator quarterly after each inspection. Any items identified in these audits will be taken care of immediately. 8. The facility conducted QA meetings on 12/30/16, 01/02/17, 01/03/17 and 01/06/17. The Medical Director has been involved with the investigation and QA process related to the incident. The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of SRNA #4's Personnel Record revealed she was hired on 01/10/11 and terminated on 01/02/17 after the pending investigation. The SRNA was not allowed to return to work. The last worked day was 12/28/16. Interview with SRNA #4, on 01/20/17, revealed she was suspended the day after the incident and was terminated on 12/30/16. 2. Interview with the DON, on 01/24/17 at 10:02 AM, revealed all staff have received training and education on the safe use of the Hoyer lift to include walking rounds, Lift equipment, the transfer of residents and incident reporting. Review of Inservice Sign In Sheets and Post Tests, revealed all clinical staff were educated by the DON and ADON by 01/07/17. Review of the signed copies of the acknowledgement forms for the facility's zero tolerance policy dated through 01/07/17 revealed staff were educated and completed a post test with no concerns identified. The acknowledgement revealed that staff would be suspended on the first offense with a three (3) day suspension and would be terminated on the second offense. Post tests were reviewed by the surveyor for completion with no concerns identified. Four unsampled residents revealed on interview that two (2) staff are always used when they are transferred with the mechanical lift. Interviews on 01/20/17 with SRNA #5 at 10:47 AM, SRNA #6 at 10:55 AM, Restorative Aide/SRNA #7 at 11:20 AM, SRNA #8 at 11:26 AM, SRNA #9 at 11:31 AM, SRNA #10 at 11:35 AM, SRNA #11 at 11:45 AM, and SRNA #12 at 11:53 AM revealed they were educated on the safe use of the Hoyer lift, battery maintenance and charging, Nurse Aide Data Sheets (NADS) must be followed and if not the Zero Tolerance will go into effect. Staff were made aware that they must check the batteries and lifts at shift change and follow the NADS at all times. 3. Review of an audit sheet shows the battery count for each hall. Observation on 01/20/17 at 9:05 AM, revealed each of the four halls have three (3) batteries. 4. Interview with the Maintenance Director, on 01/19/17 at 3:05 PM, revealed they have added an additional battery with charger to each wing so that there are now three (3) batteries and two (2) chargers on each wing. He stated all batteries have been checked since the incident with Resident #1 and all were found to be in working order. He stated he did not have any documentation that this was done. Observation on 01/20/17 at 9:05 AM, revealed all batteries and chargers on each hall were in place in the Lift storage rooms. 5. Nurse Aide Data Sheets and Care Plans for Residents #1, #2 and #3 were reviewed and the use of the Hoyer lift with a two (2) person assist was documented on the care plans. 6. On 01/03/17, nursing expanded the audit to include the mode of transfer for all residents to ensure that the NADS and Care Plan were accurate. Staff are observed and monitored by the DON for compliance with NADS. 7. Review of the Maintenance Log revealed all Hoyer lift batteries in the facility were assessed for location and appropriate voltage. This was completed 01/02/17 through 01/17/17. In addition, observation on 01/20/17 at 9:05 AM, revealed all lifts and batteries were noted to be present and fully charged. 8. Interview with the Administrator revealed the facility conducted QA meetings on 12/30/16, 01/02/17, 01/03/17 and 01/06/17. She stated the Medical Director has been involved with the investigation and QA process related to the incident.

Based on interview, record review and review of the facility's policy, it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (1) of three (#3) sampled residents Resident #1). Resident #1 was assessed and care planned to be transferred by a Hoyer Lift with the assistance of two (2) staff; however, on 12/28/16, State Registered Nurse Aide (SRNA) #4 transferred Resident #1 from the bed to the wheelchair without the Hoyer lift and the assistance of another staff member. Resident #1 sustained a Right Distal Femur Fracture hat required surgery. The findings include: Review of the facility's policy titled, Lifts and Transferring Devices, last revised 12/19/13, revealed it is the policy of the facility to seek methods by which lifting and trasferring of residents is conducted in the safest means possible, considering both the safety of residents and of the care providers. Residents will be evaluated for the need of a lift or transferring device on admission and when the residents ability to bear weight or transfer ability has changed. Closed record review revealed the facility admitted Resident #1 on 01/06/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment , dated 11/03/16, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. The resident was transferred to a different Long Term Care (LTC) facility on 01/12/17. Review of the Resident Lift/Transfer Analysis, dated 04/14/15, revealed the resident was assessed to require the use of a passive lifter with two (2) person assist using a basic sling, size large. Review of the Interdisciplinary Care Plan for self care deficit related to limited mobility as evidenced by requirements of assistant from staff with Activities of Daily Living (ADL's), dated 02/22/16, revealed an intervention for two (2) person assist with transfers via Hoyer Lift. Review of the Nurse Aide Data Sheet (NADS), dated 04/16/15, revealed Resident #1 required the use of a mechanical lift and the assistance of two (2) staff for transfers. Review of the facility's Final Investigation Report, undated, revealed on 12/28/16, SRNA #4 had transferred Resident #1 from the bed to the wheelchair by assisting the resident to stand and pivot around to the wheelchair without using the lift and the assistance of another staff. The resident complained of pain after the transfer but the pain was relieved with repositioning. Review of a faxed communication that was faxed to the Physician on 12/29/16 at 8:30 AM, revealed Resident #1 was complaining of right knee pain with right knee slightly larger than left, warm to touch, no redness or bruising noted and Homan's (discomfort behind the knee on forced dorsiflexion of the foot; a sign of thrombosis in the lower limb) negative. Please advise. Review of a physician's orders [REDACTED]. Review of the Radiology Report completed on 12/29/16, revealed periprosthetic fracture about the distal femur component with anterior angulation and posterior displacement. The physician was made aware of the radiology results by telephone on 12/29/16 at 6:15 PM. and orders were received to transfer the resident to the hospital for evaluation and treatment of [REDACTED]. Review of the Hospital Operative Note, dated 01/06/17, revealed Resident #1 had surgery to complete a revision right knee replacement with a hinge knee replacement with increased complexity. Interview with SRNA #4, on 01/19/17 at 2:40 PM, revealed on 12/28/16 while working with Resident #1, the resident wanted to get up from the bed so that he/she could go to church. SRNA #4 stated she explained to the resident that the batteries to the lift were both dead and that she would have to go find another one from another wing. She revealed she had reported to maintenance and the nurse's the lift batteries were not holding the charges. SRNA #4 stated she told the resident that she could assist her to the chair by herself because she knew the coworker that was with her was pregnant and she didn't want her to hurt herself. SRNA #4 revealed the resident told her no at first because she was afraid that the SRNA would hurt herself. The SRNA reports that the resident and her had their arms around each other and she pulled the resident up to a standing position then pivoted her around to the chair. The resident stated, you hurt my leg after she was positioned in the wheelchair. SRNA #4 stated she told her coworker that she needed to report it to the nurse but the resident got busy talking to them and she forgot to report the incident to the nurse. SRNA #4 revealed the following day, the Assistant Director of Nursing (ADON) called the SRNA at home and asked her if she had transferred the resident without using the lift and she admitted that she had done so. SRNA #4 stated the ADON stated the resident was complaining that her leg was hurting. She did report that one of the lifts on 300 Hall would require the user to use a pencil to keep it from getting stuck. SRNA #4 further revealed the nurses have been aware of the issues with the batteries ever since they have been in this building. She stated the batteries won't hold a charge or maybe the charger isn't working. Interviews on 01/20/17 with SRNA #5 at 10:47 AM, SRNA #6 at 10:55 AM, Restorative Aide/SRNA #7 at 11:20 AM, SRNA #8 at 11:26 AM, SRNA #9 at 11:31 AM, SRNA #10 at 11:35 AM, SRNA #11 at 11:45 AM, and SRNA #12 at 11:53 AM revealed Resident #1 was care planned for the use of the Hoyer lift with two (2) staff and they alsays use the Hoyer lift to transfer the resident. The SRNAs stated if the battery was dead, they would replace it with a charged battery. SRNA #5, SRNA #6, SRNA #7 and SRNA #10 revealed they have had to use a pencil in the past when the battery goes dead during a lift so you can finish the lift. Interview with Licensed Practical Nurse (LPN) #1, on 01/20/17 at 11:12 AM, revealed Resident #1 was a Hoyer lift with two (2) staff. She stated anytime a lift is used, it has to be completed by two (2) staff. She stated when SRNA's report a problem with a lift or a battery, staff put a work order in or tell the maintenance person directly. LPN #1 stated she was not aware of any problems with the lifts. Interview with Registered Nurse (RN) #6, on 01/22/17 at 7:31 AM, and on 01/20/17 with RN #4 at 11:05 AM, and RN #3 at 11:50 AM revealed Resident #1 was to be transferred by Hoyer lift with two (2) staff, never one person. RN #3 stated she has not received any reports from the CNA's that there has been a problem with the lifts or the batteries. Interview with the Maintenance Director, on 01/19/17 at 3:05 PM, revealed they do an annual inspection on the mechanical lifts and it was just completed in January 2017. He stated no one had reported to him that the batteries had been down. He revealed he used a volt meter to assess the batteries and they were taking a charge and the battery life is five (5) years. He reports he has received no work orders regarding problems with the batteries. The batteries where last changed in 2013. He reports that a charged battery should last a 12 hour shift. In January of 2016, the manufacturer of the mechanical lift was in the building to check all of the lifts and batteries and there were no issues identified at that time. Interview with Resident #1's Physician, on 01/20/17 at 10:33 AM, revealed he is not the Medical Director for the facility. He stated he expected staff to follow the care plan or make other accommodations as needed. He revealed he was told that the lift was not functioningat the time of the transfer. He stated Resident #1 would be difficult to handle by one (1) person. He revealed he assumed the fracture was sustained as a result of the transfer. Interview with the Director of Nursing (DON), on 01/24/17 at 10:02 AM, revealed she expected staff to follow the Nurse Aide Data Sheets and Care Plan. She stated she expected staff to take it seriously and if not the employee would be investigated and possibly terminated. Interviews with the facility Administrator, on 01/19/17 at 2:00 PM and 01/23/17 at 4:10 PM, revealed if a resident was assessed to require the use of a mechanical lift for transfer, she expected the staff to use a mechainical lift with the assist of two (2) staff at all times. **The facility implemented the following actions to correct the deficient practice: 1. SRNA #4 was suspended on 12/29/16, and ultimately terminated on 01/02/17 by the DON. 2. On 01/03/17, staff was educated by who on checking the lifts and batteries prior to shift change and the batteries are to be placed on the charger when removed from the lift. All nursing staff were educated by the DON and ADON on 01/05/17. The education included the need to check and follow the resident's NADS. Violation of planned care especially related to transfers and Hoyer lifts will not be tolerated. Violations will be investigated with disciplinary action. If they are care planned for Hoyer use, you must use the Hoyer and two (2) staff. A Post test was conducted related to follow NADS ad use of lifts and the charging of lifts. Staff who were not present for the education will be educated prior to working. On 01/17/17, all clinical staff were re-educated by the Director of Nurses (DON), Assistant Director of Nursing (ADON) & Quality Management Specialist (QMS) on the facility's Zero Tolerance policy regarding using the Nurse Aide Data Sheets and were required to sign the aknowledgement form. 3. On 01/02/17, an audit was performed by the DON and ADON to verify that additional batteries for the Hoyer lifts were available. 4. On 01/02/17, the Maintenance Department was responsible to check all batteries to verify that chargers are charging appropriately and batteries are charging. All batteries were checked for voltage output to ensure it was adequate by the Maintenance Director. 5. On 01/02/17, all residents who required the use of a lift for transfers Nurse Aide Data Sheets were reviewed by the Unit Nurses to verify it was reflected the the NADS and Care Plans. 6. On 01/03/17, nursing expanded the audit to include the mode of transfer for all residents to ensure that the NADS and Care Plan were accurate. 7. Batteries are checked at shift change by the nurse and SRNA's on walking rounds and reported to QA. The mechanical lift batteries and chargers are audited/inspected quarterly by the Director of Maintenance or appointed staff member. A log will be kept of inspections. Results of the Inspection will be reported to the Administrator quarterly after each inspection. Any items identified in these audits will be taken care of immediately. 8. The facility conducted QA meetings on 12/30/16, 01/02/17, 01/03/17 and 01/06/17. The Medical Director has been involved with the investigation and QA process related to the incident. The State Survey Agency validated the facility's plan of action was carried out by: 1. Review of SRNA #4's Personnel Record revealed she was hired on 01/10/11 and terminated on 01/02/17 after the pending investigation. The SRNA was not allowed to return to work. The last worked day was 12/28/16. Interview with SRNA #4, on 01/20/17, revealed she was suspended the day after the incident and was terminated on 12/30/16. 2. Interview with the DON, on 01/24/17 at 10:02 AM, revealed all staff have received training and education on the safe use of the Hoyer lift to include walking rounds, Lift equipment, the transfer of residents and incident reporting. Review of Inservice Sign In Sheets and Post Tests, revealed all clinical staff were educated by the DON and ADON by 01/07/17. Review of the signed copies of the acknowledgement forms for the facility's zero tolerance policy dated through 01/07/17 revealed staff were educated and completed a post test with no concerns identified. The acknowledgement revealed that staff would be suspended on the first offense with a three (3) day suspension and would be terminated on the second offense. Post tests were reviewed by the surveyor for completion with no concerns identified. Four unsampled residents revealed on interview that two (2) staff are always used when they are transferred with the mechanical lift. Interviews on 01/20/17 with SRNA #5 at 10:47 AM, SRNA #6 at 10:55 AM, Restorative Aide/SRNA #7 at 11:20 AM, SRNA #8 at 11:26 AM, SRNA #9 at 11:31 AM, SRNA #10 at 11:35 AM, SRNA #11 at 11:45 AM, and SRNA #12 at 11:53 AM revealed they were educated on the safe use of the Hoyer lift, battery maintenance and charging, Nurse Aide Data Sheets (NADS) must be followed and if not the Zero Tolerance will go into effect. Staff were made aware that they must check the batteries and lifts at shift change and follow the NADS at all times. 3. Review of an audit sheet shows the battery count for each hall. Observation on 01/20/17 at 9:05 AM, revealed each of the four halls have three (3) batteries. 4. Interview with the Maintenance Director, on 01/19/17 at 3:05 PM, revealed they have added an additional battery with charger to each wing so that there are now three (3) batteries and two (2) chargers on each wing. He stated all batteries have been checked since the incident with Resident #1 and all were found to be in working order. He stated he did not have any documentation that this was done. Observation on 01/20/17 at 9:05 AM, revealed all batteries and chargers on each hall were in place in the Lift storage rooms. 5. Nurse Aide Data Sheets and Care Plans for Residents #1, #2 and #3 were reviewed and the use of the Hoyer lift with a two (2) person assist was documented on the care plans. 6. On 01/03/17, nursing expanded the audit to include the mode of transfer for all residents to ensure that the NADS and Care Plan were accurate. Staff are observed and monitored by the DON for compliance with NADS. 7. Review of the Maintenance Log revealed all Hoyer lift batteries in the facility were assessed for location and appropriate voltage. This was completed 01/02/17 through 01/17/17. In addition, observation on 01/20/17 at 9:05 AM, revealed all lifts and batteries were noted to be present and fully charged. 8. Interview with the Administrator revealed the facility conducted QA meetings on 12/30/16, 01/02/17, 01/03/17 and 01/06/17. She stated the Medical Director has been involved with the investigation and QA process related to the incident.

Based on interview, record review, review of the facility's policy and procedure, and review of Hospital Records and laboratory (lab) reports, it was determined the facility failed to ensure the care plan was followed for two (2) of seven (7) sampled residents related to obtaining labs (Resident #1 and Resident #3). Resident #1 was care planned for [MEDICAL CONDITION] Fibrillation and the use of [MEDICATION NAME] (anticoagulant/blood thinner) with an intervention to obtain laboratory (lab) tests as ordered and report to the Physician. On [DATE], Resident #1's Physician wrote an order to repeat PT ([MEDICATION NAME])/ INR (International Normalized Ratio) in one (1) week ([DATE]) on the lab report. However, the nurse transcribed the lab to be drawn on [DATE] (five {5} weeks later) in the lab book, which resulted in Resident #1's PT/INR not being drawn. On [DATE], Resident #1 was sent to the local emergency room with stroke-like symptoms and the hospital labs revealed the resident's INR was 1.30 which was below therapeutic range (2XXX,[DATE].0). Resident #1 expired on [DATE] with a [DIAGNOSES REDACTED]. Resident #3 was care planned for Anticoagulant therapy and the use of [MEDICATION NAME] with an intervention to obtain labs as ordered and to report lab results to the Physician. On [DATE], Resident #3's Physician wrote an order to repeat PT/INR on [DATE]; and on [DATE] to repeat Resident #3's PT/INR every three (3) days until [DATE] ([DATE] and [DATE]). However, review of Resident #3's lab reports revealed there was no documented evidence the lab work was completed on [DATE] and [DATE], as ordered. The facility's failure to implement the care plan related to monitoring [MEDICATION NAME] levels through laboratory testing has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy and procedure titled, Comprehensive Care Plans, last revised [DATE], revealed it is the facility's policy that residents will have a plan of care for assessed needs and a care plan will be developed based on assessed needs. Care plan approaches will be communicated to staff for use in providing direction of care. The plan of care will be reviewed and revised when indicated, based on the resident's response. 1. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan related to Resident #1's [DIAGNOSES REDACTED]. Review of a Laboratory Report, dated [DATE], revealed Resident #1's [MEDICATION NAME] (PT) level was 18.4 seconds (normal: 9XXX,[DATE].0) and the International Normalized Ratio (INR) was 1.74 (normal: 2XXX,[DATE].0), indicating the resident's INR was below therapeutic range. Further review revealed the physician documented on the lab no change in the [MEDICATION NAME] order, repeat the PT/INR in one (1) week ([DATE]). Review of the Laboratory Book revealed the PT/INR test was documented to be completed on [DATE] (approximately five {5} weeks), instead of in one week, as ordered ([DATE]). Review of Resident #1's Laboratory Reports revealed no documented evidence the facility ensured a PT/INR test was obtained on [DATE], per the physician's orders [REDACTED]. Review of the Nurse's Note, dated [DATE] at 8:00 AM, revealed Resident #1 was transferred to the local emergency room (ER) with stroke-like symptoms. Review of lab values obtained in the ER, on [DATE], revealed Resident #1's INR was 1.30 which was below the therapeutic range. Review of hospital records, revealed Resident #1 expired on [DATE] with a [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 4:00 PM, revealed she was aware a lab order was missed for Resident #1's PT/INR. She stated she wrote the order for [DATE], instead of [DATE]. LPN #1 stated she did not know why she wrote [DATE]. Interview with the Director of Nursing (DON), on [DATE] at 2:30 PM, revealed she was not aware the residents' PT/INR tests had not been checked on [DATE] as ordered, and per the plan of care, until after Resident #1 was sent to theER on [DATE]. She stated another nurse had reviewed the resident's chart and identified the order had been transcribed to be obtained on [DATE] instead of [DATE]. Interview with Resident #1's Physician, on [DATE] at 1:40 PM, revealed he had been requesting Resident #1's labs weekly due to fluctuations in the resident's levels. He stated he did not know what the resident's PT/INR was prior to going to the ER because the facility did not get the last PT/INR that was ordered for [DATE]. He further stated, missing the ordered lab test could have affected the resident's level and if the levels were low for an extended time, this could have contributed to the resident's [MEDICAL CONDITION]/stroke. 2. Record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Comprehensive Care Plan related to the resident's Anticoagulant Therapy/use of [MEDICATION NAME], dated [DATE], revealed an intervention to obtain labs as ordered and to report lab results to the physician. Review of a physician's orders [REDACTED]. However, review of the resident's Laboratory Reports revealed there was no documented evidence a PT/INR was obtained on [DATE] per the physician's orders [REDACTED]. In addition, review of a physician's orders [REDACTED].#3's PT/INR every three (3) days until [DATE] ([DATE] and [DATE]). Review of Resident #3's Laboratory Reports revealed there was no documented evidence the PT/INR was obtained on [DATE]. Interview with Director of Nursing (DON), on [DATE] at 2:40 PM, revealed the PT/INR ordered for Resident #3 that was to be obtained on [DATE] was missed. She stated Resident #3 was transferred to another room on a different hallway for a brief period of time and that could have contributed to the omission. She stated if the resident's lab page did not get transferred over with the other paperwork it could have been a factor in the omission of the lab test. However, further interview revealed the resident was not transferred to another hall until [DATE] which was after the labs should have been obtained. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], an audit was conducted by the DON and Quality Management Nurse (QMN) on all residents receiving [MEDICATION NAME] to validate that PT/INR testing was current. PT/INR testing from [DATE] through [DATE] was reviewed to validate that all residents had current PT/INR tests. It was through this audit that it was identified Resident #3 has missed his/her ordered test for [DATE]. 2. An additional audit was conducted on [DATE] by the QMS and Regional Nurse Consultant (RNC) for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that the residents had all current ordered lab tests with no concerns identified. Any care plan that lacked the need to monitor for these medications were revised by the regional nurse consultant or the QMS at the time. 3. An audit was conducted on the care plans of all residents receiving [MEDICATION NAME] to assure that all had a care plan problem addressing their use. The care plan of any resident which did not thoroughly address the anticoagulant use was revised. This was completed by the MDS Coordinator and the MDS Nurse on [DATE]. 4. A Quality Assurance meeting was held [DATE] by the Administrator with the DON, the Staff Development Coordinator (SDC), the QMN, and the Unit Manager to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. A call was placed to the Medical Director by the Administrator on [DATE] to review the actions planned and the QA findings. Further communication was made daily until the Medical Director was reached on [DATE]. 5. A new protocol was developed on [DATE] by the QMN for writing orders to reflect changes in [MEDICATION NAME]/[MEDICATION NAME] orders. The process includes: discontinuance of the previous order, if not continued, new dose clearly stated, frequency/interval for next required test and the date scheduled to meet that frequency. The Administrator reviewed the new protocol with the Medical Director on [DATE]. 6. Protocol for nurses writing [MEDICATION NAME]/[MEDICATION NAME] orders as well as other significant medications requiring titration and or laboratory monitoring and documenting was revised to include clearly stating current orders and including both the frequency/interval of testing as well as the scheduled date. The process includes a second nurse validating accurate transcription of the order components. 7. The lab order monitoring process was revised by the QMN on [DATE] to be made a part of the active Abbreviated Quality Assurance (AQA) Program. The AQA meeting is conducted Monday through Friday except holidays. During the AQA meeting, the administrative nursing team members (DON, ADON, SDC or Unit Manager) will review lab reports, returned labs from the MD on which orders were noted, transcribed orders, and the lab book, to validate that all accurately correspond and were complete. Clinical AQA members will also monitor through the AQA process to verify that orders for PT/INR- anticoagulants are correctly written and scheduled. They were educated in the validation process by the Administrator on [DATE]. Additional education was initiated on [DATE] regarding significant medications that require lab monitoring with the clinical AQA team by the RNC, and continued with the remainder of clinical AQA nurses on their next scheduled day worked with completion on [DATE]. The new process is as follows: Upon receipt of an order for [REDACTED]. The order, as with other orders will be placed in the AQA box for review in the next AQA meeting. The night shift charge nurse will complete the lab requisitions for the ordered lab on or before the shift which they are due. If the date is designated a lab day a representative from local hospital will come draw the lab. If its not a lab day, the night shift nurse is responsible for drawing the labs and having them delivered to the local hospital. All stat labs are to be drawn by the charge nurse on duty or another nurse if difficulty is encountered. If at shift change an on coming charge nurse may draw the specimen. When a lab result is received, the charge nurse receiving the lab result is to fax the results to the physician unless the result is a critical value. If there is a critical valuer, the results will be called to the physician by the charge nurse. After the physician reviews the lab result, he will fax or call the charge nurse to acknowledge and provide new orders as indicated. When an order is written on the lab result, the charge nurse is to write a telephone order containing the order change and any future labs ordered. Anticoagulants should contain both frequency and scheduled date. The nurse will transcribe any medication change on the MAR indicated [REDACTED]. The accuracy of the transcribed order and the lab book is to be validated by a second nurse. The lab report should be placed in the AQA box and the white and yellow copies of the order in the section designated for orders. If there are no orders when the doctor acknowledges the lab results, the acknowledged results are to be placed in the AQA box for review by the clinical AQA committee. Phone orders and lab results will be brought into each AQA meeting by the DON or Unit Managers along with the lab book and the charts. During the AQA process, the lab book will be checked by the DON, SDC,Unit Managers, ADON, a with the lab orders to verify the lab was placed on the correct scheduled day. Previous days lab orders on the lab book will also be checked by the AQA team to verify they were completed and results received. The AQA meeting is conducted Monday through Friday except holidays. Proper completion of lab orders from weekends and holidays will be verified in the next AQA meeting in addition the on-call nurse validate during the weekend and holidays. The on call Administrative Nurse for the weekend or holiday will validate that all stat or follow-up labs that are ordered are scheduled and obtained. On the following working day, the AQA clinical team will review the lab results, schedule and orders to verify that all orders and results are correctly scheduled, obtained, results received, communicated to the physician and orders correctly transcribed. 8. Education was initiated with all licensed nurses regarding this protocol change on [DATE], by the QMN, the DON, SDC and the Regional Nurse Consultant. Follow-up education to reinforce the training regarding anti-coagulant medication orders was started with licensed nurses by Regional Nurse Consultant on [DATE] and post testing was given to verify comprehension. All licensed nurses have completed education except those on leave or PRN staff who have not been available for training. Any temporary or agency personal will be trained prior to being allowed to return to work. Education was initiated by the QMS, DON, SDC, RNC with licensed nurses regarding anticoagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. The written order is to include: Discontinuing the current dosage if there is to be a change, new order or statement to continue current dosage, the interval or frequency for future testing and the date that treating is to be done. Follow-up education with licensed staff regarding anti-coagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. To further validate comprehension beginning on the night shift on [DATE], nurses were required to successfully complete a packet demonstrating accurate transcription of three (3) sampled lab results of values impacted by high risk medications. Testing is ongoing, no staff members, to include temporary staff or agency staff, will be allowed to work prior to completing competency testing. The education on the lab order completion and monitoring process will be conducted with licensed staff by the SDC, DON, or QMN prior to the next shift worked. Education will include agency and temporary staff. Education with Nurses and Certified Medication Technicians (CMTs) was initiated [DATE] regarding accurate documentation on Medication Administration Records (MAR). This education has been provided by the Staff Development Coordinator (SDC), DON, QMS and the Regional Nurse Consultant. CMTs and licensed nurses were educated to document in accordance with professional standards and to complete documentation immediately following delivery of the medication. They are to review documentation at the end of their shift with the oncoming staff member or peer. If documentation omissions are identified, the nurse/CMT may document only if they recall with certainty that the medication was provided. If the medication was missed they are to contact the MD and follow the medication error process and physician's actions that are ordered. This education has been ongoing and will continue with oncoming staff prior to their next shift worked to include temporary or agency staff. PRN staff who have not been available for education were sent a letter by the SDC on [DATE] explaining that they must complete education prior to working again. They will also be required to demonstrate competency. Education reinforcing the requirement to review MAR/TAR, and initial to signify the administration of the medication or task after it is completed was initiated by the DON, QMS, SDC, RNC on [DATE]. Follow up education was started on [DATE] by the RNC and was completed on [DATE] with scheduled licensed nursing staff. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. Any additional PRN, temporary or agency staff, who will be assigned shifts in the future will receive training and post testing prior to beginning their next shift duties. 9. To heighten the nurses' awareness of anti-coagulants and the need to monitor corresponding labs, all anti-coagulants were moved to the nurses MAR for administration by a licensed nurse. Prior to this review, [MEDICATION NAME]/[MEDICATION NAME], and [MEDICATION NAME] were the only anticoagulants exclusively administered by the nurses. This change was made by the QMN on [DATE]. 10. As part of the QA investigation it was noted that there were documentation omissions/errors on the residents MAR. Omissions/errors in administration of medication and inaccurate documentation regarding obtaining PT/INR on [DATE] were identified. LPN #1 inaccurately transcribed the order that should have been scheduled for [DATE] as [DATE], on the physicians order, and initialed as [DATE] on the MAR. She was issued a final written warning by the DON on [DATE], and instructed that she must have a second nurse verify all transcribed orders of any kind. She was further instructed by the DON to have an administrative nurse conduct an additional review. In the absence of a administrative nurse an alternate nurse will be assigned on the assigned shift. (This nurse is not assigned to work weekends). 11. The Regional Nurse Consultant met with LPN #3 on [DATE] to discuss documentation omissions on the MAR. LPN #3 was the usual nurse on that unit on her scheduled days, followed a regular routine, and the administration of his medication was a standard part of her routine. She had failed to initial the medication when she administered it. The following day, further discussion was held with Nurse B and the Quality Management Specialist. A written warning (disciplinary action) was prepared by the Director of Nursing and was issued on [DATE] by the Quality Management Specialist for failure to document medication administration. 12. To monitor ongoing accurate transcription of [MEDICATION NAME] and PT/INR orders as well as other significant medications and corresponding lab monitoring and completion of ordered testing and compliance with care plan as it relates to obtaining labs as ordered. All telephone orders from the previous day are being reviewed by the Unit Manager, or in his/her absence a member of the administrative nursing team such as the DON, or SDC. The administrative nurse is validating that the order was correctly transcribed on the MAR/TAR. All orders, lab results, and the Lab Log are being brought to the morning QA meeting to confirm the orders were correctly transcribed from the lab result to the physician's orders [REDACTED]. The lab schedule is also being checked confirm that the scheduled testing was obtained, and that results have been received for tests that were previously obtained. On weekends, the charge nurse will have a charge nurse from another hall verify that significant medication labs orders are accurately transcribed and entered on the lab log. If variances are identified, immediate corrective measure will be taken. The day shift charge nurse on each unit will check the lab books on the corresponding units to validate that all labs scheduled to be obtained have been drawn. The weekend on call administrative nurse, will validate that ordered labs have been obtained. Orders received on the weekend that are checked by the charge nurse at the time transcribed, will also be verified through the AQA process the next day. To verify that the monitoring process is effective the Administrator will observe /validate the process three (3) times a week for four (4 ) weeks, then monthly for twelve (12) weeks. Monthly observation and validation of accuracy will be continued monthly. The Regional Nurse Consultant will validate compliance monthly for three (3) months then quarterly. 13. Charge Nurses will review the MAR indicated [REDACTED]. Unresolved omissions will be addressed by the charge nurse as medication errors, including physician notification. The AQA team member or Regional Consultant will also do an audit daily including weekends for three (3) weeks of the MARs to verify that all ordered medications have been addressed either with initials or an explanation as to why it wasn't given After three (3) weeks, if the process is determined to be effectively working by the AQA committee, over site by the AQA team may be reduced to three (3) times a week for six (6) weeks, then weekly if ongoing effectiveness is determined. 14. The MDS Coordinator will develop the care plans that reflect the need to obtain and monitor lab values for residents on medications that require titration or monitoring. Additional monitoring will be provided through review of the care plan interventions through the quarterly review by the interdisciplinary care plan team. In the event a concern is identified through the interdisciplinary review, the identified concern will be immediately reported to the DON and Administrator for action. Audit of the care plans of residents receiving significant medications requiring lab monitoring will be conducted monthly for three (3) months and then quarterly for one (1) year by the DON, ADON, or RNC. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the facility's audits completed on [DATE] revealed, an audit was completed for all residents receiving [MEDICATION NAME] to validate that PT/INR testing was current. Record reviews for four (4) residents (Residents #3, #7, #8, and #9) revealed the residents had current PT/INR testing. 2. Review of documentation revealed the QMS and RNC completed an additional audit on [DATE]. An audit for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that all residents had all current lab results. 3. Review of the care plan audits revealed the MDS Coordinator and MDS Nurse had completed an audit on care plans for all residents receiving [MEDICATION NAME] and requiring PT/INR and all revisions were completed. Interview with the MDS Coordinator and the MDS Nurse, on [DATE] at 4:14 PM, revealed they both had been educated related to the new changes and would be continuing the audit process along with other members of the AQA team. 4. Review of the Quality Assurance (QA) Meeting Sign in Sheet, revealed on [DATE], the Administrator had a meeting with the QA team to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. Review of the Plan of Action developed in the AQA meeting, revealed there were measurable goals and interventions put in place to prevent future problems with documentation and missed labs. Further review revealed additional information was initiated on [DATE] regarding significant medications that require lab monitoring with the AQA team and continued with the remainder of the clinical AQA nurses on their next day worked with completion on [DATE]. 5. Review of the Lab Results Policy revealed it was revised on [DATE], to add clarification of employee responsibility to ensure a consistent system for obtaining a laboratory test order to transcription and overall tracking of the laboratory process. 6. Review of the protocol for nurses writing orders to refect changes in medications revealed the protocol was revised to include a second nurse to validate the order was transcribed correctly. 7. Review of the new AQA process for monitoring labs developed on [DATE] by the Quality Management Nurse for Anti-coagulant Therapy orders, revealed instructions for monitoring and transcription of labs to reflect changes in [MEDICATION NAME] orders from the physician as well as transcribing the new order in the Lab Book. Further review revealed all telephone orders from the previous day are being reviewed by the Unit Manager, or in his/her absence a member of the Administrative nursing team. Review of the Sign in Sheet dated [DATE], revealed all the clinical members of the AQA team received training and education related to the new lab monitoring procedure. Interviews with the AQA staff (the Clinical Nurse Specialist on [DATE] at 3:15 PM and the MDS Coordinator on [DATE] at 4:14 PM) revealed they had been inserviced on the new AQA process and had a good understanding of the process and felt comfortable with monitoring the staff. Phone interview with LPN #5/Unit Manager, on [DATE] at 5:30 PM, revealed he received in-service from the Administrator and the Quality Management Nurse regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing lab orders and placing them in the lab book. He stated he has been involved in the process of checking nurses' MAR prior to leaving from their assigned shift. Interview with Minimum Data Set (MDS) Coordinator, on [DATE] at 4:15 PM, revealed compliance with obtaining lab values for residents' medication will be monitored through the second check by charge nurse and the AQA team. He stated he received in-service from the Administrator and the Quality Management Nurse regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing of lab orders and placing them in the lab book. Interview with the Quality Management Nurse, on [DATE] at 2:00 PM, revealed the lab order monitoring process was revised on [DATE] to be made a part of the active Abbreviated Quality Assurance (AQA) program. She further stated the AQA meeting will be conducted Monday through Friday except holidays and that during the meeting, the administrative nursing team members will review lab reports, returned labs from Medical Providers on which orders are noted, transcribed orders, and the lab book, to validate that all accurately correspond and are complete. Interview with the Staff Development Coordinator (SDC) on [DATE] at 1:30 PM, revealed she received in-service from the Administrator and the Quality Management Nurse regarding their assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing lab orders and placing them in the lab book. Interview with the Director of Nursing (DON), on [DATE] at 3:15 PM, revealed she has been actively involved in the AQA process. She further revealed she has received training about the new policies put in place related to the lab monitoring, correctly documenting physician's orders [REDACTED]. She further revealed the facility will continue the daily monitoring process and the audits even after the documented time frame has passed. She further revealed the facility had implemented all the new changes into the new employee packet for new employees. She further revealed the facility had implemented all the new changes into the new employee packet for new employees and had developed a corrective monitoring check list to aid in the verification process. 8. Review of inservice records revealed education was initiated with all licensed nurses regarding the protocol changes on [DATE]. Follow up education to reinforce the training regarding anti-coagulant medication orders was started with licensed nurses on [DATE] and post testing was given to verify comprehension. Review of Sign in sheets from in-services held on [DATE], [DATE] and [DATE] revealed staff was in-serviced on the new lab monitoring procedure. Review of in-service records revealed the education on the lab order completion and monitoring process was initiated on [DATE] by the DON and the RNC and was conducted with all licensed staff prior to their next scheduled shift to work. Documented sign in sheets indicated last in-service completed on [DATE]. Review of sign in sheets revealed, all licensed nurses were provided education by the Regional Nurse Specialists on [DATE] on the need to accurately follow the residents' plan of care and nurses not available for education were being trained prior to being allowed to work. Reviewed sign in sheet for in-service education with licensed staff and Certified Medication Technicians related to proper documentation following professional standards initiated on [DATE] and completed [DATE]. Interviews on [DATE] with LPN #11 at 5:03 PM, LPN #5 at 5:30 PM, RN #3 at 4:52 PM, RN #1 at 3:32 PM, LPN #12 at 4:00 PM and RN #2 on at 4:52 PM; and, on [DATE] with LPN #7 at 2:40 PM, LPN #10 at 8:40 AM, CMT #5 at 9:00 AM, CMT #6 at 9:05 AM and LPN #8 at 11:15 AM, revealed they had been in-serviced on the new policies and that audits were being completed by the AQA staff members. All staff interviewed verified they had completed a post test as indicated in the AOC. The staff interviewed revealed they were completing the verification checks with another staff member at the change of shift as outlined in the facility's plan. Interview with LPN #1, on [DATE] at 4:00 PM, revealed she was required to have another nurse check her work after she transcribes or carries out any type of physicians order. She stated she was required to have another nurse check her MAR indicated [REDACTED]. Interview with LPN #11, on [DATE] at 5:03 PM, revealed she currently works 6:30 AM to 6:30 PM, and has been employed by the facility for one and half (1.5) years. She stated she had been in-serviced on the new policy put in place related to documentation of lab orders, transcribing the orders as well as documenting in the lab book. She further stated she has been checking the other nurses MAR indicated [REDACTED]. Interview with RN #2, on [DATE]

Based on interview, record review, facility policy and procedure review, and hospital record review, it was determined the facility failed to have an effective system in place to ensure drug level monitoring was completed as ordered for residents who were on [MEDICATION NAME] Therapy (anticoagulant/blood thinner) for two (2) of seven (7) sampled residents (Resident #1 and Resident #3). Resident #1 was receiving [MEDICATION NAME] 9 milligrams (mg) each Monday, Tuesday, Thursday, Friday, and Sunday; and 10 mg each Wednesday and Saturday. On [DATE], Resident #1's Physician ordered a [MEDICATION NAME] (PT)/International Normalized Ratio (INR) to be completed in one (1) week ([DATE]) due to the resident's PT/INR level being below therapeutic level; however, the nurse documented in the lab book to draw the PT/INR on [DATE] (five {5}weeks later) instead of [DATE]. The facility's system to check the laboratory orders to ensure the labs were obtained as ordered by the physician was ineffective as it failed to identify the nurse's transcription error. On [DATE], Resident #1 was admitted to the hospital with [REDACTED].#1's PT/INR at the hospital was below therapeutic range. Resident #1 expired at the hospital on [DATE]. Resident #3 was receiving [MEDICATION NAME] 3 mg daily. On [DATE], Resident #3's Physician ordered to recheck the resident's PT/INR on [DATE], however, the lab was not completed. The facility's system to ensure lab orders were obtained as ordered was ineffective as they failed to identify the lab was not completed on [DATE]. The facility's system for ensuring Laboratory Tests were obtained as ordered was ineffective as they failed to identify Resident #1's order was not transcribed as ordered and failed to identify Resident #3's lab was not obtained. The facility's failure to ensure their system of monitoring [MEDICATION NAME] levels per physician's orders [REDACTED]. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Lab Results Process, not dated, revealed when an order is obtained for a lab test, the nurse who received the order is responsible for placing the lab on the lab book on the corresponding dated page. When an order is received from the lab result, the nurse is to note the lab and then file the lab in the chart under LAB. The nurse is to transcribe any medication change on to the MAR indicated [REDACTED]. Phone orders will be brought into each Abbreviated Quality Assurance (AQA) meeting along with the lab book and the charts. During the AQA process, the lab book will be checked according to the lab orders to verify the lab was placed on the correct day. The previous day's lab orders on the lab book will also be checked to verify they were completed. 1. A closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1's cognition to be intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was interviewable. Review of the physician's orders [REDACTED]. Review of the [DATE] Medication Administration Record [REDACTED]. Review of the Comprehensive Care Plan related to Resident #1's [DIAGNOSES REDACTED]. Review of a Laboratory Report, dated [DATE], revealed Resident #1's PT level was 18.4 seconds (normal: 9XXX,[DATE].0) and INR was 1.74 (normal 2XXX,[DATE].0), which indicated the INR level was not in therapeutic range. The physician documented no change in the [MEDICATION NAME] order, and to repeat the PT/INR test in one (1) week, on [DATE]. Review of Resident #1's [DATE] MAR indicated [REDACTED]. Review of Resident #1's Laboratory Reports revealed no documented evidence the PT/INR was conducted on [DATE]. Review of Nurses Notes, dated [DATE] at 8:00 AM, revealed the resident was sent to the emergency roiagnom on the morning of [DATE] with stroke like symptoms and change in mental status. Review of Resident #1's PT/INR results taken in the emergency roiagnom on [DATE] at 8:43 AM, revealed the resident's PT was 13.6 and INR was 1.30 which was below the therapeutic range. Review of the Hospital Records revealed Resident #1 was admitted to the hospital on [DATE] and died on [DATE] with [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse #1, on [DATE] at 4:00 PM, revealed the Physician documented on the Laboratory Report to recheck Resident #1's PT/INR in one (1) week, on [DATE]. Further interview revealed when LPN #1 documented it on the physician's orders [REDACTED]. She stated she was not aware of the error until she was counseled by her Supervisor on [DATE]. Interview (Post Survey) with LPN #1, on [DATE] at 1:20 PM, revealed she did not remember if she had initialed Resident #1's MAR indicated [REDACTED]. Interview with the Director of Nursing (DON), on [DATE] at 2:30 PM, revealed she was not aware the resident's PT/INR had not been checked on [DATE] as ordered until after the resident was sent to theER on [DATE]. She stated another nurse had reviewed the resident's chart and identified the order had been transcribed to be obtained on [DATE] instead of [DATE]. Interview (Post Survey) with the DON, on [DATE] at 3:00 PM, revealed they were having the AQA Meeting every morning and staff would bring the resident's charts which included the laboratory orders and physician's orders [REDACTED].#1's ([DATE]) lab order was not identified because the nurse had documented the physician's orders [REDACTED]. She stated they did not look at the Laboratory Report to compare with the physician's orders [REDACTED]. Interview with the Quality Consultant Manager, on [DATE] at 2:30 PM and 3:00 PM, revealed Resident #1's PT/INR was not drawn on [DATE] as ordered, because the nurse (LPN #1) transcribed the order to the Lab Book as due on [DATE], instead of [DATE]. She stated the Unit Managers were responsible for checking the lab book daily to ensure labs were completed. Interview (Post Survey) with LPN #5/Unit Manager, on [DATE] at 5:30 PM, revealed he was responsible for checking the lab orders to ensure any order written was transcribed to the Lab Book and to make sure they followed up on all labs. He stated at the time of the residents' missed labs he had transferred to another position and he did not know who was responsible for checking the lab book at that time. Interview with Resident #1's Physician, on [DATE] at 1:40 PM, revealed he tried to keep the resident's INR blood levels between 2.0 and 3.0. He stated if the resident's level was too low for a long period of time, this could have contributed to the resident's [MEDICAL CONDITION]. He further stated he didn't know what the resident's PT/INR level was prior to going to the emergency room because the resident did not get the lab test that was ordered on [DATE]. Resident #1's Physician stated that missing the ordered lab test could have affected the resident's PT/INR level. Continued interview revealed he had been monitoring the resident's lab levels weekly due to fluctuations in the resident's levels. He stated he expected the facility to have a tracking system in place to ensure the Laboratory Book and the Medication Administration Record [REDACTED]. 2. Record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated [DATE], revealed the resident's cognition was intact with a BIMS score of thirteen (13), indicating the resident was interviewable. Review of the Comprehensive Care Plan related to the resident's Anticoagulant Therapy and use of [MEDICATION NAME], dated [DATE], revealed an intervention to obtain labs as ordered and to report lab results to Physician. Review of the physician's orders [REDACTED]. Review of a Laboratory Report, dated [DATE], revealed Resident #3's PT was 25.7 which was high and the INR was 2.40 which was therapeutic (normal 2XXX,[DATE].0). Further review of the report and review of a physician's orders [REDACTED]. Review of the Lab Book revealed the PT/INR was documented to be completed on [DATE]; however, further review of lab reports revealed no documented evidence the lab work was completed as ordered. Further review revealed a physician's orders [REDACTED]. Review of a Pharmacy Recommendation, dated [DATE], revealed recommendations to monitor for an increase in [MEDICATION NAME] (deficiency of blood clotting factor in the blood) response to anticoagulants during administration of [MEDICATION NAME]. Review of a physician's orders [REDACTED]. antibiotic was started on [DATE]. However, review of Resident #3's Laboratory Reports revealed a PT/INR was not completed on [DATE] as ordered. Interview with the Director of Nursing (DON), on [DATE] at 2:40 PM; and, on [DATE] at 1:00 PM, revealed the facility completed an audit of all residents receiving [MEDICATION NAME] on [DATE], and identified Resident #3 had went a period without lab monitoring being completed as ordered. The DON stated Resident #3's PT/INR that was ordered for [DATE] was missed and the next one was not drawn until [DATE]. The DON stated they had attempted to call Resident #3's Physician and he was scheduled to make rounds at the facility on [DATE] (next day). The DON said they were unable to find the cause of the error. She stated she did not review Resident #3's chart after she received the Pharmacist's Recommendation to repeat the PT/INR on [DATE], because it was a recommendation based on medication being administered not the facility's failure to obtain labs. Review of Lab Report, dated on [DATE], revealed Resident #3's PT 22.9 and INR was 2.15 which was a therapeutic level. Interview with the Quality Management Consultant, on [DATE] at 2:30 PM; and, on [DATE] at 12:00 noon, revealed the facility was not aware Resident #3's PT/INR level had not been completed as ordered on [DATE] until they completed an audit of all residents receiving [MEDICATION NAME] on [DATE]. She stated when the facility receives an order for [REDACTED]. She further stated after the results were sent from the lab, the nurse is responsible for faxing the results to the medical provider and following up with any orders written on the lab result printout. She stated the Unit Managers were responsible to review the Lab Book daily and report to the morning meeting if all labs were completed. They would compare the physician's orders [REDACTED]. She stated at that time there may not have been a Unit Manager for that unit. She further revealed when the order was written for Resident #3 to have PT/INRs completed every three (3) days while on antibiotic therapy, the resident had not started the new antibiotic. However, review of the [DATE] MAR indicated [REDACTED]. She stated the first PT/INR was completed after the resident was on antibiotic therapy on [DATE] and again on [DATE]. Further interview revealed she was not aware there were any problems with the PT/INR orders until after they completed the audits on [DATE]. She stated the facility was going through a transition period with the DON still in orientation and the transitioning of Administrators at the time of the missed labs. Interview with Administrator on [DATE] at 4:55 PM, revealed Resident #1 and Resident #3, were both taken care of by the same Physician and the Physician did not always have standing orders for lab work, he will make rounds and then order the lab work at that time. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], an audit was conducted by the DON and Quality Management Nurse (QMS) on all residents receiving [MEDICATION NAME] to validate that PT/INR testing was current. PT/INR testing from [DATE] through [DATE] was reviewed to validate that all residents had current PT/INR tests. It was through this audit that it was identified Resident #3 has missed his/her ordered test for [DATE]. 2. An additional audit was conducted on [DATE] by the QMS and Regional Nurse Consultant (RNC) for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that the residents had all current ordered lab tests with no concerns identified. Any care plan that lacked the need to monitor for these medications were revised by the regional nurse consultant or the QMS at the time. 3. An audit was conducted on the care plans of all residents receiving [MEDICATION NAME] to assure that all had a care plan problem addressing their use. The care plan of any resident which did not thoroughly address the anticoagulant use was revised. This was completed by the MDS Coordinator and the MDS Nurse on [DATE]. 4. A Quality Assurance meeting was held [DATE] by the Administrator with the DON, the Staff Development Coordinator (SDC), the QMN, and the Unit Manager to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. A call was placed to the Medical Director by the Administrator on [DATE] to review the actions planned and the QA findings. Further communication was made daily until the Medical Director was reached on [DATE]. 5. A new protocol was developed on [DATE] by the QMN for writing orders to reflect changes in [MEDICATION NAME]/[MEDICATION NAME] orders. The process includes: discontinuance of the previous order, if not continued, new dose clearly stated, frequency/interval for next required test and the date scheduled to meet that frequency. The Administrator reviewed the new protocol with the Medical Director on [DATE]. 6. Protocol for nurses writing [MEDICATION NAME]/[MEDICATION NAME] orders as well as other significant medications requiring titration and or laboratory monitoring and documenting was revised to include clearly stating current orders and including both the frequency/interval of testing as well as the scheduled date. The process includes a second nurse validating accurate transcription of the order components. 7. The lab order monitoring process was revised by the QMN on [DATE] to be made a part of the active Abbreviated Quality Assurance (AQA) Program. The AQA meeting is conducted Monday through Friday except holidays. During the AQA meeting, the administrative nursing team members (DON, ADON,SDC or Unit Manager) will review lab reports, returned labs from the MD on which orders were noted, transcribed orders, and the lab book, to validate that all accurately correspond and were complete. Clinical AQA members will also monitor through the AQA process to verify that orders for PT/INR- anticoagulants are correctly written and scheduled. They were educated in the validation process by the Administrator on [DATE]. Additional education was initiated on [DATE] regarding significant medications that require lab monitoring with the clinical AQA team by the RNC, and continued with the remainder of clinical AQA nurses on their next scheduled day worked with completion on [DATE]. The new process is as follows: Upon receipt of an order for [REDACTED]. The order, as with other orders will be placed in the AQA box for review in the next AQA meeting. The night shift charge nurse will complete the lab requisitions for the ordered lab on or before the shift which they are due. If the date is designated a lab day a representative from local hospital will come draw the lab. If its not a lab day, the night shift nurse is responsible for drawing the labs and having them delivered to local hospital. All stat labs are to be drawn by the charge nurse on duty or another nurse if difficulty is encountered. If at shift change an on coming charge nurse may draw the specimen. When a lab result is received, the charge nurse receiving the lab result is to fax the results to the physician unless the result is a critical value. If there is a critical valuer, the results will be called to the physician by the charge nurse. After the physician reviews the lab result, he will fax or call the charge nurse to acknowledge and provide new orders as indicated. When an order is written on the lab result, the charge nurse is to write a telephone order containing the order change and any future labs ordered. Anticoagulants should contain both frequency and scheduled date. The nurse will transcribe any medication change on the MAR indicated [REDACTED]. The accuracy of the transcribed order and the lab book is to be validated by a second nurse. The lab report should be placed in the AQA box and the white and yellow copies of the order in the section designated for orders. If there are no orders when the doctor acknowledges the lab results, the acknowledged results are to be placed in the AQA box for review by the clinical AQA committee. Phone orders and lab results will be brought into each AQA meeting by the DON or Unit Managers along with the lab book and the charts. During the AQA process, the lab book will be checked by the DON,SDC,Unit Managers,ADON,a with the lab orders to verify the lab was placed on the correct scheduled day. Previous days lab orders on the lab book will also be checked by the AQA team to verify they were completed and results received. The AQA meeting is conducted Monday through Friday except holidays. Proper completion of lab orders from weekends and holidays will be verified in the next AQA meeting in addition the on-call nurse validate during the weekend and holidays. The on call Administrative Nurse for the weekend or holiday will validate that all stat or follow-up labs that are ordered are scheduled and obtained. On the following working day, the AQA clinical team will review the lab results, schedule and orders to verify that all orders and results are correctly scheduled, obtained, results received, communicated to the physician and orders correctly transcribed. 8. Education was initiated with all licensed nurses regarding this protocol change on [DATE], by the QMN, the DON, SDC and the Regional Nurse Consultant. Follow-up education to reinforce the training regarding anti-coagulant medication orders was started with licensed nurses by Regional Nurse Consultant on [DATE] and post testing was given to verify comprehension. All licensed nurses have completed education except those on leave or PRN staff who have not been available for training. Any temporary or agency personal will be trained prior to being allowed to return to work. Education was initiated by the QMS, DON, SDC, RNC with licensed nurses regarding anticoagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. The written order is to include: Discontinuing the current dosage if there is to be a change, new order or statement to continue current dosage, the interval or frequency for future testing and the date that treating is to be done. Follow-up education with licensed staff regarding anti-coagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. To further validate comprehension beginning on the night shift on [DATE], nurses were required to successfully complete a packet demonstrating accurate transcription of three (3) sampled lab results of values impacted by high risk medications. Testing is ongoing, no staff members, to include temporary staff or agency staff, will be allowed to work prior to completing competency testing. The education on the lab order completion and monitoring process will be conducted with licensed staff by the SDC, DON, or QMN prior to the next shift worked. Education will include agency and temporary staff. Education with Nurses and Certified Medication Technicians (CMTs) was initiated [DATE] regarding accurate documentation on Medication Administration Records (MAR). This education has been provided by the Staff Development Coordinator (SDC), DON, QMS and the Regional Nurse Consultant. CMTs and licensed nurses were educated to document in accordance with professional standards and to complete documentation immediately following delivery of the medication. They are to review documentation at the end of their shift with the oncoming staff member or peer. If documentation omissions are identified, the nurse/CMT may document only if they recall with certainty that the medication was provided. If the medication was missed they are to contact the MD and follow the medication error process and physician's actions that are ordered. This education has been ongoing and will continue with oncoming staff prior to their next shift worked to include temporary or agency staff. PRN staff who have not been available for education were sent a letter by the SDC on [DATE] explaining that they must complete education prior to working again. They will also be required to demonstrate competency. Education reinforcing the requirement to review MAR/TAR, and initial to signify the administration of the medication or task after it is completed was initiated by the DON, QMS, SDC, RNC on [DATE]. Follow up education was started on [DATE] by the RNC and was completed on [DATE] with scheduled licensed nursing staff. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. Any additional PRN, temporary or agency staff ,who will be assigned shifts in the future will receive training and post testing prior to beginning their next shift duties. 9. To heighten the nurses' awareness of anti-coagulants and the need to monitor corresponding labs, all anti-coagulants were moved to the nurses MAR for administration by a licensed nurse. Prior to this review, [MEDICATION NAME]/[MEDICATION NAME], and [MEDICATION NAME] were the only anticoagulants exclusively administered by the nurses. This change was made by the QMN on [DATE]. 10. As part of the QA investigation it was noted that there were documentation omissions/errors on the residents MAR. Omissions/errors in administration of medication and inaccurate documentation regarding obtaining PT/INR on [DATE] were identified. LPN #1 inaccurately transcribed the order that should have been scheduled for [DATE] as [DATE], on the physicians order, and initialed as [DATE] on the MAR. She was issued a final written warning by the DON on [DATE], and instructed that she must have a second nurse verify all transcribed orders of any kind. She was further instructed by the DON to have an administrative nurse conduct an additional review. In the absence of a administrative nurse an alternate nurse will be assigned on the assigned shift. (This nurse is not assigned to work weekends). 11. The Regional Nurse Consultant met with LPN #3 on [DATE] to discuss documentation omissions on the MAR. LPN #3 was the usual nurse on that unit on her scheduled days, followed a regular routine, and the administration of his medication was a standard part of her routine. She had failed to initial the medication when she administered it. The following day, further discussion was held with Nurse B and the Quality Management Specialist. A written warning (disciplinary action) was prepared by the Director of Nursing and was issued on [DATE] by the Quality Management Specialist for failure to document medication administration. 12. To monitor ongoing accurate transcription of [MEDICATION NAME] and PT/INR orders as well as other significant medications and corresponding lab monitoring and completion of ordered testing and compliance with care plan as it relates to obtaining labs as ordered. All telephone orders from the previous day are being reviewed by the Unit Manager, or in his/her absence a member of the administrative nursing team such as the DON, or SDC. The administrative nurse is validating that the order was correctly transcribed on the MAR/TAR. All orders, lab results, and the Lab Log are being brought to the morning QA meeting to confirm the orders were correctly transcribed from the lab result to the physician's orders [REDACTED]. The lab schedule is also being checked confirm that the scheduled testing was obtained, and that results have been received for tests that were previously obtained. On weekends, the charge nurse will have a charge nurse from another hall verify that significant medication labs orders are accurately transcribed and entered on the lab log. If variances are identified, immediate corrective measure will be taken. The day shift charge nurse on each unit will check the lab books on the corresponding units to validate that all labs scheduled to be obtained have been drawn. The weekend on call administrative nurse, will validate that ordered labs have been obtained. Orders received on the weekend that are checked by the charge nurse at the time transcribed, will also be verified through the AQA process the next day. To verify that the monitoring process is effective the Administrator will observe /validate the process three (3) times a week for four (4 ) weeks, then monthly for twelve (12) weeks. Monthly observation and validation of accuracy will be continued monthly. The Regional Nurse Consultant will validate compliance monthly for three (3) months then quarterly. 13. Charge Nurses will review the MAR indicated [REDACTED]. Unresolved omissions will be addressed by the charge nurse as medication errors, including physician notification. The AQA team member or Regional Consultant will also do an audit daily including weekends for three (3) weeks of the MARs to verify that all ordered medications have been addressed either with initials or an explanation as to why it wasn't given After three (3) weeks, if the process is determined to be effectively working by the AQA committee, over site by the AQA team may be reduced to three (3) times a week for six (6) weeks, then weekly if ongoing effectiveness is determined. 14. The MDS Coordinator will develop the care plans that reflect the need to obtain and monitor lab values for residents on medications that require titration or monitoring. Additional monitoring will be provided through review of the care plan interventions through the quarterly review by the interdisciplinary care plan team. In the event a concern is identified through the interdisciplinary review, the identified concern will be immediately reported to the DON and Administrator for action. Audit of the care plans of residents receiving significant medications requiring lab monitoring will be conducted monthly for three (3) months and then quarterly for one (1) year by the DON, ADON, or RNC. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the facility's audits completed on [DATE] revealed, an audit was completed for all residents receiving [MEDICATION NAME] to validate that PT/INR testing was current. Record reviews for four (4) residents (Residents #3, #7, #8, and #9 ) revealed the residents had current PT/INR testing. 2. Review of documentation revealed the QMS and RNC completed an additional audit on [DATE]. An audit for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that all residents had all current lab results. 3. Review of the care plan audits revealed the MDS Coordinator and MDS Nurse had completed an audit on care plans for all residents receiving [MEDICATION NAME] and requiring PT/INR and all revisions were completed. Interview with the MDS Coordinator and the MDS Nurse, on [DATE] at 4:14 PM, revealed they both had been educated related to the new changes and would be continuing the audit process along with other members of the AQA team. 4. Review of the Quality Assurance (QA) Meeting Sign in Sheet, revealed on [DATE], the Administrator had a meeting with the QA team to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. Review of the Plan of Action developed in the AQA meeting, revealed there were measurable goals and interventions put in place to prevent future problems with documentation and missed labs. Further review revealed additional information was initiated on [DATE] regarding significant medications that require lab monitoring with the AQA team and continued with the remainder of the clinical AQA nurses on their next day worked with completion on [DATE].

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure the Consultant Pharmacist identified the facility's failure to monitor Protime (PT)/ International Normalized Ratio (INR) related to Coumadin Therapy; and failed to act on the Pharmacist's Recommendations for PT/INRs for two (2) of seven (7) sampled residents (Resident #1 and Resident #3). Resident #1 was receiving Coumadin nine (9) milligrams (mg) each Monday, Tuesday, Thursday, Friday, and Sunday; and ten (10) mg each Wednesday and Saturday. On [DATE], Resident #1's Physician ordered a Protime (PT)/International Normalized Ratio (INR) to be completed in one (1) week ([DATE]) to monitor the resident's Coumadin; however, the facility failed to obtain the PT/INR. The Pharmacist failed to identify the PT/INR was not obtained on [DATE] during the Medication Regimen Review on [DATE]. Resident #1 was admitted to the hospital with [REDACTED].#1's PT/INR at the hospital was below therapeutic range. Resident #1 expired at the hospital on [DATE]. Resident #3 was receiving Coumadin three (3) mg daily. On [DATE], Resident #3's Physician ordered to recheck the resident's PT/INR on [DATE]. However, a PT/INR was not completed until [DATE]. The Pharmacist failed to identify Resident #3's medication was not monitored as ordered during the medication Regiment Review on [DATE]. In addition, the Pharmacist recommended the resident's Coumadin be monitored every three (3) days ([DATE] and [DATE]); however, the facility failed to obtain the PT/INR per the Pharmacist Recommendations and physician's orders [REDACTED]. The facility's failure to ensure Pharmacist Recommendations were acted upon and the Pharmacist identified when medication was not being monitored has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Medication Regimen Review, (effective date [DATE]), revealed 1.) The Consultant Pharmacist will conduct Medical Record Reviews if required under a Pharmacy Consult Agreement; 2.) Facility should ensure that the Consultant Pharmacist has access to: 2.1) The resident and/or the resident's responsible party: 2.2) The resident's records: 2.2) The resident's laboratory tests: 2.4) Physician/Prescriber Progress Notes, Nurses Notes, and other documents which may assist the Consultant Pharmacist in making a professional judgement as to whether or not irregularities exist in the medication regimen; and any necessary information. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of a Laboratory Report, dated [DATE], revealed Resident #1's PT level was 18.4 seconds (normal: 9XXX,[DATE].0) and INR was 1.74 (normal 2XXX,[DATE].0), which indicated the INR level was not in therapeutic range. The physician documented no change in the Coumadin order, and to repeat the PT/INR test in one (1) week, on [DATE]; however, review of Resident #1's Laboratory Reports revealed there was no PT/INR from [DATE] until the resident was sent to the hospital on [DATE]. Review of the Pharmacist Consultation Report, dated [DATE], revealed there was no documented evidence that the Pharmacist had identified the resident's Coumadin was not monitored as ordered. Review of Nurses Notes, dated [DATE] at 8:00 AM, revealed the resident was sent to the emergency roiagnom on the morning of [DATE] with stroke like symptoms and a change in his/her mental status. Review of Resident #1's PT/INR results taken in the emergency roiagnom on [DATE] at 8:43 AM, revealed the resident's PT was 13.6; and, his/her INR was 1.30 which was below the therapeutic range. Review of the Hospital Records revealed Resident #1 was admitted to the hospital on [DATE] and died on [DATE] with [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON), on [DATE] at 2:30 PM, revealed she was not aware the resident's PT/INR had not been checked on [DATE] as ordered until after the resident was sent to theER on [DATE]. She stated another nurse had reviewed the resident's chart and identified the order had been transcribed to be obtained on [DATE] instead of [DATE]. Interview (Post Survey) with the Pharmacy Manager, on [DATE] at 11:30 AM, revealed he was not sure if Coumadin was looked at very closely during the pharmacy audit. He stated someone else at the facility was responsible for following the Coumadin laboratory (lab) due to the frequency of the lab order changes as well as dosage changes. 2. Record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].>Review of a Laboratory Report, dated [DATE], revealed Resident #3's PT was 25.7 (normal: 9XXX,[DATE].0) which was high and the INR was 2.40 which was therapeutic (normal 2XXX,[DATE].0). Further review of the report and review of a physician's orders [REDACTED].#3 did not have a PT/INR conducted until [DATE]. Review of the Pharmacy Consultation Report, dated [DATE], revealed the Pharmacist did not identify the resident had not received a PT/INR since [DATE] and the PT/INR ordered for [DATE] had not been obtained. Further review revealed a physician's orders [REDACTED]. Review of a Pharmacy Recommendation, dated [DATE], revealed recommendations to monitor for an increase in hypoprothrombinemic (deficiency of blood clotting factor in the blood) response to anticoagulants during administration of penicillin every three (3) days from the start of the antibiotic. Review of a physician's orders [REDACTED]. However, review of Resident #3's Laboratory Reports revealed a PT/INR was not completed on [DATE] as recommended by the Pharmacist and ordered by the Physician. Interview with the Director of Nursing (DON), on [DATE] at 2:40 PM; and, on [DATE] at 1:00 PM, revealed she did not review Resident #3's chart after she received the Pharmacist's Recommendation to repeat the PT/INR on [DATE], because it was a recommendation based on medication being administered not the identification of the facility's failure to obtain labs. Interview (Post Survey) with the Clinical Nurse Specialist, on [DATE] at 3:00 PM, revealed the Unit Managers were responsible for reviewing the pharmacy recommendations and obtaining the orders. She stated the Pharmacist looked to see if the resident had a recent lab completed but they were not part of their monitoring system to ensure labs were completed. Interview (Post Survey) with Pharmacy Clinical Manager, on [DATE] at 7:40 AM, revealed during the monthly pharmacy review process, she expected the Pharmacist to review the current physician's orders [REDACTED]. She stated she expected the Pharmacist to review the residents lab results to ensure the lab was completed as ordered and a new order was written for future labs if indicated on the physician's orders [REDACTED]. Interview (Post Survey) with Administrator, on [DATE] at 7:40 AM, revealed she expected the pharmacy audits to include the monitoring of critical lab levels (PT/INR) to ensure they are being completed as part of the monthly pharmacy review. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], an audit was conducted by the DON and Quality Management Nurse (QMS) on all residents receiving Coumadin to validate that PT/INR testing was current. PT/INR testing from [DATE] through [DATE] was reviewed to validate that all residents had current PT/INR tests. It was through this audit that it was identified Resident #3 has missed his/her ordered test for [DATE]. 2. An additional audit was conducted on [DATE] by the QMS and Regional Nurse Consultant (RNC) for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that the residents had all current ordered lab tests with no concerns identified. Any care plan that lacked the need to monitor for these medications were revised by the regional nurse consultant or the QMS at the time. 3. An audit was conducted on the care plans of all residents receiving warfarin to assure that all had a care plan problem addressing their use. The care plan of any resident which did not thoroughly address the anticoagulant use was revised. This was completed by the MDS Coordinator and the MDS Nurse on [DATE]. 4. A Quality Assurance meeting was held [DATE] by the Administrator with the DON, the Staff Development Coordinator (SDC), the QMN, and the Unit Manager to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. A call was placed to the Medical Director by the Administrator on [DATE] to review the actions planned and the QA findings. Further communication was made daily until the Medical Director was reached on [DATE]. 5. A new protocol was developed on [DATE] by the QMN for writing orders to reflect changes in warfarin/coumadin orders. The process includes: discontinuance of the previous order, if not continued, new dose clearly stated, frequency/interval for next required test and the date scheduled to meet that frequency. The Administrator reviewed the new protocol with the Medical Director on [DATE]. 6. Protocol for nurses writing coumadin/warfarin orders as well as other significant medications requiring titration and or laboratory monitoring and documenting was revised to include clearly stating current orders and including both the frequency/interval of testing as well as the scheduled date. The process includes a second nurse validating accurate transcription of the order components. 7. The lab order monitoring process was revised by the QMN on [DATE] to be made a part of the active Abbreviated Quality Assurance (AQA) Program. The AQA meeting is conducted Monday through Friday except holidays. During the AQA meeting, the administrative nursing team members (DON, ADON,SDC or Unit Manager) will review lab reports, returned labs from the MD on which orders were noted, transcribed orders, and the lab book, to validate that all accurately correspond and were complete. Clinical AQA members will also monitor through the AQA process to verify that orders for PT/INR- anticoagulants are correctly written and scheduled. They were educated in the validation process by the Administrator on [DATE]. Additional education was initiated on [DATE] regarding significant medications that require lab monitoring with the clinical AQA team by the RNC, and continued with the remainder of clinical AQA nurses on their next scheduled day worked with completion on [DATE]. The new process is as follows: Upon receipt of an order for [REDACTED]. The order, as with other orders will be placed in the AQA box for review in the next AQA meeting. The night shift charge nurse will complete the lab requisitions for the ordered lab on or before the shift which they are due. If the date is designated a lab day a representative from local hospital will come draw the lab. If its not a lab day, the night shift nurse is responsible for drawing the labs and having them delivered to local hospital. All stat labs are to be drawn by the charge nurse on duty or another nurse if difficulty is encountered. If at shift change an on coming charge nurse may draw the specimen. When a lab result is received, the charge nurse receiving the lab result is to fax the results to the physician unless the result is a critical value. If there is a critical valuer, the results will be called to the physician by the charge nurse. After the physician reviews the lab result, he will fax or call the charge nurse to acknowledge and provide new orders as indicated. When an order is written on the lab result, the charge nurse is to write a telephone order containing the order change and any future labs ordered. Anticoagulants should contain both frequency and scheduled date. The nurse will transcribe any medication change on the MAR indicated [REDACTED]. The accuracy of the transcribed order and the lab book is to be validated by a second nurse. The lab report should be placed in the AQA box and the white and yellow copies of the order in the section designated for orders. If there are no orders when the doctor acknowledges the lab results, the acknowledged results are to be placed in the AQA box for review by the clinical AQA committee. Phone orders and lab results will be brought into each AQA meeting by the DON or Unit Managers along with the lab book and the charts. During the AQA process, the lab book will be checked by the DON,SDC,Unit Managers,ADON,a with the lab orders to verify the lab was placed on the correct scheduled day. Previous days lab orders on the lab book will also be checked by the AQA team to verify they were completed and results received. The AQA meeting is conducted Monday through Friday except holidays. Proper completion of lab orders from weekends and holidays will be verified in the next AQA meeting in addition the on-call nurse validate during the weekend and holidays. The on call Administrative Nurse for the weekend or holiday will validate that all stat or follow-up labs that are ordered are scheduled and obtained. On the following working day, the AQA clinical team will review the lab results, schedule and orders to verify that all orders and results are correctly scheduled, obtained, results received, communicated to the physician and orders correctly transcribed. 8. Education was initiated with all licensed nurses regarding this protocol change on [DATE], by the QMN, the DON, SDC and the Regional Nurse Consultant. Follow-up education to reinforce the training regarding anti-coagulant medication orders was started with licensed nurses by Regional Nurse Consultant on [DATE] and post testing was given to verify comprehension. All licensed nurses have completed education except those on leave or PRN staff who have not been available for training. Any temporary or agency personal will be trained prior to being allowed to return to work. Education was initiated by the QMS, DON, SDC, RNC with licensed nurses regarding anticoagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. The written order is to include: Discontinuing the current dosage if there is to be a change, new order or statement to continue current dosage, the interval or frequency for future testing and the date that treating is to be done. Follow-up education with licensed staff regarding anti-coagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. To further validate comprehension beginning on the night shift on [DATE], nurses were required to successfully complete a packet demonstrating accurate transcription of three (3) sampled lab results of values impacted by high risk medications. Testing is ongoing, no staff members, to include temporary staff or agency staff, will be allowed to work prior to completing competency testing. The education on the lab order completion and monitoring process will be conducted with licensed staff by the SDC, DON, or QMN prior to the next shift worked. Education will include agency and temporary staff. Education with Nurses and Certified Medication Technicians (CMTs) was initiated [DATE] regarding accurate documentation on Medication Administration Records (MAR). This education has been provided by the Staff Development Coordinator (SDC), DON, QMS and the Regional Nurse Consultant. CMTs and licensed nurses were educated to document in accordance with professional standards and to complete documentation immediately following delivery of the medication. They are to review documentation at the end of their shift with the oncoming staff member or peer. If documentation omissions are identified, the nurse/CMT may document only if they recall with certainty that the medication was provided. If the medication was missed they are to contact the MD and follow the medication error process and physician's actions that are ordered. This education has been ongoing and will continue with oncoming staff prior to their next shift worked to include temporary or agency staff. PRN staff who have not been available for education were sent a letter by the SDC on [DATE] explaining that they must complete education prior to working again. They will also be required to demonstrate competency. Education reinforcing the requirement to review MAR/TAR, and initial to signify the administration of the medication or task after it is completed was initiated by the DON, QMS, SDC, RNC on [DATE]. Follow up education was started on [DATE] by the RNC and was completed on [DATE] with scheduled licensed nursing staff. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. Any additional PRN, temporary or agency staff ,who will be assigned shifts in the future will receive training and post testing prior to beginning their next shift duties. 9. To heighten the nurses' awareness of anti-coagulants and the need to monitor corresponding labs, all anti-coagulants were moved to the nurses MAR for administration by a licensed nurse. Prior to this review, Coumadin/Warfarin, and Lovenox were the only anticoagulants exclusively administered by the nurses. This change was made by the QMN on [DATE]. 10. As part of the QA investigation it was noted that there were documentation omissions/errors on the residents MAR. Omissions/errors in administration of medication and inaccurate documentation regarding obtaining PT/INR on [DATE] were identified. LPN #1 inaccurately transcribed the order that should have been scheduled for [DATE] as [DATE], on the physicians order, and initialed as [DATE] on the MAR. She was issued a final written warning by the DON on [DATE], and instructed that she must have a second nurse verify all transcribed orders of any kind. She was further instructed by the DON to have an administrative nurse conduct an additional review. In the absence of a administrative nurse an alternate nurse will be assigned on the assigned shift. (This nurse is not assigned to work weekends). 11. The Regional Nurse Consultant met with LPN #3 on [DATE] to discuss documentation omissions on the MAR. LPN #3 was the usual nurse on that unit on her scheduled days, followed a regular routine, and the administration of his medication was a standard part of her routine. She had failed to initial the medication when she administered it. The following day, further discussion was held with Nurse B and the Quality Management Specialist. A written warning (disciplinary action) was prepared by the Director of Nursing and was issued on [DATE] by the Quality Management Specialist for failure to document medication administration. 12. To monitor ongoing accurate transcription of Coumadin and PT/INR orders as well as other significant medications and corresponding lab monitoring and completion of ordered testing and compliance with care plan as it relates to obtaining labs as ordered. All telephone orders from the previous day are being reviewed by the Unit Manager, or in his/her absence a member of the administrative nursing team such as the DON, or SDC. The administrative nurse is validating that the order was correctly transcribed on the MAR/TAR. All orders, lab results, and the Lab Log are being brought to the morning QA meeting to confirm the orders were correctly transcribed from the lab result to the physician's orders [REDACTED]. The lab schedule is also being checked confirm that the scheduled testing was obtained, and that results have been received for tests that were previously obtained. On weekends, the charge nurse will have a charge nurse from another hall verify that significant medication labs orders are accurately transcribed and entered on the lab log. If variances are identified, immediate corrective measure will be taken. The day shift charge nurse on each unit will check the lab books on the corresponding units to validate that all labs scheduled to be obtained have been drawn. The weekend on call administrative nurse, will validate that ordered labs have been obtained. Orders received on the weekend that are checked by the charge nurse at the time transcribed, will also be verified through the AQA process the next day. To verify that the monitoring process is effective the Administrator will observe /validate the process three (3) times a week for four (4 ) weeks, then monthly for twelve (12) weeks. Monthly observation and validation of accuracy will be continued monthly. The Regional Nurse Consultant will validate compliance monthly for three (3) months then quarterly. 13. Charge Nurses will review the MAR indicated [REDACTED]. Unresolved omissions will be addressed by the charge nurse as medication errors, including physician notification. The AQA team member or Regional Consultant will also do an audit daily including weekends for three (3) weeks of the MARs to verify that all ordered medications have been addressed either with initials or an explanation as to why it wasn't given After three (3) weeks, if the process is determined to be effectively working by the AQA committee, over site by the AQA team may be reduced to three (3) times a week for six (6) weeks, then weekly if ongoing effectiveness is determined. 14. The MDS Coordinator will develop the care plans that reflect the need to obtain and monitor lab values for residents on medications that require titration or monitoring. Additional monitoring will be provided through review of the care plan interventions through the quarterly review by the interdisciplinary care plan team. In the event a concern is identified through the interdisciplinary review, the identified concern will be immediately reported to the DON and Administrator for action. Audit of the care plans of residents receiving significant medications requiring lab monitoring will be conducted monthly for three (3) months and then quarterly for one (1) year by the DON, ADON, or RNC. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the facility's audits completed on [DATE] revealed, an audit was completed for all residents receiving Coumadin to validate that PT/INR testing was current. Record reviews for four (4) residents (Residents #3, #7, #8, and #9 ) revealed the residents had current PT/INR testing. 2. Review of documentation revealed the QMS and RNC completed an additional audit on [DATE]. An audit for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that all residents had all current lab results. 3. Review of the care plan audits revealed the MDS Coordinator and MDS Nurse had completed an audit on care plans for all residents receiving warfarin and requiring PT/INR and all revisions were completed. Interview with the MDS Coordinator and the MDS Nurse, on [DATE] at 4:14 PM, revealed they both had been educated related to the new changes and would be continuing the audit process along with other members of the AQA team. 4. Review of the Quality Assurance (QA) Meeting Sign in Sheet, revealed on [DATE], the Administrator had a meeting with the QA team to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. Review of the Plan of Action developed in the AQA meeting, revealed there were measurable goals and interventions put in place to prevent future problems with documentation and missed labs. Further review revealed additional information was initiated on [DATE] regarding significant medications that require lab monitoring with the AQA team and continued with the remainder of the clinical AQA nurses on their next day worked with completion on [DATE]. 5. Review of the Lab Results Policy revealed it was revised on [DATE], to add clarification of employee responsibility to ensure a consistent system for obtaining a laboratory test order to transcription and overall tracking of the laboratory process. 6. Review of the protocol for nurses writing orders to refect changes in medications revealed the protocol was revised to include a second nurse to validate the order was transcribed correctly. 7. Review of the new AQA process for monitoring labs developed on [DATE] by the Quality Management Nurse for Anti-coagulant Therapy orders, revealed instructions for monitoring and transcription of labs to reflect changes in Coumadin orders from the physician as well as transcribing the new order in the Lab Book. Further review revealed all telephone orders from the previous day are being reviewed by the Unit Manager, or in his/her absence a member of the Administrative nursing team. Review of the Sign in Sheet dated [DATE], revealed all the clinical members of the AQA team received training and education related to the new lab monitoring procedure. Interviews with the AQA staff (the Clinical Nurse Specialist on [DATE] at 3:15 PM and the MDS Coordinator on [DATE] at 4:14 PM) revealed they had been inserviced on the new AQA process and had a good understanding of the process and felt comfortable with monitoring the staff. Phone interview with LPN #5/Unit Manager on [DATE] at 5:30 PM, revealed he received in-service from the Administrator and the Quality Management Nurse regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing lab orders and placing them in the lab book. He stated he has been involved in the process of checking nurses' MAR prior to leaving from their assigned shift. Interview with Minimum Data Set (MDS) Coordinator, on [DATE] at 4:15 PM, revealed compliance with obtaining lab values for residents' medication will be monitored through the second check by charge nurse and the AQA team. He stated he received in-service from the Administrator and the Quality Management Nurse regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing of lab orders and placing them in the lab book. Interview with the Quality Management Nurse on [DATE] at 2:00 PM, revealed the lab order monitoring process was revised on [DATE] to be made a part of the active Abbreviated Quality Assurance (AQA) program. She further stated the AQA meeting will be conducted Monday through Friday except holidays and that during the meeting, the administrative nursing team members will review lab reports, returned labs from Medical Providers on which orders are noted, transcribed orders, and the lab book, to validate that all accurately correspond and are complete. Interview with the Staff Development Coordinator (SDC) on [DATE] at 1:30 PM, revealed she received in-service from the Administrator and the Quality Management Nurse regarding their assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing lab orders and placing them in the lab book. Interview with the Director of Nursing (DON) on [DATE] at 3:15 PM, revealed she has been actively involved in the AQA process. She further revealed she has received training about the new policies put in place related to the lab monitoring, correctly documenting physician's orders [REDACTED]. She further revealed the facility will continue the daily monitoring process and the audits even after the documented time frame has passed. She further revealed the facility had implemented all the new changes into the new employee packet for new employees. She further revealed the facility had implemented all the new changes into the new employee packet for new employees and had developed a corrective monitoring check list to aid in the verification process. 8. Review of inservice records revealed education was initiated with all licensed nurses regarding the protocol changes on [DATE]. Follow up education to reinforce the training regarding anti-coagulant medication orders was started with licensed nurses on [DATE] and post testing was given to verify comprehension. Review of Sign in sheets from in-services held on [DATE], [DATE] and [DATE] revealed staff was in-serviced on the new lab monitoring procedure. Review of in-service records revealed the education on the lab order completion and monitoring process was initiated on [DATE] by the DON and the RNC and was conducted with all licensed staff prior to their next scheduled shift to work. Documented sign in sheets indicated last in-service completed on [DATE]. Review of sign in sheets revealed, all licensed nurses were provided education by the Regional Nurse Specialists on [DATE] on the need to accurately follow the residents' plan of care and nurses not available for education were being trained prior to being allowed to work. Reviewed sign in sheet for in-service education with licensed staff and Certified Medication Technicians related to proper documentation following professional standards initiated on [DATE] and completed [DATE]. Interviews on [DATE] with LPN #11 at 5:03 PM, LPN #5 at 5:30 PM, RN #3 at 4:52 PM, RN #1 at 3:32 PM, LPN #12 at 4:00 PM and RN #2 on at 4:52 PM; and, on [DATE] with LPN #7 at 2:40 PM, LPN #10 at 8:40 AM, CMT #5 at 9:00 AM, CMT #6 at 9:05 AM and LPN #8 at 11:15 AM, revealed they had been in-serviced on the ne

Based on interview, record review, facility policy and procedure review, and review of Hospital Records and laboratory reports, it was determined the facility failed to ensure the clinical record was complete and accurately documented related to medications being documented on the Medication Administration Record (MAR) and critical labs being documented to be drawn accurately for one (1) of seven (7) sampled residents (Resident #1). The facility failed to ensure drug level monitoring was completed as ordered for Resident #1. Licensed Practical Nurse (LPN) #1 documented to draw Resident #1's [MEDICATION NAME] (PT)/International Normalization Ratio (INR) on [DATE] on the physician's orders [REDACTED]. This failure resulted in the lab not being drawn and the opportunity for Resident #1's Physician to adjust the resident's medication. In addition, there were multiple missed entries for the administration of Resident #1's [MEDICATION NAME] (anticoagulant/blood thinner) on the [DATE] MAR on [DATE], [DATE], [DATE], [DATE] and [DATE] and missed entries for the administration of high blood pressure medication. The facility failed to have an effective system in place to ensure the documentation on the MAR was complete. Resident #1 had a critical [MEDICATION NAME] level when he/she was admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Resident #1 expired at the hospital on [DATE]. The facility's failure to ensure residents' clinical records were complete and accurately documented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, General Dose Preparation and Medication Administration, last revised [DATE], revealed after medication administration, facility staff should take all measures required by facility policy and applicable laws, including but not limited to documenting necessary medication administration/treatment information when medications were given, when medications were opened, the injection site of a medication, and to document on the appropriate forms. Review of the facility's policy titled, Medical Records Documentation Standards, last revised [DATE], revealed it is the policy of this facility that documentation will reflect medical presence, team approach, and established professional ethics and practices. Charting should contain specific and accurate details to inform staff, demonstrate awareness of the resident's condition, and or problems, and facilitate quality of care. Record significant changes in the residents condition, response to treatments/medications, follow up with physicians/allied health professionals, and notification of resident/representative. 1. Closed record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Medication Administration Record (MAR), revealed the resident was receiving [MEDICATION NAME] ( anticoagulant/blood thinner) six (6) milligram (mg) tablet and a three (3) mg tablet once daily, on Mondays, Tuesdays, Thursdays, Fridays and Sundays; and, [MEDICATION NAME] 10 mg tablet once daily on Wednesdays and Saturdays. Review of a Laboratory Report, dated [DATE], revealed the physician documented there was no change to the [MEDICATION NAME] order, but to repeat the PT/INR test in one (1) week, on [DATE]. Further review of the [DATE] MAR revealed the order for the [DATE] PT/INR was on the MAR and the MAR was initialed that the lab had been completed; however, review of Resident #1's Laboratory Reports revealed there was no PT/INR completed on [DATE]. Interview with Licensed Practical Nurse (LPN) #1, on [DATE] at 4:00 PM, revealed the Physician documented on the Laboratory Report to recheck the PT/INR in one (1) week, on [DATE] but when she documented it on the physician's orders [REDACTED]. She stated she was not aware of the error until she was counseled by her Supervisor on [DATE]. Interview (Post Survey) with LPN #1, on [DATE] at 1:20 PM, revealed she did not remember if she had initialed Resident #1's MAR indicating the PT/INR was drawn received. However, there was no documented evidence of a Laboratory Report for [DATE]. In addition, review of the [DATE] MAR revealed multiple missed entries for the administration of the [MEDICATION NAME] 10 mg on [DATE], and [MEDICATION NAME] three (3) mg on [DATE], [DATE], [DATE] and [DATE]; and, [MEDICATION NAME] six (6) mg on [DATE], [DATE]. Further review revealed there were also missed documentation of entries for critical medication to control the resident's blood pressure and heart rate. The following medications were not initialed as having been administered or not administered: [MEDICATION NAME] 25 mg (hypertension) on [DATE], [MEDICATION NAME] (slow,strengthens heart rate) on [DATE] and [DATE], [MEDICATION NAME] 25 mg (hypertension) on [DATE], and [MEDICATION NAME] 100 mg tabs (hypertension) on [DATE], [DATE], and [DATE]. Review of Resident #1's blood pressure readings for [DATE] through [DATE] revealed the resident's blood pressure ranged from ,[DATE]-,[DATE] (normal ,[DATE]) and on [DATE] when he/she was sent to the hospital it was ,[DATE]. Interview with LPN #3, on [DATE] at 12:10 PM, revealed she was aware Resident #1 was taking [MEDICATION NAME] and also received multiple blood pressure medications. She stated Resident #1 had been taking [MEDICATION NAME] since he/she was admitted to the facility and she administered the medication every day as prescribed but did not sign it out. She further stated she was not sure why she did not sign it out and she realized the legal ramifications of not signing out the medications. She said she was positive the medications were administered and she also understood the importance of the blood pressure medication being administered as ordered. Review of the Nurses Notes, dated [DATE] at 8:00 AM, revealed Resident #1 was sent to the emergency room with stoke like symptoms and a change in mental status. Review of Resident #1's PT/INR results taken in the emergency roiagnom on [DATE] at 8:43 AM, revealed the resident's PT was 13.6 (normal ,[DATE]) and INR was 1.30 which was below the therapeutic range (normal 2XXX,[DATE].0). Review of Hospital Records, dated [DATE], revealed Resident #1 was admitted to the hospital and later died on [DATE] with [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON) on [DATE] at 2:40 PM, revealed she was not aware of the documentation issues in Resident #1's MAR until she completed a chart audit on [DATE]. She stated she expected the nursing staff to administer the medication as ordered and initial the MAR at the time the medication was given. Interview with the Clinical Nurse Specialist, on [DATE] at 3:00 PM, revealed she was aware the facility had a problem with documentation, but not to that extent. She stated the facility did not have a system in place to monitor the MARs monthly. She further stated Resident #1's medical provider is also the facility's Medical Director and, had voiced concerns with her related to the frequency of medication errors being made and wanted the facility to try and improve their medication error rate. She stated if the resident didn't get his/her medication as prescribed by the medical provider it could have affected the residents blood pressure readings. Interview with Resident #1's Medical Provider, on [DATE] at 1:40 PM, revealed that missing the residents' labs (PT/INR) as ordered could have effected the resident's levels. He stated he had been ordering the resident's lab work to be drawn weekly due to fluctuations in the lab results. He stated he had concerns about possible missed doses and had voiced his concern with the nurses when they called with the lab results as well as the previous Administrator. He further stated if the resident had actually missed doses of prescribed medication it could have influenced his/her [MEDICATION NAME] level as well as the resident's blood pressure. He stated if the resident's [MEDICATION NAME] level got too low for a long period of time it could have contributed to his/her [MEDICAL CONDITIONS]. He further stated he would have expected the facility to have a better tracking system in place regarding [MEDICATION NAME] levels as well as some type of audit system in place to review the MARs and ensure labs were obtained. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], an audit was conducted by the DON and Quality Management Nurse (QMS) on all residents receiving [MEDICATION NAME] to validate that PT/INR testing was current. PT/INR testing from [DATE] through [DATE] was reviewed to validate that all residents had current PT/INR tests. It was through this audit that it was identified Resident #3 has missed his/her ordered test for [DATE]. 2. An additional audit was conducted on [DATE] by the QMS and Regional Nurse Consultant (RNC) for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that the residents had all current ordered lab tests with no concerns identified. Any care plan that lacked the need to monitor for these medications were revised by the regional nurse consultant or the QMS at the time. 3. An audit was conducted on the care plans of all residents receiving [MEDICATION NAME] to assure that all had a care plan problem addressing their use. The care plan of any resident which did not thoroughly address the anticoagulant use was revised. This was completed by the MDS Coordinator and the MDS Nurse on [DATE]. 4. A Quality Assurance meeting was held [DATE] by the Administrator with the DON, the Staff Development Coordinator (SDC), the QMN, and the Unit Manager to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. A call was placed to the Medical Director by the Administrator on [DATE] to review the actions planned and the QA findings. Further communication was made daily until the Medical Director was reached on [DATE]. 5. A new protocol was developed on [DATE] by the QMN for writing orders to reflect changes in [MEDICATION NAME]/[MEDICATION NAME] orders. The process includes: discontinuance of the previous order, if not continued, new dose clearly stated, frequency/interval for next required test and the date scheduled to meet that frequency. The Administrator reviewed the new protocol with the Medical Director on [DATE]. 6. Protocol for nurses writing [MEDICATION NAME]/[MEDICATION NAME] orders as well as other significant medications requiring titration and or laboratory monitoring and documenting was revised to include clearly stating current orders and including both the frequency/interval of testing as well as the scheduled date. The process includes a second nurse validating accurate transcription of the order components. 7. The lab order monitoring process was revised by the QMN on [DATE] to be made a part of the active Abbreviated Quality Assurance (AQA) Program. The AQA meeting is conducted Monday through Friday except holidays. During the AQA meeting, the administrative nursing team members (DON, ADON,SDC or Unit Manager) will review lab reports, returned labs from the MD on which orders were noted, transcribed orders, and the lab book, to validate that all accurately correspond and were complete. Clinical AQA members will also monitor through the AQA process to verify that orders for PT/INR- anticoagulants are correctly written and scheduled. They were educated in the validation process by the Administrator on [DATE]. Additional education was initiated on [DATE] regarding significant medications that require lab monitoring with the clinical AQA team by the RNC, and continued with the remainder of clinical AQA nurses on their next scheduled day worked with completion on [DATE]. The new process is as follows: Upon receipt of an order for [REDACTED]. If the lab is to be performed on an upcoming month, or is recurring, it will be listed on the future date page. The order, as with other orders will be placed in the AQA box for review in the next AQA meeting. The night shift charge nurse will complete the lab requisitions for the ordered lab on or before the shift which they are due. If the date is designated a lab day a representative from the Hospital will come draw the lab. If its not a lab day, the night shift nurse is responsible for drawing the labs and having them delivered to the local Hospital. All stat labs are to be drawn by the charge nurse on duty or another nurse if difficulty is encountered. If at shift change an on coming charge nurse may draw the specimen. When a lab result is received, the charge nurse receiving the lab result is to fax the results to the physician unless the result is a critical value. If there is a critical valuer, the results will be called to the physician by the charge nurse. After the physician reviews the lab result, he will fax or call the charge nurse to acknowledge and provide new orders as indicated. When an order is written on the lab result, the charge nurse is to write a telephone order containing the order change and any future labs ordered. Anticoagulants should contain both frequency and scheduled date. The nurse will transcribe any medication change on the MAR as indicated and place the ordered test on the appropriate date on the lab book. The accuracy of the transcribed order and the lab book is to be validated by a second nurse. The lab report should be placed in the AQA box and the white and yellow copies of the order in the section designated for orders. If there are no orders when the doctor acknowledges the lab results, the acknowledged results are to be placed in the AQA box for review by the clinical AQA committee. Phone orders and lab results will be brought into each AQA meeting by the DON or Unit Managers along with the lab book and the charts. During the AQA process, the lab book will be checked by the DON,SDC,Unit Managers,ADON,a with the lab orders to verify the lab was placed on the correct scheduled day. Previous days lab orders on the lab book will also be checked by the AQA team to verify they were completed and results received. The AQA meeting is conducted Monday through Friday except holidays. Proper completion of lab orders from weekends and holidays will be verified in the next AQA meeting in addition the on-call nurse validate during the weekend and holidays. The on call Administrative Nurse for the weekend or holiday will validate that all stat or follow-up labs that are ordered are scheduled and obtained. On the following working day, the AQA clinical team will review the lab results, schedule and orders to verify that all orders and results are correctly scheduled, obtained, results received, communicated to the physician and orders correctly transcribed. 8. Education was initiated with all licensed nurses regarding this protocol change on [DATE], by the QMN, the DON, SDC and the Regional Nurse Consultant. Follow-up education to reinforce the training regarding anti-coagulant medication orders was started with licensed nurses by Regional Nurse Consultant on [DATE] and post testing was given to verify comprehension. All licensed nurses have completed education except those on leave or PRN staff who have not been available for training. Any temporary or agency personal will be trained prior to being allowed to return to work. Education was initiated by the QMS, DON, SDC, RNC with licensed nurses regarding anticoagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. The written order is to include: Discontinuing the current dosage if there is to be a change, new order or statement to continue current dosage, the interval or frequency for future testing and the date that treating is to be done. Follow-up education with licensed staff regarding anti-coagulant orders and the required components to be included in the transcribed physician's orders [REDACTED]. To further validate comprehension beginning on the night shift on [DATE], nurses were required to successfully complete a packet demonstrating accurate transcription of three (3) sampled lab results of values impacted by high risk medications. Testing is ongoing, no staff members, to include temporary staff or agency staff, will be allowed to work prior to completing competency testing. The education on the lab order completion and monitoring process will be conducted with licensed staff by the SDC, DON, or QMN prior to the next shift worked. Education will include agency and temporary staff. Education with Nurses and Certified Medication Technicians (CMTs) was initiated [DATE] regarding accurate documentation on Medication Administration Records (MAR). This education has been provided by the Staff Development Coordinator (SDC), DON, QMS and the Regional Nurse Consultant. CMTs and licensed nurses were educated to document in accordance with professional standards and to complete documentation immediately following delivery of the medication. They are to review documentation at the end of their shift with the oncoming staff member or peer. If documentation omissions are identified, the nurse/CMT may document only if they recall with certainty that the medication was provided. If the medication was missed they are to contact the MD and follow the medication error process and any physician's actions that are ordered. This education has been ongoing and will continue with oncoming staff prior to their next shift worked to include temporary or agency staff. PRN staff who have not been available for education were sent a letter by the SDC on [DATE] explaining that they must complete education prior to working again. They will also be required to demonstrate competency. Education reinforcing the requirement to review MAR/TAR, and initial to signify the administration of the medication or task after it is completed was initiated by the DON, QMS, SDC, RNC on [DATE]. Follow up education was started on [DATE] by the RNC and was completed on [DATE] with scheduled licensed nursing staff. Any PRN staff, temporary staff and agency staff have been trained prior to beginning work. Any additional PRN, temporary or agency staff ,who will be assigned shifts in the future will receive training and post testing prior to beginning their next shift duties. 9. To heighten the nurses' awareness of anti-coagulants and the need to monitor corresponding labs, all anti-coagulants were moved to the nurses MAR for administration by a licensed nurse. Prior to this review, [MEDICATION NAME]/[MEDICATION NAME], and [MEDICATION NAME] were the only anticoagulants exclusively administered by the nurses. This change was made by the QMN on [DATE]. 10. As part of the QA investigation it was noted that there were documentation omissions/errors on the residents MAR. Omissions/errors in administration of medication and inaccurate documentation regarding obtaining PT/INR on [DATE] were identified. LPN #1 inaccurately transcribed the order that should have been scheduled for [DATE] as [DATE], on the physicians order, and initialed as [DATE] on the MAR. She was issued a final written warning by the DON on [DATE], and instructed that she must have a second nurse verify all transcribed orders of any kind. She was further instructed by the DON to have an administrative nurse conduct an additional review. In the absence of a administrative nurse an alternate nurse will be assigned on the assigned shift. (This nurse is not assigned to work weekends). 11. The Regional Nurse Consultant met with LPN #3 on [DATE] to discuss documentation omissions on the MAR. LPN #3 was the usual nurse on that unit on her scheduled days, followed a regular routine, and the administration of his medication was a standard part of her routine. She had failed to initial the medication when she administered it. The following day, further discussion was held with Nurse B and the Quality Management Specialist. A written warning (disciplinary action) was prepared by the Director of Nursing and was issued on [DATE] by the Quality Management Specialist for failure to document medication administration. 12. To monitor ongoing accurate transcription of [MEDICATION NAME] and PT/INR orders as well as other significant medications and corresponding lab monitoring and completion of ordered testing and compliance with care plan as it relates to obtaining labs as ordered. All telephone orders from the previous day are being reviewed by the Unit Manager, or in his/her absence a member of the administrative nursing team such as the DON, or SDC. The administrative nurse is validating that the order was correctly transcribed on the MAR/TAR. All orders, lab results, and the Lab Log are being brought to the morning QA meeting to confirm the orders were correctly transcribed from the lab result to the physician's orders [REDACTED]. The lab schedule is also being checked to confirm that the scheduled testing was obtained, and that results have been received for tests that were previously obtained. On weekends, the charge nurse will have a charge nurse from another hall verify that significant medication labs orders are accurately transcribed and entered on the lab log. If variances are identified, immediate corrective measure will be taken. The day shift charge nurse on each unit will check the lab books on the corresponding units to validate that all labs scheduled to be obtained have been drawn. The weekend on call administrative nurse, will validate that ordered labs have been obtained. Orders received on the weekend that are checked by the charge nurse at the time transcribed, will also be verified through the AQA process the next day. To verify that the monitoring process is effective the Administrator will observe /validate the process three (3) times a week for four (4 ) weeks, then monthly for twelve (12) weeks. Monthly observation and validation of accuracy will be continued monthly. The Regional Nurse Consultant will validate compliance monthly for three (3) months then quarterly. 13. Charge Nurses will review the MAR with a second charge nurse or CMT to verify that all ordered medications have been addressed either with initials or with an explanation as to why it wasn't completed. Unresolved omissions will be addressed by the charge nurse as medication errors, including physician notification. The AQA team member or Regional Consultant will also do an audit daily including weekends for three (3) weeks of the MARs to verify that all ordered medications have been addressed either with initials or an explanation as to why it wasn't given After three (3) weeks, if the process is determined to be effectively working by the AQA committee, over site by the AQA team may be reduced to three (3) times a week for six (6) weeks, then weekly if ongoing effectiveness is determined. 14. The MDS Coordinator will develop the care plans that reflect the need to obtain and monitor lab values for residents on medications that require titration or monitoring. Additional monitoring will be provided through review of the care plan interventions through the quarterly review by the interdisciplinary care plan team. In the event a concern is identified through the interdisciplinary review, the identified concern will be immediately reported to the DON and Administrator for action. Audit of the care plans of residents receiving significant medications requiring lab monitoring will be conducted monthly for three (3) months and then quarterly for one (1) year by the DON, ADON, or RNC. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of the facility's audits completed on [DATE] revealed, an audit was completed for all residents receiving [MEDICATION NAME] to validate that PT/INR testing was current. Record reviews for four (4) residents (Residents #3, #7, #8, and #9 ) revealed the residents had current PT/INR testing. 2. Review of documentation revealed the QMS and RNC completed an additional audit on [DATE]. An audit for all residents receiving other significant medications requiring titration and/or lab monitoring to validate that all residents had all current lab results. 3. Review of the care plan audits revealed the MDS Coordinator and MDS Nurse had completed an audit on care plans for all residents receiving [MEDICATION NAME] and requiring PT/INR and all revisions were completed. Interview with the MDS Coordinator and the MDS Nurse, on [DATE] at 4:14 PM, revealed they both had been educated related to the new changes and would be continuing the audit process along with other members of the AQA team. 4. Review of the Quality Assurance (QA) Meeting Sign in Sheet, revealed on [DATE], the Administrator had a meeting with the QA team to identify the root cause of the missed testing and to develop action plans to prevent re-occurrence. Review of the Plan of Action developed in the AQA meeting, revealed there were measurable goals and interventions put in place to prevent future problems with documentation and missed labs. Further review revealed additional information was initiated on [DATE] regarding significant medications that require lab monitoring with the AQA team and continued with the remainder of the clinical AQA nurses on their next day worked with completion on [DATE]. 5. Review of the Lab Results Policy revealed it was revised on [DATE], to add clarification of employee responsibility to ensure a consistent system for obtaining a laboratory test order to transcription and overall tracking of the laboratory process. 6. Review of the protocol for nurses writing orders to refect changes in medications revealed the protocol was revised to include a second nurse to validate the order was transcribed correctly. 7. Review of the new AQA process for monitoring labs developed on [DATE] by the Quality Management Nurse for Anti-coagulant Therapy orders, revealed instructions for monitoring and transcription of labs to reflect changes in [MEDICATION NAME] orders from the physician as well as transcribing the new order in the Lab Book. Further review revealed all telephone orders from the previous day are being reviewed by the Unit Manager, or in his/her absence a member of the Administrative nursing team. Review of the Sign in Sheet dated [DATE], revealed all the clinical members of the AQA team received training and education related to the new lab monitoring procedure. Interviews with the AQA staff (the Clinical Nurse Specialist on [DATE] at 3:15 PM and the MDS Coordinator on [DATE] at 4:14 PM) revealed they had been inserviced on the new AQA process and had a good understanding of the process and felt comfortable with monitoring the staff. Phone interview with LPN #5/Unit Manager on [DATE] at 5:30 PM, revealed he received in-service from the Administrator and the Quality Management Nurse regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing lab orders and placing them in the lab book. He stated he has been involved in the process of checking nurses' MAR prior to leaving from their assigned shift. Interview with Minimum Data Set (MDS) Coordinator, on [DATE] at 4:15 PM, revealed compliance with obtaining lab values for residents' medication will be monitored through the second check by charge nurse and the AQA team. He stated he received in-service from the Administrator and the Quality Management Nurse regarding his assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing of lab orders and placing them in the lab book. Interview with the Quality Management Nurse on [DATE] at 2:00 PM, revealed the lab order monitoring process was revised on [DATE] to be made a part of the active Abbreviated Quality Assurance (AQA) program. She further stated the AQA meeting will be conducted Monday through Friday except holidays and that during the meeting, the administrative nursing team members will review lab reports, returned labs from Medical Providers on which orders are noted, transcribed orders, and the lab book, to validate that all accurately correspond and are complete. Interview with the Staff Development Coordinator (SDC) on [DATE] at 1:30 PM, revealed she received in-service from the Administrator and the Quality Management Nurse regarding their assigned duties which included performing or delegating lab audits, and the protocol for nurses who receive new lab orders as well as proper transcribing lab orders and placing them in the lab book. Interview with the Director of Nursing (DON) on [DATE] at 3:15 PM, revealed she has been actively involved in the AQA process. She further revealed she has received training about the new policies put in place related to the lab monitoring, correctly documenting physician's orders [REDACTED]. She further revealed the facility will continue the daily monitoring process and the audits even after the documented time frame has passed. She further revealed the facility had implemented all the new changes into the new employee packet for new employees. She further revealed the facility had implemented all the new changes into the new employee packet for new employees and had developed a corrective monitoring check list to aid in the verification process. 8. Review of inservice records revealed education was initiated with all licensed nurses regarding the protocol changes on [DATE]. Follow up education to reinforce the training regarding anti-coagulant medication orders was started with licensed nurses on [DATE] and post testing was given to verify comprehension. Review of Sign in sheets from in-services held on [DATE], [DATE] and [DATE] revealed staff was in-serviced on the new lab monitoring procedure. Review of in-service records revealed the education on the lab order completion and monitoring process was initiated on [DATE] by the DON and the RNC and was conducted with all licensed staff prior to their next scheduled shift to work. Documented sign in sheets indicated last in-service completed on [DATE]. Review of sign in sheets revealed, all licensed nurses were provided education by the Regional Nurse Specialists on [DATE] on the need to accurately follow the residents' plan of care and nurses not available for education were being trained prior to being allowed to work. Reviewed sign in sheet for in-service education with licensed staff and Certified Medication Technicians related to proper documentation following professional standards initiated on [DATE] and completed [DATE]. <b

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure the resident environment remained as free of accident hazards as is possible for four (4) residents (#11, #13, #14 and #15), in the selected sample of twenty-seven (27) residents. The facility failed to identify identify the hazards related to the resident's use of Oxygen (O2) while using the hairdryer, in the beauty shop. The facility failed to ensure all staff assisting residents to the beauty shop and the beautician were educated on the dangers of O2 with heat and ignition sources. On 03/27/13, Resident #11 was observed under the running hair dryer while being administered O2 at five (5) liters per minute (L/m) per the nasal cannula and a portable O2 tank. This failure to ensure the residents' environment remained as free from accidents as is possible, was likely to cause serious injury, harm, impairment or death. The facility was notified of the Immediate Jeopardy on 03/27/13. An acceptable Allegation of Compliance (AoC) was received on 03/29/13 with the facility alleging the Immediate Jeopardy was removed on 03/29/12; however, through interview and record review the State Survey Agency (SSA) identified one staff was not in-serviced, prior to returning to work, on 03/29/13, per the AoC. The education was provided to this employee by the Staff Development Coordinator and validated by the SSA, on 03/29/13. The SSA determined the Jeopardy continued through 03/29/13. The scope and severity was lowered to a "D" while the facility develops and implements a plan of correction (PoC) and the facility's Quality Assurance monitors the effectiveness of the systemic changes. The findings include: A review of the facility's Policy and Procedure for "Oxygen Safety", dated 02/02/10, revealed the staff was to keep flammable materials away from the oxygen equipment; keep oxygen equipment away from open flames and electrical appliances; and to keep oxygen equipment in a well ventilated area, at all times. A review of the facility's list of residents provided by the Administrator revealed four residents (Resident #11, #13, #14 and #15) who had a history of [REDACTED]. 1. An observation of Resident #11, on 03/27/13 at 9:30 AM, revealed the resident was seated under the hard plastic, helmet-type hair dryer that contained the heating element in the helmet. Oxygen was infusing, per the nasal cannula tubing and a portable oxygen tank at five (5) L/m. Two other residents, (#3 and #12,) were in the beauty shop and receiving services. A record review revealed Resident #11 was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment, dated 02/12/13, revealed the facility assessed Resident #11 as independently cognitively intact, needing the extensive assistance of one staff member with Activities of Daily Living (ADLs) and was short of breath with minimal exertion, at rest and with lying flat. A review of the physician's orders [REDACTED]. A review of the O2 saturation rates on room air revealed the resident dropped into the 70 percentile, without O2. A review of the Comprehensive Care Plan, dated 02/25/13, revealed staff members were to administer O2, as ordered. Interviews with Resident #11, on 03/27/13 at 2:25 PM and 3:20 PM, revealed he/she went to the beauty shop "almost every Wednesday and sat under the dryer." The resident had always worn oxygen when having his/her hair done, had been wearing O2 constantly since 1998 and "had never been able to go without it". 2. A record review revealed Resident #14 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the admission MDS assessment, dated 01/11/13, revealed the facility assessed Resident #14 as severely cognitively impaired. A review of the physician's orders [REDACTED]. A review of the Comprehensive Care Plan, dated 01/11/13, revealed staff were to administer oxygen "as ordered". 3. A record review revealed Resident #15 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#15 as moderately cognitively impaired and on O2 therapy. A review of the physician's orders [REDACTED]. A review of the Comprehensive Care Plan, dated 03/21/13, revealed for staff to administer O2 as ordered; however, the care plan did not identify and address the hazards associated with the continuous use of oxygen. An interview with Resident #15, on 03/27/13 at 3:40 PM, revealed he/she went to the beauty shop, "whenever he/she wanted to". An interview with LPN #2, on 03/27/13 at 3:35 PM, revealed Resident #15 went to the beauty shop once a week. 4. A record review revealed Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician orders, dated 03/01/13, revealed an order for [REDACTED]. A review of the Comprehensive Care Plan, dated 02/08/12, revealed to provide oxygen as ordered. An interview with the Beautician, on 03/28/13 at 10:30 AM, revealed she had not been trained about not having residents on oxygen sit under the dryer or about oxygen use in the beauty shop and stated she "didn't think anyone ever thought about this being dangerous." Interviews with the MDS Coordinator, Licensed Practical Nurse (LPN) #5, LPN #3, Certified Medication Aide (CMA) #1, Certified Nurse Aide (CNA) #4, CNA #1 and CNA #7 on 03/27/13 at 11:03 AM, 11:05 AM, 11:08 AM, 11:15 AM, 11:18 AM, and 4:15 PM respectively, revealed they were unaware of the dangers involved with oxygen use and had not been trained on oxygen hazards in the beauty shop and/or keeping oxygen sources away from hair dryers and electrical appliances. An interview with the Administrator, on 03/27/13 at 2:33 PM, revealed the facility had no type of training on the safety of oxygen. She stated the facility did have an oxygen safety precaution policy but there had been no training conducted at the facility that included this policy. She revealed that while the residents were in the beauty shop the beautician was responsible for the residents, but ultimately the facility was always responsible for them. **The facility implemented the following actions to abate the Immediate Jeopardy: * On 03/27/13 at approximately 9:45 AM, the Beautician removed Resident #11 from under the hair dryer and Residents #3 and #12, were also assisted out of the area. Beauty shop operation was suspended until investigation of circumstances, development of alternative service provision, completion of training for the beautician and review/revision of the beautician contract could be completed. *On 03/27/13, all current residents, who required oxygen and utilized The Beauty Shop, in the last six months, had their oxygen saturation levels, with and without oxygen, reviewed by the Administrative Staff comprised of the Administrator, Director of Nursing, Assistant Directors of Nursing, Unit Managers, the MDS Coordinator and the Staff Development Coordinator (SDC). This information was forwarded to the residents' physicians to review to determine if and how long the oxygen could be removed for future salon uses. * A Beauty Shop Plan for physician authorization, was created by the Administrative Staff, on 03/27/13, to ensure assessment of residents with oxygen, who utilized the salon services had the approval of the physician, for these services. The written plan will be provided to the Beautician, by the Unit Manager or Clinical Supervisor. The Beauty Shop Plan would ensure the beautician knows whether the physician authorized for the oxygen to be removed for hair drying and if so for how long. If a resident arrives for service without a plan, he/she will be redirected until appropriate information is available from the physician. The information regarding removal of oxygen for salon services, provided by the physicians of Resident #13, #14, and #15 will be utilized to complete a Beauty Shop Plan for each resident. * On 03/27/13, it was determined bonnet type hair dryers would meet the criteria of being more than 12 inches away from the electrical components of the device. Six devices were purchased on 03/27/13, for use with residents who were deemed not appropriate for withholding of oxygen during salon services. * On 03/27/13, a sign was posted in the Beauty Shop stating, "DO NOT USE OXYGEN IN THIS AREA" and another on the door to the salon stating "NO OXYGEN BEYOND THIS POINT". After relocation, the salon will be large enough to ensure the oxygen is not closer than 12 inches of a electrical appliance. This will eliminate the need for the signs after relocation. * On 03/27/13, staff education was initiated, to include training that no resident was to be in the Beauty Shop while using oxygen and that blow dryers were not to be used on residents utilizing oxygen until a safer alternative could be determined. The training was provided by the Administrator, Staff Development Coordinator, and Quality Management Nurse. * The Oxygen Safety Awareness Guideline/Policy was reviewed and revised by the Administrative Staff on 03/28/13 and additional training was provided to the staff. A post test, covering contents of training materials, was given to persons who were educated to verify comprehension, beginning 03/27/13. Staff members who work PRN (as needed) and two that were on medical leave were sent letters informing them of the need for training prior to beginning work duties. The SDC had a facility listing and staffing reports, and was to ensure and validate training was complete for all shifts, to include PRN and staff on medical leave, as well as post tests to be completed. * The Beautician was provided training by the Administrator and Quality Management Nurse on 03/27/13, on oxygen not being permitted in the Beauty Shop and on the Beautify Shop Plan and the Oxygen Safety Awareness Guidelines. * Educational material on oxygen safety, a post-test, and a statement of acknowledgement was added to the orientation material by the Administrator and is to be covered with future new hires. * Unannounced rounds will be conducted during beauty shop hours or resident/staff interviews will be conducted each day the salon is open to assure that no oxygen is in use in the salon and to verify the planned method of salon services established in the Beauty Shop Plan are being followed. Follow-up training sessions to reinforce safety guidelines will be conducted monthly during the all staff meeting for three months, then quarterly at all staff meetings in September and December by the Administrator, Director of Nursing or Staff Development Coordinator. * In the event there is a change in the Beautician, training on all processes will be provided by the Administrator or Director of Nursing. * On 03/28/13, Education was provided to the Administrator to review the responsibilities of effectively administering and managing the day to day operation of the facility in a manner that meets and exceeds the minimum licensure standards, promotes the safety and well-being of the residents entrusted to her care. The training was provided by the Quality Management Specialist. *Beauty shop appointments will be reviewed in an Abbreviated Quality Assurance Meeting to identify if residents using oxygen are scheduled for appointments and validate that a Beauty Shop Plan has been developed to manage the resident's oxygen needs safely during salon service, or that if none is present, the default plan for no rinse shampoo or bonnet hair dryer is scheduled to be used. This will be monitored daily by the Administrator or Director of Nursing for four weeks, during the week when Beauty Shop appointments are scheduled. Unannounced rounds will be conducted by the Administrator, Director of Nursing, or ADON to verify that residents receiving services in the beauty salon are not using oxygen within 12 inches of electrical equipment. * Administrator or Quality Assurance Committee representative from the Administrative Nursing team will review 100% of the orientation records for new hires for one month, to verify Oxygen Safety training is provided and post test successfully completed. After one month, a random selection of 50% of new hires records from across all departments will be audited for three months, then 25% for three months, then 10% for three months. The finding of the monitoring audits will be reported to the Quality Assurance and Assessment Committee. Based on the findings, the quantities and frequency of the audits may be increased by the committee. * The Quality Management Specialist or the Regional Director of Operations will audit documentation of the facility's monitoring and training activities to validate ongoing compliance. Initial audit was conducted on 03/27/13 by the Quality Management Specialist. Repeat audits will be conducted weekly for four weeks, then every two weeks for eight weeks, then monthly times three months. **The surveyors validated the corrective action taken by the facility as follows: Observations verified Beauty Shop operations were suspended, on 03/27/13 at approximately 12:15 PM, and that signs were posted to prevent oxygen use in this area. The Beauty Shop was not reopened, as of the completion of the survey, on 03/29/13 at 4:30 PM. A copy of the Oxygen saturation records was received by the survey team and included in the record review for Resident #11, #13, #14 and #15, who were identified by the Administrator, as having utilized oxygen and the hair dryer, in the Beauty Shop. Record review for Residents #11, #13, #14 and #15 (who were identified as the residents who used the hair dryer in the beauty shop while each resident was receiving oxygen) revealed the residents were reviewed on 03/28/13, to determine if resident oxygen safety concerns were met. A review of the letter sent to the physicians revealed the letter was sent to the physicians and addressed the removal of oxygen for salon services. A review of the Beauty Shop Plan procedures and plan revealed it addressed the the procedures that should be followed when a resident on oxygen expressed the desire to use the beauty shop. The plan identifies the resident's name, MD orders on whether to remove oxygen while the hair dryer is in use and for how long or the hair dryer cannot be used. In addition, it states the oxygen must be off for ten minutes prior to hair dryer use. A review of the Policies and Guidelines revealed they were revised on 03/27/13 to address the use of the hair dryer in the beauty shop on residents who used oxygen. Record review of inservice sign in sheets validated the completion of all training of staff on 03/29/13 related to the oxygen policies and guidelines. Interviews with the Staff Development Coordinator (SDC), Medical Record Aide, Occupational Therapy Assistant #1, Cook, RN #1, #2, and #3; Maintenance Director, LPN #1 and #2; SRNAs #1, #2, #11, #12, #13 and #14; Dietary Aide (DA) #1; Certified Medication Technician (CMT) #1 and #3; and Laundry Aide #1, on 03/29/13 at 11:00 AM, 11:05 AM, 2:35 PM, 2:44 PM, 2:45 PM, 2:55 PM, 3:00 PM, 3:05 PM, 3:10 PM, 3:15 PM and 3:25 PM respectively, revealed the staff received the training related to the oxygen policy and procedures regarding the need to prevent oxygen related fire hazards and completed the post-test. The survey team identified one laundry worker had not been trained prior to working the floor. The SDC had failed to train a laundry worker, who started the shift at 2:00 PM on 03/29/13. The education was provided to this employee, by the SDC, on 03/29/13. Interviews of the above staff, completed by the survey team on 03/29/13, revealed the staff was able to verbally demonstrate understanding of the new policy. The Beautician was interviewed on 03/28/13 at 2:00 PM, and was able to verbalize understanding of the policies. Further interview with the Beautician and Administrator revealed six bonnet type hair dryers were purchased. The survey team reviewed new material included in the orientation process and the SDC was interviewed regarding the changes for new employees on 03/29/13. Interview with the Administrator and Quality Management Specialist on 03/29/13 revealed training was completed with the Administrator to review the responsibilities of effectively administering and managing the day to day operation of the facility. Interviews with the Administrator, Director of Nursing and Staff Development Coordinator on 03/29/13 revealed they were aware of the rounds, audits, review of new hire records and monitoring they were responsible for to ensure the actions put in place were being followed. A review of the audit conducted on 03/27/13 related to the documentation of the facility's monitoring and training activities revealed no concerns were identified. An interview with the Quality Management Specialist on 03/29/13 revealed she was aware she would be auditing the facility's monitoring and training activities documentation to ensure ongoing compliance. Interviews with the Administrator and Director of Nursing, on 03/29/13, confirmed there was a Quality Assurance Committee meeting held on 03/29/13 to review the alleged deficient practice as well as the plan for removal and no further recommendations were identified.