Every finding on record at Cumberland Nursing and Rehabilitation Center

Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure the proper beneficiary notifications were provided to residents who were being discharged from Medicare Part A services with benefit days remaining. The deficient practice affected 1 (Resident 60) of 3 residents reviewed for beneficiary notification requirements.Findings included: An undated facility policy titled, Notice of Medicare Non-Coverage NOMNC Best Practices, indicated, 4. The insured will also require an SNF/ABN [Skilled Nursing Facility/Advance Beneficiary Notice] if the resident has remaining Medicare days and will remain in the facility after the skilled stay ends. The SNF/ABN will be issued by the Social Services Department. An admission Face Sheet, revealed that the facility most recently admitted Resident (R) 60 on 09/16/2025. According to the admission Face Sheet, the resident had a medical history that included diagnoses of hematuria (blood in urine), dysphagia (difficulty swallowing), and contracture of muscles. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/12/2025, revealed that R60 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had mild cognitive impairment. The MDS indicated that the resident was dependent on staff for all activities of daily living (ADLs). The MDS indicated that Resident 60's primary medical diagnosis was debility, cardiorespiratory conditions. Per the MDS, Resident 60 had completed 46 Distinct Calendar Days of Part A Therapies. A list of residents discharged from a Medicare covered Part A stay with benefit days remaining during the six months prior to the survey revealed R60 was discharged from a Medicare covered Part A stay on 11/12/2025 but remained in the facility. A SNF Beneficiary Notification Review Centers for Mediare and Medicaid Services (CMS) form 20052, completed by the facility staff as a part of the recertification survey process, revealed that R60's start date for Part A Medicare services was on 09/16/2025 and the last covered day was 11/12/2025. The form indicated that the facility initiated the discharge from Medicare Part A services when the resident still had benefit days remaining but indicated they were unable to find a copy of the SNF/ABN, Form CMS-10055. During an interview on 04/16/2026 at 12:46 PM, the Social Services Director (SSD) stated that she was responsible for providing SNF/ABN forms to the residents or their responsible party. She stated that she was unable to locate the SNF/ABN form for R60. During an interview on 04/17/2026 at 10:57 AM, the SSD stated that the therapy department notified her when they planned to discharge a resident from skilled therapy services. She stated that she had seven days before the discharge to make the notifications. She stated that she normally provided the forms even if the primary payor source was Medicaid. She stated she called R60's responsible party the day before, but the SNF/ABN was not given. During an interview on 04/18/2026 at 10:23 AM, the Director of Nursing (DON) stated she did not know the process for when a resident was discharged from skilled therapy. The DON stated that the SSD sent papers to the families, and they would send them back, but she was not aware of what the forms were or what should be filled out and provided at what time. She stated that she expected that the appropriate forms be given for each type of discharge from Part A Skilled Services. During an interview on 04/18/2026 at 10:45 AM, the Administrator stated that when a resident was discharged from Medicare Part A, they received a NOMNC. She stated that the families were called right away and told they could appeal. She stated that she thought there was a form for when they remained in the facility. The Administrator confirmed that they did not have a SNF/ABN form for Resident 60 and stated that she did not know why.

Based on facility policy review, record review, facility document review, and interview, the facility failed to ensure they reported allegations of abuse to law enforcement and to the state survey agency within two hours, which affected 1 (Resident 94) of 3 residents reviewed for abuse.Findings included: A facility policy titled, Abuse Prohibition Standard of Practice, last reviewed 03/2026, revealed, the Purpose was To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigating of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State laws. The policy further indicated, 7. Reporting/Response included Alleged violation/violations will be reported to the Administrator and or designee immediately; Alleged violations shall be reported to the state survey agency, adult protective services, and all other required agencies (e.g. [exempli gratia; for example], law enforcement when applicable) within specific time frames; The results of all investigations will be reported to the appropriate state agency within 5 working days of the alleged violation initial report; and The Administrator or designee will report suspicion of a crime to local law enforcement authorities and any other agencies as required by law. An admission Face Sheet revealed the facility admitted Resident (R)94 on 06/19/2025. According to the admission Face Sheet, the resident had a medical history that included diagnoses of anemia, difficulty in walking, dislocation of internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/24/2025, revealed R94 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had mild cognitive impairment. R 94's Care plan Report, included a problem area initiated 06/24/2025, that indicated the resident had impaired cognition with a progressive decline in intellectual functioning, a decline in memory thought process, decision making, and judgement. Interventions initiated 06/24/2026 directed staff to address the resident in a quiet and slow manner, allow the resident time to respond, provide reminders and reassurance as needed, and use simple words and sentences. The Care plan Report included a problem area initiated 06/24/2025, that indicated the resident was at risk for an alteration in their psychosocial wellbeing related to psychosocial adjustment difficulties with regards to their diagnosis of anemia. Interventions initiated 06/24/2025 directed staff to establish a daily routine, gently redirect the resident, and provide cueing and prompting. An Initial Report document, dated 07/01/2025, indicated that the facility reported an allegation of physical abuse to the state survey agency on 07/01/2025. The report indicated that R 94's family member reported to the facility on [DATE] that the resident reported to them that someone smacked them across their face the previous day after lunch or dinner. The report indicated that the Administrator was notified at 9:45 AM. Per the Initial Report, notifications did not indicate that local law enforcement was notified of the allegation. An email from the Administrator to the state survey agency indicated that the initial report was sent to the state survey agency on 07/01/2025 at 1:41 PM, over three and a half hours after the Administrator was notified of the allegation. During an interview on 04/17/2026 at 10:57 AM, the Social Service Director (SSD) stated that if a resident reported any allegations of abuse, they tried to get it reported to the state survey agency within two hours. She stated that she remembered taking R94 to the Administrator's office the morning of 07/01/2025 but did not remember how she initially heard about the allegation of abuse. During a concurrent interview with the Director of Nursing (DON) and the Administrator on 04/17/2026 at 4:18 PM, the DON stated that allegations of abuse should be reported to the state survey agency within two hours, as soon as they could get an idea of what happened. Regarding R94's allegation, she stated that she did not remember who reported the allegation first. The Administrator stated that reports should be called into the state survey agency as soon as they had enough information to report and should be done within the two hours after they received the allegation. The Administrator stated she did not know why R94's allegation was not reported to the state survey agency within the required two hours. She further stated that their process was to notify law enforcement when a resident requested, or there was a chance that a law had been broken. The Administrator stated that she did not follow the appropriate process to notify law enforcement and should have.

Based on facility policy review, record review, facility document review, and interview, the facility failed to thoroughly investigate allegations of abuse, including misappropriation of property, for 2 (Resident 31 and Resident 94) of 3 residents reviewed for abuse. Findings included: A facility policy titled, Abuse Prohibition Standard of Practice, last reviewed 03/2026, indicated the Purpose was To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigating of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State laws. The policy further indicated, 5. Investigation included If an actual or alleged violation occurs, the resident will immediately be assessed and removed from any potential harm (as applicable); The administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of abuse, neglect, exploitation, injury of unknown source, misappropriation of resident property, or involuntary seclusion and report the results of the investigation to the enforcement agency in accordance with state law including the state survey agency within five working days of the incident; and Investigations will be prompt, comprehensive and responsive to the situation and contain founded conclusions. The investigation will include but not limited to, which included (iv) Interviews of all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations to obtain factual information, and (v) Follow up resolution and measures to prevent repeat incidents. 1. An admission Face Sheet indicated the facility admitted Resident (R)31 on 03/20/2026. According to the admission Face Sheet, the resident had a medical history that included diagnoses of aftercare following explanation (surgical removal of medical device) of knee joint prosthesis, generalized anxiety disorder, and major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/22/2026, revealed R31 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident 31's Careplan Report included a problem area initiated 03/24/2026, that indicated the resident had a progressive decline in intellectual functioning and had deficits in memory. Interventions initiated 03/24/2026 directed staff to provide cues and reminders and reassurance as needed. The Careplan Report also included a problem area initiated 03/24/2026, that indicated the resident was at risk for alteration in psychosocial difficulties related to a diagnosis of anxiety, and that the resident was agitated, short tempered and got angry easily. Interventions initiated 03/24/2026 directed staff to address the resident's concerns as they arose, administer psychotropic medications as per the physician's orders, and give the resident a cooling off period. An Initial Report document, dated 04/03/2026, indicated that the facility reported an allegation of missing money to the state survey agency. Per the report, R31 stated that $350.00 was missing from their wallet, along with their driver's license and insurance card. The report included the first name of the person who the resident alleged took the items. A Final Report/5-Day Follow-Up, dated 04/08/2026 at 12:03 PM, indicated that R31 was interviewed again and stated that they knew they had $350.00 in their purse and then they did not. The document indicated that the resident did not divulge any cash in their wallet on admission, and none was recorded on their initial inventory sheet. The Final Report/5-Day follow up indicated that no staff by the name that the resident alleged worked at the facility on the day of the report. A facility document titled, Monthly Schedule April 2026 revealed that State Registered Nurse Aide (SRNA) 2, who shared the same first name as the person R31 alleged took their money, insurance card, and driver's license, was scheduled to work on 04/02/2026 from 6:30 PM to 7:00 AM on 04/03/2026 (the day of the alleged incident). An investigation packet provided by the facility included 20 written statements from staff who worked on the day of the alleged incident. There was no written statement present from a staff member by the name the resident alleged took the items, including SRNA 2. During an interview on 04/16/2026 at 8:46 AM, the Social Service Director (SSD) stated that R31 reported that they were missing $350.00. She stated that the resident reported that a person with the same first name as SRNA 2 had been there and had taken their $350.00. The SSD stated that she obtained staff statements from everybody who worked that day. The SSD stated that SRNA 2 was not interviewed because she did not work that day. During an interview on 04/16/2026 at 9:26 AM, SRNA 2 stated that she worked at the facility from 7:00 PM to 7:00 AM shift. She stated that she was familiar with R31 and had provided care to the resident. SRNA 2 stated that she did not remember the resident having any money or identification and was not aware of the resident's money being missing until that morning when the nurse told her. She stated that she was not asked to write a statement and was not interviewed about the issue. During an interview on 04/16/2026 at 9:36 AM, the Director of Nursing (DON) stated that she did not interview SRNA 2 as she did not work in the facility and was not on duty the day it was reported, and the resident stated that the incident occurred on the day that it was reported. During an interview on 04/16/2026 at 12:55 PM, the DON stated that she was unaware of the investigative process and had never delt with that type of resident issue before. She stated that SRNA 2 had worked on 04/01/2026 and 04/02/2026 from 7:00 PM to 7:00 AM the following day. She stated that she did not know if there was a process for investigating the allegations, and she did not usually complete the forms. The DON stated that her expectation was to eliminate anyone who was not guilty and narrow it down to the person who was involved in the incident. During an interview on 04/16/2026 at 1:23 PM, the Administrator stated that she was the Abuse Coordinator, and usually lead the investigations, but in R 31's case, she did not. She stated that R31 reported that their money was there on 04/02/2026 at 10:00 AM, but she did not document that information in the report. The Administrator stated that the regular process when dealing with abuse and neglect, including misappropriation of resident property, was to prevent further harm, start an investigation, and make notifications. She stated that the process was to ask the staff if they had seen the resident with money. She stated that if the victim mentioned a certain staff member, that staff should have been interviewed. She stated that SRNA 2 was not interviewed or asked to write a statement related to the allegation. The administrator stated that her expectation was to solve the problem, and she expected staff to follow the facility's procedure for investigations. 2. An admission Face Sheet revealed the facility admitted Resident 94 on 06/19/2025. According to the admission Face Sheet, the resident had a medical history that included diagnoses of anemia, difficulty in walking, dislocation of internal right hip prosthesis, muscle weakness, and other symbolic dysfunctions. An admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/24/2025, revealed R94 had a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had mild cognitive impairment. Resident 94's Careplan Report, included a problem area initiated 06/24/2025, that indicated the resident had impaired cognition with a progressive decline in intellectual functioning, a decline in memory thought process, decision making, and judgement. Interventions initiated 06/24/2025 directed staff to address the resident in a quiet and slow manner, allow the resident time to respond, provide reminders and reassurance as needed, and use simple words and sentences. The Careplan Report included a problem area initiated 06/24/2025, that indicated the resident was at risk for an alteration in their psychosocial wellbeing related to psychosocial adjustment difficulties with regards to their diagnosis of anemia. Interventions initiated 06/24/2025 directed staff to establish a daily routine, gently redirect the resident, and provide cueing and prompting. An Initial Report form, dated 07/01/2025, indicated that the facility reported an allegation of physical abuse to the state survey agency on 07/01/2025. The report indicated that R 94's family member reported to the facility on [DATE] that the resident reported to them that someone smacked them across their face the previous day after lunch or dinner. Per the report, the resident did not know who did it. The report indicated that the Administrator was notified at 9:45 AM. The facility's Final Report/5 Day Follow-Up, dated 07/03/2025, indicated that R94 was interviewed and stated that someone slapped them when they were in a hall after their meal. The report indicated that the resident could not recall which meal it was and could not describe the individual. The report indicated that the resident stated that they reported the incident to an employee in the back office. The report indicated that the facility was unable to substantiate the allegation. A typed statement by the Social Services Director (SSD), dated 07/01/2025, revealed that a family member of R94 called the social services office and stated that R94 told them that the manager over the office smacked them. The facility's investigation packet included statements from 17 staff members, including 11 floor staff (eight state registered nurse aides [SRNAs], two licensed practical nurses [LPNs], and one registered nurse [RN]). The investigation did not include any statements from any of the office staff. The facility's Daily Staffing Guide documents, dated 06/30/2025 and 07/01/2025 (the timeframe of the alleged incident), revealed that a total of 34 different floor staff worked the two 12-hour shifts on 06/30/2025 and the day shift on 07/01/2025. The facility's investigation revealed that they did not include statements from the following staff who worked on 06/30/2025 and/or the day shift on 07/01/2025:- RN 4 or RN 19- SRNAs 5, 6, 7, 8, 10, 12, 13, 15, 16, 18, 28, 29, 30, or 31- LPNs 9, 14, 24, 25, or 26- Kentucky Medication Aide (KMA) 11 or KMA 27 The facility's investigation documents included skin assessments completed on residents who resided on Hall A (the hall where Resident 94 resided) with BIMS scores of 7 or below and completed interviews with the residents on the Hall A with BIMS scores of 8 or higher. There was no evidence of resident interviews or skin assessments being completed for residents who resided on Halls B, C, or D. During an interview on 04/16/2026 at 2:25 PM, RN 4 stated she had not had anyone report any allegations of abuse to her. She stated that she did remember R 94's name but did not remember anyone asking if she had witnessed anyone slap a resident or being asked to provide any statements about abuse involving Resident 94. During an interview on 04/16/2026 at 2:34 PM, SRNA 5 stated that she stated that she did not remember any times that any resident said they had been abused and stated that she had not witnessed any abuse. She stated that she did not remember R94 at all and that no one talked to her about any residents being slapped the previous summer. During an interview on 04/16/2026 at 2:36 PM, SRNA 6 stated that R 94's name sounded familiar, but she did not recall anyone asking her about the resident being abused. During an interview on 04/16/2026 at 2:45 PM, SRNA 7 stated she had not ever seen anyone abused. She stated that she did not remember R94 and stated that no one had ever asked her if she had seen a resident be slapped. During an interview on 04/16/2026 at 2:56 PM, SRNA 8 stated that no residents had ever reported any abuse to her. She stated that she thought she remembered R94 but did not work on the hallway the resident was on a lot. SRNA stated that she did not remember any allegations that someone slapped the resident or being asked to write a statement about anything with the resident. During an interview on 04/16/2026 at 2:59 PM, LPN 9 stated that he did not remember R94 and did not remember anyone asking about any residents being slapped or any reports of residents being slapped. During an interview on 04/16/2026 at 3:19 PM, SRNA 12 stated that she had not had any residents report any abuse. She stated that she did not remember any time that she was asked to write a statement about anyone being abused. During a telephone interview on 04/16/2026 at 7:59 PM, SRNA 15 stated she did not remember anyone talking about any incidents with R94 at all. During a telephone interview on 04/16/2026 at 8:08 PM, SNRA 16 stated she remembered R94 but never worked with the resident. She stated that she did not remember anyone talking to her about any abuse. During a telephone interview on 04/16/2026 at 8:40 PM, SRNA 18 stated she had not heard any reports of abuse and was not aware of any abuse. She stated that she did not think she remembered anyone asking her about a resident being abused. During a concurrent interview with the Director of Nursing (DON) and the Administrator on 04/17/2026 at 4:18 PM, the DON stated that whenever they had a report of abuse of any kind, first she listened to the allegation and went from there. She stated that her role was to do skin assessments on anyone with a BIMS score less than 8 and obtain statements and interview staff who were working at the time and staff who were not there when the allegation was made in some cases. Regarding R94's allegation, she did not remember who initially reported the allegation. She stated that normally, they handled all allegations the same way; they interviewed the staff who were there when it was reported. She stated that she thought the facility had interviewed the therapy staff and the office staff. The DON stated that she was not thinking that it was the back nurses' station but more of somewhere in the therapy hall. She stated that she expected residents to be safe and that the facility investigate all allegations of abuse fully. The DON stated that she did not review the surveillance cameras and did not know if the Administrator had done so during the investigation. The Administrator stated that when conducting the investigation, they had to narrow it down some so they knew what to report and so they could get a better idea of what they were looking at. The Administrator stated that after R94 made the allegation, she talked to the resident. The Administrator stated, We don't want the residents to be hurt or abused. The Administrator stated that they did not look at the cameras as they would only show hallways and not the back hallway where the offices and therapy areas were located.

Based on observation, interview, and facility policy review, it was determined the facility failed to provide housekeeping services to ensure a clean and sanitary environment for four (Resident (R) 6, R7, R64, and R37) of 21 sampled residents. Each of these resident rooms, as well as all four of four shower rooms used by residents, were noted to need cleaning, with a black, fuzzy-appearing substance (which had a strong odor), growing around sinks, in bathrooms, on tiles, and high moisture areas. The findings include: Review of the undated facility policy titled, Resident Rights, revealed the resident had a right to a safe, clean, comfortable and homelike environment. A policy for housekeeping titled Housekeeping Daily Duties, dated 12/2001, revealed a schedule of what housekeeping would do on each day of the week. The policy states All corners and along all baseboards must be dust mopped to prevent buildup. When water pushes dust into corners, problems occur. 1. Observation during a tour of the A, B, C, and D-Hall shower rooms on 04/23/2025 revealed that all four shower rooms had a black substance with a fuzzy-like texture, that was observed on the ceramic tile in the shower. The substance, which smelled very earthy and was potentially indicative of mold, was all over high moisture areas in the showers and bathrooms. The observations in these areas included: a. At 9:08AM, observation of the C-hall shower room revealed the black substance on the ceramic tile in the shower. In addition, a cracked piece of ceiling tile was observed to be laying over the tub with remnants/particles of tile all over the shelving, in the tub, and on the floor of the room. b. At 9:28AM, observation of the D-hall shower room revealed the black substance on the ceramic tile in the shower, as well as on the bottom of the lid of the shower chair. c. At 9:42AM, observation of the A-hall shower room revealed the black substance was on the sink of the faucet and on the ceramic tile in the shower. d. At 9:58AM, observation of the B-hall shower room revealed a bag of garbage laying in the floor of the shower. The black substance was observed in the ceramic tile in the shower. 2. On 04/22/2025 at 10:14AM, observation of R6's room revealed the black substance was growing on tiles under the sink and in the bathroom, and a strong odor was noted. Continued observation of R6's room revealed three tiles were cracked in R6's bathroom close to the base board. The overbed table was observed to have the rubber piece around the edge missing, which exposed wood that had a sharp edge on it. 3. On 04/22/2025 at 10:31AM, observation of R7's room revealed the black substance on the baseboard of the bathroom. The bathroom had a brown substance on the commode lid that appeared to be feces, which had a foul odor emitting from it. 4. On 04/22/2025 at 10:54AM, observation of R64's room revealed a black substance on the baseboards. Two tiles in the resident's bathroom were cracked. 5. On 04/22/2025 at 11:08AM, observation of R37's room revealed a black substance on the baseboards of the resident's room. Interview with the resident revealed that staff come in the room every day and clean, but the black substance remains. Interview with the Maintenance Assistant on 04/23/2025 at 11:42AM, revealed that the black substance seen throughout the facility was a housekeeping issue. In an interview with the Director of Nursing (DON) on 04/23/2025 at 12:13PM, she stated that she was unaware of any black substance on the walls or baseboards of any of the resident rooms or shower rooms. The DON further stated that if there was something like that growing on the walls and baseboards, housekeeping should notify her, and they would have someone come in and look at it and find out what it is and how to treat it. During an interview with the Housekeeping Manager on 04/23/2025 at 1:12PM, she stated, Every resident room gets a deep clean once a week and on the days we don't deep clean, we spot clean. She confirmed the multiple areas where the black, foul-smelling substance was observed, saying, I was not aware of this black substance, but I see what you are talking about. We will have to use some bleach and try to clean them up. Interview with Administrator on 04/23/2025 at 1:15PM revealed that housekeeping services were contracted out and they were supposed to be making sure that all areas were clean and sanitary. Further interview with the Administrator on 04/23/2025 at 1:44PM revealed that she relied on maintenance and housekeeping to keep the floors and shower rooms clean at all times. She stated she did not have any knowledge of a black substance growing on any surface of the facility and added that having a black substance growing in high moisture environments could be mold, which could create a bad outcome for the residents of the facility.

Based on observation, interview, record review, and policy review, the facility failed to ensure that two of four corridors were equipped with firmly secured handrails on each side of the hallway. Failure to have firmly secured handrails could affect residents' ability to safely ambulate down the hallways. The findings include: Review of an undated facility policy titled Resident Rights, revealed residents have a right to a safe environment. No specific policies related to maintenance or inspection of handrails were provided during the survey. Observation during a tour of the A and B Halls on 04/22/2025, initiated at 11:46 AM, revealed the following: 1. The handrail outside of resident room A7 was loose and shifted when light pressure was applied. 2. A corner joint was missing from the handrail outside of resident room A8 with a blunt end exposed. 3. The handrail outside of resident room A10 was missing screws that connected it to the support brackets, allowing the handrail to be easily moved when pressure was applied. 4. The handrail outside of resident room B2 did not have screws securing it to support brackets, allowing the handrail to be easily moved when light pressure was applied. 5. The handrail outside of resident room B3 was missing screws and easily moved when pressure was applied. 6. The handrail outside of resident room B4 had loose screws and was not securely connected to the support brackets. 7. The handrail outside of resident room B5 was loose and not securely fastened to the support brackets. Review of the logs from the facility's TELS system (used to report and track maintenance issues) revealed no evidence of reports or work orders related to handrails. In an interview on 04/24/2025 at 9:15 AM, the Assistant Director of Maintenance confirmed that the handrails noted above were loose. He stated that he was responsible for checking the handrails and did checks every time he walked up and down the halls. He further stated that he did not have any current work orders for the handrails and that he had just done a facility walkthrough with the Administrator, and they did not have any concerns with the handrails. The Assistant Director of Maintenance stated that having handrails that were loose and not securely connected to the support brackets could create a fall risk for residents. Further interview with the Assistant Director of Maintenance revealed that he was currently in charge of facility maintenance, as the previous Maintenance Director walked out after the survey was initiated. In an interview on 04/24/2025 at 9:55 AM, Restorative Nurse 1 stated that she was aware of loose handrails on the A and B halls. She added that she noticed the loose rails within the last three months. Restorative Nurse 1 further stated that residents could fall and get hurt if they tried to use a handrail because it was not securely mounted to the wall, and she should have reported the loose railing, but did not. In an interview on 04/24/2025 at 10:20AM, the Housekeeping Supervisor stated that the housekeepers clean the handrails in the facility; however, they but do not inspect them to ensure they are safely mounted to the wall, as that would be up to the maintenance department. In an interview on 04/24/2025 at 1:36 PM, the Administrator stated that it was her expectation for all staff to report any maintenance related issues to her. She stated that she was not aware of any issues with the handrail but added that the facility did not have any lists or checkoff sheets to monitor their condition. The Administrator noted that with a building as old as theirs, there was always something going on, and they had just missed the rails being loose/in poor repair. The Administrator confirmed that she and the Assistant Director of Maintenance had recently done a walkthrough of the facility together; however, she continued, they had not looked at the rails during this walkthrough. The Administrator further stated that residents could be cut or have their fingers get stuck in the handrail with the missing corner piece.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure that one resident (Resident (R) 6), who was unable to carry out activities of daily living (ADLs), out of a total sample of 21 sampled residents, received the necessary services to maintain good grooming and personal hygiene. R6 failed to receive nail care as needed, and was noted with long, dirty nails on multiple occasions. The findings include: Review of the facility policy Activities of Daily Living Tasks, dated 01/012001, revealed, Any resident that has a deficit that keeps them from doing any kind of ADL's will be helped with whatever need they have. Per the policy, Nails should be observed daily and cut when appropriate. Review of the electronic medical record revealed R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and cerebrovascular accident (CVA) with left-sided weakness. Review of R6's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/2025, revealed a Brief Interview for Mental Status (BIMS) score of 6/15, indicating R6 was severely cognitively impaired. Review of R6's comprehensive care plan, last revised 02/03/2025, revealed the resident will have fingernails and toenails trimmed by staff to maintain adequate personal grooming health. Observation on 04/22/2025 at 9:14AM revealed R6 was sitting in her wheelchair. The resident's nails were observed to be approximately ½ inch long with an unidentified black substance (which appeared to be grime/dirt) underneath eight out of 10 nails. On 04/22/2025 at 12:18PM, R6 was observed in the dining room, eating her lunch. R6 was eating spaghetti and garlic bread, and she was seen licking her fingernails. The resident still had a black substance present underneath eight of the 10 nails. Interview with R6's family member (FM6), on 04/22/2025 at 4:18 PM, revealed she was not happy with how her mother's nails currently looked, adding that normally the facility was good about keeping her nails trimmed and clean. In an interview with State Registered Nurse Aid (SRNA) 1 on 04/23/2025 at 9:13AM, she stated that residents' nails were examined daily and cleaned if needed. SRNA1 stated that nail care was done at the same time that residents received showers. SRNA1 added that long nails could lead to dirt or grime getting under the nail and the resident could potentially put that in their mouth, which could cause them to become sick. During this interview, SRNA1 stated she gave R6 nail care on 04/22/2025 (the prior day), before she left her shift. However, observation on 04/23/2025 at 8:42AM, revealed R6, who was in her wheelchair on the C hallway, continued to have a black unidentified substance underneath eight out of 10 nails. The resident's nails were still ½ inch long and in need of care. Review of shower sheets (where staff documented when the resident was bathed/showered) revealed that the sheets also included a place for staff to document nail care. Review of shower sheets revealed that the last nail care documented for R6 (prior to the initial observation on 04/22/2025) was 03/28/2025. In an interview with Registered Nurse (RN)1 on 04/23/2025 at 9:41AM, she stated that it was up to the SRNA's and nurses to check residents' nails daily and give them care if needed. RN1 stated that the SRNA's look at the residents when they are in the shower, and then tell the nurse if they provided nail care or they need the nurse to provide nail care to the resident. RN1 noted that it was up to the nurse to check to make sure this is getting done though. She stated it was important to cut the residents' nails because long nails can hold dirt and bacteria and could be harmful to residents. In an interview with the Director of Nursing (DON) on 04/23/2025 at 12:20PM, she stated I expect my nurses and my aides to check on residents daily and to provide them the appropriate care needed for their ADL's. She further stated, I guess I need to be more proactive and get out on the floor more. Interview with the Administrator on 04/23/2025 at 1:44 PM revealed that she expects all residents' nails to be properly trimmed and clean at all times. The Administrator stated, I expect my nurses and aides to keep all of our residents' nails clean and trimmed. We have some residents that like to put their fingers in their mouth, and this is especially important for them to not get sick. Long dirty nails are sources of bacteria. We want our residents to be as clean as possible at all times.

Based on interview and record review it was determined the facility failed to provide one (1) of twenty-two (22) sampled residents (Resident #283) and their representative with a summary of the baseline care plan that included resident goals, a summary of the resident's medications, dietary instructions, and services/treatments to be administered by the facility. Prior to Resident #238's admission, the facility's Admission Coordinator obtained a list of medications from the Home Health Agency (HHA) who had provided services for the resident. However, the medication list was not accurate and did not reflect the resident's correct home medication regimen. In addition, the facility failed to provide the resident/resident representative with a summary of the base line care plan, which should have included reconciling the resident's medications and giving the resident/resident representative a copy of the medication list. Therefore, Resident #1 received the wrong medication regimen from 06/17/2021 through 06/27/2021, while at the facility. Further review revealed the resident did not receive [MEDICATION(S)] 20 milligram (mg) twice a day that the resident had been taking for approximately two (2) years. On 06/27/2021, ten (10) days after admission to the facility, the facility transferred Resident #283 to the hospital. The hospital admitted the resident to the Intensive Care Unit (ICU) and diagnosed him/her with severe [CONDITION(S)], secondary to an Adrenal Crisis (potentially fatal condition associated insufficient levels of [MEDICATION(S)]) due to the resident having abruptly stopped taking [MEDICATION(S)]. The facility's failure to provide residents and the resident's representative with a summary of the baseline care plan has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/16/2021 and was determined to exist on 06/17/2021 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 07/16/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 07/21/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/21/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Baseline Care Plan Standard of Practice revised February 2017, revealed the facility must develop/implement a baseline care plan for each resident, within forty-eight (48) hours of admission which included the instruction needed to provide effective and person-centered care, that met professional standards, for the resident. The policy also stated the intention of the baseline care plan was to promote continuity of care and communication among nursing home staff and increase resident safety and safeguard against adverse events, which were most likely to occur right after admission. The policy also stated the facility must provide the resident and the representative, as applicable, with a written summary of the baseline care plan, which included a summary of the resident's medications. Continued review of the policy revealed the medical record would show evidence that the facility provided the baseline care plan to the resident and/or the resident's representative as soon as the baseline care plan process was completed. Review of Resident #283's medical record revealed the facility admitted the resident on 06/17/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #283's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a brief interview for mental status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. Review of Resident #283's baseline care plan revealed the resident was admitted to the facility on [DATE], however, the resident's baseline care plan was not completed until 06/25/2021 (eight days after admission). The care plan listed the resident's medications, dietary needs, and stated Resident #238 was alert, cognitively intact and verbal. Further review of the baseline care plan revealed under the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, there was no evidence found to indicate the resident or the resident's representative was involved in or provided with a summary of the baseline care plan, which was required to include the initial goals for the resident, treatments to be provided to the resident, and a summary of the resident's medications and dietary instructions. Interview with Resident #238's Power of Attorney (POA), on 07/13/2021 at 9:10 PM, revealed Resident #238 resided at home with her and she was the resident's primary caregiver before the resident was admitted to the facility. The POA stated the facility's Admission Coordinator came to their home on 06/16/2021, to facilitate the resident's transfer to the facility. The POA stated at that time she provided the Admission Coordinator a hand written list of Resident #238's medications. However, the POA stated she later learned that the Admission Coordinator had not utilized the medication list she provided, but obtained an erroneous medication list from the Home Health agency that provided services to Resident #283. Interview with the Admissions Coordinator on 07/13/2021 at 7:30 PM, confirmed she obtained a medication list from the Home Health agency and took that to the physician who would be caring for the resident in the facility to sign and act as admitting MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Licensed Practical Nurse (LPN) #3, on 07/13/2021 at 4:00 PM, revealed she admitted Resident #283 to the facility on [DATE]. LPN #3 stated she had not been trained or instructed that the baseline care plan was required be completed within 48 hours of a resident's admission to the facility. Continued interview with LPN #3, revealed as an admitting nurse, her responsibility was to open the care plan and document only basic information such as the resident's name, date of admission, diagnoses, etc. LPN #3 stated the baseline care plan was in the facility's computer system and she did not know whose responsibility it was to complete the baseline care plan or when it had to be completed. Interview with MDS Nurse #2, on 07/13/2021 at 4:45 PM, revealed she completed Resident #283's baseline care plan on 06/25/2021 (eight days after admission). She stated she had done MDS assessments for six (6) months at the facility, but did not receive training on completing the baseline care plan and the facility had never told her she had to have it completed within 48 hours of a resident's admission. The MDS nurse also stated she had not contacted the resident/resident representative regarding discussion of the care plan or provided the resident/resident representative a copy of the care plan. In addition, MDS Nurse #2 stated that she had not discussed the resident's medications with the resident/resident representative as required, when completing the baseline care plan. The nurse stated she had no responsibility regarding obtaining or reconciling resident medications. Further interview with the MDS nurse revealed she denied having knowledge of the questions on Resident #238's care plan that asked the facility if it had reconciled the resident's medications with the resident/resident's representative or provided the resident/resident's representative with a copy of the resident's medication list the facility would be administering to the resident. Interview with the MDS Coordinator, on 07/13/2021 at 5:00 PM, revealed the facility's process for a baseline care plan was for the admitting nurse to open up the care plan in the system to initiate the process and the MDS nurses tried to complete the baseline care plan within seven (7) days after admission. The MDS coordinator stated she was not aware of the 48-hour requirement or that staff was required to provide the resident/resident representative a summary of the baseline care plan. The MDS Coordinator stated she had not met with Resident #283 or his/her resident representative or any other resident or their family members to discuss care to be provided at the facility because she had never been told it was a requirement to do so. The MDS Coordinator stated she had not discussed the resident's medications or care the facility would be providing to Resident #283, or the resident's representative as outlined in the baseline care plan requirements. The MDS Coordinator stated she had never noticed the questions on the baseline care plan that prompted the facility to ensure they reconciled the resident's medications with the resident/resident responsible and provided them with a medication list. Comparison of the medications Resident #238 was receiving at home prior to admission to the facility and the medications administered to the resident by the facility revealed Resident #283 received more [MEDICATION(S)] (blood pressure medication) and [MEDICATION(S)] (cholesterol medication) than the resident was receiving at home. Further, the resident received less [MEDICATION(S)] (blood pressure medication) and [MEDICATION(S)] (diabetic medication) than the resident received at home. Further, the resident received [MEDICATION(S)] (heart medication) and [MEDICATION(S)] (diabetic medication) that the resident did not receive at home. The facility also failed to administer Resident #238 [MEDICATION(S)] (blood pressure medication), [MEDICATION(S)] (diabetic medication), [MEDICATION(S)], and [MEDICATION(S)], all of which the resident received at home. On 06/27/2021 at 3:25 PM, Nursing Notes for Resident #238, revealed the resident was sent to the hospital after the staff could not get the resident to speak to them. Review of the EMS record, dated 06/27/2021, revealed the resident was diaphoretic (sweaty), weak, non-verbal, had a blood glucose level of 26 mg/dl (normal range 70-130). Review of Resident #283's hospital record dated 06/27/2021 revealed the ED Physician diagnosed the resident to be in an Adrenal Crisis due to the abrupt discontinuation of the resident's [MEDICATION(S)] medication. Resident #238 was admitted to the Intensive Care Unit. Continued interview with Resident #238's POA, on 07/13/2021 at 9:10 PM, revealed she had not realized the facility administered the resident the wrong medication regimen until the facility sent the resident to the hospital on 06/27/2021. However, the POA stated she would have immediately recognized the medication discrepancy had the facility discussed with her the resident's regimen. The POA stated the facility never provided her or the resident a summary of the resident's baseline care plan after the facility admitted the resident. Interview with the Director of Nursing (DON), on 07/16/2021 at 3:00 PM, revealed she was not aware the facility was required to complete a baseline care plan within 48 hours of a resident's admission and provide a summary of care to be provided to the resident/resident's responsible party. The DON stated staff followed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the DON stated if the facility had given the POA a copy of the resident's baseline care plan as required, it could have prevented abruptly stopping the resident's [MEDICATION(S)]. Interview with the Administrator on 07/16/2021 at 4:55 PM, revealed she was not aware the facility was required to complete a baseline care plan within 48 hours of a resident's admission, or provided a summary of care the facility planned to provide to the resident/resident representative, but stated she could see why it was important. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/21/21: 1. The facility discharged Resident #283 to the hospital on 06/27/2021. The resident has not returned to the facility 2. The Social Services Director (SSD) and Minimum Data Set (MDS) Nurse completed an audit on 07/15/2021 to review the past 30 days of new admissions to ensure the baseline care plan included an accurate summary of the resident's medications. The facility gave the resident/representative a summary of the baseline care plan. 3. The Vice President (VP) of Operations and the Regional Quality Manager (RQM) educated the Administrator and Director of Nursing on 07/17/2021 regarding the regulatory intent of F-655. Specific training included instruction that the facility must develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to care for a resident properly, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The training also included the fact that the facility must provide the resident/representative with a summary of the baseline care plan that includes, but not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and any services or treatments the facility would administer. 4. On 07/17/2021, the Director of Nursing (DON) provided education to the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses on base line care plans including the above information. A post-test with a score of one-hundred percent was required. 5. On 07/19/2021, the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses educated all other licensed nurses, including agency nurses, on the facility's baseline care plans procedures above. A post-test with a score of one-hundred percent was required. 6. Any new licensed nurses, including agency, hired would receive the baseline care plan training prior to providing care and assuming duties. 7. Beginning 07/17/2021, the DON and Nurse Unit Manager reviewed all new admissions to validate that the baseline care plan included an accurate summary of the resident's reconciled medications, and ensure the facility provided the resident/representative with a summary. The DON and Nurse Unit Manager corrected any issues at time of discovery. This would continue for a minimum of 8 weeks. A licensed nurse and/or MDS nurse would review with the resident/responsible party the baseline care plan within 48 hours of admission. A post-test with a score of 100% was required. The baseline care plan remains a working document until the comprehensive care plan was developed. 8. The facility discharged Resident #75 home on 07/13/2021. 9. On 7/17/2021, the MDS staff completed an audit to verify residents identified at risk for elopement had wander guard bracelets in place and the care plan was accurate with updated information reflecting the resident's status. 10. On 07/17/2021, the VP of Operations and Regional Quality Manager provided education to the Administrator and Director of Nursing regarding the regulatory intent of F-657. Specific education included staff must complete a comprehensive care plan within seven days after completion of the comprehensive assessment. The training also included that the interdisciplinary team (IDT) would prepare the care plan, review and revise after each assessment, including both the comprehensive and quarterly assessments, and as needed. Examples include but were not limited to the need to revise a care plan when a resident presented with exit seeking behavior, or the exit seeking behavior increases. 11. The DON then provided the above education regarding care plans and F-657 to the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director and MDS staff on 07/17/2021. A post-test with a score of one-hundred percent was required. 12. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director or the MDS staff provided the training to the facility's licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 13. Any new licensed nurse, including agency, hired would receive the comprehensive care plan training prior to providing care and assuming duties. 14. Beginning 07/17/2021, the Director of Nursing, Unit Manager, or assigned on-call weekend nurse that served as clinical nurse manager would audit and visually inspect all resident's determined to at risk for elopement to verify the resident has a wander guard bracelet in place and it was functioning. In addition, they would verify the resident's care plan was updated and accurate to reflect the resident's status. Staff would correct any identified issues at the time of discovery. This would continue for a minimum of eight weeks. 15. Beginning 7/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of exit seeking behavior and validate the staff have assessed the resident and that staff had updated the care plan accordingly. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager would do this on weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 16. Resident #283 discharged to the hospital on 6/27/2021, and has not returned to the facility at this time. 17. On 7/16/2021, the Director of Nursing audited each resident's medical record to ensure staff documented resident vital signs, including blood sugar and blood pressure in the record as ordered or per policy. They identified no additional concerns for additional resident assessment. 18. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-684. Including the fundamental principle that quality of Care applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Included in Quality of Care, but were not limited to monitoring blood sugar as ordered or as indicated with signs/symptoms of hypo/[CONDITION(S)] which may include, but not limited to excess sweating, excess hunger, shakiness, increased thirst, weakness, dry mouth; obtaining vital signs as required by facility protocol and/or physician orders. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. 19. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-684. A post-test with a score of one-hundred percent was required. 20. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-684 to facility-licensed nurses,including agency. A post-test with a score of one-hundred percent was required. 21. Any new licensed nurse hire, including agency, would receive this education related to F-684 prior to assuming duties. 22. Beginning 7/17/2021, the Director of Nursing, MDS staff , RN Wound Nurse and/or the assigned Unit Manager reviewed each resident's medical record to ensure that vital signs,including blood sugar and blood pressure, were documented in the record as ordered or per policy. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. Staff would correct and identified issues at the time of discovery. This process would continue daily while the facility remains in immediate jeopardy. 23. Beginning 07/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of a change in resident condition that would warrant obtaining blood sugar or additional vital signs, and validate this/these were obtained. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager completed on the weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 24. On 07/16/2021, the Administrator and Maintenance Director completed an audit to assess all facility exit doors for proper functioning/alarming. They identified no additional doors as having function issues. 25. On 7/16/2021, the Maintenance Director and Assistant adjusted C-Wing exit door magnet lock to ensure alarming during fifteen second egress, and re-set the key code to the physical therapy exit door to work without issue with the wander guard sensor. 26. The contracted service vendor completed a general inspection/service, on 7/20/2021, of facility doors. They identified no concerns. 27. On 07/17/2021, the VP of Operations and RQM educated the Administrator and DON regarding the regulatory intent of F-689. Specifically the facility must ensure the resident environment remained as free of accident hazards as possible; each resident received adequate supervision and assistance devices to prevent accidents. This included identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Example included, but not limited to identifying the supervision needs of a resident identified as an elopement risk; maintaining and/or modify interventions if supervision needs was still required; revising the care plan with interventions to monitor the resident; assessment of exit doors for proper functioning/alarming. 28. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-689. A post-test with a score of one-hundred percent was required. 29. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-689 to facility-licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 30. Any new licensed nurse hire, including agency, would receive this education related to F-689 prior to assuming duties. 31. On 07/17/2021, the Administrator educated the Maintenance staff to check door alarms twice daily to ensure doors are alarming when opened. This included checking the emergency egress and validating the alarm sounds upon door release, utilizing a wander guard sensor for applicable doors to ensure the magnetic lock responds to lock the door, and inputting the door code to ensure the alarm sounds when the wander guard sensor passes the doorway. Staff would complete this daily while the facility remains in immediate jeopardy. 32. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-760 specifically the facility must ensure residents were free of any significant medication errors. The errors may include issues with the prescriber's order; manufacturer's specifications regarding preparation and administration; accepted professional standards and principles that apply to professionals providing services. Examples to prevent medication errors includes, but not limited to validating medication lists received for residents from home health agencies etc. with family/responsible party to ensure accuracy; reconciling medication lists received for residents and reviewing with physician for administration orders. 33. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-760. A post-test with a score of one-hundred percent was required. 34. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F760 to facility-licensed nurses, including agency. A post-test with a score of one hundred percent was required. 35. Any new licensed nurse hire (including agency) would receive this education related to F-760 prior to assuming duties. 36. The facility held an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 07/16/2021 to review the Immediate Jeopardy citations and discuss the development of the action items to be completed. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Admissions, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director per phone. The team adopted the plan. 37. The facility held a second ad hoc QAPI meeting on held 07/20/2021 to review the status of education and audits. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director via phone. **The State Survey Agency validated the removal of Immediate Jeopardy on 07/21/2021 as follows: 1. Review of a discharge form dated 06/27/2021 revealed the facility discharged Resident #283 from the facility. Interview conducted on 07/30/2021 at 12:27 PM with the DON, revealed the facility discharged Resident #283 from the facility on 06/27/2021. 2. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. Interviews conducted on 07/29/2021 at 2:15 PM with MDS #1, and at 2:35 PM with the SW, revealed they had completed the audits on 07/15/2021, for all new admissions in the past thirty days. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. 3. Review of an in-service roster dated 07/17/2021, revealed the Vice President of Operations (VPO) and RQM provided an in-service for the DON and Administrator related to the development and implementation of a baseline care plan for each resident. Interviews conducted on 07/30/2021, with the DON at 12:30 PM, the VPO at 12:35 PM, and the RQM at 12:40 PM, revealed the DON and the Administrator had attended an in-service provided by the VPO and the RQM. The in-services related to the development and implementation of a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. 4. Review of an in-service roster dated 07/17/2021, revealed the DON had provided an in-service for the Wound Care Nurse (WCN), UM #1, UM #2, SDC, MDS #1, and MDS #2, related to development and implementation of a baseline care plan for each resident. Interviews were conducted on 07/29/2021 at 1:40 PM, with UM #1, 07/29/2021 at 1:55 PM with the WCN, on 7/29/2021 at 2:01 PM with the SDC, 07/29/2021 at 2:15 PM with MDS #1, on 07/30/2021 at 11:04 AM with MDS #2, 07/30/2021 at 12:27 PM. The staff interviewed stated they had attended the in-service provided by the DON related to related to development and implementation of a baseline care plan for each resident. 5. Review of an in-service roster, dated 07/19/2021, revealed all licensed nursing staff had been provided an in-service related to development and implementation of a baseline care plan for each resident. Interviews were conducted, on 07/29/2021 at 1:33 PM with SRNA #8, at 1:34 PM with SRNA #1, at 1:39 PM with SRNA #2, at 1:32 PM with SRNA #12, at 2:15 PM with SRNA #5, at 2:20 PM with SRNA #13, at 2:25 PM with SRNA #6, at 2:10 PM with KMA #1, at 1:31 with LPN #6, and at 1:34 PM with LPN #3. The staff stated they had attended the in-service provided by the SDC related to development and implementation of a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the residents that meet professional standards of care. 6. Review of a New Employee Orientation packet, revealed the in-service related to development and implementation of a baseline care plan for each resident included instructions needed to provide effective and person-centered care of the residents that met professional standards of care. The baseline care plan must be developed within forty-eight hours of a resident's admission; include the minimum healthcare information necessary to care for a resident, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview conducted on 07/29/2021 at 2:01 PM, with the SDC, revealed she had included the training in the new employee training. 7. Review of audits conducted by UM #1, UM #2, and by the DON, revealed since 07/17/2021, all new admissions had been reviewed by the DON and/or UM #1 or UM #2. The audits validated the baseline care plan included an accurate summary of the resident's reconciled medications and the resident representative had been provided an accurate summary of the resident's baseline care plan. The audits also revealed Resident #37 and Resident #133's medical records both who were re-admissions, had baseline care plans developed within forty eight hours of admission/readmission. The medical records revealed the facility gave the resident/responsible party a copy of a summary that included the initial goals of the resident, a summary of the resident's medications and dietary instructions. It also had services or treatments the facility would administer to the resident. Interviews conducted on 07/29/2021 at 1:40 PM, with UM #1 and on 07/30/2021 at 12:27 PM with the DON, revealed they had completed the audits beginning 07/17/2021, for all new admissions. The audits validated the baseline care plan included an accurate summary of the resident's reconciled medications and that the resident representative had been provided an accurate summary of the resident's baseline care plan. 8. Review of a discharge form dated 07/13/2021, revealed the facility discharged Resident #75 from the facility. Interviews conducted on 07/29/2021 at 1:33 PM with SRNA #8, 07/29/2021 at 1:34 PM with SRNA #1, and on 07/29/2021 at 1:39 PM with SRNA #2, revealed the facility had discharged Resident [TRUNCATED]

Based on interview, record review, and review of facility policy, it was determined the facility failed to revise the care plan for one (1) of twenty-two (22) sampled residents (Resident #75). The facility failed to review/revise Resident #75's care plan when the resident's exit-seeking behavior increased. On 07/02/2021, Resident #75 exited the facility via the D wing door. Staff responded to the alarm, assisted the resident inside, and implemented an intervention to monitor the resident every 15 minutes. On 07/05/2021, the facility discontinued the 15-minute checks, despite the resident's continued exit seeking behaviors, and failed to revise the care plan with interventions to monitor/supervise the resident. Interviews with staff revealed the next day, 07/06/2021, Resident #75's wandering/exit seeking behavior worsened. At approximately 9:45 PM, Resident #75 left the facility without staff knowledge. At approximately 9:50 PM, someone driving down the street observed the resident on the roadway approximately 90 yards from the facility entrance. After the individual and others who responded assisted the resident out of the roadway, Resident #75's nurse came outside looking for the resident, and assisted the resident back inside the facility with no injury. The facility's failure to ensure resident care plans were revised to ensure residents were supervised has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/16/2021 and was determined to exist on 06/17/2021 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 07/16/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 07/21/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/21/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760), while the facility monitors the effectiveness of systemic changes and quality assurance activities. Findings include: Review of facility policy titled, Incidents and Accidents, undated, revealed an incident was defined as any unusual occurrence that was an unexpected, unintentional event, which can cause a resident bodily harm. Further review revealed all incidents and accidents were reviewed by the Interdisciplinary Team (IDT) and care plans and interventions were individualized for each resident. The policy stated a seventy-two (72) hour follow-up was also completed by the IDT to ensure appropriate interventions and actions had been taken. Review of facility policy titled, Behavior Assessment and Monitoring, dated April 2007, revealed problematic behavior would be identified and managed appropriately. Nursing staff were required to identify and document onset, duration, and frequency of problematic behaviors. Review of facility policy titled, Wandering, Unsafe Resident, undated, revealed the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who were at risk for elopement. Further review revealed the resident's care plan would indicate interventions to try to maintain safety. Staff were required to document circumstances related to unsafe actions, including wandering by a resident, and institute a detailed monitoring plan, as indicated, for residents assessed to have a high risk for elopement. Review of Resident #75's medical record revealed the facility admitted the resident on 06/23/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. Review of an Elopement/Wanderer risk assessment dated [DATE], revealed Resident #75 was assessed by the facility as high risk for elopement with a score of twenty (20). Continued review of Resident #75's MDS, dated [DATE], revealed the facility coded a one (1) for wandering, indicating the behavior occurred one (1) to three (3) days during the assessment observation period. Review of Resident #75's Comprehensive Care Plan, dated 06/24/2021, revealed the facility identified the resident was at risk for wandering/wandering. The facility implemented interventions following admission to include a Wanderguard bracelet to the right ankle (check placement and function every shift), offer redirection and reassurance per required need, redirect to a safe area, and place a photograph of the resident with a description on a protected list of at-risk residents. The facility revised the resident's Comprehensive Care Plan on 06/25/2021 with interventions to take the resident to a visual area in the facility and play religious music at his/her request. Review of a nursing note, dated 07/02/2021 at 7:04 PM, revealed staff heard an alarm sounding at the D hall exit door and observed Resident #75 go out the exit door. Staff went to the door assisted him/her back inside of the facility. The resident was placed on fifteen (15) minute monitoring checks and the Administrator, Director of Nursing, physician, and responsible party were notified. Interview with Registered Nurse (RN) #3, on 07/16/2021 at 12:45 PM, revealed she provided care to Resident #75 on 07/02/2021. The RN stated Resident #75 displayed exit-seeking behaviors, wandered, and talked about wanting to go home; however, the RN stated the resident had not attempted to exit the facility prior to the incident. The RN stated on 07/02/2021, she was working on D wing hall and was getting ready to administer medication. Per the RN, a door alarm sounded for the D wing exit door and staff quickly retrieved Resident #75 as he/she was going outside the door. The RN stated the resident was placed on fifteen (15) minute checks to monitor the resident's where a bouts after the incident. Review of fifteen (15) minute check monitoring record, dated 07/02/2021-07/05/2021, revealed Resident #75's fifteen (15) minute checks were discontinued on 07/05/2021 at 11:30 AM. There was no documentation regarding the rationale for the discontinuation of the monitoring. Interviews with State Registered Nurse Aide (SRNA) #4 and SRNA #12, on 07/15/2021 at 4:00 PM, revealed the resident continued to frequently wander throughout the facility. The Resident often walked to exit doors and stated he/she wanted to go home, and staff would attempt to redirect the resident. The SRNAs stated they did not document Resident #75's behaviors because the resident had behaviors (wandering/verbalizing wanting to go home) on admission. Per the SRNA's, they thought only new behaviors were to be documented on the behavior record. Interview with Licensed Practical Nurse (LPN) #1, on 07/14/2021 at 3:05 PM, revealed he worked the day shift on 07/06/2021, when Resident #75's fifteen (15) minute monitoring was discontinued. He stated Resident #75 exhibited exit-seeking behavior and wandered the facility all day. The LPN stated the resident wandered to the D wing exit door several times and staff had to redirect the resident away from the door. Further review of Resident #75's Comprehensive Care plan, initiated on 06/24/2021, revealed no revisions or additional interventions were implemented for the resident on 07/05/2021 following the discontinuation of the fifteen (15) minute monitoring, even though staff interviews revealed the resident's exit seeking/wandering behavioral symptoms were unchanged and/or had increased. In addition, even though interviews with staff revealed Resident #75 continued to exhibit wandering/exit seeking behavior, review of the residents Behavior Monitoring record, dated from admission on 06/23/2021 until 07/13/2021, revealed staff did not document any wandering/exit seeking behaviors for Resident #75. Interview with Social Services Director, on 07/16/2021 at 1:22 PM, revealed she was aware Resident #75 displayed wandering behaviors. Per the Social Service Director, the resident's representative informed her on admission, the resident became more agitated in the evenings. She stated she completed the behavior portion of the care plan and had care planned Resident #75's wandering behaviors. Per the Social Service Director, staff were required to document behaviors daily. She stated she printed a log each morning to review and monitor resident behaviors and utilized the log to determine changes in resident behavior in order to review and revise resident care plans. The Social Services Director stated she was a member of the IDT where decisions were made to revise care plans, but did not recall discussing discontinuation of Resident #75's fifteen (15) minute monitoring. Interview with Unit Coordinator #1, on 07/16/2021 at 2:24 PM, revealed if a behavior monitoring record was on the kiosk (computer record) for a resident, then staff should be documenting behaviors and reporting any exit seeking behaviors to the DON or Administrator. The Unit Coordinator stated she was unaware staff were not documenting Resident #75's behaviors. The Unit Coordinator stated the DON determined when resident fifteen (15) minute checks were discontinued. Interview with the Director of Nursing, on 07/16/2021 and 3:34 PM, revealed the facility was aware Resident #75 displayed wandering behaviors and was at risk for elopement. She stated once a resident was placed on fifteen (15) minute checks, the IDT determined when the fifteen (15) minute checks could be discontinued, and was based upon behaviors and discussion with staff. She further stated Resident #75 was placed on fifteen (15) minute checks for exit seeking and attempted elopement on 07/02/2021, and the checks continued for seventy-two (72) hours. The DON stated she was not in the facility on 07/05/2021, for the IDT meeting when the fifteen (15) minute checks were discontinued for Resident #75 and was unable to find notes for the meeting. The DON stated the care plan should have been reviewed and revised prior to making the decision to discontinue increased monitoring for Resident #75. The DON stated the potential outcome of a resident who was at high risk for elopement with no increased supervision was elopement and injury to the resident. Interview with Administrator, on 07/16/2021 at 4:15 PM, revealed if behavior-monitoring records were not completed for residents, the facility could not effectively monitor changes in resident behavior. The Administrator stated if staff had completed the behavior monitoring record for Resident #75, it would have influenced the decision to discontinue the fifteen (15) minute checks. Interviews with SRNA #10, on 07/14/2021 at 10:00 AM, SRNA #8, on 07/14/2021 at 3:25 PM, Unit Coordinator #2, on 07/14/2021 at 4:00 PM, and with Registered Nurse (RN) #4, on 07/15/2021 at 8:25 PM, revealed Resident #75 wandered the facility the evening of 07/06/2021 and stood near exit doors. SRNA #10 it was difficult to provide care to other residents because she had to supervise and redirect the resident continuously during the shift. According to SRNA #8 and #10, on the evening of 07/06/2021, Resident #75's exit seeking and wandering behaviors were worse than usual. However, there was no documented evidence staff increased supervision of Resident #75 to prevent accidents. Interview with LPN #5, on 07/15/2021 at 4:48 PM, revealed Resident #75 continuously wandered on the evening of 07/06/2021. She stated she had to go search for the resident multiple times during the shift. According to LPN #5, the resident probably needed 1:1 supervision. However, there was no documentation the resident's care plan was revised to ensure the resident was supervised. Review of incident report dated 07/06/2021 revealed at approximately 9:45PM Resident #75 exited the facility without staff knowledge. The facility located the resident at 9:50 PM, with staff from a neighboring facility accompanying the resident. The resident was assisted back inside the facility and was assessed to have no injuries. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/21/2021: 1. The facility discharged Resident #283 to the hospital on 06/27/2021. The resident has not returned to the facility 2. The Social Services Director (SSD) and Minimum Data Set (MDS) Nurse completed an audit on 07/15/2021 to review the past 30 days of new admissions to ensure the baseline care plan included an accurate summary of the resident's medications. The facility gave the resident/representative a summary of the baseline care plan. 3. The Vice President (VP) of Operations and the Regional Quality Manager (RQM) educated the Administrator and Director of Nursing on 07/17/2021 regarding the regulatory intent of F-655. Specific training included instruction that the facility must develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to care for a resident properly, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The training also included the fact that the facility must provide the resident/representative with a summary of the baseline care plan that includes, but not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and any services or treatments the facility would administer. 4. On 07/17/2021, the Director of Nursing (DON) provided education to the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses on base line care plans including the above information. A post-test with a score of one-hundred percent was required. 5. On 07/19/2021, the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses educated all other licensed nurses, including agency nurses, on the facility's baseline care plans procedures above. A post-test with a score of one-hundred percent was required. 6. Any new licensed nurses, including agency, hired would receive the baseline care plan training prior to providing care and assuming duties. 7. Beginning 07/17/2021, the DON and Nurse Unit Manager reviewed all new admissions to validate that the baseline care plan included an accurate summary of the resident's reconciled medications, and ensure the facility provided the resident/representative with a summary. The DON and Nurse Unit Manager corrected any issues at time of discovery. This would continue for a minimum of 8 weeks. A licensed nurse and/or MDS nurse would review with the resident/responsible party the baseline care plan within 48 hours of admission. A post-test with a score of 100% was required. The baseline care plan remains a working document until the comprehensive care plan was developed. 8. The facility discharged Resident #75 home on 07/13/2021. 9. On 7/17/2021, the MDS staff completed an audit to verify residents identified at risk for elopement had wander guard bracelets in place and the care plan was accurate with updated information reflecting the resident's status. 10. On 07/17/2021, the VP of Operations and Regional Quality Manager provided education to the Administrator and Director of Nursing regarding the regulatory intent of F-657. Specific education included staff must complete a comprehensive care plan within seven days after completion of the comprehensive assessment. The training also included that the interdisciplinary team (IDT) would prepare the care plan, review and revise after each assessment, including both the comprehensive and quarterly assessments, and as needed. Examples include but were not limited to the need to revise a care plan when a resident presented with exit seeking behavior, or the exit seeking behavior increases. 11. The DON then provided the above education regarding care plans and F-657 to the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director and MDS staff on 07/17/2021. A post-test with a score of one-hundred percent was required. 12. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director or the MDS staff provided the training to the facility's licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 13. Any new licensed nurse, including agency, hired would receive the comprehensive care plan training prior to providing care and assuming duties. 14. Beginning 07/17/2021, the Director of Nursing, Unit Manager, or assigned on-call weekend nurse that served as clinical nurse manager would audit and visually inspect all resident's determined to at risk for elopement to verify the resident has a wander guard bracelet in place and it was functioning. In addition, they would verify the resident's care plan was updated and accurate to reflect the resident's status. Staff would correct any identified issues at the time of discovery. This would continue for a minimum of eight weeks. 15. Beginning 7/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of exit seeking behavior and validate the staff have assessed the resident and that staff had updated the care plan accordingly. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager would do this on weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 16. Resident #283 discharged to the hospital on 6/27/2021, and has not returned to the facility at this time. 17. On 7/16/2021, the Director of Nursing audited each resident's medical record to ensure staff documented resident vital signs, including blood sugar and blood pressure in the record as ordered or per policy. They identified no additional concerns for additional resident assessment. 18. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-684. Including the fundamental principle that quality of Care applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Included in Quality of Care, but were not limited to monitoring blood sugar as ordered or as indicated with signs/symptoms of hypo/[CONDITION(S)] which may include, but not limited to excess sweating, excess hunger, shakiness, increased thirst, weakness, dry mouth; obtaining vital signs as required by facility protocol and/or physician orders. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. 19. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-684. A post-test with a score of one-hundred percent was required. 20. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-684 to facility-licensed nurses,including agency. A post-test with a score of one-hundred percent was required. 21. Any new licensed nurse hire, including agency, would receive this education related to F-684 prior to assuming duties. 22. Beginning 7/17/2021, the Director of Nursing, MDS staff , RN Wound Nurse and/or the assigned Unit Manager reviewed each resident's medical record to ensure that vital signs,including blood sugar and blood pressure, were documented in the record as ordered or per policy. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. Staff would correct and identified issues at the time of discovery. This process would continue daily while the facility remains in immediate jeopardy. 23. Beginning 07/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of a change in resident condition that would warrant obtaining blood sugar or additional vital signs, and validate this/these were obtained. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager completed on the weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 24. On 07/16/2021, the Administrator and Maintenance Director completed an audit to assess all facility exit doors for proper functioning/alarming. They identified no additional doors as having function issues. 25. On 7/16/2021, the Maintenance Director and Assistant adjusted C-Wing exit door magnet lock to ensure alarming during fifteen second egress, and re-set the key code to the physical therapy exit door to work without issue with the wander guard sensor. 26. The contracted service vendor completed a general inspection/service, on 7/20/2021, of facility doors. They identified no concerns. 27. On 07/17/2021, the VP of Operations and RQM educated the Administrator and DON regarding the regulatory intent of F-689. Specifically the facility must ensure the resident environment remained as free of accident hazards as possible; each resident received adequate supervision and assistance devices to prevent accidents. This included identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Example included, but not limited to identifying the supervision needs of a resident identified as an elopement risk; maintaining and/or modify interventions if supervision needs was still required; revising the care plan with interventions to monitor the resident; assessment of exit doors for proper functioning/alarming. 28. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-689. A post-test with a score of one-hundred percent was required. 29. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-689 to facility-licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 30. Any new licensed nurse hire, including agency, would receive this education related to F-689 prior to assuming duties. 31. On 07/17/2021, the Administrator educated the Maintenance staff to check door alarms twice daily to ensure doors are alarming when opened. This included checking the emergency egress and validating the alarm sounds upon door release, utilizing a wander guard sensor for applicable doors to ensure the magnetic lock responds to lock the door, and inputting the door code to ensure the alarm sounds when the wander guard sensor passes the doorway. Staff would complete this daily while the facility remains in immediate jeopardy. 32. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-760 specifically the facility must ensure residents were free of any significant medication errors. The errors may include issues with the prescriber's order; manufacturer's specifications regarding preparation and administration; accepted professional standards and principles that apply to professionals providing services. Examples to prevent medication errors includes, but not limited to validating medication lists received for residents from home health agencies etc. with family/responsible party to ensure accuracy; reconciling medication lists received for residents and reviewing with physician for administration orders. 33. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-760. A post-test with a score of one-hundred percent was required. 34. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F760 to facility-licensed nurses, including agency. A post-test with a score of one hundred percent was required. 35. Any new licensed nurse hire (including agency) would receive this education related to F-760 prior to assuming duties. 36. The facility held an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 07/16/2021 to review the Immediate Jeopardy citations and discuss the development of the action items to be completed. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Admissions, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director per phone. The team adopted the plan. 37. The facility held a second ad hoc QAPI meeting on held 07/20/2021 to review the status of education and audits. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director via phone. **The State Survey Agency validated the removal of Immediate Jeopardy on 07/21/2021 as follows: 1. Review of a discharge form dated 06/27/2021 revealed the facility discharged Resident #283 from the facility. Interview conducted on 07/30/2021 at 12:27 PM with the DON, revealed the facility discharged Resident #283 from the facility on 06/27/2021. 2. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. Interviews conducted on 07/29/2021 at 2:15 PM with MDS #1, and at 2:35 PM with the SW, revealed they had completed the audits on 07/15/2021, for all new admissions in the past thirty days. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. 3. Review of an in-service roster dated 07/17/2021, revealed the Vice President of Operations (VPO) and RQM provided an in-service for the DON and Administrator related to the development and implementation of a baseline care plan for each resident. Interviews conducted on 07/30/2021, with the DON at 12:30 PM, the VPO at 12:35 PM, and the RQM at 12:40 PM, revealed the DON and the Administrator had attended an in-service provided by the VPO and the RQM. The in-services related to the development and implementation of a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. 4. Review of an in-service roster dated 07/17/2021, revealed the DON had provided an in-service for the Wound Care Nurse (WCN), UM #1, UM #2, SDC, MDS #1, and MDS #2, related to development and implementation of a baseline care plan for each resident. Interviews were conducted on 07/29/2021 at 1:40 PM, with UM #1, 07/29/2021 at 1:55 PM with the WCN, on 7/29/2021 at 2:01 PM with the SDC, 07/29/2021 at 2:15 PM with MDS #1, on 07/30/2021 at 11:04 AM with MDS #2, 07/30/2021 at 12:27 PM. The staff interviewed stated they had attended the in-service provided by the DON related to related to development and implementation of a baseline care plan for each resident. 5. Review of an in-service roster, dated 07/19/2021, revealed all licensed nursing staff had been provided an in-service related to development and implementation of a baseline care plan for each resident. Interviews were conducted, on 07/29/2021 at 1:33 PM with SRNA #8, at 1:34 PM with SRNA #1, at 1:39 PM with SRNA #2, at 1:32 PM with SRNA #12, at 2:15 PM with SRNA #5, at 2:20 PM with SRNA #13, at 2:25 PM with SRNA #6, at 2:10 PM with KMA #1, at 1:31 with LPN #6, and at 1:34 PM with LPN #3. The staff stated they had attended the in-service provided by the SDC related to development and implementation of a baseline care plan for each resident that included instructions needed to provide effective and person-centered care of the residents that meet professional standards of care. 6. Review of a New Employee Orientation packet, revealed the in-service related to development and implementation of a baseline care plan for each resident included instructions needed to provide effective and person-centered care of the residents that met professional standards of care. The baseline care plan must be developed within forty-eight hours of a resident's admission; include the minimum healthcare information necessary to care for a resident, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview conducted on 07/29/2021 at 2:01 PM, with the SDC, revealed she had included the training in the new employee training. 7. Review of audits conducted by UM #1, UM #2, and by the DON, revealed since 07/17/2021, all new admissions had been reviewed by the DON and/or UM #1 or UM #2. The audits validated the baseline care plan included an accurate summary of the resident's reconciled medications and the resident representative had been provided an accurate summary of the resident's baseline care plan. The audits also revealed Resident #37 and Resident #133's medical records both who were re-admissions, had baseline care plans developed within forty eight hours of admission/readmission. The medical records revealed the facility gave the resident/responsible party a copy of a summary that included the initial goals of the resident, a summary of the resident's medications and dietary instructions. It also had services or treatments the facility would administer to the resident. Interviews conducted on 07/29/2021 at 1:40 PM, with UM #1 and on 07/30/2021 at 12:27 PM with the DON, revealed they had completed the audits beginning 07/17/2021, for all new admissions. The audits validated the baseline care plan included an accurate summary of the resident's reconciled medications and that the resident representative had been provided an accurate summary of the resident's baseline care plan. 8. Review of a discharge form dated 07/13/2021, revealed the facility discharged Resident #75 from the facility. Interviews conducted on 07/29/2021 at 1:33 PM with SRNA #8, 07/29/2021 at 1:34 PM with SRNA #1, and on 07/29/2021 at 1:39 PM with SRNA #2, revealed the facility had discharged Resident #75. 9. Review of audits completed by MDS #1 and MDS #2 on 07/17/2021, revealed the audits to ensure residents assessed to be at risk f [TRUNCATED]

Based on interview and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #283) received treatment and care in accordance with professional standards of practice and physician orders. The facility admitted Resident #283 to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility failed to obtain the resident's heart rate/blood pressure as ordered by the physician on 06/18/2021, and per the facility's COVID-19 protocol. On 06/18/2021, nursing staff assessed Resident #283 to be ashy in color and cool/clammy to touch, although staff contacted the physician and sent the resident to the hospital, staff failed to obtain the resident's glucose level. On 06/27/2021, Resident #283 would not talk to staff and the facility contacted Emergency Medical Services (EMS) to transport the resident to the hospital. However, there was no evidence the facility obtained the resident's blood glucose level before transferring the resident, even though the resident was assessed to be sweaty, weak, and non-verbal. Review of EMS documentation revealed when they arrived to the facility the resident was diaphoretic (sweating), weak, and would not speak. EMS personnel obtained the resident's blood glucose level, which was 26 mg/dl, administered the resident [MEDICATION(S)] intravenously, and transported the resident to the hospital. Review of hospital records revealed the hospital admitted Resident #283 to the Intensive Care Unit (ICU) and diagnosed him/her with Acute Metabolic [CONDITION(S)] secondary to [CONDITION(S)]. The facility's failure to ensure residents received treatment and care in accordance with professional standards of practice has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/16/2021 and was determined to exist on 06/17/2021 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 07/16/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 07/21/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/21/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Nursing Care of the Resident with Diabetes Mellitus, revised April 2011, revealed the purpose of the policy was to prevent recurrent [CONDITION(S)]/[CONDITION(S)], to help residents control their diabetes, and to recognize, manage and document the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON), on 07/16/2021 at 3:00 PM, revealed the facility did not have a policy related to professional standards of practice. However, the DON stated staff monitored residents with Diabetes for signs/symptoms of [CONDITION(S)]/[CONDITION(S)], and documented that monitoring in the resident's medical record. Continued interview with the DON, on 07/16/2021 at 3:00 PM revealed the facility did not have written policy related to specifically obtaining vital signs in the facility. However, the DON stated the facility's procedure was to obtain the resident's blood pressure, heart rate, pulse rate, temperature, oxygen saturation and lung sounds every four (4) hours for fourteen (14) days after admission or re-admission into the facility due to COVID-19 monitoring. Further interview with the DON, on 07/16/2021 at 3:00 PM revealed the facility had no written policy on following physician orders when residents returned from a Hospital or Emergency Department (ED) visit. However, the DON stated staff should always follow physician orders when providing care/treatment to residents. Review of Resident #283's medical record revealed the facility admitted the resident on 06/17/2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #283's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a brief interview for mental status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. Review of Resident #283's admitting physician orders dated 06/17/2021, revealed staff were to administer the resident medication for the management of the resident's diabetes including [MEDICATION(S)] and [MEDICATION(S)] Extended Release, both of which were medications used to treat Diabetes by lowering blood glucose levels. Although, the resident's admitting orders revealed there were no physician orders to check the resident's blood glucose level on a routine basis, on 06/18/2021 staff obtained physician orders to check Resident #283's blood glucose level every six (6) hours as needed. Further review of the resident's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the admitting orders did not contain, and the facility did not initiate specific instructions for staff on when to obtain the resident's blood pressure and/or heart rate since the resident was taking the medications. However, per the facility's COVID-19 procedure, staff would be monitoring Resident #283's vital signs every four (4) hours for fourteen (14) days. Continued review of Resident #283's medical record revealed on 06/18/2021 at 11:52 AM, Licensed Practical Nurse (LPN) #3 documented Resident #283 was complaining of back pain. The LPN documented the resident's vital signs were blood pressure 122/68 mm (millimeters) HG (mercury) (normal range 120/80 mm HG), heart rate was 44-50 beats per minute (bpm) (normal range 60-100 bpm), respirations 16 per minute (normal range 12-16 per minute), and temperature 97.6 degrees Fahrenheit (normal 98.6 Fahrenheit). In addition, LPN #3 documented the resident was ashy in color, and the resident's skin was cool, and clammy to touch. LPN #3 contacted Resident #283's physician, who ordered staff to send the resident to the hospital for further evaluation and treatment. However, there was no evidence found to indicate that LPN #3 checked the resident's blood glucose level prior to Emergency Medical Services (EMS) transporting the resident to the hospital. Interview with Licensed Practical Nurse (LPN) #3, on 07/15/2021 at 1:20 PM, revealed she did not check the resident's glucose level on 06/18/2021 when she assessed the resident to be ashy in color and had cool/clammy skin, because she did not consider that a sign/symptom of [CONDITION(S)] or [CONDITION(S)]. Review of EMS documentation for Resident #283, dated 06/18/2021 at 11:41 AM, revealed the facility called and reported a lethargic patient, which needed transportation to the hospital. At 11:59 AM EMS was at the facility and assessed the resident's blood pressure to be 79/54 mm HG, heart rate was 101, and the resident's blood glucose was 300 mg/dl (normal range 70-130 mg/dl). In addition, the EMS record revealed EMS personnel administered 250 ml of normal saline intravenously (IV) in route to the hospital, to treat Resident #283's low blood pressure. Review of Resident #283's hospital record for 06/18/2021, revealed the resident's vital signs on arrival to the Emergency Department (ED) were blood pressure 93/52 mm HG, heart rate was 86 bpm, respirations were 20 per minute, and the residents body temperature was 98.0 degrees Fahrenheit. Continued review of the hospital record revealed the resident's blood glucose level was 256 when evaluated in the ED. According to the record, ED staff administered an additional two-thousand ml's of normal saline to the resident in the ED, because the resident's blood pressure continued to be low with readings of 81/51 mm HG at 1:00 PM and 94/53 mm HG at 2:01 PM. The ED record also indicated Resident #283 was transferred back to the facility on [DATE], with orders to hold the resident's blood pressure medications and to check the resident's blood pressure at least twice a day for the next 2-3 day. Further review of Resident #238's medical record, revealed Resident #238 arrived back to the facility on [DATE], and review of resident's Medication Administration Record, [MEDICAL RECORD OR PHYSICIAN ORDER] . However, there was no evidence found to indicate the staff obtained the residents blood pressure at least twice daily as ordered per the ED physician. In addition, there was also no evidence staff obtained the resident's vital signs every four (4) hours as required by the facility's procedure for new/readmitted resident's per the facility's COVID-19 protocol. Continued review of Resident #283's record revealed the facility only obtained the resident's blood pressure four (4) times during the next (3) days. On 06/19/2021 at 1:32 AM, the staff obtained and documented the resident's blood pressure as 122/60 mm HG. On 06/20/2021 at 2:37 AM, staff obtained the resident's blood pressure and documented it was 126/80 mm HG; and twice on 06/21/2021 at 4:06 AM and at 11:51 PM staff obtained the resident's blood pressure and documented it was 124/79 on both occasions. In addition, review of Resident #283's medical record reveled no evidence that staff ever obtained or documented the resident's blood pressure, heart rate, pulse rate, temperature, oxygen saturation and lung sounds every four (4) hours as required per the facility's COVID-19 procedure. Continued review of Resident #283's medical record revealed for 06/27/2021 at 9:15 AM, revealed LPN #3 documented the resident would not speak to staff and the resident's skin was pink, warm and dry to the touch. The staff notified Resident #283's physician who ordered staff to transport the resident to the hospital for further evaluation and treatment. However, there was no evidence in the resident's medical record to indicate that staff checked the resident's glucose level when the resident was not responsive to staff. Interview with Licensed Practical Nurse (LPN) #3, on 07/15/2021 at 1:20 PM, revealed she did not check the resident's glucose level on 06/27/2021 when she assessed the resident to be non-verbal, because she did not consider that a sign/symptom of [CONDITION(S)]/[CONDITION(S)]. Review of EMS documentation for Resident #283, dated for 06/27/2021, revealed they arrived to the facility and was at the resident's bedside at 10:03 AM. EMS noted the resident was diaphoretic (sweating), weak, and would not speak. Further review of EMS documentation, revealed facility staff told EMS personnel they thought the resident was acting out because he/she wanted to go home. However, at 10:14 AM, EMS personnel obtained the resident's blood glucose level, which was 26 mg/dl. According to the EMS record, they administered 100 ml's of normal saline fluid and 25 grams of [MEDICATION(S)] 50% to treat Resident #283's critically low blood glucose level. Review of Resident #283's hospital record, dated 06/27/2021, revealed the resident presented with a chief complaint of [CONDITION(S)]. According to the hospital record, EMS personnel had administered the resident one (1) [MEDICATION(S)] of [MEDICATION(S)] 50 before the resident arrived to the hospital. Continued review of the record revealed the ED physician determined the resident had acute Metabolic [CONDITION(S)] secondary to [CONDITION(S)]. In addition, the hospital record revealed the resident's blood glucose level continued to drop to abnormally low levels after arrival and the resident required an intravenous [MEDICATION(S)] drip (used to increase blood glucose levels) and was admitted to the Intensive Care Unit (ICU). Further interview with LPN #3 on 07/15/2021 at 1:20 PM, revealed she admitted Resident #283 on 06/17/2021. However, the LPN acknowledged she had not placed the monitoring of the resident's vital signs every four (4) hours as required by the facility's procedure on the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, LPN #3 stated she also failed to document on the resident's MARS/TARS for staff to monitor the resident for signs/symptoms of [CONDITION(S)]/[CONDITION(S)] since the resident was a diabetic. In addition, LPN #3 stated she also should have documented on the resident's MARS/TARS to obtain the resident's vital signs every four (4) hours per the facility's COVID-19 protocol. LPN #2 stated the nurses were responsible to ensure they obtained and documented resident vital signs, but would not say why she had not included the blood glucose and vital sign monitoring on Resident # 283's MARS/TARS. Interview with Minimum Data Set (MDS) Assessment Nurse #2, on 07/16/2021 at 4:00 PM, revealed staff who admitted the resident to the facility was responsible to implement diabetic monitoring and COVID-19 vital sign monitoring for new admissions on the resident's MAR/TAR. The MDS nurse stated she was not sure why this was not done for Resident #283. Interview with the facility's Pharmacist on 07/16/2021 at 4:25 PM, revealed she expected staff to obtain physician orders to monitor diabetic resident's glucose levels routinely, especially if the resident was a new admission and was receiving a hypoglycemic medication. The Pharmacist also stated it was a standard of practice to obtain a resident's blood pressure/heart rate before administering any medication that may increase or decrease the rates, stating, even if it's just one medication, especially when the resident was new to the facility and staff were not familiar with the resident. Interview with Physician #1, on 07/15/2021 at 3:00 PM, revealed he was the resident's physician at the facility, but was not familiar with the resident prior to being admitted to the facility. The physician stated he would have expected staff to monitor any newly admitted diabetic resident's blood glucose levels at least twice daily to see how the resident's blood sugar ran, especially when medications were administered which would affect blood glucose levels. In addition, the physician stated staff should monitor vital signs per the facility's COVID-19 processes and obtain the resident's heart rate/blood pressure before administering medications that would affect the resident's heart rate/blood pressure, especially if the resident was new to the facility. Continued interview with the Director of Nursing (DON), on 07/16/2021 at 3:00 PM, revealed staff should have obtained Resident #283's vital signs every four hours as outlined in the facility COVID-19 process, and staff should have followed directions given by the ED physician on 06/18/2021. She also stated staff should have implemented diabetic monitoring on Resident 3283's MAR/TAR, which included assessing the resident for signs/symptoms of [CONDITION(S)]/[CONDITION(S)]. The DON also stated the nurse should have obtained Resident #283's blood glucose anytime the resident displayed signs/symptoms of [CONDITION(S)]/[CONDITION(S)]. However, the DON acknowledged the staff had not received training related to specific care or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator, on 07/16/2021 at 4:55 PM, revealed staff should have been assessing Resident #283's vital signs as directed in the facility COVID-19 process. She also stated she would have expected staff to assess the resident's blood glucose levels and would have expected them to obtain vital signs before administering medications that affect their heart rate/blood pressure. The Administrator also stated staff should follow acceptable standards of practice when providing care to residents in the facility. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/21/2021: 1. The facility discharged Resident #283 to the hospital on 06/27/2021. The resident has not returned to the facility 2. The Social Services Director (SSD) and Minimum Data Set (MDS) Nurse completed an audit on 07/15/2021 to review the past 30 days of new admissions to ensure the baseline care plan included an accurate summary of the resident's medications. The facility gave the resident/representative a summary of the baseline care plan. 3. The Vice President (VP) of Operations and the Regional Quality Manager (RQM) educated the Administrator and Director of Nursing on 07/17/2021 regarding the regulatory intent of F-655. Specific training included instruction that the facility must develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to care for a resident properly, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The training also included the fact that the facility must provide the resident/representative with a summary of the baseline care plan that includes, but not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and any services or treatments the facility would administer. 4. On 07/17/2021, the Director of Nursing (DON) provided education to the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses on base line care plans including the above information. A post-test with a score of one-hundred percent was required. 5. On 07/19/2021, the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses educated all other licensed nurses, including agency nurses, on the facility's baseline care plans procedures above. A post-test with a score of one-hundred percent was required. 6. Any new licensed nurses, including agency, hired would receive the baseline care plan training prior to providing care and assuming duties. 7. Beginning 07/17/2021, the DON and Nurse Unit Manager reviewed all new admissions to validate that the baseline care plan included an accurate summary of the resident's reconciled medications, and ensure the facility provided the resident/representative with a summary. The DON and Nurse Unit Manager corrected any issues at time of discovery. This would continue for a minimum of 8 weeks. A licensed nurse and/or MDS nurse would review with the resident/responsible party the baseline care plan within 48 hours of admission. A post-test with a score of 100% was required. The baseline care plan remains a working document until the comprehensive care plan was developed. 8. The facility discharged Resident #75 home on 07/13/2021. 9. On 7/17/2021, the MDS staff completed an audit to verify residents identified at risk for elopement had wander guard bracelets in place and the care plan was accurate with updated information reflecting the resident's status. 10. On 07/17/2021, the VP of Operations and Regional Quality Manager provided education to the Administrator and Director of Nursing regarding the regulatory intent of F-657. Specific education included staff must complete a comprehensive care plan within seven days after completion of the comprehensive assessment. The training also included that the interdisciplinary team (IDT) would prepare the care plan, review and revise after each assessment, including both the comprehensive and quarterly assessments, and as needed. Examples include but were not limited to the need to revise a care plan when a resident presented with exit seeking behavior, or the exit seeking behavior increases. 11. The DON then provided the above education regarding care plans and F-657 to the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director and MDS staff on 07/17/2021. A post-test with a score of one-hundred percent was required. 12. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director or the MDS staff provided the training to the facility's licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 13. Any new licensed nurse, including agency, hired would receive the comprehensive care plan training prior to providing care and assuming duties. 14. Beginning 07/17/2021, the Director of Nursing, Unit Manager, or assigned on-call weekend nurse that served as clinical nurse manager would audit and visually inspect all resident's determined to at risk for elopement to verify the resident has a wander guard bracelet in place and it was functioning. In addition, they would verify the resident's care plan was updated and accurate to reflect the resident's status. Staff would correct any identified issues at the time of discovery. This would continue for a minimum of eight weeks. 15. Beginning 7/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of exit seeking behavior and validate the staff have assessed the resident and that staff had updated the care plan accordingly. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager would do this on weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 16. Resident #283 discharged to the hospital on 6/27/2021, and has not returned to the facility at this time. 17. On 7/16/2021, the Director of Nursing audited each resident's medical record to ensure staff documented resident vital signs, including blood sugar and blood pressure in the record as ordered or per policy. They identified no additional concerns for additional resident assessment. 18. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-684. Including the fundamental principle that quality of Care applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Included in Quality of Care, but were not limited to monitoring blood sugar as ordered or as indicated with signs/symptoms of hypo/[CONDITION(S)] which may include, but not limited to excess sweating, excess hunger, shakiness, increased thirst, weakness, dry mouth; obtaining vital signs as required by facility protocol and/or physician orders. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. 19. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-684. A post-test with a score of one-hundred percent was required. 20. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-684 to facility-licensed nurses,including agency. A post-test with a score of one-hundred percent was required. 21. Any new licensed nurse hire, including agency, would receive this education related to F-684 prior to assuming duties. 22. Beginning 7/17/2021, the Director of Nursing, MDS staff , RN Wound Nurse and/or the assigned Unit Manager reviewed each resident's medical record to ensure that vital signs,including blood sugar and blood pressure, were documented in the record as ordered or per policy. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. Staff would correct and identified issues at the time of discovery. This process would continue daily while the facility remains in immediate jeopardy. 23. Beginning 07/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of a change in resident condition that would warrant obtaining blood sugar or additional vital signs, and validate this/these were obtained. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager completed on the weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 24. On 07/16/2021, the Administrator and Maintenance Director completed an audit to assess all facility exit doors for proper functioning/alarming. They identified no additional doors as having function issues. 25. On 7/16/2021, the Maintenance Director and Assistant adjusted C-Wing exit door magnet lock to ensure alarming during fifteen second egress, and re-set the key code to the physical therapy exit door to work without issue with the wander guard sensor. 26. The contracted service vendor completed a general inspection/service, on 7/20/2021, of facility doors. They identified no concerns. 27. On 07/17/2021, the VP of Operations and RQM educated the Administrator and DON regarding the regulatory intent of F-689. Specifically the facility must ensure the resident environment remained as free of accident hazards as possible; each resident received adequate supervision and assistance devices to prevent accidents. This included identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Example included, but not limited to identifying the supervision needs of a resident identified as an elopement risk; maintaining and/or modify interventions if supervision needs was still required; revising the care plan with interventions to monitor the resident; assessment of exit doors for proper functioning/alarming. 28. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-689. A post-test with a score of one-hundred percent was required. 29. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-689 to facility-licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 30. Any new licensed nurse hire, including agency, would receive this education related to F-689 prior to assuming duties. 31. On 07/17/2021, the Administrator educated the Maintenance staff to check door alarms twice daily to ensure doors are alarming when opened. This included checking the emergency egress and validating the alarm sounds upon door release, utilizing a wander guard sensor for applicable doors to ensure the magnetic lock responds to lock the door, and inputting the door code to ensure the alarm sounds when the wander guard sensor passes the doorway. Staff would complete this daily while the facility remains in immediate jeopardy. 32. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-760 specifically the facility must ensure residents were free of any significant medication errors. The errors may include issues with the prescriber's order; manufacturer's specifications regarding preparation and administration; accepted professional standards and principles that apply to professionals providing services. Examples to prevent medication errors includes, but not limited to validating medication lists received for residents from home health agencies etc. with family/responsible party to ensure accuracy; reconciling medication lists received for residents and reviewing with physician for administration orders. 33. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-760. A post-test with a score of one-hundred percent was required. 34. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F760 to facility-licensed nurses, including agency. A post-test with a score of one hundred percent was required. 35. Any new licensed nurse hire (including agency) would receive this education related to F-760 prior to assuming duties. 36. The facility held an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 07/16/2021 to review the Immediate Jeopardy citations and discuss the development of the action items to be completed. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Admissions, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director per phone. The team adopted the plan. 37. The facility held a second ad hoc QAPI meeting on held 07/20/2021 to review the status of education and audits. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director via phone. **The State Survey Agency validated the removal of Immediate Jeopardy on 07/21/2021 as follows: 1. Review of a discharge form dated 06/27/2021 revealed the facility discharged Resident #283 from the facility. Interview conducted on 07/30/2021 at 12:27 PM with the DON, revealed the facility discharged Resident #283 from the facility on 06/27/2021. 2. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. Interviews conducted on 07/29/2021 at 2:15 PM with MDS #1, and at 2:35 PM with the SW, revealed they had completed the audits on 07/15/2021, for all new admissions in the past thirty days. Review of audits dated 07/15/2021, revealed the Social Worker (SW) and MDS Nurse #1 reviewed all new admissions in the past thirty days to ensure the baseline care plan included an accurate summary of the resident's medications, and with a summary provided to the resident and/or resident representative. 3. Review of an in-service roster dated 07/17/2021, revealed the Vice President of Operations (VPO) and RQM provided an in-service for the DON and Administrator related to the development and implementation of a baseline care plan for each resident. Interview [TRUNCAT

Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to supervise one (1) of twenty-two (22) sampled residents (Resident #75) to prevent accidents. The facility identified Resident #75 was at risk for elopement due to dementia and placed a Wanderguard bracelet on the resident on admission on 06/23/2021. Interviews with staff revealed on the evening of 07/06/2021, Resident #75 was wandering continuously and attempted to exit the building. On 07/06/2021, at approximately 9:45 PM, Resident #75 left the facility without staff knowledge. At approximately 9:50 PM, a staff member arriving for work at the assisted living facility across the street, observed the resident on the roadway approximately 90 yards from the facility entrance. The individual and other employees from the assisted living facility assisted the resident to their parking lot and was calling 911, when Resident #75's nurse came outside looking for the resident. Resident #75 was assisted back inside the facility and assessed to have no injuries. However, according to the facility's investigation, the resident was found outside the facility on the sidewalk. Interviews with staff revealed the facility's Wanderguard alarm failed to sound when the resident exited the facility on 07/06/2021 and staff were unaware the resident had exited the facility. Observation of the facility doors on 07/14-16/2021 revealed the C-wing exit and/or one of the Physical Therapy exit doors/door alarms were not functioning properly. The facility's failure to ensure residents were free from accidents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/16/2021 and was determined to exist on 06/17/2021 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 07/16/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 07/21/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/21/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of facility protocol, titled, Elopement Standard of Practice, dated 08/2020, revealed the facility maintained a process to assess all residents for risk of elopement, implement prevention strategies for those identified as an elopement risk, and institute measures for resident identification and conduct a missing resident procedure. If a resident was identified at risk, a Wanderguard bracelet (the bracelet triggers alarms at doors to prevent residents from leaving unattended) would be placed on the resident for safety. Further review revealed if a resident with a Wanderguard attempted to exit the facility, an alarm would sound and the alarm panel at the nurse's station would identify which door was alarming. According to the protocol, staff members should immediately go to the door to assist the resident away from the door. Review of Resident #75's medical record revealed the facility admitted the resident on 06/23/2021 with diagnoses of Dementia, Type II Diabetes Mellitus and Generalized Weakness. Review of the resident's Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. Further review revealed Resident #75 required staff supervision, oversight, and encouragement or cueing for ambulation in his/her room and on the unit, with no mobility devices. Continued review of Resident #75's MDS revealed the resident exhibited wandering behavior, which occurred one (1) to three (3) days during the assessment observation period. Review of Resident #75's Elopement/Wanderer Risk assessment dated [DATE] revealed the facility assessed the resident as high risk for elopement, with a score of twenty (20) (scores of greater than ten (10) indicate a resident is high risk for elopement. Review of Resident #75's Comprehensive Care Plan dated 06/24/2021 revealed the facility identified the resident was at risk for wandering/elopement and had the following interventions to keep the resident safe: a Wanderguard bracelet on the right ankle, check the bracelet placement and function every shift, offer redirection and reassurance per required need, redirect to a safe area, place a photograph of the resident with a description on a protected list of at-risk residents. On 06/25/2021, the facility implemented another intervention to take Resident #75 to a highly visual area in the facility and play religious music at his/her request. Review of an incident report dated 07/06/2021, revealed at approximately 9:45 PM, Resident #75 exited the facility without staff knowledge. The report stated staff located the resident at approximately 9:50 PM, outside the facility on the adjacent sidewalk. The resident was accompanied by staff from the neighboring facility at the time he/she was located. However, interview with Resident Care Partner (RCP) #1, on 07/14/2021 at 9:20 PM, revealed she was coming to work at the Assisted Living Facility across at the street, at approximately 9:50 PM on 07/06/2021. She stated she observed the resident as her headlights shined on the resident. The resident was standing on the roadway at the end of the street beside the stop sign past the facility. She stated she immediately parked her vehicle, ran to the resident, and the resident asked if she was going home. She stated she initially thought it was a resident from her facility, but then realized it was not. The RCP stated she called co-workers for assistance and four staff members were able the get the resident out of the roadway. She stated they were going up the hill toward the assisted living parking lot, when a staff member from the long-term care facility came out and stated the individual was one of their residents. A second staff member from the assisted living, RCP #2, stated during an interview on 07/14/2021 10:50 AM, she was coming to work about 9:50 PM on 07/06/2021. She stated when she pulled into the parking lot at her facility, she saw people walking up the street toward her. She stated RCP #1 and Resident #75 were about half way up the street when she and two other staff went to assist the resident up the hill to the entrance of the assisted living. RCP #2 stated she was calling 911 when a staff member came from the long-term care facility and stated the resident lived at their facility. She stated she canceled the 911 call, and the nurse assisted the resident to the long-term care facility without any issues. Interview with Licensed Practical Nurse (LPN) #5, on 07/15/2021 at 4:48 PM, revealed she was responsible for providing care for Resident #75 on 07/06/2021. Per the LPN, she assisted Resident #75 to bed the evening of 07/06/2021 around dusk, but the resident got out of bed. At approximately 9:30 PM, LPN #5 stated she assisted the resident to a chair next to her medication cart outside the resident's room. She stated she wanted to keep a closer eye on the resident because the resident continuously wandered and she had to search for the resident multiple times during the shift. She stated she and other staff had attempted to redirect the resident that evening with magazines, snacks, crayons and coloring books, but the resident would frequently say he/she wanted to go home and had voiced wanting to go home several times the night of 07/06/2021. According to the LPN, Resident #75 probably needed 1:1 supervision. LPN #5 stated at approximately 9:45 PM, she entered a resident's room to administer medication and provide other care. She stated when she returned to the medication cart, Resident #75 was no longer sitting in the chair. The LPN stated she immediately looked down C and D wing halls and did not see the resident. She met SRNA #8 and SRNA #10 coming out of a resident room, and asked if they had seen Resident #75, but they had not. Immediately both SNRAs began a head count on C and D wing and she proceeded to A and B wing to notify staff to begin searching. Per the LPN, although staff heard no door alarms, she went into the dining area because she suspected the resident might have exited the facility via the door to the smoke area. The LPN stated she suspected that particular door because the exterior exit door was not equipped with an alarm that required a code be entered prior to opening the door. The LPN stated she then exited the building via the smoke area door and walked to front of facility. She further stated she saw several people across the street with Resident #75 and they were on the phone with 911. She stated they then canceled the call when she approached them and told them Resident #75 was their missing resident. The LPN stated she assisted Resident #75 through the front entrance, conducted a skin and pain assessment, and found no injuries or complaints of pain from the resident. Interview with Registered Nurse (RN) #4, on 07/15/2021 at 8:25 PM, revealed he notified the DON on 07/06/2021 at approximately 10:00 PM that Resident #75 had eloped. He stated Resident #75 had exhibited exit seeking behavior and wandered the facility on the evening of 07/06/2021, and he last saw the resident shortly after 9:00 PM. RN #4 stated he heard no alarms sound in the facility to indicate a resident had exited. Interview with Unit Coordinator #2, on 07/14/2021 at 4:00 PM, revealed she was working on 07/06/2021 when Resident #75 eloped. She stated she had seen the resident wandering the facility that evening, but was unsure what time she last saw the resident. However, the Unit Coordinator stated she recalled seeing the resident on B wing that evening and had escorted him/her back to C wing to a chair next to the medication cart. She stated she had not seen the resident attempt to exit the facility that night and did not hear any alarms in the facility that night. The Unit Coordinator stated later in the evening, SRNA #10 notified her that the resident was missing. At that time, they exited the front entrance to search outside the building and saw LPN #5 standing with the resident and several other staff from the facility across the street. Interview with SRNA #10, on 07/14/2021 at 10:00 AM, revealed she was working D hall the night Resident #75 eloped and had seen him/her wandering the halls of C and D wing all evening. She stated it was difficult to provide care to residents and do rounds due to trying to supervise and redirect the resident continuously during the shift. She further stated she directed the resident to sit next to the medication cart with LPN #5 and had provided snacks to the resident. According to SRNA #10, on the evening of 07/06/2021, Resident #75's exit seeking and wandering behaviors were worse than usual. She stated the resident had been going to the D wing door staring outside and LPN #5 had told her the resident had attempted to exit the C wing door area near the break room earlier that evening. Continued interview with SRNA #10 revealed she and SRNA #8 were in another resident's room getting the resident ready for bed. When they exited the room, LPN #5 met them and asked if they had seen Resident #75. The SRNA stated they had not seen the resident, and began doing a resident count on C and D wing. SRNA #10 stated she had last seen Resident #75 at approximately 8:45 PM. The SRNA stated after completing a head count on C and D wings, she was on her way to search another area when she observed LPN #5 across the street at the neighboring facility with the resident. According to SRNA #10, she had not heard any alarms that evening. She stated Wanderguards and doors were checked following the incident and it was discovered the smoke area interior door Wanderguard was not alarming. She stated she was unsure if the outside door to smoke area as working properly. Interview with SRNA #8, on 07/14/2021 at 3:25 PM, revealed she was working on the evening of 07/06/2021 when Resident #75 eloped. She stated the resident had been wandering throughout the facility all evening and stood near exit doors, but was unaware the resident attempted to exit prior to the incident. The SRNA stated she heard no alarms sound in the facility that evening/night. Review of facility logbook documentation, dated 07/03/2021-07/14/2021, for exits and alarms in the facility, revealed all exit doors and alarms passed daily inspection, on 07/06/2021. However, the smoke break door exit failed inspection from 07/07/2021-07/09/2021. Observation with the Maintenance Director of the facility exit doors and alarm operation, on 07/14/2021 at 2:10 PM, revealed the exit door on C wing had no egress alarm when pushed open. Continued observation revealed the therapy room exit door was equipped with a Wanderguard sensor; however, did not alarm when a Wanderguard bracelet was passed through the doorway. During a second attempt the alarm sounded, but was not consistently alarming when the Wanderguard passed through the exit door. Observation of C wing exit door and alarm operation, on 07/15/2021, revealed it was not functioning properly and no egress alarm sounded with attempts to exit the exit door. Interview with Maintenance Director, on 07/16/2021 at 12:30 PM, revealed all facility exit doors were equipped with a Wanderguard alert system except the C wing door and B wing door because both of those were emergency exits. The Maintenance Director stated if an attempt was made to open the C wing emergency exit door, it required significant force to get the door to release. According to the Maintenance Director, the C wing door had been malfunctioning for about a year. However, he stated there were no current work orders to repair the door, but it had been discussed. He stated the front door was replaced and the company who did the work was supposed to fix the C wing exit door, but had not yet completed any repairs. Per the Maintenance Director, he checked the functioning of door alarms each day using a Wanderguard bracelet and doors with keypads were checked by entering the code. He stated he also checked to ensure the egress was functioning. The Maintenance Director stated he documented the door alarm function daily in the TELS (computer system) and he documented whether the door alarm passed or failed the test. Per the Maintenance Director, when he checked the doors on the morning (just before 8:00 AM) of 07/06/2021, the doors were functioning properly. Further interview with the Maintenance Director, revealed he came in on 07/06/2021, after Resident #75 eloped, and the smoke room exit doors were not functioning properly. He stated the Wanderguard system did not alarm. He further stated at that time, the interior and exterior doors were not equipped with a pass code to exit. He stated the door alarm company came in at approximately 4:00 AM on 07/07/2021, and fixed the Wanderguard on the interior door, and installed code alarm pads on the interior and exterior doors to smoke break area. Observation of the area outside of facility, on 07/16/2021 at 8:25 AM, revealed the smoke break area had two sets of exit doors, separated by a short hallway. Observation revealed the interior door was equipped with a Wanderguard that functioned properly when tested . Further observation revealed a key pad had been installed on the interior and exterior doors so that a code had to be entered to exit the door. Observation of the area where Resident #75 was found by RCP #1 was approximately 90 yards walking distance from the front entrance of the facility. Further observation revealed the area surrounding the stop sign where the resident was found had a hazardous, large rocky drainage ditch areas on either side of the roadway, which were approximately three (3) feet below the road level. Interview with Director of Nursing, on 07/16/2021 and 3:34 PM, revealed RN #4 notified her on 07/06/2021, that Resident #75 had eloped from the facility. According to the DON, she was notified the resident was seen and located by staff from the neighboring facility; however, the DON stated staff told her the resident was found between the facility sidewalk and the parking lot, and was not aware the resident was found at the stop sign at the end of the street. The DON stated they checked the resident's Wanderguard bracelet and the smoke area exit door Wanderguard system did not alarm. The DON stated the potential outcome of a resident who was at high risk for elopement with no supervision, was elopement and injury to the resident. Interview with Administrator, on 07/16/2021 at 4:15 PM, revealed the facility door alarms and Wanderguard systems were monitored by nursing each shift. The Administrator stated proper function of facility security doors, alarms, and equipment would be a critical aspect of maintaining resident safety. She stated a potential outcome of malfunctioning security alarms, doors, or equipment could result in elopement or harm to a resident. The Administrator stated she arrived after Resident #75 was assisted into the facility following the elopement on 07/06/2021. She stated she immediately checked on the resident then proceeded to check doors and code alerts for the Wanderguard. The Administrator stated the smoke area door was not functioning properly and the Wanderguard alert on the door did not alarm when the Wanderguard sensor passed through the door. The Administrator stated all other residents' Wanderguard were checked, then the maintenance director was called and all alarms and doors in facility were checked. According to the Administrator, she was not aware that Resident #75 was found at the stop sign at the end of the street, even though she had interviewed the staff member from the Assisted Living Facility who found the resident. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/21/2021: 1. The facility discharged Resident #283 to the hospital on 06/27/2021. The resident has not returned to the facility 2. The Social Services Director (SSD) and Minimum Data Set (MDS) Nurse completed an audit on 07/15/2021 to review the past 30 days of new admissions to ensure the baseline care plan included an accurate summary of the resident's medications. The facility gave the resident/representative a summary of the baseline care plan. 3. The Vice President (VP) of Operations and the Regional Quality Manager (RQM) educated the Administrator and Director of Nursing on 07/17/2021 regarding the regulatory intent of F-655. Specific training included instruction that the facility must develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to care for a resident properly, but not limited to initial goals based on admission orders, physician orders, dietary orders, therapy services and social services recommendations. The training also included the fact that the facility must provide the resident/representative with a summary of the baseline care plan that includes, but not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and any services or treatments the facility would administer. 4. On 07/17/2021, the Director of Nursing (DON) provided education to the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses on base line care plans including the above information. A post-test with a score of one-hundred percent was required. 5. On 07/19/2021, the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses educated all other licensed nurses, including agency nurses, on the facility's baseline care plans procedures above. A post-test with a score of one-hundred percent was required. 6. Any new licensed nurses, including agency, hired would receive the baseline care plan training prior to providing care and assuming duties. 7. Beginning 07/17/2021, the DON and Nurse Unit Manager reviewed all new admissions to validate that the baseline care plan included an accurate summary of the resident's reconciled medications, and ensure the facility provided the resident/representative with a summary. The DON and Nurse Unit Manager corrected any issues at time of discovery. This would continue for a minimum of 8 weeks. A licensed nurse and/or MDS nurse would review with the resident/responsible party the baseline care plan within 48 hours of admission. A post-test with a score of 100% was required. The baseline care plan remains a working document until the comprehensive care plan was developed. 8. The facility discharged Resident #75 home on 07/13/2021. 9. On 7/17/2021, the MDS staff completed an audit to verify residents identified at risk for elopement had wander guard bracelets in place and the care plan was accurate with updated information reflecting the resident's status. 10. On 07/17/2021, the VP of Operations and Regional Quality Manager provided education to the Administrator and Director of Nursing regarding the regulatory intent of F-657. Specific education included staff must complete a comprehensive care plan within seven days after completion of the comprehensive assessment. The training also included that the interdisciplinary team (IDT) would prepare the care plan, review and revise after each assessment, including both the comprehensive and quarterly assessments, and as needed. Examples include but were not limited to the need to revise a care plan when a resident presented with exit seeking behavior, or the exit seeking behavior increases. 11. The DON then provided the above education regarding care plans and F-657 to the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director and MDS staff on 07/17/2021. A post-test with a score of one-hundred percent was required. 12. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director or the MDS staff provided the training to the facility's licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 13. Any new licensed nurse, including agency, hired would receive the comprehensive care plan training prior to providing care and assuming duties. 14. Beginning 07/17/2021, the Director of Nursing, Unit Manager, or assigned on-call weekend nurse that served as clinical nurse manager would audit and visually inspect all resident's determined to at risk for elopement to verify the resident has a wander guard bracelet in place and it was functioning. In addition, they would verify the resident's care plan was updated and accurate to reflect the resident's status. Staff would correct any identified issues at the time of discovery. This would continue for a minimum of eight weeks. 15. Beginning 7/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of exit seeking behavior and validate the staff have assessed the resident and that staff had updated the care plan accordingly. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager would do this on weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 16. Resident #283 discharged to the hospital on 6/27/2021, and has not returned to the facility at this time. 17. On 7/16/2021, the Director of Nursing audited each resident's medical record to ensure staff documented resident vital signs, including blood sugar and blood pressure in the record as ordered or per policy. They identified no additional concerns for additional resident assessment. 18. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-684. Including the fundamental principle that quality of Care applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Included in Quality of Care, but were not limited to monitoring blood sugar as ordered or as indicated with signs/symptoms of hypo/[CONDITION(S)] which may include, but not limited to excess sweating, excess hunger, shakiness, increased thirst, weakness, dry mouth; obtaining vital signs as required by facility protocol and/or physician orders. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. 19. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-684. A post-test with a score of one-hundred percent was required. 20. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-684 to facility-licensed nurses,including agency. A post-test with a score of one-hundred percent was required. 21. Any new licensed nurse hire, including agency, would receive this education related to F-684 prior to assuming duties. 22. Beginning 7/17/2021, the Director of Nursing, MDS staff , RN Wound Nurse and/or the assigned Unit Manager reviewed each resident's medical record to ensure that vital signs,including blood sugar and blood pressure, were documented in the record as ordered or per policy. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. Staff would correct and identified issues at the time of discovery. This process would continue daily while the facility remains in immediate jeopardy. 23. Beginning 07/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of a change in resident condition that would warrant obtaining blood sugar or additional vital signs, and validate this/these were obtained. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager completed on the weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 24. On 07/16/2021, the Administrator and Maintenance Director completed an audit to assess all facility exit doors for proper functioning/alarming. They identified no additional doors as having function issues. 25. On 7/16/2021, the Maintenance Director and Assistant adjusted C-Wing exit door magnet lock to ensure alarming during fifteen second egress, and re-set the key code to the physical therapy exit door to work without issue with the wander guard sensor. 26. The contracted service vendor completed a general inspection/service, on 7/20/2021, of facility doors. They identified no concerns. 27. On 07/17/2021, the VP of Operations and RQM educated the Administrator and DON regarding the regulatory intent of F-689. Specifically the facility must ensure the resident environment remained as free of accident hazards as possible; each resident received adequate supervision and assistance devices to prevent accidents. This included identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Example included, but not limited to identifying the supervision needs of a resident identified as an elopement risk; maintaining and/or modify interventions if supervision needs was still required; revising the care plan with interventions to monitor the resident; assessment of exit doors for proper functioning/alarming. 28. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-689. A post-test with a score of one-hundred percent was required. 29. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-689 to facility-licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 30. Any new licensed nurse hire, including agency, would receive this education related to F-689 prior to assuming duties. 31. On 07/17/2021, the Administrator educated the Maintenance staff to check door alarms twice daily to ensure doors are alarming when opened. This included checking the emergency egress and validating the alarm sounds upon door release, utilizing a wander guard sensor for applicable doors to ensure the magnetic lock responds to lock the door, and inputting the door code to ensure the alarm sounds when the wander guard sensor passes the doorway. Staff would complete this daily while the facility remains in immediate jeopardy. 32. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-760 specifically the facility must ensure residents were free of any significant medication errors. The errors may include issues with the prescriber's order; manufacturer's specifications regarding preparation and administration; accepted professional standards and principles that apply to professionals providing services. Examples to prevent medication errors includes, but not limited to validating medication lists received for residents from home health agencies etc. with family/responsible party to ensure accuracy; reconciling medication lists received for residents and reviewing with physician for administration orders. 33. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-760. A post-test with a score of one-hundred percent was required. 34. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F760 to facility-licensed nurses, including agency. A post-test with a score of one hundred percent was required. 35. Any new licensed nurse hire (including agency) would receive this education related to F-760 prior to assuming duties. 36. The facility held an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 07/16/2021 to review the Immediate Jeopardy citations and discuss the development of the action items to be completed. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Admissions, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director per phone. The team adopted the plan. 37. The facility held a second ad hoc QAPI meeting on held 07/20/2021 to review the status of education and audits. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Social Services [TRUNCATED]

Based on observation, interview and record review it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents (Resident #283) was free from significant medication errors. The facility admitted Resident #283 to the facility on [DATE], and instead of utilizing the medication regimen the resident's POA/Caregiver provided the facility, the facility obtained an erroneous medication regimen from the Home Health agency who was providing services to the resident and administered that regimen to the resident. Subsequently, the facility administered the resident more [MEDICATION(S)] (blood pressure medication) and [MEDICATION(S)] (cholesterol medication) than the resident received at home. The facility administered the resident less [MEDICATION(S)] (blood pressure medication) and [MEDICATION(S)] (diabetic medication) than the resident received at home. The facility administered the resident [MEDICATION(S)] (blood pressure medication) and [MEDICATION(S)] Extended Release (diabetic medication) that the resident did not receive at home. The facility also failed to administer the resident [MEDICATION(S)] (diabetic medication), [MEDICATION(S)] (blood pressure medication), [MEDICATION(S)] (diabetic medication), and [MEDICATION(S)] (corticosteroid medication) that the resident received at home. On 06/27/2021, ten (10) days after admission to the facility, staff found Resident #283 unable to speak and staff transferred the resident to the hospital. Review of the hospital record indicated Resident #283's blood sugar obtained by Emergency Medical Services (EMS) in route to the hospital was 26 mg/dl (normal range 70 - 130). The hospital admitted Resident #238 to the Intensive Care Unit (ICU), and diagnosed him/her with severe [CONDITION(S)] likely secondary to an Adrenal Crisis (a life-threatening medical emergency that occurs when there is not enough [MEDICATION(S)]) due to abruptly stopping [MEDICATION(S)] medication. The facility's failure to ensure residents were free from significant medication errors has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 07/16/2021 and was determined to exist on 06/17/2021 at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760). The facility was notified of the Immediate Jeopardy on 07/16/2021. An acceptable Allegation of Compliance was received on 07/23/2021, which alleged removal of the Immediate Jeopardy on 07/21/2021. The State Survey Agency determined the Immediate Jeopardy was removed on 07/21/2021, which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F655 and F657), 42 CFR 483.25 Quality of Care (F684 and F689) and 42 CFR 483.45 Pharmacy Services (F760), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Interview with the Director of Nursing (DON), on 07/13/2021 at 12:00 PM, revealed the facility did not have a policy related to medication errors. However, the DON stated if staff discovered a medication error, they would complete an incident report, notify her, and initiate an investigation to determine cause of the error. Continued interview with the DON revealed the facility did not have a policy/procedure related to reconciliation of medications for new admissions to the facility to ensure the facility ordered and administered the correct medications. However, review of the facility's policy titled Baseline Care Plan Standard of Practice, revised February 2017, revealed the facility would provide the resident/resident representative with a written summary of the baseline care plan, which included a summary of the resident's medications. Review of Resident #283's medical record revealed the facility admitted the resident from home on 06/17/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #238's admission Minimum Data Set (MDS) assessment, dated 06/23/2021, revealed the facility assessed the resident to have a brief interview for mental status (BIMS) score of fifteen (15), indicating the resident had no cognitive impairment. Review of Resident #283's Baseline Care Plan initiated on 06/17/2021, revealed the resident was admitted to the facility on [DATE], however the care plan was not completed until 06/25/2021, six (6) days after the care plan was required to be completed. Continued review of the care plan revealed no evidence the facility had provided the resident and/or their representative with a summary of the baseline care plan that included a summary of the care the facility would provide for the resident and the medication the facility would administer. Interview with Resident #238's Power of Attorney (POA), on 07/13/2021 at 9:10 PM, revealed the resident resided with her prior to admission to the facility. The POA stated Home Health provided some services for Resident #238 in the home, but stated she was the resident's primary caregiver. According to the POA, the facility's Admission Coordinator came to their home on 06/16/2021, to facilitate the resident's transfer to the facility. The POA stated at that time she provided the Admission Coordinator a hand written list of Resident #238's medications, including instructions on how and when she administered the medications to the resident. The POA stated the medication list included the following medications and instruction: [MEDICATION(S)] (corticosteroid) 10 mg twice a day by mouth; [MEDICATION(S)] (heart medication) 25 mg daily by mouth; [MEDICATION(S)] (high blood pressure medication) 5 mg daily by mouth; [MEDICATION(S)] (diabetes medication) 2 mg daily by mouth; [MEDICATION(S)] (blood pressure medication) 20 mg daily by mouth; [MEDICATION(S)] (diabetes medication) 50 mg three (3) times per day with meals by mouth; and [MEDICATION(S)] (cholesterol medication) 40 mg at bedtime by mouth. In addition, the POA stated the list also stated Resident #238 received an injection of 14 units of [MEDICATION(S)] every evening. Continued interview with the POA revealed it was her understanding that the medication list she provided to the facility was the medication the facility would administer to the resident. However, review of Resident #283's admission physician orders, dated 06/17/2021, revealed the medication regimen signed by the physician and the medication regimen the POA had provided to the Admissions Coordinator did not match. The physician ordered medications for Resident #283 included: [MEDICATION(S)] 10 mg daily by mouth (5 mg more than taken at home); [MEDICATION(S)] (cholesterol medication) 80 mg at bedtime by mouth (40 mg more than taken at home); [MEDICATION(S)] 2.5 mg daily by mouth (17.5 mg less than taken at home) and [MEDICATION(S)] 1 mg daily by mouth (1 mg less than taken at home). In addition, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, the orders failed to include the resident's routine medications of [MEDICATION(S)] 25 mg daily by mouth, [MEDICATION(S)] 50 mg 3 times per day by mouth, and [MEDICATION(S)] 10 mg twice daily by mouth. Interview with the Admissions Coordinator, on 07/13/2021 at 7:30 PM, confirmed she had visited Resident #238's home prior to the resident's admission to the facility. However, the Admissions Coordinator stated she did not recall receiving a hand written list of medications from the POA, but she could have, and just did not remember the POA giving her one. The Coordinator stated she obtained a list of the resident's medications from the Home Health agency who was seeing the resident, but acknowledged she did not go over the medications with the POA to ensure the medications were accurate. The Coordinator stated the facility had never directed her to verify resident's medications with the caregiver when the facility admitted a resident from home. According to the Coordinator, facility staff took the medication list she received from the home health agency to the physician's office for the physician to review and sign, so the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the Admissions Coordinator acknowledged the Physician who signed the medication orders was not familiar with Resident #283 and had no way of knowing the resident's medication regimen prior to admission. Interview with Licensed Practical Nurse (LPN) #3, on 07/13/2021 at 4:00 PM, revealed she admitted Resident #283 to the facility on [DATE], and transcribed the resident's signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 stated she initiated the resident's medication regimen on 06/17/2021, during the facility's evening medication administration pass. Review of Resident #283's MAR for 06/17/2021, revealed at 9:00 PM, during the evening medication pass, staff administered the resident's evening medications, which included [MEDICATION(S)] 80 mg (40 mg more than taken at home). Continued review of Resident #283's MAR for June 2021, revealed during the morning medication administration pass conducted, at 8:00 AM on 06/18/2021, medications administered to Resident #238 included: [MEDICATION(S)] 30 mg, [MEDICATION(S)] 1,000 mg and [MEDICATION(S)] 1 mg, all of which the resident did not receive at home. In addition, the resident received [MEDICATION(S)] 10 mg (5 mg more than taken at home) and [MEDICATION(S)] 2.5 mg (17.5 mg less than taken at home). Further, Resident #283 failed to receive [MEDICATION(S)] 25 mg, [MEDICATION(S)] 50 mg, and [MEDICATION(S)] 20 mg, all of which the resident was receiving prior to being admitted to the facility. Review of Resident #283's Nursing Notes, dated 06/18/2021 at 11:52 AM, revealed LPN #3 documented Resident #1 was complaining of severe back pain and the resident's skin was ashy in color and cool and clammy to the touch. The facility contacted Resident #1's physician and received an order to send the resident to the hospital for further evaluation and treatment. Review of hospital records for Resident #238 dated 06/18/2021, revealed the hospital evaluated the resident in the Emergency Department (ED) at 12:18 PM, due to a chief complaint of increased heart rate. Continued review of the ED record revealed the hospital transferred Resident #283 back to the facility on [DATE], with orders to hold blood pressure medications and monitor the resident's blood pressure for the next 2-3 days. Continued review of Resident #283's MAR for June 2021, revealed staff held the residents [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] and [MEDICATION(S)] medications on 06/19/2021 and 06/20/2021, related to the orders received from the ED on 06/18/2021. The resident then resumed the medications on 06/21/2021. Further review of Resident #238's MARS, for 06/17/2021 through 06/27/2021, revealed the resident received 5 mg more of [MEDICATION(S)] daily (8 doses), and 40 mg more of [MEDICATION(S)] daily (10 doses), than the resident was receiving at home. Further, the resident received 30 mg of [MEDICATION(S)] daily (8 doses) and 1000 mg of [MEDICATION(S)] Extended Release daily (10 doses) that the resident did not receive at home. Continued review of the MARS, revealed the resident received 17.5 mg less of [MEDICATION(S)] daily (8 doses) and 1 mg less of [MEDICATION(S)] daily (10 doses) than the resident received at home. Additionally, the June MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, Resident #238 failed to receive a daily injection of [MEDICATION(S)] (10 injections) that the resident received at home. Review of Resident #283's Nursing Notes, dated 06/27/2021 at 3:25 PM, revealed documentation stated Resident #238 would not speak. The facility notified the resident's physician of the assessment and the facility transferred the resident to the hospital for further evaluation and treatment per Emergency Medical Services (EMS). Review of EMS documentation for 06/27/2021, revealed upon arrival to the facility at 10:03 AM, Resident #283 was diaphoretic (sweaty), weak, and non-verbal. At 10:14 AM, EMS personnel obtained the resident's blood glucose level, which was critically low at 26 mg/dl (normal range 70-130). EMS administered the resident Dextrose to increase the resident's blood glucose level and transported the resident to the hospital. Review of Resident #283's hospital record, dated 06/27/2021, revealed the resident presented with a chief complaint of [CONDITION(S)]. Continued review of the record revealed the physician diagnosed the resident with Acute Metabolic [CONDITION(S)] secondary to [CONDITION(S)] likely resulting from an Adrenal Crisis (a life-threatening medical emergency that occurs when there is not enough [MEDICATION(S)]) caused by the resident's abrupt discontinuation of long- term steroid therapy ([MEDICATION(S)]). The record further indicated Resident #283 had been taking [MEDICATION(S)] 10 mg twice daily for two (2) years related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued interview with Resident #238's POA, on 07/13/2021 at 9:10 PM, revealed she was not aware the facility administered the resident the wrong medication regimen until the facility transferred the resident to the hospital on 06/27/2021. She stated hospital staff informed her of the medications administered to the resident at the facility, and according to the POA, that was when she realized the facility was administering the resident the wrong medication regimen. The POA stated hospital physicians informed her that the abrupt discontinuation of the resident's [MEDICATION(S)] medication placed the resident in an Adrenal Crisis. Further interview with the POA revealed no one from the facility ever contacted her regarding discussing Resident #283's plan of care in the facility, or gave her a summary of any care the resident would receive in the facility, including the medications staff would administer to Resident #283. In addition, the POA stated she had no idea the facility had obtained a list of the resident's medications from the home health agency, and was unaware of when the last time the home health agency updated that medication list, stating Resident #238 had taken [MEDICATION(S)] for two (2) years and it apparently was not on the list. Interview with the facility's Pharmacist, on 07/16/2021 at 4:25 PM, revealed she expected staff to reconcile the resident's list of medications with the resident and/or the resident's representative to ensure the facility administered the correct medications and the correct dosages to newly admitted facility residents. The Pharmacist also stated abruptly discontinuing steroid therapy could definitely cause significant problems resulting in serious harm and possible death. In addition, the Pharmacist stated Resident #238 not receiving [MEDICATION(S)] insulin, [MEDICATION(S)] and [MEDICATION(S)], receiving too much [MEDICATION(S)] and [MEDICATION(S)], not enough [MEDICATION(S)] and [MEDICATION(S)], and receiving [MEDICATION(S)] and [MEDICATION(S)] Extended Release that the resident had not taken at home, all could have significantly impacted the resident's health and were significant medication errors. Interview with Physician #1, on 07/15/2021 at 3:00 PM, revealed he was not familiar with Resident #283 before the facility admitted the resident. However, he stated he would have expected the facility staff to contact the resident's family, who cared for the resident at home to reconcile and ensure an accurate medication list. The physician also stated he was unaware Resident #283 had been taking [MEDICATION(S)] 10 mg twice daily at home for a period of two years. The physician stated if he had known this, he would have continued the resident's [MEDICATION(S)] because of the risks involved in abruptly discontinuing steroids, which included the resident going into an Adrenal Crisis and other things, which could have been life threatening to the resident. Interview with the Director of Nursing (DON), on 07/16/2021 at 3:00 PM, revealed she was not aware the facility was required to provide a summary of care, which included a list of medications to the resident/responsible party within 48 hours of admission to the facility. The DON stated the staff followed signed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the DON stated residents had the right to be free from significant medication errors, and acknowledged if staff administered the wrong medications to a resident, the practice could potentially lead to harm or death for the resident. Interview with the Administrator, on 07/16/2021 at 4:55 PM, revealed the facility had not been discussing newly admitted resident's plan of care or medication regimen with the resident or resident representative. She stated the facility should administer the resident the correct medications and not doing so could potentially cause harm to the resident. **The facility implemented the following actions to remove the Immediate Jeopardy on 07/21/2021: 1. The facility discharged Resident #283 to the hospital on 06/27/2021. The resident has not returned to the facility 2. The Social Services Director (SSD) and Minimum Data Set (MDS) Nurse completed an audit on 07/15/2021 to review the past 30 days of new admissions to ensure the baseline care plan included an accurate summary of the resident's medications. The facility gave the resident/representative a summary of the baseline care plan. 3. The Vice President (VP) of Operations and the Regional Quality Manager (RQM) educated the Administrator and Director of Nursing on 07/17/2021 regarding the regulatory intent of F-655. Specific training included instruction that the facility must develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person- centered care of the residents that meet professional standards of care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to care for a resident properly, but not limited to initial goals based on admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The training also included the fact that the facility must provide the resident/representative with a summary of the baseline care plan that includes, but not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and any services or treatments the facility would administer. 4. On 07/17/2021, the Director of Nursing (DON) provided education to the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses on base line care plans including the above information. A post-test with a score of one-hundred percent was required. 5. On 07/19/2021, the Wound Nurse, Nurse Unit Managers, Education Training Director and MDS nurses educated all other licensed nurses, including agency nurses, on the facility's baseline care plans procedures above. A post-test with a score of one-hundred percent was required. 6. Any new licensed nurses, including agency, hired would receive the baseline care plan training prior to providing care and assuming duties. 7. Beginning 07/17/2021, the DON and Nurse Unit Manager reviewed all new admissions to validate that the baseline care plan included an accurate summary of the resident's reconciled medications, and ensure the facility provided the resident/representative with a summary. The DON and Nurse Unit Manager corrected any issues at time of discovery. This would continue for a minimum of 8 weeks. A licensed nurse and/or MDS nurse would review with the resident/responsible party the baseline care plan within 48 hours of admission. A post-test with a score of 100% was required. The baseline care plan remains a working document until the comprehensive care plan was developed. 8. The facility discharged Resident #75 home on 07/13/2021. 9. On 7/17/2021, the MDS staff completed an audit to verify residents identified at risk for elopement had wander guard bracelets in place and the care plan was accurate with updated information reflecting the resident's status. 10. On 07/17/2021, the VP of Operations and Regional Quality Manager provided education to the Administrator and Director of Nursing regarding the regulatory intent of F-657. Specific education included staff must complete a comprehensive care plan within seven days after completion of the comprehensive assessment. The training also included that the interdisciplinary team (IDT) would prepare the care plan, review and revise after each assessment, including both the comprehensive and quarterly assessments, and as needed. Examples include but were not limited to the need to revise a care plan when a resident presented with exit seeking behavior, or the exit seeking behavior increases. 11. The DON then provided the above education regarding care plans and F-657 to the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director and MDS staff on 07/17/2021. A post-test with a score of one-hundred percent was required. 12. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, the RN Education Training Director or the MDS staff provided the training to the facility's licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 13. Any new licensed nurse, including agency, hired would receive the comprehensive care plan training prior to providing care and assuming duties. 14. Beginning 07/17/2021, the Director of Nursing, Unit Manager, or assigned on-call weekend nurse that served as clinical nurse manager would audit and visually inspect all resident's determined to at risk for elopement to verify the resident has a wander guard bracelet in place and it was functioning. In addition, they would verify the resident's care plan was updated and accurate to reflect the resident's status. Staff would correct any identified issues at the time of discovery. This would continue for a minimum of eight weeks. 15. Beginning 7/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of exit seeking behavior and validate the staff have assessed the resident and that staff had updated the care plan accordingly. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager would do this on weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 16. Resident #283 discharged to the hospital on 6/27/2021, and has not returned to the facility at this time. 17. On 7/16/2021, the Director of Nursing audited each resident's medical record to ensure staff documented resident vital signs, including blood sugar and blood pressure in the record as ordered or per policy. They identified no additional concerns for additional resident assessment. 18. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-684. Including the fundamental principle that quality of Care applied to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Included in Quality of Care, but were not limited to monitoring blood sugar as ordered or as indicated with signs/symptoms of hypo/[CONDITION(S)] which may include, but not limited to excess sweating, excess hunger, shakiness, increased thirst, weakness, dry mouth; obtaining vital signs as required by facility protocol and/or physician orders. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. 19. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-684. A post-test with a score of one-hundred percent was required. 20. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-684 to facility-licensed nurses,including agency. A post-test with a score of one-hundred percent was required. 21. Any new licensed nurse hire, including agency, would receive this education related to F-684 prior to assuming duties. 22. Beginning 7/17/2021, the Director of Nursing, MDS staff , RN Wound Nurse and/or the assigned Unit Manager reviewed each resident's medical record to ensure that vital signs,including blood sugar and blood pressure, were documented in the record as ordered or per policy. This would include routine orders indicated by resident physical status and/or the need to obtain with a change in condition. Staff would correct and identified issues at the time of discovery. This process would continue daily while the facility remains in immediate jeopardy. 23. Beginning 07/17/2021 and ongoing, the Director of Nursing, RN Wound Nurse and/or assigned Unit Manager would review the twenty-four hour report and nurses notes for the prior day. They would identify any instance of a change in resident condition that would warrant obtaining blood sugar or additional vital signs, and validate this/these were obtained. Staff would correct any issues at time of discovery. The on-call nurse who served as a clinical nurse manager completed on the weekends. On Mondays, staff reviewed the information for the prior seventy-two hours as a second layer of review. 24. On 07/16/2021, the Administrator and Maintenance Director completed an audit to assess all facility exit doors for proper functioning/alarming. They identified no additional doors as having function issues. 25. On 7/16/2021, the Maintenance Director and Assistant adjusted C-Wing exit door magnet lock to ensure alarming during fifteen second egress, and re-set the key code to the physical therapy exit door to work without issue with the wander guard sensor. 26. The contracted service vendor completed a general inspection/service, on 7/20/2021, of facility doors. They identified no concerns. 27. On 07/17/2021, the VP of Operations and RQM educated the Administrator and DON regarding the regulatory intent of F-689. Specifically the facility must ensure the resident environment remained as free of accident hazards as possible; each resident received adequate supervision and assistance devices to prevent accidents. This included identifying hazards and risks; evaluating and analyzing hazards and risks; implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. Example included, but not limited to identifying the supervision needs of a resident identified as an elopement risk; maintaining and/or modify interventions if supervision needs was still required; revising the care plan with interventions to monitor the resident; assessment of exit doors for proper functioning/alarming. 28. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-689. A post-test with a score of one-hundred percent was required. 29. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F-689 to facility-licensed nurses, including agency. A post-test with a score of one-hundred percent was required. 30. Any new licensed nurse hire, including agency, would receive this education related to F-689 prior to assuming duties. 31. On 07/17/2021, the Administrator educated the Maintenance staff to check door alarms twice daily to ensure doors are alarming when opened. This included checking the emergency egress and validating the alarm sounds upon door release, utilizing a wander guard sensor for applicable doors to ensure the magnetic lock responds to lock the door, and inputting the door code to ensure the alarm sounds when the wander guard sensor passes the doorway. Staff would complete this daily while the facility remains in immediate jeopardy. 32. On 07/17/2021, the VP of Operations and Regional Quality Manager educated the Administrator and Director of Nursing regarding the regulatory intent of F-760 specifically the facility must ensure residents were free of any significant medication errors. The errors may include issues with the prescriber's order; manufacturer's specifications regarding preparation and administration; accepted professional standards and principles that apply to professionals providing services. Examples to prevent medication errors includes, but not limited to validating medication lists received for residents from home health agencies etc. with family/responsible party to ensure accuracy; reconciling medication lists received for residents and reviewing with physician for administration orders. 33. On 07/17/2021, the Administrator and Director of Nursing provided the education to the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director and MDS staff regarding F-760. A post-test with a score of one-hundred percent was required. 34. On 07/19/2021, the RN Wound Nurse, Nurse Unit Managers, RN Education Training Director or MDS staff provided the above education related to F760 to facility-licensed nurses, including agency. A post-test with a score of one hundred percent was required. 35. Any new licensed nurse hire (including agency) would receive this education related to F-760 prior to assuming duties. 36. The facility held an ad hoc Quality Assurance Process Improvement (QAPI) meeting on 07/16/2021 to review the Immediate Jeopardy citations and discuss the development of the action items to be completed. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Admissions, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director per phone. The team adopted the plan. 37. The facility held a second ad hoc QAPI meeting on held 07/20/2021 to review the status of education and audits. This meeting included the Administrator, Director of Nursing, Unit Managers, MDS staff, Staff Development, Wound Nurse, Business Office Manager, Business Office Assistant, Social Services, Activity Director, Maintenance, Housekeeping/Laundry and the Medical Director via phone. **The State Survey Agency validated the removal of Immediate Jeopardy on 07/21/2021 as follows: 1. Review of a discharge form dated 06/27/2021 revealed the facility discharged Resident #283 from the facility. Interview conducted on 07/30/2021 at 12:

Based on interview and record review, it was determined the facility failed to conduct a comprehensive annual assessment within the required timeframe for one (1) of twenty-two (22) sampled residents (Resident #1). A review of Resident #1's Minimum Date Set (MDS) assessments revealed the resident had not had an annual assessment completed in March 2021, as required. The findings include: Interview with the Director of Nursing (DON), on 07/16/2021 at 2:58 PM, revealed the facility did not have a policy for completing the Minimum Data Set (MDS) assessments, but stated the facility followed the Resident Assessment Instrument (RAI) process to complete the assessments. A review of the Long-Term Care Facility Resident Assessment Instrument version 3.0 User's Manual, revealed the annual assessment was a comprehensive assessment for a resident that the facility must complete on an annual basis. Review of Resident #1's medical record revealed the facility admitted the resident on 06/07/2020, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's MDS last annual assessment revealed the facility had completed it on 03/29/2020, and the facility had completed no further assessments for the resident. Interview with MDS Nurse #1, on 07/15/2021 at 03:24 PM, revealed she should have completed the annual MDS assessment for Resident #1 in March 2021, but had missed completing the assessment. The MDS nurse stated she completed a missing assessment report monthly, and did not know how she had overlooked completing the resident's assessment. The MDS nurse stated it was important to complete the reports timely to ensure the resident receives appropriate care and services. Interview with the Director of Nursing (DON), on 07/16/2021 at 2:58 PM, revealed the DON monitored the completion of the MDS assessments by completing audits to ensure the assessments were completed timely. However, the DON stated she had not identified that Resident #1's Annual MDS assessments was more than three months late. According to the DON, if staff did not complete MDS assessments timely, it could result in a change of condition being missed resulting in a care plan not being developed or revised with interventions to address any potential problems. Interview with the Administrator, on 07/16/2021 at 4:55 PM, revealed she relied on the MDS staff and the DON to complete and monitor MDS assessments in the facility.

Based on observation, interview, and review of the facility's policies/procedures, it was determined the facility failed to prevent the possible spread of COVID-19. Observations on 09/08/2020 revealed a nurse on the facility-designated COVID Unit entering a resident's room, who was on transmission-based precautions, without donning the required Personal Protective Equipment (PPE). Housekeeping staff was observed on the B Hall with a mask positioned below the nose. In addition, laundry staff was observed on 09/08/2020 to transport a laundry cart from the designated COVID Unit and enter the designated clean side of the laundry without cleaning or sanitizing the cart. The findings include: A review of the infection control policy titled, Infection Prevention and Control Policy and Procedure, with a revision date of 03/25/2020, revealed the facility will conduct infection control and prevention strategies to reduce the risk of transmission of the novel [MEDICAL CONDITION] (COVID-19). A review of the facility guidance for use of Personal Protective Equipment (PPE) for patients who were COVID positive revealed staff were required to wear Full PPE, to include eye protection, gown, gloves, and mask. All facility staff were required to wear eye protection and a mask at all times because the facility has current active cases of COVID-19 in residents and staff. A review of the facility policy for transporting linen titled, Handling, Transport and Storage of Laundry, with a revision date of 07/22/2020, revealed laundry was required to be transported and handled by staff with appropriate measures to prevent cross-contamination. Further review revealed clean linen must always be kept separate from contaminated linen through the use of separate rooms or designated spaces to reduce the risk of accidental contamination. (a) Observation of the B Wing hall during an initial tour on 09/08/2020 at 10:12 AM revealed Housekeeper #1 wearing a K95 facemask positioned below the nose with nares exposed, mopping resident room B-9. An interview with Housekeeper #1 on 09/08/2020 revealed he was supposed to wear the mask covering his nose and mouth but had the mask pulled down so he could breathe easier. (b) Observations conducted on the facility-designated COVID Unit on 09/08/2020 at 10:45 AM revealed RN #1 entered room D-10 without donning a required gown and gloves. A sign was observed on the room door for transmission-based precautions. An interview with RN #1 on 09/08/2020 at 10:50 AM revealed the RN was not aware she was required to wear a gown when entering the resident rooms due to a recent change in the use of PPE on the COVID Unit. Per the RN, she had been trained on the use of PPE but was confused. (c) Observation on 09/08/2020 at 11:00 AM revealed a laundry staff person transporting a linen cart from the facility-designated COVID Unit to the clean side of the laundry without the cart being cleaned or sanitized. An interview with the Laundry Worker on 09/08/2020 at 11:00 AM revealed she was nervous because the surveyor was observing the COVID Unit. The Laundry Worker stated she did not realize she had entered the designated clean side of the laundry with the cart after leaving the COVID Unit. An interview with the Laundry/Housekeeping Supervisor on 09/08/2020 at 1:25 PM revealed staff were required to wear a mask at all times covering the mouth and nose, and use the required PPE when cleaning resident rooms based on the type of precautions the residents require. Further interview revealed any carts or equipment used for laundry on the COVID Unit was required to be cleaned/sanitized and should not be transported to the clean side of the laundry until cleaned/sanitized. According to the Laundry/Housekeeping Supervisor, she makes daily rounds to observe and monitor staff and to identify problems. The Laundry\Housekeeping Supervisor had not identified any concerns. Interview with the Director of Nursing on 09/08/2020 at 2:25 PM revealed nurses on the COVID Unit were required to wear a K95 mask and face shield at all times and were required to don a gown and gloves when entering resident rooms. The DON further stated the nurses were required to remove and discard the gloves and gown when exiting the resident rooms. According to the DON, since the facility no longer had a shortage of gowns, the facility was no longer reusing gowns and now used disposable gowns. The DON stated the change in PPE use (use of disposable gowns) had occurred last week and staff were trained on this change. Further interview with the DON revealed RN #1 should have donned a gown and gloves prior to entering room D-10. The DON stated she had not been on the COVID Unit to monitor and was not aware of any concerns. An interview with the Administrator on 09/08/2020 at 2:37 PM revealed the facility had experienced an outbreak of COVID-19 starting on 08/14/2020 when a resident tested positive. As of 09/08/2020, the facility had 39 current resident cases of COVID-19. Testing was being done weekly to identify any additional positive cases and if a resident tested positive, they were moved to the COVID Unit on the C and D Hall. According to the Administrator, she made rounds throughout the day in the facility to include the COVID Unit and addressed problems. However, the Administrator stated she was not aware of staff (RN #1 and Housekeeper #1) not utilizing PPE as required (masks, gown, and gloves) or of staff transporting a contaminated laundry cart to the clean side of laundry.

Based on interview, record review, and a review of the facility policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistive devices to prevent accidents. In March 2020, the facility front door keypad (used to unlock the door) malfunctioned and was inoperable. The non-functioning keypad was switched with the functioning keypad on the D-Hall exit door on 03/20/2020. Maintenance staff rewired the keypad to the D-Hall exit door and left the wires exposed so that staff could reset the egress alarm if activated. The D-Hall door keypad exposed wires had become disconnected at some point, which deactivated the door lock and alarm on the D-Hall exit door. On 04/26/2020, Resident #1 exited the facility through the D-hall exit door without staff knowledge. The resident was last seen by staff inside the facility between 10:50 AM and 10:55 AM on 04/26/2020. The resident was found outside at approximately 10:58 AM by a facility staff member in the facility parking lot uninjured. The findings include: A review of the facility policy for elopement titled Missing Resident/Elopement Policy and Procedure, undated, revealed the purpose of the policy was to ensure that all necessary steps are taken in the event that a resident wanders away from the facility. According to the policy if a staff member observed a resident attempting to leave the facility the staff member would attempt to prevent such departure. Further review of the policy revealed Maintenance personnel were responsible for seeing that alarms were operational and checked on a routine basis. A review of the medical record for Resident #1 revealed the facility admitted the resident on 12/10/2019 with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to use a wheelchair for mobility. Further review of the assessment revealed the resident required supervision and setup help with ambulation and had no wandering behaviors. The resident was assessed to be moderately impaired for cognition with a Brief Interview for Mental Status (BIMS) score of ten (10). A review of the plan of care developed for Resident #1 revealed interventions to provide assistance of one staff member for ambulation. Further review of the plan of care revealed the plan of care was revised on 04/26/2020 with interventions for the resident to wear a wanderguard. There was no evidence of any elopement behaviors in the resident's record prior to 04/26/2020. A review of an incident report completed for Resident #1 revealed the resident was found outside in the facility parking lot on 04/26/2020 at 11:58 AM by a facility staff member. According to the report, the resident stated that he/she didn't know why (he/she) went out the door and didn't mean to cause any problems. The resident was returned to the facility and assessed to have no injuries. The resident's vital signs were recorded as: blood pressure of 119/74, heart rate of 79, respirations of 18, and an oxygen saturation of 90%. A review of the facility investigation summary dated 05/01/2020 revealed Resident #1 exited the facility via the D-Hall exit door and walked toward an alternate entrance to the facility. The resident was observed by a staff member and escorted back into the facility without incident. Prior to the incident, the resident was not assessed to be an elopement risk. According to the investigation, the resident was observed in the doorway of his/her room between 11:50 AM and 11:55 AM. A facility housekeeper clocked out at 11:58 PM, exited the building, and observed Resident #1 outside in the parking lot. Per the investigation summary, the resident was escorted back into the building, placed on fifteen (15) minute checks, and a wanderguard was placed on the resident. A review of the investigation revealed the temperature was forty-eight degrees and the resident was dressed in long-sleeve fleece pajamas and high-top slippers with rubber soles. A review of an elopement risk assessment completed for Resident #1 on 04/26/2020 revealed the resident was assessed to not be at risk for elopement, even though the resident had exited the facility the same day. Interview with the Minimum Data Set (MDS) Nurse on 05/06/2020 at 11:23 AM revealed she had completed an MDS assessment for Resident #1. The MDS Nurse stated the resident did not have a history of attempting to exit the building since the resident was admitted and no history of eloping prior to being admitted . According to the MDS nurse, she incorrectly marked the resident's elopement risk assessment in the computer but did consider the resident to be at risk for elopement after the incident on 04/26/2020 and added the wanderguard intervention to the resident's plan of care. An interview with Resident #1 on 05/04/2020 at 10:00 AM revealed the resident had exited the building but the resident could not recall the day. According to the resident, he/she was not hurt and staff assisted the resident back into the building. The resident did not reply when asked where he/she was going or why he/she had exited the building. An interview with Housekeeper (HK) #1 on 05/04/2020 at 12:58 PM revealed the housekeeper was going to lunch on 04/26/2020 and had clocked out at 11:58 AM. HK #1 stated he was walking down the sidewalk toward the parking lot and he observed Resident #1 standing beside his vehicle. HK #1 stated he immediately alerted staff that the resident was outside, a code yellow was called, and staff assisted the resident back into the building. An interview with State Registered Nurse Aide (SRNA) #1 on 05/05/2020 at 10:13 AM revealed the SRNA was alerted by HK #1 on 4/26/2020 that Resident #1 was outside. Per the SRNA, a code yellow was called and SRNA #1 assisted Resident #1 back into the building. According to SRNA #1 the resident had no injuries or was in no distress. SRNA #1 stated Resident #1 told him that the resident wanted to go home. Further interview with SRNA #1 revealed Resident #1 had never attempted to exit the building before. The SRNA stated the resident was placed on 15-minute checks and a wanderguard bracelet was applied to the resident. An interview with the Maintenance Director on 05/06/2020 at 9:23 AM revealed on 04/26/2020 the Maintenance Director came to the facility to check the door after Resident #1 had exited the facility. Further interview with the Maintenance Director revealed he had switched the front door keypad and the D-Hall keypad when the front door keypad became inoperable. The Maintenance Director stated he was instructed by the former Administrator due to budget issues to switch the keypads on the front door and the D-hall door. The Maintenance Director switched the keypads on 03/20/2020, rewired the D-hall keypad, and left the wire exposed so staff could disconnect the wires and reset the door if the alarm was activated. The Maintenance Director also stated he should have placed the wires inside the keypad box to prevent anyone from deactivating the door by disconnecting the wires. The Maintenance Director stated that when the new Administrator became aware of the door keypad being inoperable a new keypad was ordered, obtained, and installed on 05/01/2020. An interview with the Administrator on 05/05/2020 at 10:45 AM revealed the Administrator was not aware of the D-Hall keypad being rewired and not working as intended. According to the Administrator, she was called to the facility on [DATE] after Resident #1 had eloped. The Administrator stated she observed the wires to the keypad were disconnected and reconnected the wires. The Administrator stated she then had the Maintenance Director to install the wires inside the keypad box so the box would have to be taken apart by Maintenance to reset the alarm. The Administrator stated this was done until the box could be replaced. Per the Administrator, a new keypad was ordered, the keypad was installed by a contract company, and the door was checked for function on 05/01/2020.

Based on observation, interview, and review of the facility policy it was determined the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect, and ensure allegations are investigated. Interviews revealed staff had reported a nurse aide smelling of alcohol in November 2019 and a resident reported that the same nurse aide smelled like alcohol on 02/16/2020. However, the facility failed to investigate these allegations as required by the facility's policy. The findings include: Review of the facility policy titled Abuse Prohibition Standard of Practice, last revised March 2019, revealed the purpose of the policy was to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property, and to ensure immediate reporting and investigation of alleged violations to the Administrator. The policy defined an alleged violation as a situation or occurrence that is observed or reported by team members, a resident, relative or visitors, or others that has not been investigated. Review of an attachment to the policy titled Reasonable Suspicion Checklist revealed the form should be filled out, and witness statements obtained if necessary, if staff have body odors of alcohol or marijuana. 1. Interview with State Registered Nurse Aide (SRNA) #3 on 02/26/2020 at 2:55 PM revealed she attended SRNA class with SRNA #1 in November 2019 and she, as well as the SRNA class instructor, smelled alcohol on SRNA #1. SRNA #3 stated in November 2019 she witnessed the class instructor say he smells like alcohol and I'm pulling him up front, in reference to SRNA #1. Interview with Licensed Practical Nurse (LPN) #1 on 02/25/2020 at 11:40 AM revealed she conducted an SRNA class for the facility in November 2019. She stated SRNA #1 smelled of alcohol in November 2019 (unable to recall exact date) and she took the SRNA to Registered Nurse (RN) #1 because they were scheduled to do clinicals in the facility that day, and she didn't want to put residents at risk. LPN #1 stated the SRNA remained out of the patient care area for approximately one hour and returned to the floor. LPN #1 stated RN #1 informed her that the SRNA could continue to do clinicals as long as I was keeping an eye on him. The LPN stated RN #1 never obtained a witness statement when the allegation was voiced. Interview with SRNA #1 on 02/24/2020 at 2:50 PM revealed in November 2019 LPN #1 took him to RN #1 and reported that he smelled like alcohol. The SRNA stated the RN drug screened me and let me go back to work, she told me I passed. The SRNA stated he had drank alcohol the night before, but had had not drank alcohol before reporting to work. Interview with RN #1 on 02/24/2020 at 3:40 PM revealed LPN #1 reported to her that SRNA #1 smelled like alcohol; however, the RN stated she thought the LPN had smelled the alcohol on the SRNA the day before. The RN stated the SRNA was drug screened, and results were negative, and he was permitted to work with facility residents the remainder of the shift. RN #1 also stated she reported the allegation to the Administrator as required, and was not directed to take any further action related to the allegation. The RN stated she did not obtain witness statements from the LPN, or fill out a reasonable suspicion checklist as directed in the facility policy because I didn't think of it as an allegation. Interview with the Administrator on 02/26/2020 at 9:45 AM revealed RN #1 reported the allegation that SRNA #1 smelled of alcohol to her in November 2019. However, the Administrator stated she understood that the allegation was from the night before and he volunteered for the drug test and no further actions had been taken related to the allegation. She also stated staff should have filled out the reasonable suspicion checklist when allegations were voiced in the facility and witness statements should also be obtained as outlined in the facility policy. 2. Interview with Resident #4 on 02/24/2020 at 5:15 PM revealed the resident reported that SRNA #1 smelled like alcohol last week to LPN #2. The resident also stated it took SRNA #1 ten minutes to put a fitted sheet on my roommate's bed and I smelled alcohol on him, and no one asked me anything else about it until you. Interview with LPN #2 on 02/25/2020 at 8:40 PM revealed Resident #4 had reported on 02/16/2020 that SRNA #1 smelled like alcohol the night before and she reported the allegation to the weekend supervisor, RN #2. The LPN stated she informed RN #2 that SRNA #1 needed to be drug tested and she filled out the reasonable suspicion checklist, and they decided that was what action they would take; however, the SRNA did not report to work on 02/16/2020 as scheduled, and no further actions had been taken related to the alleged violation. Interview with RN #2 on 02/26/2020 at 8:45 AM revealed on 02/16/2020 LPN #2 reported that a resident alleged that SRNA #1 smelled like alcohol on 02/15/2020. The RN stated he had planned to drug test the SRNA when he reported to work on 02/16/2020; however, the SRNA called in, and no further actions had been taken, and the SRNA continued to work all shifts he was scheduled since 02/16/2020. The supervisor stated he did not report the resident's allegation to the Director of Nursing (DON) or the Administrator, but stated he should have. Interview with the Administrator on 02/27/2020 at 12:30 PM revealed RN #2 had not reported the resident's allegation to her, related to SRNA #1 smelling like alcohol as required. The Administrator stated the RN should have reported the allegation to her. She also stated all staff had been trained to report all alleged violations to her immediately.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to follow the plan of care when one (1) of three (3) sampled residents (Resident #1) was transferred. Review of Resident #1's care plan revealed he/she required a mechanical lift when he/she was transferred. However, on 02/15/2020 staff failed to utilize the lift as directed in the care plan, which resulted in the resident sustaining bruising to his/her left side and the loss of one (1) of thirty-eight (38) staples in his/her surgical wound on the resident's left lower extremity. The findings include: Review of the facility policy titled Comprehensive Care Plans Standard of Practice, not dated, revealed staff were required to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing and psychosocial needs. Review of Resident #1's record revealed the facility admitted the resident on 01/31/2020 with [DIAGNOSES REDACTED]. Review of Resident #1's admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she required extensive assistance of two (2) staff members with transfers. The MDS also revealed Resident #1 was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15). Review of Resident #1's care plan dated February 2020 revealed the resident required the assistance of two (2) staff members and the use of a mechanical lift when he/she was transferred. Review of an incident report dated 02/15/2020 revealed staff failed to transfer Resident #1 with a mechanical lift as outlined in his/her care plan. Further review revealed staff's failure to implement the resident's plan of care resulted in discoloration to the resident's left side that measured 17 centimeters (cm) by 19 cm. Interview with Registered Nurse (RN) #1 on 02/24/2020 at 11:00 AM, as well as observations conducted of the resident's post-operative surgical wound to his/her left [MEDICAL CONDITION], revealed she had evaluated his/her wound when the resident was admitted to the facility and thirty-eight staples were present. The RN stated after the incident occurred on 02/15/2020 she reevaluated Resident #1's wound and one staple came out; therefore, thirty-seven staples remained in the resident's surgical site. Interview with Resident #1 on 02/24/2020 at 10:00 AM revealed staff failed to utilize a lift when he/she was transferred on 02/15/2020. Resident #1 stated he/she landed stump first on the floor because my good leg buckled and they couldn't hold me up. Interview with SRNA #1 on 02/24/2020 at 2:50 PM revealed Resident #1 required the assistance of a mechanical lift; however, the SRNA stated he thought since Resident #1 was receiving therapy he/she would be stronger so we just used a gait belt. The SRNA stated that when they transferred the resident without a mechanical lift on 02/15/2020 we had a mishap and it was a near miss, and he was not sure if Resident #1's stump hit the floor or not. He also stated a lift should have been utilized as outlined in the resident's plan of care, which would have prevented the incident on 02/15/2020. Interview with State Registered Nurse Aide (SRNA) #2 on 02/24/2020 at 2:35 PM revealed she was aware that Resident #1's care plan directed staff to utilize a mechanical lift when being transferred; however, she failed to utilize the lift as required. SRNA #2 stated she and SRNA #1 attempted to transfer the resident with the use of a gait belt only; however, the gait belt slipped during the transfer and we couldn't hold (the resident) up. She also stated the resident's stump may have hit the floor but his/her bottom didn't. SRNA #2 stated she should have used a lift as outlined in the resident's plan of care. Interview with Registered Nurse (RN) #3 on 02/24/2020 at 12:40 PM revealed she was caring for Resident #1 when the incident occurred on 02/15/2020. The RN stated staff had been trained to follow the resident's care plan and staff were aware that Resident #1 required a mechanical lift when transferred. RN #1 also stated staff should have used a mechanical lift as outlined in his/her care plan on 02/15/2020. Interview with the Director of Nursing (DON) on 02/27/2020 at 10:15 AM revealed staff were required to follow residents' care plans to prevent accidents in the facility. The DON also stated staff should have transferred Resident #1 with a mechanical lift on 02/15/2020.

Based on observation, interview, record review, and review of the facility policy it was determined the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Resident #1 required a mechanical lift when he/she was transferred. However, staff failed to utilize the lift as required when the resident was transferred on 02/15/2020, which resulted in the resident's left lower extremity landing on the floor. The resident sustained [REDACTED]. The findings include: Review of the facility policy titled Accidents and Incident Policy, dated June 2019, revealed staff were required to ensure the resident's environment was as free from accident hazards over which the facility had control and should ensure that each resident received adequate supervision and assistive devices to prevent avoidable accidents according to the regulatory guidelines. Review of Resident #1's record revealed the facility admitted the resident on 01/31/2020 with [DIAGNOSES REDACTED]. Review of his/her admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident required extensive assistance of two (2) staff members with bed mobility and transfers. The MDS also indicated the resident was interviewable with a Brief Interview for Mental Status (BIMS) score of fifteen (15). Review of Resident #1's care plan dated February 2020 indicated he/she required the assistance of two (2) staff members and a mechanical lift when transferred. Review of an incident report for Resident #1 dated 02/15/2020 revealed staff failed to transfer him/her with a mechanical lift as outlined in the resident's care plan. Further review of the incident report revealed staff's failure to follow his/her plan of care resulted in discoloration to his/her left side that measured 17 centimeters (cm) by 19 cm. Interview with Resident #1 on 02/24/2020 at 10:00 AM revealed staff failed to utilize a lift as required when he/she was being transferred to the bed on 02/15/2020. Resident #1 stated he/she landed stump first on the floor because my good leg buckled and they couldn't hold me up. Interview with Registered Nurse (RN) #1 on 02/24/2020 at 11:00 AM, as well as observations conducted of Resident #1's post-operative surgical wound to his/her left [MEDICAL CONDITION], revealed RN #1 evaluated the resident's wound when he/she was admitted to the facility, and thirty-eight staples were observed at that time. RN #1 stated that after the incident occurred on 02/15/2020, Resident #1's wound was reevaluated and she determined one staple came out. Continued interview and observations revealed thirty-seven staples remained in the resident's surgical site. Interview with State Registered Nurse Aide (SRNA) #1 on 02/24/2020 at 2:50 PM revealed he was aware Resident #1 required the assistance of a mechanical lift; however, the SRNA stated he thought since the resident was receiving therapy he/she would be stronger so we just used a gait belt. SRNA #1 also stated that when they transferred the resident without a mechanical lift on 02/15/2020 we had a mishap and it was a near miss, and he was not sure if Resident #1's stump hit the floor or not. Interview with SRNA #2 on 02/24/2020 at 2:35 PM revealed she was aware that Resident #1 required a mechanical lift when he/she was transferred; however, she failed to utilize one as required. She stated she and SRNA #1 attempted to transfer the resident with a gait belt only; however, the gait belt slipped during the transfer and we couldn't hold (the resident) up. SRNA #2 also stated the resident's stump may have hit the floor but his/her bottom didn't. Interview with Registered Nurse (RN) #3 on 02/24/2020 at 12:40 PM revealed she was assigned to care for Resident #1 when the incident occurred on 02/15/2020. She stated staff had been trained and were aware that Resident #1 required a mechanical lift when transferred, and she stated staff should have used the lift as required to assist in ensuring the resident's safety. Interview with the Director of Nursing (DON) on 02/27/2020 at 10:15 AM revealed staff had been trained to follow residents' care plans to prevent accidents in the facility. She also stated staff should have transferred Resident #1 with a mechanical lift on 02/15/2020.

Based on observations, interview, and review of facility policy, it was determined the facility failed to ensure all mechanical equipment was in safe operating condition. Observation in the dish room revealed a pan underneath the dishwasher sink was full of water. Interviews revealed during the night when the kitchen was closed water overflowed into the kitchen and storage room. The findings include: Review of the facility Equipment policy, revised (MONTH) (YEAR), revealed all food service equipment would be clean, sanitary, and in proper working condition. Observation at 3:20 PM on 07/18/19 revealed a large plastic pan sitting on the floor underneath the sink that was connected to the dishwasher. The pan contained two to three gallons of water. The water was coming from a constant leak from a [MEDICATION NAME] fitting underneath the scrapping sink that was connected to the dishwasher. Interview with Dietary Employee #1 at 4:30 PM on 07/18/19 revealed when she entered the kitchen at 5:00 AM each morning, the pan underneath the dishwasher/sink had overflowed onto the floor. The employee stated the water would overflow into the kitchen and a storage room where milk is stored. The employee stated she had to mop up the water as soon as she went into the kitchen every morning. Interview with Dietary Employee #2 at 4:35 PM on 07/18/19 revealed she worked evenings and had to empty the pan underneath the sink/dishwasher at least two to three times while doing the evening meal dishes. Interview with the Dietary Manager (DM) at 4:40 PM on 07/18/19 revealed she had put in a work order to get the leak fixed and Maintenance had put in a new drain pipe. However, that did not stop the leak from the [MEDICATION NAME] fittings underneath the sink.

Based on observation and interview, it was determined that the facility failed to maintain a safe, clean, homelike environment for residents who utilized one (1) of seven (7) bathrooms on the A Hall. Observation on 07/17/19 and 07/18/19, revealed a bedpan, fracture bedpan, and an emesis basin were lying on the bathroom floor in the bathroom for rooms A1 and A3. The items were being stored in a stack, uncovered, and not labeled with a resident name. The findings include: An interview with the Director of Nursing (DON) on 07/19/19 at 9:00 AM, revealed the facility did not have a policy for storage of reusable resident equipment such as bedpans and basins. However, an interview with the Wound Care/Infection Control Nurse on 07/19/19 at 2:11 PM, revealed reusable resident supplies should be stored in plastic bags and labeled with the resident's name. Observation of the bathroom located between resident rooms A1 and A3 on 07/17/19 at 11:07 AM, revealed a bedpan with a fracture bedpan and an emesis basin placed inside it, lying on the floor beside the toilet. The items were not in a plastic bag, nor were they labeled with a resident's name. Observation of the same bathroom on 07/18/19 at 2:04 PM, revealed the bedpan, fracture bedpan, and emesis basin were still lying on the floor beside the toilet. The items were not stored in a plastic bag or labeled. Interview with State Registered Nurse Aides #1 and #2 on 07/19/19 at 2:05 PM, and with Registered Nurse (RN) #1 on 07/19/19 at 2:07 PM, revealed items such as bedpans and basins were required to be placed in a plastic bag and labeled with the resident's name. The staff stated the items should then be stored either in the bathroom or in the resident's closet. Interview with the Housekeeping Supervisor on 07/19/19 at 2:04 PM, revealed if she found a bedpan or basin on the floor, not in a plastic bag or labeled, she would place it in the trash. She stated these items were required to be stored in a plastic bag and labeled. Interview with the Admissions Coordinator on 07/19/19 at 2:49 PM, revealed department heads were assigned to monitor certain residents and resident rooms daily to ensure the residents' needs were met. According to the Coordinator, staff should also monitor residents' bathrooms. She stated she was assigned to monitor rooms A1 and A3; however, she stated she did not go into the bathroom because none of the residents in either room used that bathroom. She stated she was aware that items such as a bedpan and a basin were supposed to be labeled and stored in a plastic bag to maintain infection control. Interview with the Wound Care/Infection Control Nurse on 07/19/19 at 2:11 PM, revealed department heads should monitor for infection control issues during their daily observations.

Based on observation, interview, and record review, it was determined that the facility failed to provide treatment and services to prevent urinary tract infection for one (1) of nineteen (19) sampled residents (Resident #66). Observations on 7/16/19 and 7/17/19 revealed Resident #66's catheter bag was touching and/or dragging the floor while hanging beneath the resident's wheelchair. The findings include: The Administrator stated on 07/18/19 at 1:04 PM, that the facility did not have a policy regarding indwelling urinary catheter care. However, interview with the Director of Nursing (DON) on 07/18/19 at 3:18 PM, revealed her expectation was that a urinary catheter drainage bag should not touch the floor. Review of Resident #66's medical record revealed the facility admitted the resident on 06/14/18 with [DIAGNOSES REDACTED]. Review of Resident #66's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Further review of the MDS revealed the resident had an indwelling urinary catheter. Review of Resident #66's Comprehensive Care Plan dated 09/12/18 revealed the resident had a urinary catheter to a bedside drainage bag due to urinary obstruction. According to the care plan, Resident #66 was at risk for infection related to the catheter. Observation of Resident #66 on 07/16/19 at 11:30 AM and on 07/17/19 at 11:04 AM revealed the resident was in a wheelchair. The resident's urinary catheter drainage bag was observed attached to the resident's wheelchair, but was dragging the floor. Interview with State Registered Nurse Aide (SRNA) #2 on 07/19/19 at 10:42 AM, revealed the catheter bag should not be touching the floor. Interview with the Infection Control Nurse on 07/18/19 at 1:35 PM, revealed she educated staff that a urinary catheter drainage bag should always be positioned to allow for gravity drainage and should not be touching the floor. She stated she monitored to ensure infection control practices were being followed, but had not had the opportunity to monitor some of the employees who had been employed at the facility for a long period of time.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure the physician was notified when one (1) of three (3) sampled residents (Resident #2) had an increase in behavioral symptoms and was combative with staff. Interviews with staff revealed that although the resident had a history of [REDACTED]. Interviews revealed the resident was refusing incontinence care and was upset with staff because he/she believed the staff member had stolen the resident's cigarettes. The resident's care plan and facility policy required staff to notify the resident's physician of a change in the resident's condition; however, the facility failed to notify the resident's physician regarding the resident's worsening behavior and refusal of care. At approximately 10:00 PM, three (3) facility staff members transferred the resident to his/her room in a wheelchair to provide incontinence care, even though the resident was refusing care, was combative, and was putting his/her feet to the floor attempting stop the chair's movement. On the next day, 10/20/18, Resident #2 had pain and [MEDICAL CONDITION] to the right foot, and was diagnosed with [REDACTED]. The findings include: Review of the facility's Notification of Resident Change in Condition policy, not dated, revealed Clinicians will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is a significant change in the resident's physical, mental, or psychosocial status (i.e. deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). Review of Resident #2's medical record revealed the facility admitted the resident on 05/31/18, with [DIAGNOSES REDACTED]. On 10/09/18, [DIAGNOSES REDACTED]. cognitively impaired) in October. According to the 10/08/18 assessment, the resident was assessed to display verbal behavioral symptoms directed toward others 1-3 days during the seven (7) day assessment period. Review of Resident #2's nursing notes dated 10/18/18, revealed the facility contacted the resident's physician because the resident was hitting and yelling at staff. The resident's physician ordered a urinalysis and culture of the resident's urine. Further review revealed the facility revised the resident's care plan with the new physician's orders [REDACTED]. Interview with SRNA #3 on 10/29/18 at 3:00 PM and SRNA #2 on 10/29/18 at 3:55 PM, revealed they provided care for Resident #2 the next day, 10/19/18, during the evening shift (3:00 PM to 11:00 PM). SRNA #3 stated the resident got upset with her early in the shift and accused her of stealing his/her cigarettes. Both nurse aides stated the resident routinely had behaviors during the evening shift; however, on the evening of 10/19/18, the resident's behaviors were worse than usual. According to SRNA #3, she had never seen the resident's behaviors as bad as it was on 10/19/18. Both nurse aides stated the resident refused care most of the evening and was incontinent and very wet by the end of the shift. The SRNAs stated they consulted the resident's nurse, Licensed Practical Nurse (LPN) #1, regarding the resident's behavior, and LPN #1 instructed them to transfer the resident to bed and provide incontinence care. The SRNAs said the resident fought with them and did not want to go with them. The SRNAs further stated the resident kept putting his/her feet on the floor attempting to stop the wheelchair. According to the SRNAs, LPN #1 saw the resident's behaviors as they were taking the resident to his/her room. An interview with SRNA #7 on 10/30/18 at 12:40 PM revealed he asked LPN #1 about Resident #2 and the LPN stated the resident was really agitated and instructed the SRNAs to transfer the resident to bed. The SRNA stated the resident was fighting us and the resident's behaviors got worse when they were transferring the resident to bed. Further review of Resident #2's medical record revealed no evidence the physician was notified of the resident's increased behaviors on the evening of 10/19/18. Review of the nurse's notes dated 10/20/18 at 5:00 AM revealed the resident had extreme pain to the right foot, [MEDICAL CONDITION] noted. The note stated the resident was yelling out when touching to check pp (pedal pulses) which +(positive). The nurse's note further stated that the physician was contacted and an x-ray was ordered. Review of a facility investigation revealed Resident #2 was transferred to the hospital on [DATE]. Review of the resident's History and Physical from the hospital stay revealed an x-ray of the resident's right leg showed a spiral (a spiral fracture, a.k.a. torsion fracture, is a bone fracture occurring when torque (a rotating force) is applied along the axis of a bone) distal tibia fracture. Interview with LPN #1 on 10/29/18 at 2:52 PM revealed she was assigned to provide care for Resident #2 on 10/19/18. LPN #1 stated Resident #2 routinely had behaviors, and initially stated the resident was refusing care and was combative with staff on 10/19/18. However, the LPN then stated the SRNAs did not report that the resident was combative, and she did not notify Resident #2's physician related to the resident's increase in behaviors. Interview with the Unit Manager on 10/30/18 at 11:24 AM revealed a resident's physician should be notified when a resident refuses care.

Based on interview, record review, and review of a facility investigation and facility policy, it was determined the facility failed to ensure the comprehensive care plan was implemented when one (1) of three (3) sampled residents (Resident #2) displayed an increase in behavioral symptoms and was combative with staff. Resident #2's plan of care directed staff to leave the immediate area if the resident refused/rejected care and to avoid confrontation when the resident was agitated. However, on 10/19/18, Licensed Practical Nurse (LPN) #1 instructed three State Registered Nurse Aides (SRNAs) to transfer Resident #1 to bed and provide incontinence care even though the resident was upset, refusing care, combative, and putting his/her feet to the floor attempting stop the wheelchair's movement while staff transferred the resident down the hallway. The next morning, Resident #2 had [MEDICAL CONDITION] and complained of pain to the right foot. The resident was sent to the hospital for evaluation and was diagnosed with [REDACTED].k.a. torsion fracture, is a bone fracture occurring when torque (a rotating force) is applied along the axis of a bone) to the distal right tibia (bone in the lower leg). The findings include: Review of the facility's Comprehensive Care Plans Standard of Practice, not dated, revealed It is the practice of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment for Resident #2 dated 06/07/18 and the quarterly assessment dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 upon admission and 4 (severely cognitively impaired) on 10/08/18. Further review of the quarterly MDS revealed Resident #2 displayed verbal behavioral symptoms directed toward others 1-3 days during the seven (7) day assessment period. Review of Resident #2's care plan initially dated 09/21/18 revealed the facility identified that the resident had behaviors of anger, frustration, and delusions and volatile behaviors characterized by thinking staff are taking his/her monthly check, that he/she had been taken to jail, that the police were there for him/her, and that staff did not take care of the residents like they do the Caucasian residents. In addition, the facility revised the resident's care plan (date unknown) that stated the resident called staff racial names, and chanted for hours that men were out with their woman. Further review revealed on 10/16/18, staff revised the resident's care plan to include behaviors of hitting/yelling during care. The facility developed interventions that included, If the resident refuses rejects care assure safety and leave the immediate area. Reapproach in 5-10 minutes or provide alternate caregiver. Document response. Avoid Confrontation when agitated. Notify MD (physician), family, responsible party of changes as needed. Interview with SRNA #3 on 10/29/18 at 3:00 PM, SRNA #2 on 10/29/18 at 3:55 PM, and SRNA #7 on 10/30/18 at 12:40 PM revealed they had cared for Resident #2 on the evening shift (3:00 PM to 11:00 PM) on 10/19/18. SRNA #3 stated the resident got upset early in the shift and accused her of stealing his/her cigarettes. SRNAs #2 and #3 stated the resident routinely had behaviors during their shift; however, the resident's behaviors that evening were definitely worse. According to SRNA #3, she had never seen the resident's behavior as bad as it was that evening. SRNAs #2 and #3 stated the resident refused care most of the evening, and was incontinent and very wet by the end of the shift. The SRNAs stated they consulted LPN #1 regarding interventions they should implement and the LPN instructed them to take the resident to his/her room and provide incontinence care. The SRNAs stated when they explained to the resident that they were going to provide care, the resident became upset, was combative, and did not want to go with the staff. According to the SRNAs, Resident #2 kept putting his/her feet to the floor in an attempt to stop the resident's wheelchair. The SRNAs stated the resident did not complain of pain that evening, but stated it could have caused the resident's right leg fracture. Further interview revealed the resident fought with them the entire time the resident was being transported to his/her room and while the resident was transferred to bed. The SRNAs stated the nurse saw the resident's behaviors as they were taking the resident to his/her room but gave no further instruction. SRNA #3 stated when the resident was upset, staff were supposed to try and calm the resident or let the resident call his/her friend. According to SRNA #7, staff were trained to let residents calm before providing care and to notify the nurse if staff were not able to provide care. However, there was no evidence staff implemented the resident's care plan when providing care on the evening of 10/19/18. Review of Resident #2's nurse's notes dated 10/20/18 at 5:00 AM, revealed the resident had [MEDICAL CONDITION] and extreme pain to the right foot and yelled when his/her foot was touched. Review of a facility investigation revealed Resident #2 was diagnosed with [REDACTED]. Interview with the Social Worker (SW) on 10/30/18 at 10:50 AM revealed Resident #2's behavioral symptoms started shortly after admission. The SW said the resident did not understand his/her finances and would frequently complain that someone was stealing his/her check. Per the SW, the resident often chanted statements such as You are stealing my money or You are stealing my woman. The SW stated staff were unable to reason with the resident and, to deal with the resident's behaviors, staff had to leave the resident alone until he/she could cool down. The SW stated she had helped developed the care plan for the resident's behaviors and had instructed staff to leave the resident to calm down when he/she was upset. The SW stated she checked the nurse's notes each day for documentation of the resident's behaviors and talked to staff about what interventions had been effective. However, the SW stated that they had not found anything that really worked. According to the SW, forcing care on the resident would make the resident's behavior worse. Interview with the Staff Development Nurse on 10/30/18 at 10:15 AM revealed the facility provided routine training regarding how to deal with residents with behaviors and Dementia Care. The Staff Development Nurse said staff were trained they should not force care and to keep residents safe. Interview with the Unit Manager on 10/30/18 at 11:24 AM revealed that staff were trained to never force care on a resident. Per the Unit Manager, staff should walk away if a resident was upset or combative.

Based on interview, record review, and review of a facility investigation, it was determined the facility failed to provide quality care and treatment based on the resident's person-centered care plan and the resident's choice for one (1) of three (3) sampled residents (Resident #2). The facility assessed the resident to have verbal behavioral symptoms and developed a care plan with interventions to leave the immediate area if the resident refused/rejected care and avoid confrontation when the resident was agitated. Further review revealed the resident required assistance of two staff members for transferring and toileting. However, on 10/19/18, three (3) State Registered Nurse Aides (SRNAs) transferred Resident #1 to his/her room and provided incontinence care, even though the resident was combative, refusing to go, and was putting his/her feet to the floor attempting stop the wheelchair's movement while staff pulled the resident down the hallway. The next morning the resident complained of pain in the right foot and the resident had [MEDICAL CONDITION] to the foot. The facility transferred the resident to the hospital for evaluation and the resident was diagnosed with [REDACTED].k.a. torsion fracture, is a bone fracture occurring when torque (a rotating force) is applied along the axis of a bone) of the right distal tibia (lower leg bone). The findings include: Interview with the Administrator on 10/29/18 at 2:15 PM revealed the facility did not have a policy addressing resident behaviors. Review of a facility investigation dated 10/25/18 revealed the facility transferred Resident #2 to the hospital on [DATE]. The investigation revealed the resident was diagnosed with [REDACTED]. Further review of the investigation revealed Resident #2 had not had any falls and nothing in his/her living space that would indicate a reason for the swelling. However, according to the investigation, the resident had combative behavior on 10/19/18, and staff were re-educated regarding combative residents, transferring residents, and activities of daily living, etc. Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In addition, on 10/09/18, the resident was diagnosed with [REDACTED]. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] (admission assessment) and the quarterly assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 upon admission and 4 (severely cognitively impaired) on the quarterly assessment in (MONTH) (YEAR). Further review of the 10/08/18 assessment revealed Resident #2 required extensive assistance of two staff members for bed mobility and toileting, and was totally dependent on two staff members for assistance with transfers. The facility also documented that the resident displayed verbal behavioral symptoms directed toward others 1-3 days during the seven (7) day assessment period. Review of Resident #2's care plan dated 09/21/18 revealed the facility identified that the resident had behaviors and developed interventions that included assuring the resident's safety and leaving the immediate area if the resident refused/rejected care, reapproaching the resident in 5-10 minutes or providing an alternate caregiver, and documenting the resident's response; avoid confrontation when the resident is agitated; and notifying the resident's physician, family, and responsible party of changes as needed. Review of a nurse's note dated 10/18/18, revealed Resident #2 was hitting and yelling at staff. The note stated the resident's physician was notified and an order was received for a urinalysis and culture. The facility also updated the resident's care plan on 10/18/18, with an intervention to complete acute charting for three (3) days for an increase in behaviors and to notify the physician/responsible party. Further review of the nurse's notes dated 10/20/18 at 5:00 AM, revealed Resident #2 had extreme pain to the right foot, [MEDICAL CONDITION] noted with (the resident) yelling out when touching to check pp (pedal pulses) which is +. The note continued that the physician was contacted and an x-ray was ordered. Interview with the Physical Therapy Assistant (PTA) on 10/29/18 at 4:15 PM revealed she had provided therapy for Resident #2 on 10/19/18 at approximately 3:30 to 4:00 PM, and did not notice anything unusual. The PTA stated the resident did not complain of pain and she did not notice any increased [MEDICAL CONDITION] when she examined the resident's legs. Interview with SRNA #3 on 10/29/18 at 3:00 PM and SRNA #2 on 10/29/18 at 3:55 PM revealed they cared for Resident #2 on the evening shift (3:00 PM to 11:00 PM) on 10/19/18. SRNA #3 stated the resident got upset early in the shift and accused her of stealing his/her cigarettes. Both nurse aides stated the resident routinely had behaviors during the evening shift, but on the evening of 10/19/18, the resident's behavior was definitely worse. According to SRNA #3, she had never seen the resident's behaviors that bad. Both nurse aides stated the resident refused care most of the evening, and due to his/her incontinence, was very wet by the end of the shift. SRNAs #2 and #3 stated they consulted the nurse, LPN #1, regarding how to care for the resident and the nurse told them to take the resident to his/her room and provide incontinence care. The SRNAs stated when they started transferring the resident to his/her room to provide incontinence care, the resident fought with them and did not want to go with them. They stated the resident kept putting his/her feet on the floor attempting to stop the wheelchair. SRNA #2 further stated that she turned the resident's wheelchair around and pulled the resident down the hallway backward in the chair because she was afraid the resident would get hurt from trying to stop the wheelchair. SRNAs #2 and #3 further stated they asked SRNA #7 to help with Resident #2's care due to the resident's combative behavior. The SRNAs stated the nurse saw the resident's behaviors as they were taking the resident to his/her room. Per the SRNAs, the resident fought with them during transport to the resident room and transfer to the bed. After the resident was changed, the resident calmed. SRNAs #2 and #3 further stated the resident did not complain of pain at any time during the transfer or after they assisted the resident to bed. They stated they did not know how the fracture occurred unless it was when the resident kept placing his/her feet on the floor when being transferred to the resident's room. An interview with SRNA #7 on 10/30/18 at 12:40 PM revealed he worked on the evening shift on 10/19/18 and a nurse aide asked him to help with Resident #2. SRNA #7 stated the nurse (LPN #1) saw how agitated the resident was at that time; however, the nurse had instructed the SRNAs to put the resident to bed. The SRNA stated they explained to the resident that they were going to help him/her to bed, and the resident was fighting. SRNA #7 further stated the resident tried to put his/her feet down when staff were pushing the resident in a wheelchair to his/her room. SRNA #7 stated the facility trained staff to let residents calm before providing care and to let the nurse know if you were not able to provide care; however, the nurse had instructed them to provide care even though the resident was refusing care. The SRNA stated the resident did not complain of pain and he did not know how the resident's injury occurred, but stated it might have occurred when the resident was being moved in the wheelchair. Interview with LPN #1 on 10/29/18 at 2:52 PM revealed she had cared for Resident #2 on 10/19/18. The LPN stated Resident #2 routinely had behaviors. Initially, the LPN said on Friday, 10/19/18, Resident #2 was refusing care and was combative with staff. Then, when asked about the SRNAs' report of the resident's behavior and refusal of care, the LPN stated the SRNAs did not report that the resident was combative. In addition, although three SRNAs stated they reported Resident #2's behaviors to LPN #1 and the LPN instructed them to provide incontinence care, the LPN stated she would not have told the staff to change the resident if the resident was combative. Further, the LPN stated she did not call Resident #2's physician on 10/19/18 related to the resident's behaviors. The LPN stated she did not remember any other details about that evening. Interview with the Social Worker (SW) on 10/30/18 at 10:50 AM revealed Resident #2's behavioral symptoms started shortly after admission. Per the SW, the resident did not understand that his/her monthly income was used to pay for his/her stay at the facility and frequently stated that someone was stealing his/her check. The SW stated the resident would chant You are stealing my money or You are stealing my woman. The SW stated staff were unable to reason with the resident and should leave the resident alone until he/she could cool down. The SW stated she had instructed staff to leave the resident to calm when he/she was upset. The SW stated she had never seen staff force care on the resident, but stated forcing care would have made the resident's behavior worse. Interview with the Unit Manager on 10/30/18 at 11:24 AM revealed staff were trained that they should not force care on a resident. Per the Unit Manager, if a resident kept refusing care the physician should be notified. Interview with the Administrator on 10/30/18 at 1:35 PM revealed the facility had investigated Resident #2's injury and determined the resident was not abused. The Administrator stated the facility had identified that the resident's behaviors were a problem and believed staff had gotten used to Resident #2's behavioral symptoms.

Based on observation, interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to immediately consult with the physician for one (1) of four (4) sampled residents (Resident #1) when there was a significant change in the resident's physical condition and a need to alter treatment significantly. On 09/11/17 and 09/14/17, Resident #1's Responsible Party (RP) and facility staff reported that Resident #1's right lower extremity was swollen and discolored, and the resident was exhibiting pain to the area. Although documentation revealed Resident #1 was administered Tylenol (an [MEDICATION NAME] medication), the facility failed to notify Resident #1's Physician of the change in the resident's condition and ensure appropriate treatment was obtained for the resident. On 09/15/17, Resident #1's family requested an x-ray of the resident's right foot. The facility assessed the resident and documented the resident's right lower extremity was swollen with bruising noted. Further documentation revealed the resident yelled out and grimaced when his/her right foot was moved. The facility notified the resident's physician and obtained an order for [REDACTED].#1 dated 09/18/17, revealed the resident had a displaced spiral fracture (occurs due to a rotational or twisting force) to the distal third of the tibia and an oblique fracture (bone was broken at an angle) to the distal third of the fibula (lower leg/ankle area) (refer to F282, F309, and F514). The facility's failure to ensure that each resident's physician was notified of a change in condition when it warranted an alteration in treatment has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/06/17 and determined to exist on 09/11/17 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514). The facility was notified of the Immediate Jeopardy on 10/06/17. An acceptable Allegation of Compliance was received on 10/12/17, which alleged removal of the Immediate Jeopardy on 10/10/17. The State Survey Agency determined the Immediate Jeopardy was removed on 10/10/17, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Notification of Resident Change in Condition, not dated, revealed clinicians would immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Review of Resident #1's medical record revealed the facility admitted the resident on 02/23/15, with [DIAGNOSES REDACTED]. Observations of Resident #1 on 10/03/17 at 11:14 AM and 2:22 PM, revealed the resident was in bed with the right lower extremity elevated on a pillow. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/13/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2), indicating severe cognitive impairment. Further review of the MDS revealed the resident required total assistance of two (2) staff members for all activities of daily living. The MDS indicated Resident #1 did not exhibit indicators of pain. Review of Resident #1's Comprehensive Care Plan dated 12/12/16, revealed the resident had impaired communication and speech disturbance, and staff was to be aware and responsive to nonverbal communication such as facial gestures and moaning. The Care Plan directed staff to notify the resident's physician of changes in condition when needed. Interview with Resident #1's Responsible Party (RP) on 10/04/17 at 10:05 AM, revealed she visited Resident #1 on 09/11/17, during second shift. She stated she repositioned the resident's right leg and the resident yelled out in pain. She stated she looked at the resident's right foot and ankle and it was swollen and hot to the touch. The Resident's RP stated she reported this to Licensed Practical Nurse (LPN) #2 and the LPN observed the resident's right lower extremity and administered Tylenol. This was the resident's as needed pain medication. Additionally, interviews with Certified Nursing Assistant (CNA) #1 on 10/04/17 at 4:45 PM and CNA #2 at 5:00 PM, revealed they also reported to LPN #2 on 09/11/17, that Resident #1's right lower extremity was swollen. However, interviews with LPN #2 on 10/03/17 at 3:07 PM and 5:21 PM, and review of Resident #1's medical record revealed no evidence that Resident #1's Physician was notified of the concerns. Further interview with Resident #1's RP on 10/04/17 at 10:05 AM revealed the Resident's RP went to an appointment with Resident #1 on 09/14/17, to have a Modified [MEDICATION NAME] Swallow (MBS) test at the hospital. The RP stated at that time the resident's right foot and ankle remained swollen, red, and very painful to touch. She stated while at the hospital, the Radiologist performing the MBS noticed Resident #1's right lower extremity and informed the RP that the resident needed to have it looked at because something was wrong with it. Interview with the Unit Manager (UM) on 10/05/17 at 11:33 AM revealed on 09/14/17, after Resident #1 returned from the MBS, CNA #3 and CNA #5 reported to her that the resident had something wrong with (Resident #1's) leg. The UM stated she told the CNAs to notify LPN #1 of the concerns with Resident #1's leg; however, there was no evidence the UM took any action to ensure the resident's leg was assessed and the physician notified. Review of a written statement signed by CNA #5 on 09/19/17, and interviews with CNA #5 on 10/03/17 at 1:11 PM, and on 10/04/17 at 2:32 PM, revealed she reported her concerns to the UM and LPN #1 about Resident #1's right lower extremity being swollen and red, and that the resident grimaced when the extremity was moved. Review of LPN #1's written statement revealed she assessed Resident #1's right lower extremity on 09/14/17, and the area was swollen, had slight discoloration, and the resident was exhibiting pain during the assessment. However, there was no documented evidence LPN #1 notified Resident #1's Physician of the change in the resident's condition. In addition to LPN #1 and the UM, interview with the Administrator on 10/05/17 at 5:54 PM, revealed she was also made aware on 09/14/17, that Resident #1's right lower extremity was swollen and sore to touch. However, the Administrator stated she was told the physician had been notified on 09/14/17. Continued interview with Resident #1's RP on 10/04/17 at 10:05 AM, revealed on 09/15/17, she went to the facility to talk to the UM. She stated she insisted that the UM go to the resident's room and look at the resident's right lower extremity, and requested that an x-ray be performed. The RP stated that LPN #1, the nurse caring for Resident #1 on 09/15/17, also came to Resident #1's room and assessed the resident's right lower extremity. Review of a Situation, Background, Assessment, and Response (SBAR) dated 09/15/17 at 11:30 AM, and a Medicare Note dated 09/15/17 (no time documented), revealed LPN #1 assessed the resident and documented the resident's right foot/ankle was swollen and bruised, and the resident was yelling out in pain and grimaced when the foot was moved. LPN #1 notified Resident #1's Physician of the resident's change in condition, and received an order to obtain an x-ray of the resident's right lower extremity on 09/15/17. However, there was no evidence the facility contacted the mobile x-ray service to notify them of the order for the x-ray on 09/15/17. Interview with the Administrator on 10/05/17 at 5:54 PM, revealed on the morning of 09/18/17, Resident #1's RP came to her office and wanted to know what was being done for Resident #1's right lower extremity, and what the results of the resident's x-ray had shown. The Administrator stated that at that time staff checked the resident's medical record and discovered that the x-ray ordered by the Resident's Physician on 09/15/17, had not been obtained. The facility contacted the mobile x-ray supplier and notified them of the order for the x-ray. The x-ray was obtained on 09/18/17, three (3) days after being ordered by the physician and seven (7) days after Resident #1 was first discovered to have swelling, discoloration, and pain to the right lower extremity. Review of a Radiology Report for Resident #1 dated 09/18/17, revealed the resident was diagnosed with [REDACTED]. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Since 09/18/17, pain assessments are completed every four (4) hours for Resident #1 to monitor for any change in the resident's pain level or any change of condition. The assessments will continue at least until the resident's scheduled orthopedic appointment on 10/19/17. 2. On 10/06/17, the LPN was re-educated on change of condition and physician notification protocol by the Staff Educator. 3. A Quality Assurance (QA) Meeting was held on 10/06/17 to discuss the IJ allegation and to develop an action plan. Attendees included the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Nurse (SCN), Social Services (SS), Medical Records, the Regional Quality Manager, and the Medical Director (via phone). 4. On 10/06/17, 100% of residents were assessed for a change of condition by the Unit Managers (2 licensed nurses). The Comprehensive Pain Assessment Form was utilized for the assessment as this tool assesses mental status, verbal and non-verbal signs of discomfort, current or prior history of pain, effectiveness of any medications or treatments, and ability to meet goals of daily living. Changes of condition/concerns identified received follow-up with immediate notification to the MD and documentation in the medical record. 5. On 10/06/17, the Director of Nursing completed an audit of residents with x-ray orders for August, September, and (MONTH) (YEAR) to validate that the x-rays had been completed, the physician had been notified, and the results were in the medical records. No issues were identified. 6. On 10/07/17 and 10/08/17, an audit of current residents' care plans was completed by the Director of Nursing and members of the Interdisciplinary Team (IDT) that included the Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator. This audit was to validate the care plans had been implemented as written. Any concerns were immediately addressed by those completing the audit. 7. On 10/08/17, the Director of Nursing and the IDT (Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator) reviewed the prior 24 hour Nurses' Notes and nursing 24-hour report sheet for all residents for any entries regarding pain issues or needs that may require follow-up or physician notification. No issues were identified. 8. On 10/06/17, the Regional Quality Manager provided re-education to the Administrator and Director of Nursing in regards to the regulatory intent and their responsibilities in regards to F157 Physician Notification, F282 Care Planning, F309 Quality of Care, and F514 Maintaining Resident Records. 9. On 10/06/17, the Director of Nursing re-educated the RN Educator and Unit Managers regarding physician notification with all changes of condition, care plan implementation, process for obtaining and following up on x-rays as ordered, pain management protocol, and documenting change of condition in the medical record and the 24-hour nursing report. Example scenarios were reviewed with discussion and follow-up questions were included to validate understanding of the content. 10. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing, and Unit Managers re-educated all licensed nurses and certified medication aides regarding notifying the physician/responsible party of change of condition and documenting who was notified. Any new nurse or medication aide or any licensed nurse or certified medication aide on family medical leave, vacation, or who works as needed, will receive education prior to assuming duties. The education is being monitored by the RN Educator that is assigned to orientation and the facility scheduler with oversight by the Administrator and Director of Nursing who are tracking record of those that will require education to confirm that no person works without receiving the re-education. 11. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing and Unit Managers educated staff from each department regarding resident change of condition that included the Stop and Watch system to allow anyone to report a change of condition; the requirement for Situation, Background, Appearance, and Review (SBAR) and documentation of the change of condition in the medical record; and, the definition of a change of condition, which includes a change in behavior or mental status, change of vitals, change in pain, identified skin issues, change in responsiveness, or any variation from the resident's baseline. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance at the educations. The sign-in sheets were reviewed by the Administrator to ensure all staff scheduled had been re-educated prior to working. 12. On 10/06/17, the Interdisciplinary Team consisting of the Social Service Director, Activity Director, Dietary Manager, Admission Coordinator, Unit Managers, Staff Educator and MDS Coordinator were re-educated regarding following care plans to include pain management. This education was provided by the Director of Nursing. 13. On 10/06/17, 100% of licensed nurses were re-educated by the Director of Nursing and RN Educator in regards to the following: A. Pain assessment and evaluation, B. Pain documentation in the electronic medical record and in the nurses' notes, C. Physician notification, D. Change of condition, E. Receiving and follow up with physician orders [REDACTED].>F. Stop and watch forms, G. SBAR completion, and H. X-ray tracking and acute documentation in the medical record. Any new hire or any nurse on family medical leave, vacation, or who works as needed, will receive the education prior to assuming duties upon start or return to the facility. This is being monitored by the RN Educator and the facility scheduler with oversight by the Administrator and Director of Nursing, to monitor to ensure no staff member works without completing the training. 14. On 10/06/17, a form was created by the Director of Nursing and the Administrator to track orders for x-rays. This form includes the resident's name, room number, date the x-ray was ordered, the confirmation number of the x-ray, date and time the physician was notified, date and time the family/responsible party was notified, initials of the nurse receiving the x-ray order, and initials of the nurse providing any follow-up. The form is now maintained in the 24-hour shift report book and nurses are required to review the form during the change of shift report. For any x-ray ordered on the weekend or after normal business hours, the Charge Nurse must notify the On-call nurse, who will follow-up with any x-ray results. Any abnormal x-rays must be reported to the Director of Nursing or the Administrator immediately. The form was implemented on 10/06/17 and all licensed nurses were educated by the Staff Educator on this date in regards to utilization and location of the form. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance. 15. Effective 10/09/17, the licensed nurse for each assigned unit will monitor for signs/symptoms of new or unrelieved pain each shift. Nurses will initial on the resident's Medication Administration Record [REDACTED]. Below their initials on the MAR, the nurse will also put a Y indicating the resident had new pain, or a N indicating the resident had no new pain or unrelieved pain. If YES is noted, the nurse is to notify the resident's physician and document in the medical record. The Director of Nursing, Administrator, and/or Unit Managers will validate the completion of MARS Monday through Friday to ensure nurses have monitored for new or unrelieved pain with appropriate follow-up. On Saturday and Sunday, nurses assigned to the C & D Hall will check the MARSs for the A & B Halls, and nurses from the A & B Halls will check the MARS for the C & D Hall. For any YES documentation, the weekend nurse will notify the on-call licensed nurse to validate the appropriate follow-up and sign the 24- hour report indicating it was addressed. Education to licensed nurses in regards to this process was provided by the Director of Nursing on 10/08/17, and the process was implemented on 10/09/17. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 16. Effective 10/09/17, in addition to review of the 24-hour report sheet (which now includes the x-ray tracking form) and new physician orders, review of all resident Nursing Notes for the previous 24 hours has been added to the morning Clinical Meeting to ensure a comprehensive review for any resident change of condition. The assigned weekend nurse will also validate that care plans were being followed. Education regarding this process was provided to licensed nurses on 10/06/17, by Director of Nursing and Nurses Educator. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 17. Beginning 10/09/17, a minimum of five (5) residents will be evaluated for pain daily by the Director of Nursing and/or Unit Managers for eight (8) weeks to validate the resident was accurately assessed; appropriate nursing documentation was completed; physician notification was made if indicated; and any follow-up actions were completed if required, including new orders and family/responsible party notifications. Any identified issues will be addressed immediately by the reviewing nurse and audit results will be reviewed at the weekly QA meeting by the Director of Nursing. 18. Beginning 10/09/17, audits will be conducted by the Director of Nursing and/or Unit Managers on a minimum of five (5) residents' weekly times four (4) weeks, then three (3) residents weekly times eight (8) weeks to validate physician notification, accurate assessment, care plan implementation, and appropriate medical record documentation. Any identified issue will be addressed immediately by the reviewing nurse. The residents are selected from the 24-hour report and review of nursing notes in the morning clinical meeting. Results of the audit will be reviewed at the weekly QA meeting by the Director of Nursing. 19. The 24-hour report book was updated to include x-ray tracking and how to follow up on the status of the order to ensure any required follow-up is completed. Attendees of the morning Clinical Meeting Monday through Friday will include at a minimum the Director of Nursing, Unit Managers, MDS staff, and Social Services staff. On weekends, the Director of Nursing and/or the assigned licensed nurse will be responsible to conduct the review. A follow-up look back by the Clinical Team will occur on Mondays. 20. On 10/09/17, a QA Committee Meeting was held to review the status of the education that had been provided to staff, review all audit information and discuss progress of plan. A QA meeting will be held a minimum of weekly until substantial compliance is achieved. A member of the Regional Team (Regional Director of Operations, Regional Quality Manager, Regulatory Liaison, or Regional Reimbursement Nurse) will be in attendance. WAS THE MEDICAL DIRECTOR INVOLVED? ***The State Survey Agency validated the correction actions taken by the facility as follows: 1. Review of Resident #1's medical record revealed since 09/18/17, pain assessments were being completed every four (4) hours for Resident #1 to monitor for any change in resident's pain level or change of condition. Review of a facility in-service revealed the Staff Educator re-educated LPN #1 on 10/06/17, regarding change of condition policies and physician notification protocol. 2. Interview with LPN #1 on 10/19/17 at 12:15 PM, revealed she received the re-education regarding change of condition and physician notification protocols from the Staff Educator. 3. Review of a QA meeting sign in sheet revealed a QA meeting was held on 10/06/17 to discuss the IJ allegations and develop an action plan. Further review revealed the Administrator, Director of Nursing, two (2) Unit Managers, MDS Coordinator, Staff Development Nurse, Social Services, Medical Records, the Regional Quality Manager, and the Medical Director (via phone) attended the QA meeting. Interviews conducted on 10/19/17 at 12:20 PM with Unit Manager #1, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, Social Services Director at 12:50 PM, and the Medical Director at 1:30 PM, revealed they attended the QA meeting on 10/06/17, discussed the IJ allegation, and developed an action plan. 4. Review of the facility's census dated 10/06/17 and review of the facility's Comprehensive Pain Assessment Form revealed on 10/06/17, 100% of current residents were assessed for Pain and any change of condition by Unit Manager #1 and Unit Manager #2. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM and at 12:30 PM with Unit Manager #2 revealed they conducted the Comprehensive Pain Assessment on all residents. 5. Review of a facility audit tool revealed on 10/06/17, the Director of Nursing completed an audit of residents that had x-ray orders for August, September, and (MONTH) (YEAR) to validate that the x-rays were completed with physician notification and the results were in the medical records. 6. Review of facility audits dated 10/7/17 and 10/8/17, revealed the DON and members of the IDT audited current residents' care plans. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, Social Services Director at 12:50 PM, and the DON on 10/19/17 at 1:15 PM, revealed they audited current residents care plans on 10/07/17 and 10/08/17. Record review for Resident #1, Resident #2, Resident #3 and Resident #4 revealed no concerns related to the residents' care plans. 7. Review of the facility's 24 hour change of condition report dated 10/08/17, revealed the Director of Nursing and members of the IDT (Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director and the Admissions Coordinator) reviewed the nurses' notes for the previous 24 hours and the 24-hour report sheet for to ensure any pain care needs were appropriately addressed. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, with Unit Manager #2 at 12:30 PM, with the Activities Director at 12:45 PM, with Social Services Director at 12:50 PM, and with the DON on 10/19/17 at 1:15 PM, revealed they audited 24 hour reports and Nurses' Notes for any entries regarding pain or anything that may require physician notification. 8. Review of a facility Education Note dated 10/06/17, revealed the Regional Quality Manager provided re-education to the Administrator and Director of Nursing in regards to the regulatory intent and their responsibilities regarding F157 Physician Notification, F282 Care Planning, F309 Quality of Care, and F514 Maintaining Resident Records. Interview on 10/19/17 with the DON at 1:15 PM, and the Administrator at 1:50 PM, revealed they received re-education from the Regional Quality Manager regarding the regulatory intent and their responsibilities. 9. Review of a facility Education note dated 10/06/17, revealed the DON educated the RN Educator and the Unit Managers regarding physician notification with all changes of condition, care plan implementation, process for obtaining and following up on x-rays as ordered, the facility's pain management protocol, documenting change of condition in the medical record, and the 24 hour nursing report. Interview with Unit Manager #1 on 10/19/17 at 12:20 PM, Unit Manager #2 at 12:30 PM, and the RN Educator at 1:00 PM, revealed they received the education from the DON. 10. Review of the facility's In-service Training Records dated 10/06/17 and 10/07/17, revealed all licensed nurses and certified medication aides received re-education by the Staff Educator, Director of Nursing and Unit Managers that included notifying the physician/responsible party of a change in condition and documenting who was notified. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had received training regarding notifying the physician/responsible party when a change of condition occurs, including documenting who was notified. Interview with the DON on 10/19/17 at 1:15 PM, revealed all staff had completed the training and the facility had no new employees since 10/10/17. Interviews conducted on 10/19/17 with the Scheduler at 12:55 PM and the RN Educator at 1:00 PM, revealed they were responsible for monitoring to confirm that no staff worked without receiving the re-education. 11. Review of the facility's In-service Training Records dated 10/06/17 and 10/07/17, revealed education was provided to staff from each department by the Staff Educator, Director of Nursing and Unit Managers related to resident change of condition. Further review revealed the training included the Stop and Watch system to allow anyone to report a change of condition, documentation of a change in condition on an SBAR and in the medical record. Interview with the Administrator on 10/19/17 at 1:50 PM, revealed she reviewed in-service sign-in sheets to ensure all staff scheduled had been re-educated prior to working. 12. Review of the facility's In-service Training Records dated 10/06/17, revealed the Interdisciplinary Team consisting of the Social Service Director, Activity Director, Dietary Manager, Admission Coordinator, Unit Managers, Staff Educator and MDS Coordinator were re-educated by the DON regarding updating care plans with change of condition including pain. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM and the Social Services Director at 12:50 PM, revealed they had received the training provided by the DON. 13. Review of the facility's In-service Training Records dated 10/06/17, revealed 100% of licensed nurses were re-educated by the DON and RN Educator related to pain assessment and evaluation, pain documentation in the electronic medical record and in the Nurses' Notes, physician notification, change of condition, receiving and follow up with physician orders [REDACTED]. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had received training regarding the aforementioned topics. Interviews conducted on 10/19/17 with the Scheduler at 12:55 PM and the RN Educator at 1:00 PM, revealed they were responsible for monitoring to confirm that no person works without receiving the re-education. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they were providing oversight to ensure education was provided prior to any staff working a shift. 14. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they had developed a form to track orders for x-rays. Observations of the 24-hour shift reports revealed the form was being utilized during shift change to ensure x-rays were completed. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed when an x-ray was ordered on the weekend or after normal business hours, they were required to notify the on-call nurse. In addition, LPN #1, LPN #5, and LPN #6 stated any abnormal x-ray results were required to be reported to the Director of Nursing or the Administrator immediately. Continued interview with LPN #5, LPN #6, and LPN #1 revealed they were educated by the RN Educator regarding utilization and location of the form. Review of the facility Sign-In sheets dated 10/06/17, revealed staff were in attendance of the trainings. 15. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had been instructed to monitor residents for signs/symptoms of new or unrelieved pain each shift. If new or unrelieved pain was identified, the staff stated they would notify the physician and document in the medical record. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they validated all residents' MARS Monday through Friday to ensure nurses have monitored for new or unrelieved pain and conducted appropriate follow-up. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed on Saturday and Sunday, nurses monitored each hall to ensure pain assessments were completed and signed the 24- hour report, indicating the assessments were complete. Review of the facility In-Service Training Records dated 10/08/17 revealed licensed nurses had been educated in regards to this process. 16. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, and the Social Services Director at 12:50 PM, revealed all resident nursing notes for the previous 24 hours, 24 hour report, and physician orders, and care plans were reviewed in the morning Clinical Meeting to ensure any resident change of condition is addressed and appropriate interventions were implemented. 17. Review of facility audits dated 10/09/17 and 10/08/17 revealed the DON completed audits on a minimum of five (5) residents daily to ensure appropriate evaluation of pain and to validate that residents were accurately assessed, physician notification had been made as indicated, and appropriate nursing documentation was completed. 18. Review of facility audits dated 10/09/17 and 10/08/17, revealed the DON and Unit Managers conducted audit of at a minimum of five (5) residents weekly to validate physician notification, accurate assessment, care plan implementation, and appropriate medical record documentation. Interviews conducted on 10/19/17, with the DON at 1:15 PM, and the Administrator at 1:50 PM, revealed beginning 10/09/17, all resident Nursing Notes for the previous 24 hours, 24 hour reports, and new physician orders [REDACTED]. 19. Review of the 24 hour report (TRUNCATED)

Based on observation, interview, record review, and review of the facility's care plan policy, it was determined the facility failed to ensure staff provided care in accordance with the written plan of care for one (1) of four (4) sampled residents (Resident #1). The facility assessed and care planned Resident #1 to be at risk for alteration in comfort. Staff was required to complete pain assessments as needed, identify and report unrelieved or unacceptable levels of pain to the physician as needed, and give pain medications as ordered. However, on 09/11/17, Resident #1 was assessed to be exhibiting pain to the right lower extremity and continued to exhibit signs/symptoms of pain to the area until 09/18/17, when Resident #1 was diagnosed with [REDACTED]. However, staff only administered one dose of Tylenol 650 milligrams to Resident #1 from 09/11/17 until 09/18/17, when the resident was diagnosed with [REDACTED]. The facility's failure to ensure each resident received services in accordance with their comprehensive plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/06/17 and determined to exist on 09/11/17 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514). The facility was notified of the Immediate Jeopardy on 10/06/17. An acceptable Allegation of Compliance was received on 10/12/17, which alleged removal of the Immediate Jeopardy on 10/10/17. The State Survey Agency determined the Immediate Jeopardy was removed on 10/10/17, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Care Plan Policy Statement, dated 09/13/12, revealed an individualized comprehensive care plan including measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs would be developed for each resident. The policy stated the comprehensive care plan would be based on a thorough assessment. The goal of the care plan was to aid in preventing and reducing declines in the resident's functional status and/or functional levels. Review of Resident #1's medical record revealed the facility admitted the resident on 02/23/15, with [DIAGNOSES REDACTED]. Observations of Resident #1 on 10/03/17 at 11:14 AM, and 2:22 PM, revealed the resident was in bed with his/her closed eyes and the right lower extremity was elevated on a pillow. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/13/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2), indicating severe cognitive impairment. Further review of the MDS revealed Resident #1 displayed no behavioral symptoms and did not exhibit indicators of pain. Review of Resident #1's care plan dated 12/01/16, revealed the resident was at risk for alteration in comfort related to [MEDICAL CONDITION], debility, and right-sided [MEDICAL CONDITION]. The plan instructed staff to conduct pain assessments as needed, identify the location and rate the resident's pain, administer the resident's medications as ordered, and monitor for effectiveness of the pain medication. Review of (MONTH) (YEAR) Physician order [REDACTED]. Interview on 10/04/17, at 10:05 AM with Resident #1's Responsible Party (RP) revealed on 09/11/17, the RP reported to LPN #2 that Resident #1's right lower extremity was swollen, bruised, hot to touch, and painful. Interviews with LPN #2 on 10/03/17, at 3:07 PM and 5:21 PM, and review of a written statement made by LPN #2 dated 09/21/17, revealed that on 09/11/17 (exact time unknown) she assessed the resident's right lower extremity. Review of Resident #1's Medication Administration Record [REDACTED]. However, the nurse failed to document the assessment of Resident #1's right lower extremity, failed to complete a pain assessment as required noting the location and rating of the resident's pain, failed to document the reason for administering the medication, and failed to follow up to ensure the medication effectively relieved Resident #1's pain. Further review of Resident #1's medical record revealed on 09/14/17, the facility transported Resident #1 to the hospital's Radiology Department for a previously scheduled Modified [MEDICATION NAME] Swallow (MBS). Review of a written statement signed by CNA #5 on 09/19/17, and interviews with CNA #5 on 10/03/17 at 1:11 PM, and 10/4/17 at 2:32 PM, revealed while assisting Resident #1 back to bed after returning to the facility, she reported to the UM and LPN #1 that Resident #1's right lower extremity was swollen and red, and Resident #1 grimaced when the extremity was moved. The UM instructed CNA #5 to reported her concerns to LPN #1, who was assigned to care for Resident #1. Review of a written statement signed by LPN #1 on 09/19/17, revealed that after Resident #1 returned to the facility from the MBS on 09/04/17, CNA #5 reported that Resident #1's right lower extremity was swollen. According to the written statement, LPN #1 assessed the area and noted swelling and slight discoloration. LPN #1 also documented that Resident #1 was exhibiting pain during the assessment. However, there was no evidence that LPN #1 administered the resident's pain medication that was ordered as needed for pain. LPN #1 also failed to document the assessment of Resident #1's right lower extremity, failed to complete a pain assessment as required, and failed to rate Resident #1's pain. Continued interview with Resident #1's Responsible Party (RP) on 10/04/17 at 10:05 AM, revealed on 09/15/17, she insisted the UM look at the resident's right lower extremity and requested that an x-ray be performed. The RP stated that LPN #1, the nurse caring for Resident #1 on 09/15/17, also came to Resident #1's room and assessed the resident's right lower extremity. Interview with LPN #1 on 10/04/17 at 9:18 AM, review of a Situation, Background, Assessment, and Response (SBAR) dated 09/15/17 at 11:30 AM, and review of a Medicare Note dated 09/15/17 (no time documented), revealed LPN #1 assessed Resident #1's right lower extremity, and found the area was swollen and bruised, and Resident #1 was yelling out and grimacing in pain. However, there was no documented evidence to indicate that staff administered pain medication to Resident #1. Review of a Telephone Encounter faxed from the physician's office revealed LPN #1 contacted the physician's office on 09/15/17 at 12:06 PM, requesting an x-ray of Resident #1's right lower extremity related to pain and swelling. The physician ordered an x-ray on 09/15/17 at 12:18 PM. However, LPN #1 failed to contact the mobile x-ray supplier to schedule the x-ray. Resident #1's x-ray was not obtained until 09/18/17. Interviews on 10/03/17 at 4:26 PM with CNA #11, 10/04/17 at 9:56 AM with CNA #8, and 10/04/17 at 10:39 AM with CNA #9, revealed the CNAs provided care for Resident #1 between second shift on 09/15/17 and third shift on 09/17/17. The CNAs stated they all observed Resident #1's right lower extremity to be swollen and discolored, and the resident was exhibiting signs and symptoms of pain. However, review of Resident #1's (MONTH) (YEAR) MARS revealed no pain assessments were conducted and staff did not administer any pain medication from second shift on 09/15/17 through third shift on 09/17/17. On 09/18/17, review of a Medicare Note (no time) revealed the facility discovered that the x-ray of Resident #1's right lower extremity had not been obtained as ordered on [DATE]. The facility contacted the mobile x-ray supplier and the x-ray was obtained on 09/18/17 (time unknown). Review of a Radiology Report dated 09/18/17, revealed the facility was notified at 9:50 PM, that Resident #1 had a displaced spiral fracture (occurs due to a rotational or twisting force) to the distal third of the tibia and an oblique fracture (bone was broken at an angle) to the distal third of the fibula. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Since 09/18/17, pain assessments are completed every four (4) hours for Resident #1 to monitor for any change in the resident's pain level or any change of condition. The assessments will continue at least until the resident's scheduled orthopedic appointment on 10/19/17. 2. On 10/06/17, the LPN was re-educated on change of condition and physician notification protocol by the Staff Educator. 3. A Quality Assurance (QA) Meeting was held on 10/06/17 to discuss the IJ allegation and to develop an action plan. Attendees included the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Nurse (SCN), Social Services (SS), Medical Records, the Regional Quality Manager, and the Medical Director (via phone). 4. On 10/06/17, 100% of residents were assessed for a change of condition by the Unit Managers (2 licensed nurses). The Comprehensive Pain Assessment Form was utilized for the assessment as this tool assesses mental status, verbal and non-verbal signs of discomfort, current or prior history of pain, effectiveness of any medications or treatments, and ability to meet goals of daily living. Changes of condition/concerns identified received follow-up with immediate notification to the MD and documentation in the medical record. 5. On 10/06/17, the Director of Nursing completed an audit of residents with x-ray orders for August, September, and (MONTH) (YEAR) to validate that the x-rays had been completed, the physician had been notified, and the results were in the medical records. No issues were identified. 6. On 10/07/17 and 10/08/17, an audit of current residents' care plans was completed by the Director of Nursing and members of the Interdisciplinary Team (IDT) that included the Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator. This audit was to validate the care plans had been implemented as written. Any concerns were immediately addressed by those completing the audit. 7. On 10/08/17, the Director of Nursing and the IDT (Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator) reviewed the prior 24 hour Nurses' Notes and nursing 24-hour report sheet for all residents for any entries regarding pain issues or needs that may require follow-up or physician notification. No issues were identified. 8. On 10/06/17, the Regional Quality Manager provided re-education to the Administrator and Director of Nursing in regards to the regulatory intent and their responsibilities in regards to F157 Physician Notification, F282 Care Planning, F309 Quality of Care, and F514 Maintaining Resident Records. 9. On 10/06/17, the Director of Nursing re-educated the RN Educator and Unit Managers regarding physician notification with all changes of condition, care plan implementation, process for obtaining and following up on x-rays as ordered, pain management protocol, and documenting change of condition in the medical record and the 24-hour nursing report. Example scenarios were reviewed with discussion and follow-up questions were included to validate understanding of the content. 10. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing, and Unit Managers re-educated all licensed nurses and certified medication aides regarding notifying the physician/responsible party of change of condition and documenting who was notified. Any new nurse or medication aide or any licensed nurse or certified medication aide on family medical leave, vacation, or who works as needed, will receive education prior to assuming duties. The education is being monitored by the RN Educator that is assigned to orientation and the facility scheduler with oversight by the Administrator and Director of Nursing who are tracking record of those that will require education to confirm that no person works without receiving the re-education. 11. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing and Unit Managers educated staff from each department regarding resident change of condition that included the Stop and Watch system to allow anyone to report a change of condition; the requirement for Situation, Background, Appearance, and Review (SBAR) and documentation of the change of condition in the medical record; and, the definition of a change of condition, which includes a change in behavior or mental status, change of vitals, change in pain, identified skin issues, change in responsiveness, or any variation from the resident's baseline. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance at the educations. The sign-in sheets were reviewed by the Administrator to ensure all staff scheduled had been re-educated prior to working. 12. On 10/06/17, the Interdisciplinary Team consisting of the Social Service Director, Activity Director, Dietary Manager, Admission Coordinator, Unit Managers, Staff Educator and MDS Coordinator were re-educated regarding following care plans to include pain management. This education was provided by the Director of Nursing. 13. On 10/06/17, 100% of licensed nurses were re-educated by the Director of Nursing and RN Educator in regards to the following: A. Pain assessment and evaluation, B. Pain documentation in the electronic medical record and in the nurses' notes, C. Physician notification, D. Change of condition, E. Receiving and follow up with physician orders [REDACTED].>F. Stop and watch forms, G. SBAR completion, and H. X-ray tracking and acute documentation in the medical record. Any new hire or any nurse on family medical leave, vacation, or who works as needed, will receive the education prior to assuming duties upon start or return to the facility. This is being monitored by the RN Educator and the facility scheduler with oversight by the Administrator and Director of Nursing, to monitor to ensure no staff member works without completing the training. 14. On 10/06/17, a form was created by the Director of Nursing and the Administrator to track orders for x-rays. This form includes the resident's name, room number, date the x-ray was ordered, the confirmation number of the x-ray, date and time the physician was notified, date and time the family/responsible party was notified, initials of the nurse receiving the x-ray order, and initials of the nurse providing any follow-up. The form is now maintained in the 24-hour shift report book and nurses are required to review the form during the change of shift report. For any x-ray ordered on the weekend or after normal business hours, the Charge Nurse must notify the On-call nurse, who will follow-up with any x-ray results. Any abnormal x-rays must be reported to the Director of Nursing or the Administrator immediately. The form was implemented on 10/06/17 and all licensed nurses were educated by the Staff Educator on this date in regards to utilization and location of the form. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance. 15. Effective 10/09/17, the licensed nurse for each assigned unit will monitor for signs/symptoms of new or unrelieved pain each shift. Nurses will initial on the resident's Medication Administration Record [REDACTED]. Below their initials on the MAR, the nurse will also put a Y indicating the resident had new pain, or a N indicating the resident had no new pain or unrelieved pain. If YES is noted, the nurse is to notify the resident's physician and document in the medical record. The Director of Nursing, Administrator, and/or Unit Managers will validate the completion of MARS Monday through Friday to ensure nurses have monitored for new or unrelieved pain with appropriate follow-up. On Saturday and Sunday, nurses assigned to the C & D Hall will check the MARSs for the A & B Halls, and nurses from the A & B Halls will check the MARS for the C & D Hall. For any YES documentation, the weekend nurse will notify the on-call licensed nurse to validate the appropriate follow-up and sign the 24- hour report indicating it was addressed. Education to licensed nurses in regards to this process was provided by the Director of Nursing on 10/08/17, and the process was implemented on 10/09/17. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 16. Effective 10/09/17, in addition to review of the 24-hour report sheet (which now includes the x-ray tracking form) and new physician orders, review of all resident Nursing Notes for the previous 24 hours has been added to the morning Clinical Meeting to ensure a comprehensive review for any resident change of condition. The assigned weekend nurse will also validate that care plans were being followed. Education regarding this process was provided to licensed nurses on 10/06/17, by Director of Nursing and Nurses Educator. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 17. Beginning 10/09/17, a minimum of five (5) residents will be evaluated for pain daily by the Director of Nursing and/or Unit Managers for eight (8) weeks to validate the resident was accurately assessed; appropriate nursing documentation was completed; physician notification was made if indicated; and any follow-up actions were completed if required, including new orders and family/responsible party notifications. Any identified issues will be addressed immediately by the reviewing nurse and audit results will be reviewed at the weekly QA meeting by the Director of Nursing. 18. Beginning 10/09/17, audits will be conducted by the Director of Nursing and/or Unit Managers on a minimum of five (5) residents' weekly times four (4) weeks, then three (3) residents weekly times eight (8) weeks to validate physician notification, accurate assessment, care plan implementation, and appropriate medical record documentation. Any identified issue will be addressed immediately by the reviewing nurse. The residents are selected from the 24-hour report and review of nursing notes in the morning clinical meeting. Results of the audit will be reviewed at the weekly QA meeting by the Director of Nursing. 19. The 24-hour report book was updated to include x-ray tracking and how to follow up on the status of the order to ensure any required follow-up is completed. Attendees of the morning Clinical Meeting Monday through Friday will include at a minimum the Director of Nursing, Unit Managers, MDS staff, and Social Services staff. On weekends, the Director of Nursing and/or the assigned licensed nurse will be responsible to conduct the review. A follow-up look back by the Clinical Team will occur on Mondays. 20. On 10/09/17, a QA Committee Meeting was held to review the status of the education that had been provided to staff, review all audit information and discuss progress of plan. A QA meeting will be held a minimum of weekly until substantial compliance is achieved. A member of the Regional Team (Regional Director of Operations, Regional Quality Manager, Regulatory Liaison, or Regional Reimbursement Nurse) will be in attendance. WAS THE MEDICAL DIRECTOR INVOLVED? ***The State Survey Agency validated the correction actions taken by the facility as follows: 1. Review of Resident #1's medical record revealed since 09/18/17, pain assessments were being completed every four (4) hours for Resident #1 to monitor for any change in resident's pain level or change of condition. Review of a facility in-service revealed the Staff Educator re-educated LPN #1 on 10/06/17, regarding change of condition policies and physician notification protocol. 2. Interview with LPN #1 on 10/19/17 at 12:15 PM, revealed she received the re-education regarding change of condition and physician notification protocols from the Staff Educator. 3. Review of a QA meeting sign in sheet revealed a QA meeting was held on 10/06/17 to discuss the IJ allegations and develop an action plan. Further review revealed the Administrator, Director of Nursing, two (2) Unit Managers, MDS Coordinator, Staff Development Nurse, Social Services, Medical Records, the Regional Quality Manager, and the Medical Director (via phone) attended the QA meeting. Interviews conducted on 10/19/17 at 12:20 PM with Unit Manager #1, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, Social Services Director at 12:50 PM, and the Medical Director at 1:30 PM, revealed they attended the QA meeting on 10/06/17, discussed the IJ allegation, and developed an action plan. 4. Review of the facility's census dated 10/06/17 and review of the facility's Comprehensive Pain Assessment Form revealed on 10/06/17, 100% of current residents were assessed for Pain and any change of condition by Unit Manager #1 and Unit Manager #2. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM and at 12:30 PM with Unit Manager #2 revealed they conducted the Comprehensive Pain Assessment on all residents. 5. Review of a facility audit tool revealed on 10/06/17, the Director of Nursing completed an audit of residents that had x-ray orders for August, September, and (MONTH) (YEAR) to validate that the x-rays were completed with physician notification and the results were in the medical records. 6. Review of facility audits dated 10/7/17 and 10/8/17, revealed the DON and members of the IDT audited current residents' care plans. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, Social Services Director at 12:50 PM, and the DON on 10/19/17 at 1:15 PM, revealed they audited current residents care plans on 10/07/17 and 10/08/17. Record review for Resident #1, Resident #2, Resident #3 and Resident #4 revealed no concerns related to the residents' care plans. 7. Review of the facility's 24 hour change of condition report dated 10/08/17, revealed the Director of Nursing and members of the IDT (Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director and the Admissions Coordinator) reviewed the nurses' notes for the previous 24 hours and the 24-hour report sheet for to ensure any pain care needs were appropriately addressed. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, with Unit Manager #2 at 12:30 PM, with the Activities Director at 12:45 PM, with Social Services Director at 12:50 PM, and with the DON on 10/19/17 at 1:15 PM, revealed they audited 24 hour reports and Nurses' Notes for any entries regarding pain or anything that may require physician notification. 8. Review of a facility Education Note dated 10/06/17, revealed the Regional Quality Manager provided re-education to the Administrator and Director of Nursing in regards to the regulatory intent and their responsibilities regarding F157 Physician Notification, F282 Care Planning, F309 Quality of Care, and F514 Maintaining Resident Records. Interview on 10/19/17 with the DON at 1:15 PM, and the Administrator at 1:50 PM, revealed they received re-education from the Regional Quality Manager regarding the regulatory intent and their responsibilities. 9. Review of a facility Education note dated 10/06/17, revealed the DON educated the RN Educator and the Unit Managers regarding physician notification with all changes of condition, care plan implementation, process for obtaining and following up on x-rays as ordered, the facility's pain management protocol, documenting change of condition in the medical record, and the 24 hour nursing report. Interview with Unit Manager #1 on 10/19/17 at 12:20 PM, Unit Manager #2 at 12:30 PM, and the RN Educator at 1:00 PM, revealed they received the education from the DON. 10. Review of the facility's In-service Training Records dated 10/06/17 and 10/07/17, revealed all licensed nurses and certified medication aides received re-education by the Staff Educator, Director of Nursing and Unit Managers that included notifying the physician/responsible party of a change in condition and documenting who was notified. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had received training regarding notifying the physician/responsible party when a change of condition occurs, including documenting who was notified. Interview with the DON on 10/19/17 at 1:15 PM, revealed all staff had completed the training and the facility had no new employees since 10/10/17. Interviews conducted on 10/19/17 with the Scheduler at 12:55 PM and the RN Educator at 1:00 PM, revealed they were responsible for monitoring to confirm that no staff worked without receiving the re-education. 11. Review of the facility's In-service Training Records dated 10/06/17 and 10/07/17, revealed education was provided to staff from each department by the Staff Educator, Director of Nursing and Unit Managers related to resident change of condition. Further review revealed the training included the Stop and Watch system to allow anyone to report a change of condition, documentation of a change in condition on an SBAR and in the medical record. Interview with the Administrator on 10/19/17 at 1:50 PM, revealed she reviewed in-service sign-in sheets to ensure all staff scheduled had been re-educated prior to working. 12. Review of the facility's In-service Training Records dated 10/06/17, revealed the Interdisciplinary Team consisting of the Social Service Director, Activity Director, Dietary Manager, Admission Coordinator, Unit Managers, Staff Educator and MDS Coordinator were re-educated by the DON regarding updating care plans with change of condition including pain. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM and the Social Services Director at 12:50 PM, revealed they had received the training provided by the DON. 13. Review of the facility's In-service Training Records dated 10/06/17, revealed 100% of licensed nurses were re-educated by the DON and RN Educator related to pain assessment and evaluation, pain documentation in the electronic medical record and in the Nurses' Notes, physician notification, change of condition, receiving and follow up with physician orders [REDACTED]. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had received training regarding the aforementioned topics. Interviews conducted on 10/19/17 with the Scheduler at 12:55 PM and the RN Educator at 1:00 PM, revealed they were responsible for monitoring to confirm that no person works without receiving the re-education. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they were providing oversight to ensure education was provided prior to any staff working a shift. 14. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they had developed a form to track orders for x-rays. Observations of the 24-hour shift reports revealed the form was being utilized during shift change to ensure x-rays were completed. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed when an x-ray was ordered on the weekend or after normal business hours, they were required to notify the on-call nurse. In addition, LPN #1, LPN #5, and LPN #6 stated any abnormal x-ray results were required to be reported to the Director of Nursing or the Administrator immediately. Continued interview with LPN #5, LPN #6, and LPN #1 revealed they were educated by the RN Educator regarding utilization and location of the form. Review of the facility Sign-In sheets dated 10/06/17, revealed staff were in attendance of the trainings. 15. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had been instructed to monitor residents for signs/symptoms of new or unrelieved pain each shift. If new or unrelieved pain was identified, the staff stated they would notify the physician and document in the medical record. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they validated all residents' MARS Monday through Friday to ensure nurses have monitored for new or unrelieved pain and conducted appropriate follow-up. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed on Saturday and Sunday, nurses monitored each hall to ensure pain assessments were completed and signed the 24- hour report, indicating the assessments were complete. Review of the facility In-Service Training Records dated 10/08/17 revealed licensed nurses had been educated in regards to this process. 16. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, and the Social Services Director at 12:50 PM, revealed all resident nursing notes for the previous 24 hours, 24 hour report, and physician orders, and care plans were reviewed in the morning Clinical Meeting to ensure any resident change of condition is addressed and appropriate interventions were implemented. 17. Review of facility audits dated 10/09/17 and 10/08/17 revealed the DON completed audits on a minimum of five (5) residents daily to ensure appropriate evaluation of pain and to validate that residents were accurately assessed, physician notification had been made as indicated, and appropriate nursing documentation was completed. 18. Review of facility audits dated 10/09/17 and 10/08/17, revealed the DON and Unit Managers conducted audit of at a minimum of five (5) residents weekly to validate physician notification, accurate assessment, care plan implementation, and appropriate medical record documentation. Interviews conducted on 10/19/17, with the DON at 1:15 PM, and the Administrator at 1:50 PM, revealed beginning 10/09/17, all resident Nursing Notes for the previous 24 hours, 24 hour reports, and new physician orders [REDACTED]. 19. Review of the 24 hour reports revealed they included an x-ray tracking form and information on how to follow up on the status of x-ray orders to ensure any required follow-up was completed. Interviews on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, Social Services Director at 12:50 PM, and the DON on 10/19/17 at 1:15 PM, revealed they (TRUNCATED)

Based on observation, interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to ensure each resident received the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of four (4) sampled residents (Resident #1). On 09/11/17, Resident #1's Responsible Party (RP) reported to Licensed Practical Nurse (LPN) #2 that Resident #1's right lower extremity was swollen, bruised, hot to touch, and painful. Certified Nursing Assistants (CNAs) #1 and #2 also reported to LPN #2 on 09/11/17, that Resident #1's right lower extremity was swollen. Although LPN #2 assessed the resident's right lower extremity and administered Tylenol (an [MEDICATION NAME] medication), LPN #2 failed to document the assessment as required by the facility's policy. On 09/14/17, Resident #1's RP and CNA #1 and CNA #5 reported to LPN #1 that Resident #1's right ankle/foot was swollen and red, and the resident was exhibiting pain. Additionally, interviews and record review revealed LPN #5, LPN #10, the Unit Manager, and the Administrator were also made aware on 09/14/17, that Resident #1 had swelling, [MEDICAL CONDITION], discoloration, and discomfort in the right lower extremity. However, the facility failed to document that a resident assessment was conducted, and failed to assess and treat the resident's pain. On 09/15/17, Resident #1's RP called the facility and spoke to the Unit Manager (UM) to inquire about Resident #1's right lower extremity and requested that an x-ray be obtained. The UM along with LPN #1 assessed Resident #1's right lower extremity and noted the area to be red, swollen, and warm to touch, and the resident was exhibiting pain when the area was assessed. However, the facility failed to ensure the resident's pain was treated. LPN #1 contacted the resident's physician on 09/15/17, and an order was received for an x-ray to be obtained of the resident's right lower extremity. However, the facility failed to obtain the x-ray until 09/18/17, three (3) days after the x-ray was ordered and seven (7) days after the facility was first made aware that Resident #1 was experiencing swelling, discoloration, and pain to the right lower extremity. Review of a Radiology Report dated 09/18/17, revealed Resident #1 had a displaced spiral fracture (occurs due to a rotational or twisting force) to the distal third of the tibia and an oblique fracture (bone was broken at an angle) to the distal third of the fibula (refer to F157, F282, and F514). The facility's failure to ensure residents received the necessary care and services to maintain their highest practicable physical and psychosocial well-being has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/06/17 and determined to exist on 09/11/17 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514). The facility was notified of the Immediate Jeopardy on 10/06/17. An acceptable Allegation of Compliance was received on 10/12/17, which alleged removal of the Immediate Jeopardy on 10/10/17. The State Survey Agency determined the Immediate Jeopardy was removed on 10/10/17, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Change of Condition Process, dated (MONTH) (YEAR), revealed to ensure optimal outcome for each resident the nursing process (Assessment, Plan, Intervention, and Evaluation) would be utilized. The process stated that Certified Nursing Assistants (CNAs) and other staff were required to complete a Stop and Watch early detection tool to document any change in the resident's condition. The nurse caring for the resident would be given the tool and would conduct a follow-up assessment as soon as possible, if not immediately. The nurse was then required to follow the Change in Condition Assessment Guidelines, and perform an assessment to detect a change in condition for the resident. If a change in condition was identified, the nurse was to utilize the Situation, Background, Assessment, and Request (SBAR) form to document the specifics of the change in condition to be referenced when notifying the physician. Review of the facility's policy titled Pain Policy, not dated, revealed if a resident showed signs and symptoms of pain, a pain assessment would be completed by the nurse and PRN (as needed) pain medication would be administered per physicians' orders. Review of Resident #1's medical record revealed the facility admitted the resident on 02/23/15 with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/13/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2), indicating severe cognitive impairment. Further review of the MDS revealed the resident did not exhibit signs and symptoms of pain routinely. Review of Resident #1's care plan dated 12/01/16, revealed Resident #1 would be free from signs and symptoms of pain or distress. Staff was required to administer the resident's pain medication as needed and was to always be aware of and be responsive to nonverbal communication exhibited by the resident, including facial gestures and moaning. In addition, the care plan instructed staff to elicit the support of the resident's Responsible Party as needed. Observations of Resident #1 on 10/03/17 at 11:14 AM and 2:22 PM revealed the resident was in bed with eyes closed and the right lower extremity elevated on a pillow. Interview on 10/04/17, at 10:05 AM with Resident #1's Responsible Party revealed on 09/11/17, at approximately 3:30 PM, she was visiting Resident #1 and noted that the resident's right lower extremity was swollen and hot to touch. Further interview with the RP revealed she reported her concerns regarding the resident's extremity to LPN #2. Interviews on 10/04/17 at 4:45 PM with CNA #1 and at 5:00 PM with CNA #2 revealed they also noticed that Resident #1's right lower extremity was swollen when they were providing care for the resident on 09/11/17. The CNAs stated they reported their concerns about the resident's foot/ankle to LPN #2 on 09/11/17. However, the CNAs failed to fill out the Stop and Watch tool indicating their concerns related to Resident #1. Interviews with LPN #2 on 10/03/17, at 3:07 PM and 5:21 PM, and review of a written statement made by LPN #2 dated 09/21/17, revealed that on 09/11/17 Resident #1's RP asked her to assess Resident #1's right lower extremity because it was swollen and painful to the resident. LPN #2 stated she assessed the extremity, and found that it was slightly [MEDICAL CONDITION] and pink, and the resident moaned when it was moved. However, LPN #2 dismissed the RP's concern because Resident #1's left extremity also had [MEDICAL CONDITION] and the resident also moaned when the left extremity was moved. Therefore, LPN #2 stated she did not consider the assessment to be abnormal. However, LPN #1 did not utilize the SBAR process, and she did not document the RP's concern or her assessment of the resident's right lower extremity. LPN #2 administered to the resident Tylenol 650 milligrams for pain and instructed CNAs to elevate the resident's right leg. Further review of Resident #1's medical record revealed on 09/14/17, the facility transported Resident #1 to the hospital's Radiology Department for a previously scheduled Modified [MEDICATION NAME] Swallow (MBS). Continued interview with Resident #1's RP on 10/04/17 at 10:05 AM, revealed she was present at the hospital for the resident's MBS, and the resident's right lower extremity remained swollen, red, and very painful for the resident. The RP stated the Radiologist that performed the MBS also observed the resident's right lower extremity and informed the RP that the extremity needed to be assessed and treated. Interview with the Unit Manager (UM) on 10/05/17 at 11:33 AM revealed on 09/14/17, after Resident #1 returned from the MBS, CNA #3 and CNA #5 reported to her that the resident had something wrong with (Resident #22's) leg. The UM also stated that according to the CNAs, the driver that transported the resident back to the facility also reported that something was wrong with the resident's leg and asked the CNAs to notify nursing staff. Although the UM stated she instructed the CNAs to report the information to LPN #1, the UM failed to complete a Stop and Watch detection tool to give to LPN #1, who was assigned to Resident #1's care. In addition, the UM stated she did not assess Resident #1's leg or take any action to ensure the resident was assessed. Review of a written statement signed by CNA #5 on 09/19/17, and interviews with CNA #5 on 10/03/17 at 1:11 PM, and 10/04/17 at 2:32 PM, revealed while assisting Resident #1 back to bed after returning to the facility from the MBS (after lunch exact time unknown), Resident #1's right lower extremity was swollen and red, and Resident #1 grimaced when the extremity was moved. CNA #5 reported her concerns to the UM and LPN #1. The CNA stated she did not complete a Stop and Watch form because she had verbally informed the nurse of her concerns. Review of a written statement signed by LPN #1 dated 09/19/17, revealed that after Resident #1 returned to the facility from the MBS on 09/14/17, CNA #5 reported to her that Resident #1's right lower extremity was swollen. According to the written statement, LPN #1 assessed the area and noted swelling and slight discoloration. LPN #1 also stated that Resident #1 was exhibiting pain during the assessment. However, there was no documented evidence that LPN #1 completed an SBAR form, administered pain medication to the resident, or documented the abnormal assessment of Resident #1's right lower extremity. Interviews with CNA #1 on 10/03/17 at 4:35 PM and 10/04/17 at 4:45 PM, revealed she cared for Resident #1 on 09/14/17, during second shift. The CNA reported that Resident #1's right lower extremity was swollen and the CNA elevated the extremity on a pillow. Although CNA #1 did not complete a Stop and Watch tool, the CNA reported to LPN #2 that the right lower extremity was swollen. CNA #1 stated LPN #2 told her that Resident #1's right lower extremity had already been reported to her by day shift. However, interview with LPN #2 on 10/03/17 at 5:21 PM, revealed she denied that CNAs reported any concerns to her related to Resident #1 on 09/14/17 and there was no documented evidence the LPN assessed Resident #1 or administered pain medication to the resident. Interview with CNA #10 on 10/03/17 at 12:47 PM, revealed she was assigned to care for Resident #1 on 09/14/17 and 09/15/17, during third shift. CNA #10 stated second shift staff reported that Resident #1's right lower extremity was swollen and red and that it was to be kept elevated on pillows. Further interview with the UM on 10/05/17 at 11:33 AM, revealed Resident #1's RP was at the facility on 09/15/17, and asked the UM to look at Resident #1's foot and ankle and inquired about what was being done for the resident's extremity. She stated the RP told her that while the resident was at the hospital on [DATE], the Radiologist told the RP that something needed to be done about the resident's leg. The UM stated she assessed the resident's right foot and ankle and reported to LPN #1 that the resident's leg was red, swollen, and warm to touch near the resident's shin area, and had discoloration to the right inner foot. She stated she told LPN #1 to call the resident's physician and get an order for [REDACTED].#1 received an x-ray. Interview with LPN #1 on 10/04/17 at 9:18 AM, and review of a Situation, Background, Assessment, and Response (SBAR) form dated 09/15/17 at 11:30 AM, revealed CNA #5 requested that LPN #1 assess Resident #1's right lower extremity. The CNA reported the area was swollen and bruised, and Resident #1 was yelling out in pain. LPN #1 stated she assessed Resident #1 and documented that the resident's right foot/ankle was swollen and bruised, and the resident was yelling out in pain and grimacing when the foot was moved. However, there was no documented evidence LPN #1 treated the resident's pain, despite the resident yelling out in pain. Review of a Telephone Encounter faxed from the physician's office revealed LPN #1 contacted the physician's office on 09/15/17 at 12:06 PM, requesting an x-ray of Resident #1's right lower extremity related to pain and swelling. Further review revealed the physician's office notified the facility on 09/15/17 at 12:18 PM, that the physician had ordered the x-ray. However, review of a Medicare Note dated 09/15/17, revealed the order for the x-ray was reported off to the oncoming nurse, and there was no documented evidence LPN #1 notified the mobile x-ray supplier of the order. Further interview with LPN #1 on 10/03/17 at 1:49 PM revealed she did not call and order the portable x-ray for Resident #1 on 09/15/17, because she assumed the nurse coming on to second shift (RN #1) would order the x-ray. However, interview with Registered Nurse (RN) #1 on 10/03/17 at 4:53 PM and 10/04/17 at 5:09 PM, revealed LPN #1 told her during shift change on 09/15/17 that Resident #1 had swelling, redness, and pain to his/her right foot and ankle and an x-ray had been ordered. RN #1 further stated that LPN #1 told her that she would notify the mobile x-ray supplier that an x-ray was needed for Resident #1. RN #1 stated since LPN #1 had received the physician's orders [REDACTED].#1's responsibility to order/schedule the x-ray. Therefore, RN #1 made no attempt to contact the mobile x-ray supplier and never followed up on the status of the x-ray or took any action to ensure the x-ray was obtained as ordered. Interviews on 10/03/17 at 4:26 PM with CNA #11, and on 10/04/17 at 9:56 AM with CNA #8 and 10:39 AM with CNA #9, who had cared for Resident #1 from second shift on 09/15/17 through third shift on 09/17/17, revealed the staff observed Resident #1's right lower extremity to be swollen and discolored, and the resident was exhibiting signs and symptoms of pain. However, no documentation was made regarding Resident #1's right lower extremity. Interview with LPN #3 on 10/05/17 at 10:31 AM, who cared for Resident #1 on 09/16/17 and 09/17/17 on day shift, revealed no one had notified him of any concerns with Resident #1's right lower extremity in shift report. LPN #3 stated he was not aware that an x-ray of the extremity had been ordered. LPN #3 stated a CNA reported to him on 09/16/17, that Resident #1's right lower extremity was bruised and he observed the bruising; however, CNAs stated the resident's leg had been reported to nursing staff on 09/15/17, and they had been instructed to keep the extremity elevated. The LPN stated on 09/17/17 that he did not assess Resident #1's right lower extremity. There was no evidence that LPN #3 made any documentation regarding Resident #1's right lower extremity on 09/16/17 or 09/17/17 or any attempt to ensure any ordered treatments had been carried out. Review of a written statement signed by RN #3 on 09/20/17, and interview with RN #3 on 10/05/17 at 3:52 PM, revealed he had cared for Resident #1 on 09/16/17 and 09/17/17 during second shift. RN #3 stated he had not been given any information in report on either day about Resident #1's right lower extremity. RN #3 stated the first time he became aware of a concern with the resident's leg was on 09/17/17, when the resident's RP was at the facility visiting and questioned him regarding what was being done for the resident's extremity. RN #3 stated he looked at Resident #1's right lower extremity and it was red and swollen. He stated he also checked the resident's chart and informed the RP that an x-ray had been ordered but it had not been obtained. However, RN #3 took no action to see why the x-ray had not been obtained, made no documentation regarding the right leg, and did not administer to the resident any pain medication. Interview with the Director of Nursing (DON) on 10/05/17 at 4:45 PM, revealed on 09/15/17, the UM notified her of the concern with Resident #1's right lower extremity. She stated the UM reported that she had spoken with the resident's RP that morning and the Radiologist at the hospital told her that he felt the resident's leg needed to be assessed and treated. She stated the UM told her she had assessed the resident's leg and thought the resident had [MEDICAL CONDITION] (bacterial skin infection that appears as a swollen, red area of skin that feels hot and tender). The UM also reported that an x-ray was going to be obtained of the resident's extremity. However, the DON stated she did not assess the resident's right lower extremity, and took no action to ensure the x-ray was obtained. The DON stated that all changes in a resident's status including accidents, incidents, and changes in condition were discussed in the daily morning stand-up meeting to ensure appropriate actions and interventions had been taken. However, the meeting only occurred Monday through Friday. The DON stated any incidents that occurred on Friday after the meeting (Resident #1's x-ray was ordered on Friday, 09/15/17), would not be discussed until the following Monday morning. Interview with the Administrator on 10/05/17 at 5:54 PM, revealed she was notified on 09/14/17, that Resident #1's right lower extremity was swollen and sore to touch. However, the Administrator stated she was told the physician had been notified on 09/14/17, and she took no action to ensure the resident was being treated appropriately. The Administrator stated on the morning of 09/18/17, Resident #1's RP came to her office and wanted to know what was being done for Resident #1's right lower extremity, and what the results of the resident's x-ray had shown. The Administrator stated that at that time staff checked the resident's medical record and discovered that the x-ray ordered by the resident's physician on 09/15/17 had not been obtained. The facility contacted the mobile x-ray supplier and notified them of the order for the x-ray. The x-ray was obtained on 09/18/17, three (3) days after being ordered by the physician and seven (7) days after Resident #1 was first discovered to have swelling, discoloration, and pain to the right lower extremity. Review of an x-ray report dated 09/18/17, revealed Resident #1 had sustained a displaced spiral fracture (occurs due to a rotational or twisting force) to the distal third of the tibia and an oblique fracture (bone was broken at an angle) to the distal third of the fibula. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Since 09/18/17, pain assessments are completed every four (4) hours for Resident #1 to monitor for any change in the resident's pain level or any change of condition. The assessments will continue at least until the resident's scheduled orthopedic appointment on 10/19/17. 2. On 10/06/17, the LPN was re-educated on change of condition and physician notification protocol by the Staff Educator. 3. A Quality Assurance (QA) Meeting was held on 10/06/17 to discuss the IJ allegation and to develop an action plan. Attendees included the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Nurse (SCN), Social Services (SS), Medical Records, the Regional Quality Manager, and the Medical Director (via phone). 4. On 10/06/17, 100% of residents were assessed for a change of condition by the Unit Managers (2 licensed nurses). The Comprehensive Pain Assessment Form was utilized for the assessment as this tool assesses mental status, verbal and non-verbal signs of discomfort, current or prior history of pain, effectiveness of any medications or treatments, and ability to meet goals of daily living. Changes of condition/concerns identified received follow-up with immediate notification to the MD and documentation in the medical record. 5. On 10/06/17, the Director of Nursing completed an audit of residents with x-ray orders for August, September, and (MONTH) (YEAR) to validate that the x-rays had been completed, the physician had been notified, and the results were in the medical records. No issues were identified. 6. On 10/07/17 and 10/08/17, an audit of current residents' care plans was completed by the Director of Nursing and members of the Interdisciplinary Team (IDT) that included the Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator. This audit was to validate the care plans had been implemented as written. Any concerns were immediately addressed by those completing the audit. 7. On 10/08/17, the Director of Nursing and the IDT (Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator) reviewed the prior 24 hour Nurses' Notes and nursing 24-hour report sheet for all residents for any entries regarding pain issues or needs that may require follow-up or physician notification. No issues were identified. 8. On 10/06/17, the Regional Quality Manager provided re-education to the Administrator and Director of Nursing in regards to the regulatory intent and their responsibilities in regards to F157 Physician Notification, F282 Care Planning, F309 Quality of Care, and F514 Maintaining Resident Records. 9. On 10/06/17, the Director of Nursing re-educated the RN Educator and Unit Managers regarding physician notification with all changes of condition, care plan implementation, process for obtaining and following up on x-rays as ordered, pain management protocol, and documenting change of condition in the medical record and the 24-hour nursing report. Example scenarios were reviewed with discussion and follow-up questions were included to validate understanding of the content. 10. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing, and Unit Managers re-educated all licensed nurses and certified medication aides regarding notifying the physician/responsible party of change of condition and documenting who was notified. Any new nurse or medication aide or any licensed nurse or certified medication aide on family medical leave, vacation, or who works as needed, will receive education prior to assuming duties. The education is being monitored by the RN Educator that is assigned to orientation and the facility scheduler with oversight by the Administrator and Director of Nursing who are tracking record of those that will require education to confirm that no person works without receiving the re-education. 11. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing and Unit Managers educated staff from each department regarding resident change of condition that included the Stop and Watch system to allow anyone to report a change of condition; the requirement for Situation, Background, Appearance, and Review (SBAR) and documentation of the change of condition in the medical record; and, the definition of a change of condition, which includes a change in behavior or mental status, change of vitals, change in pain, identified skin issues, change in responsiveness, or any variation from the resident's baseline. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance at the educations. The sign-in sheets were reviewed by the Administrator to ensure all staff scheduled had been re-educated prior to working. 12. On 10/06/17, the Interdisciplinary Team consisting of the Social Service Director, Activity Director, Dietary Manager, Admission Coordinator, Unit Managers, Staff Educator and MDS Coordinator were re-educated regarding following care plans to include pain management. This education was provided by the Director of Nursing. 13. On 10/06/17, 100% of licensed nurses were re-educated by the Director of Nursing and RN Educator in regards to the following: A. Pain assessment and evaluation, B. Pain documentation in the electronic medical record and in the nurses' notes, C. Physician notification, D. Change of condition, E. Receiving and follow up with physician orders [REDACTED].>F. Stop and watch forms, G. SBAR completion, and H. X-ray tracking and acute documentation in the medical record. Any new hire or any nurse on family medical leave, vacation, or who works as needed, will receive the education prior to assuming duties upon start or return to the facility. This is being monitored by the RN Educator and the facility scheduler with oversight by the Administrator and Director of Nursing, to monitor to ensure no staff member works without completing the training. 14. On 10/06/17, a form was created by the Director of Nursing and the Administrator to track orders for x-rays. This form includes the resident's name, room number, date the x-ray was ordered, the confirmation number of the x-ray, date and time the physician was notified, date and time the family/responsible party was notified, initials of the nurse receiving the x-ray order, and initials of the nurse providing any follow-up. The form is now maintained in the 24-hour shift report book and nurses are required to review the form during the change of shift report. For any x-ray ordered on the weekend or after normal business hours, the Charge Nurse must notify the On-call nurse, who will follow-up with any x-ray results. Any abnormal x-rays must be reported to the Director of Nursing or the Administrator immediately. The form was implemented on 10/06/17 and all licensed nurses were educated by the Staff Educator on this date in regards to utilization and location of the form. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance. 15. Effective 10/09/17, the licensed nurse for each assigned unit will monitor for signs/symptoms of new or unrelieved pain each shift. Nurses will initial on the resident's Medication Administration Record [REDACTED]. Below their initials on the MAR, the nurse will also put a Y indicating the resident had new pain, or a N indicating the resident had no new pain or unrelieved pain. If YES is noted, the nurse is to notify the resident's physician and document in the medical record. The Director of Nursing, Administrator, and/or Unit Managers will validate the completion of MARS Monday through Friday to ensure nurses have monitored for new or unrelieved pain with appropriate follow-up. On Saturday and Sunday, nurses assigned to the C & D Hall will check the MARSs for the A & B Halls, and nurses from the A & B Halls will check the MARS for the C & D Hall. For any YES documentation, the weekend nurse will notify the on-call licensed nurse to validate the appropriate follow-up and sign the 24- hour report indicating it was addressed. Education to licensed nurses in regards to this process was provided by the Director of Nursing on 10/08/17, and the process was implemented on 10/09/17. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 16. Effective 10/09/17, in addition to review of the 24-hour report sheet (which now includes the x-ray tracking form) and new physician orders, review of all resident Nursing Notes for the previous 24 hours has been added to the morning Clinical Meeting to ensure a comprehensive review for any resident change of condition. The assigned weekend nurse will also validate that care plans were being followed. Education regarding this process was provided to licensed nurses on 10/06/17, by Director of Nursing and Nurses Educator. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 17. Beginning 10/09/17, a minimum of five (5) residents will be evaluated for pain daily by the Director of Nursing and/or Unit Managers for eight (8) weeks to validate the resident was accurately assessed; appropriate nursing documentation was completed; physician notification was made if indicated; and any follow-up actions were completed if required, including new orders and family/responsible party notifications. Any identified issues will be addressed immediately by the reviewing nurse and audit results will be reviewed at the weekly QA meeting by the Director of Nursing. 18. Beginning 10/09/17, audits will be conducted by the Director of Nursing and/or Unit Managers on a minimum of five (5) residents' weekly times four (4) weeks, then three (3) residents weekly times eight (8) weeks to validate physician notification, accurate assessment, care plan implementation, and appropriate medical record documentation. Any identified issue will be addressed immediately by the reviewing nurse. The residents are selected from the 24-hour report and review of nursing notes in the morning clinical meeting. Results of the audit will be reviewed at the weekly QA meeting by the Director of Nursing. 19. The 24-hour report book was updated to include x-ray tracking and how to follow up on the status of the order to ensure any required follow-up is completed. Attendees of the morning Clinical Meeting Monday through Friday will include at a minimum the Director of Nursing, Unit Managers, MDS staff, and Social Services staff. On weekends, the Director of Nursing and/or the assigned licensed nurse will be responsible to conduct the review. A follow-up look back by the Clinical Team will occur on Mondays. 20. On 10/09/17, a QA Committee Meeting was held to review the status of the education that had been provided to staff, review all audit information and discuss progress of plan. A QA meeting will be held a minimum of weekly until substantial compliance is achieved. A member of the Regional Team (Regional Director of Operations, Regional Quality Manager, Regulatory Liaison, or Regional Reimbursement Nurse) will be in attendance. WAS THE MEDICAL DIRECTOR INVOLVED? ***The State Survey Agency validated the correction actions taken by the facility as follows: 1. Review of Resident #1's medical record revealed since 09/18/17, pain assessments were being completed every four (4) hours for Resident #1 to monitor for any change in resident's pain level or change of condition. Review of a facility in-service revealed the Staff Educator re-educated LPN #1 on 10/06/17, regarding change of condition policies and physician notification protocol. 2. Interview with LPN #1 on 10/19/17 at 12:15 PM, revealed she received the re-education regarding change of condition and physician notification protocols from the Staff Educator. 3. Review of a QA meeting sign in sheet revealed a QA meeting was held on 10/06/17 to discuss the IJ allegations and develop an action plan. Further review revealed the Administrator, Director of Nursing, two (2) Unit Managers, MDS Coordinator, Staff Development Nurse, Social Services, Medical Records, the Regional Quality Manager, and the Medical Director (via phone) attended the QA meeting. Interviews conducted on 10/19/17 at 12:20 PM with Unit Manager #1, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, Social Services Director at 1 (TRUNCATED)

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the medical record was complete for one (1) of five (5) sampled residents (Resident #1). Resident #1's Responsible Party (RP) and facility staff reported to licensed staff on 09/11/17, that Resident #1's right lower extremity was swollen and discolored, and the resident was exhibiting signs and symptoms of pain in the extremity. However, the facility failed to document the resident's change in condition in the medical record (refer to F157, F282, and F309). The facility's failure to ensure medical records were accurate has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 10/06/17 and determined to exist on 09/11/17 at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514). The facility was notified of the Immediate Jeopardy on 10/06/17. An acceptable Allegation of Compliance was received on 10/12/17, which alleged removal of the Immediate Jeopardy on 10/10/17. The State Survey Agency determined the Immediate Jeopardy was removed on 10/10/17, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F157), 42 CFR 483.21 Comprehensive Person-Centered Care Planning (F282), 42 CFR 483.25 Quality of Care (F309), and 42 CFR 483.70 Administration (F514), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy, Charting and Documentation, undated, revealed all services provided to the resident or changes in the resident's medical condition would be documented in the medical record. Review of Resident #1's medical record revealed the facility admitted the resident on 02/23/15 with [DIAGNOSES REDACTED]. Interview with the Responsible Party (RP) for Resident #1 on 10/04/17, at 10:05 AM revealed on 09/11/17, the RP reported to Licensed Practical Nurse (LPN) #2 that the resident had pain with movement in his/her right foot and ankle and it was swollen and hot to the touch. LPN #2 looked at the resident's foot and ankle, and administered Tylenol (pain medication) to the resident. However, the nurse failed to document the RP's concerns related to Resident #1's right lower extremity, failed to document her assessment of the resident, and failed to document the reason for administering Tylenol. Further interview with Resident #1's RP on 10/04/17 at 10:05 AM, and interviews on 10/04/17 at 4:45 PM with Certified Nursing Assistant (CNA) #1 and at 5:00 PM with CNA #2, revealed on 09/14/17 they reported to LPN #1 that Resident #1's right lower extremity was swollen and red, and the resident was exhibiting pain. Review of a written statement signed by LPN #1 on 09/19/17, revealed the LPN assessed Resident #1 right lower extremity but failed to document the assessment in the resident's medical record. Interview with LPN #3 on 10/05/17 at 10:31 AM, who cared for Resident #1 on 09/16/17 and 09/17/17 on day shift, revealed a CNA reported to him on 09/16/17, that Resident#1's right lower extremity was bruised. LPN #3 stated he observed the resident's leg; however, LPN #3 failed to document the assessment of Resident #3's right lower extremity in the resident's medical record. Interview with the Director of Nursing (DON) on 10/05/17 at 4:45 PM, revealed staff were required to document all resident assessments and any assessments of residents' pain. The DON stated she had not identified any concerns with staff failure to document assessments. Review of an x-ray report dated 09/18/17, revealed Resident #1 had sustained a displaced spiral fracture (occurs due to a rotational or twisting force) to the distal third of the tibia and an oblique fracture (bone was broken at an angle) to the distal third of the fibula. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Since 09/18/17, pain assessments are completed every four (4) hours for Resident #1 to monitor for any change in the resident's pain level or any change of condition. The assessments will continue at least until the resident's scheduled orthopedic appointment on 10/19/17. 2. On 10/06/17, the LPN was re-educated on change of condition and physician notification protocol by the Staff Educator. 3. A Quality Assurance (QA) Meeting was held on 10/06/17 to discuss the IJ allegation and to develop an action plan. Attendees included the Administrator, Director of Nursing (DON), Unit Managers, Minimum Data Set (MDS) Coordinator, Staff Development Nurse (SCN), Social Services (SS), Medical Records, the Regional Quality Manager, and the Medical Director (via phone). 4. On 10/06/17, 100% of residents were assessed for a change of condition by the Unit Managers (2 licensed nurses). The Comprehensive Pain Assessment Form was utilized for the assessment as this tool assesses mental status, verbal and non-verbal signs of discomfort, current or prior history of pain, effectiveness of any medications or treatments, and ability to meet goals of daily living. Changes of condition/concerns identified received follow-up with immediate notification to the MD and documentation in the medical record. 5. On 10/06/17, the Director of Nursing completed an audit of residents with x-ray orders for August, September, and (MONTH) (YEAR) to validate that the x-rays had been completed, the physician had been notified, and the results were in the medical records. No issues were identified. 6. On 10/07/17 and 10/08/17, an audit of current residents' care plans was completed by the Director of Nursing and members of the Interdisciplinary Team (IDT) that included the Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator. This audit was to validate the care plans had been implemented as written. Any concerns were immediately addressed by those completing the audit. 7. On 10/08/17, the Director of Nursing and the IDT (Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director, and the Admissions Coordinator) reviewed the prior 24 hour Nurses' Notes and nursing 24-hour report sheet for all residents for any entries regarding pain issues or needs that may require follow-up or physician notification. No issues were identified. 8. On 10/06/17, the Regional Quality Manager provided re-education to the Administrator and Director of Nursing in regards to the regulatory intent and their responsibilities in regards to F157 Physician Notification, F282 Care Planning, F309 Quality of Care, and F514 Maintaining Resident Records. 9. On 10/06/17, the Director of Nursing re-educated the RN Educator and Unit Managers regarding physician notification with all changes of condition, care plan implementation, process for obtaining and following up on x-rays as ordered, pain management protocol, and documenting change of condition in the medical record and the 24-hour nursing report. Example scenarios were reviewed with discussion and follow-up questions were included to validate understanding of the content. 10. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing, and Unit Managers re-educated all licensed nurses and certified medication aides regarding notifying the physician/responsible party of change of condition and documenting who was notified. Any new nurse or medication aide or any licensed nurse or certified medication aide on family medical leave, vacation, or who works as needed, will receive education prior to assuming duties. The education is being monitored by the RN Educator that is assigned to orientation and the facility scheduler with oversight by the Administrator and Director of Nursing who are tracking record of those that will require education to confirm that no person works without receiving the re-education. 11. On 10/06/17 and 10/07/17, the Staff Educator, Director of Nursing and Unit Managers educated staff from each department regarding resident change of condition that included the Stop and Watch system to allow anyone to report a change of condition; the requirement for Situation, Background, Appearance, and Review (SBAR) and documentation of the change of condition in the medical record; and, the definition of a change of condition, which includes a change in behavior or mental status, change of vitals, change in pain, identified skin issues, change in responsiveness, or any variation from the resident's baseline. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance at the educations. The sign-in sheets were reviewed by the Administrator to ensure all staff scheduled had been re-educated prior to working. 12. On 10/06/17, the Interdisciplinary Team consisting of the Social Service Director, Activity Director, Dietary Manager, Admission Coordinator, Unit Managers, Staff Educator and MDS Coordinator were re-educated regarding following care plans to include pain management. This education was provided by the Director of Nursing. 13. On 10/06/17, 100% of licensed nurses were re-educated by the Director of Nursing and RN Educator in regards to the following: A. Pain assessment and evaluation, B. Pain documentation in the electronic medical record and in the nurses' notes, C. Physician notification, D. Change of condition, E. Receiving and follow up with physician orders [REDACTED].>F. Stop and watch forms, G. SBAR completion, and H. X-ray tracking and acute documentation in the medical record. Any new hire or any nurse on family medical leave, vacation, or who works as needed, will receive the education prior to assuming duties upon start or return to the facility. This is being monitored by the RN Educator and the facility scheduler with oversight by the Administrator and Director of Nursing, to monitor to ensure no staff member works without completing the training. 14. On 10/06/17, a form was created by the Director of Nursing and the Administrator to track orders for x-rays. This form includes the resident's name, room number, date the x-ray was ordered, the confirmation number of the x-ray, date and time the physician was notified, date and time the family/responsible party was notified, initials of the nurse receiving the x-ray order, and initials of the nurse providing any follow-up. The form is now maintained in the 24-hour shift report book and nurses are required to review the form during the change of shift report. For any x-ray ordered on the weekend or after normal business hours, the Charge Nurse must notify the On-call nurse, who will follow-up with any x-ray results. Any abnormal x-rays must be reported to the Director of Nursing or the Administrator immediately. The form was implemented on 10/06/17 and all licensed nurses were educated by the Staff Educator on this date in regards to utilization and location of the form. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. Sign-in sheets were utilized to validate attendance. 15. Effective 10/09/17, the licensed nurse for each assigned unit will monitor for signs/symptoms of new or unrelieved pain each shift. Nurses will initial on the resident's Medication Administration Record [REDACTED]. Below their initials on the MAR, the nurse will also put a Y indicating the resident had new pain, or a N indicating the resident had no new pain or unrelieved pain. If YES is noted, the nurse is to notify the resident's physician and document in the medical record. The Director of Nursing, Administrator, and/or Unit Managers will validate the completion of MARS Monday through Friday to ensure nurses have monitored for new or unrelieved pain with appropriate follow-up. On Saturday and Sunday, nurses assigned to the C & D Hall will check the MARSs for the A & B Halls, and nurses from the A & B Halls will check the MARS for the C & D Hall. For any YES documentation, the weekend nurse will notify the on-call licensed nurse to validate the appropriate follow-up and sign the 24- hour report indicating it was addressed. Education to licensed nurses in regards to this process was provided by the Director of Nursing on 10/08/17, and the process was implemented on 10/09/17. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 16. Effective 10/09/17, in addition to review of the 24-hour report sheet (which now includes the x-ray tracking form) and new physician orders, review of all resident Nursing Notes for the previous 24 hours has been added to the morning Clinical Meeting to ensure a comprehensive review for any resident change of condition. The assigned weekend nurse will also validate that care plans were being followed. Education regarding this process was provided to licensed nurses on 10/06/17, by Director of Nursing and Nurses Educator. Example scenarios were reviewed with discussion and follow-up questions included to validate understanding of the content. 17. Beginning 10/09/17, a minimum of five (5) residents will be evaluated for pain daily by the Director of Nursing and/or Unit Managers for eight (8) weeks to validate the resident was accurately assessed; appropriate nursing documentation was completed; physician notification was made if indicated; and any follow-up actions were completed if required, including new orders and family/responsible party notifications. Any identified issues will be addressed immediately by the reviewing nurse and audit results will be reviewed at the weekly QA meeting by the Director of Nursing. 18. Beginning 10/09/17, audits will be conducted by the Director of Nursing and/or Unit Managers on a minimum of five (5) residents' weekly times four (4) weeks, then three (3) residents weekly times eight (8) weeks to validate physician notification, accurate assessment, care plan implementation, and appropriate medical record documentation. Any identified issue will be addressed immediately by the reviewing nurse. The residents are selected from the 24-hour report and review of nursing notes in the morning clinical meeting. Results of the audit will be reviewed at the weekly QA meeting by the Director of Nursing. 19. The 24-hour report book was updated to include x-ray tracking and how to follow up on the status of the order to ensure any required follow-up is completed. Attendees of the morning Clinical Meeting Monday through Friday will include at a minimum the Director of Nursing, Unit Managers, MDS staff, and Social Services staff. On weekends, the Director of Nursing and/or the assigned licensed nurse will be responsible to conduct the review. A follow-up look back by the Clinical Team will occur on Mondays. 20. On 10/09/17, a QA Committee Meeting was held to review the status of the education that had been provided to staff, review all audit information and discuss progress of plan. A QA meeting will be held a minimum of weekly until substantial compliance is achieved. A member of the Regional Team (Regional Director of Operations, Regional Quality Manager, Regulatory Liaison, or Regional Reimbursement Nurse) will be in attendance. WAS THE MEDICAL DIRECTOR INVOLVED? ***The State Survey Agency validated the correction actions taken by the facility as follows: 1. Review of Resident #1's medical record revealed since 09/18/17, pain assessments were being completed every four (4) hours for Resident #1 to monitor for any change in resident's pain level or change of condition. Review of a facility in-service revealed the Staff Educator re-educated LPN #1 on 10/06/17, regarding change of condition policies and physician notification protocol. 2. Interview with LPN #1 on 10/19/17 at 12:15 PM, revealed she received the re-education regarding change of condition and physician notification protocols from the Staff Educator. 3. Review of a QA meeting sign in sheet revealed a QA meeting was held on 10/06/17 to discuss the IJ allegations and develop an action plan. Further review revealed the Administrator, Director of Nursing, two (2) Unit Managers, MDS Coordinator, Staff Development Nurse, Social Services, Medical Records, the Regional Quality Manager, and the Medical Director (via phone) attended the QA meeting. Interviews conducted on 10/19/17 at 12:20 PM with Unit Manager #1, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, Social Services Director at 12:50 PM, and the Medical Director at 1:30 PM, revealed they attended the QA meeting on 10/06/17, discussed the IJ allegation, and developed an action plan. 4. Review of the facility's census dated 10/06/17 and review of the facility's Comprehensive Pain Assessment Form revealed on 10/06/17, 100% of current residents were assessed for Pain and any change of condition by Unit Manager #1 and Unit Manager #2. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM and at 12:30 PM with Unit Manager #2 revealed they conducted the Comprehensive Pain Assessment on all residents. 5. Review of a facility audit tool revealed on 10/06/17, the Director of Nursing completed an audit of residents that had x-ray orders for August, September, and (MONTH) (YEAR) to validate that the x-rays were completed with physician notification and the results were in the medical records. 6. Review of facility audits dated 10/7/17 and 10/8/17, revealed the DON and members of the IDT audited current residents' care plans. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, Social Services Director at 12:50 PM, and the DON on 10/19/17 at 1:15 PM, revealed they audited current residents care plans on 10/07/17 and 10/08/17. Record review for Resident #1, Resident #2, Resident #3 and Resident #4 revealed no concerns related to the residents' care plans. 7. Review of the facility's 24 hour change of condition report dated 10/08/17, revealed the Director of Nursing and members of the IDT (Administrator, Unit Managers, Wound Care Nurse, Activity Director, Social Service Director and the Admissions Coordinator) reviewed the nurses' notes for the previous 24 hours and the 24-hour report sheet for to ensure any pain care needs were appropriately addressed. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, with Unit Manager #2 at 12:30 PM, with the Activities Director at 12:45 PM, with Social Services Director at 12:50 PM, and with the DON on 10/19/17 at 1:15 PM, revealed they audited 24 hour reports and Nurses' Notes for any entries regarding pain or anything that may require physician notification. 8. Review of a facility Education Note dated 10/06/17, revealed the Regional Quality Manager provided re-education to the Administrator and Director of Nursing in regards to the regulatory intent and their responsibilities regarding F157 Physician Notification, F282 Care Planning, F309 Quality of Care, and F514 Maintaining Resident Records. Interview on 10/19/17 with the DON at 1:15 PM, and the Administrator at 1:50 PM, revealed they received re-education from the Regional Quality Manager regarding the regulatory intent and their responsibilities. 9. Review of a facility Education note dated 10/06/17, revealed the DON educated the RN Educator and the Unit Managers regarding physician notification with all changes of condition, care plan implementation, process for obtaining and following up on x-rays as ordered, the facility's pain management protocol, documenting change of condition in the medical record, and the 24 hour nursing report. Interview with Unit Manager #1 on 10/19/17 at 12:20 PM, Unit Manager #2 at 12:30 PM, and the RN Educator at 1:00 PM, revealed they received the education from the DON. 10. Review of the facility's In-service Training Records dated 10/06/17 and 10/07/17, revealed all licensed nurses and certified medication aides received re-education by the Staff Educator, Director of Nursing and Unit Managers that included notifying the physician/responsible party of a change in condition and documenting who was notified. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had received training regarding notifying the physician/responsible party when a change of condition occurs, including documenting who was notified. Interview with the DON on 10/19/17 at 1:15 PM, revealed all staff had completed the training and the facility had no new employees since 10/10/17. Interviews conducted on 10/19/17 with the Scheduler at 12:55 PM and the RN Educator at 1:00 PM, revealed they were responsible for monitoring to confirm that no staff worked without receiving the re-education. 11. Review of the facility's In-service Training Records dated 10/06/17 and 10/07/17, revealed education was provided to staff from each department by the Staff Educator, Director of Nursing and Unit Managers related to resident change of condition. Further review revealed the training included the Stop and Watch system to allow anyone to report a change of condition, documentation of a change in condition on an SBAR and in the medical record. Interview with the Administrator on 10/19/17 at 1:50 PM, revealed she reviewed in-service sign-in sheets to ensure all staff scheduled had been re-educated prior to working. 12. Review of the facility's In-service Training Records dated 10/06/17, revealed the Interdisciplinary Team consisting of the Social Service Director, Activity Director, Dietary Manager, Admission Coordinator, Unit Managers, Staff Educator and MDS Coordinator were re-educated by the DON regarding updating care plans with change of condition including pain. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM and the Social Services Director at 12:50 PM, revealed they had received the training provided by the DON. 13. Review of the facility's In-service Training Records dated 10/06/17, revealed 100% of licensed nurses were re-educated by the DON and RN Educator related to pain assessment and evaluation, pain documentation in the electronic medical record and in the Nurses' Notes, physician notification, change of condition, receiving and follow up with physician orders [REDACTED]. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had received training regarding the aforementioned topics. Interviews conducted on 10/19/17 with the Scheduler at 12:55 PM and the RN Educator at 1:00 PM, revealed they were responsible for monitoring to confirm that no person works without receiving the re-education. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they were providing oversight to ensure education was provided prior to any staff working a shift. 14. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they had developed a form to track orders for x-rays. Observations of the 24-hour shift reports revealed the form was being utilized during shift change to ensure x-rays were completed. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed when an x-ray was ordered on the weekend or after normal business hours, they were required to notify the on-call nurse. In addition, LPN #1, LPN #5, and LPN #6 stated any abnormal x-ray results were required to be reported to the Director of Nursing or the Administrator immediately. Continued interview with LPN #5, LPN #6, and LPN #1 revealed they were educated by the RN Educator regarding utilization and location of the form. Review of the facility Sign-In sheets dated 10/06/17, revealed staff were in attendance of the trainings. 15. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had been instructed to monitor residents for signs/symptoms of new or unrelieved pain each shift. If new or unrelieved pain was identified, the staff stated they would notify the physician and document in the medical record. Interviews conducted on 10/19/17 with the DON at 1:15 PM and the Administrator at 1:50 PM, revealed they validated all residents' MARS Monday through Friday to ensure nurses have monitored for new or unrelieved pain and conducted appropriate follow-up. Interview on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed on Saturday and Sunday, nurses monitored each hall to ensure pain assessments were completed and signed the 24- hour report, indicating the assessments were complete. Review of the facility In-Service Training Records dated 10/08/17 revealed licensed nurses had been educated in regards to this process. 16. Interviews conducted on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, the Activities Director at 12:45 PM, and the Social Services Director at 12:50 PM, revealed all resident nursing notes for the previous 24 hours, 24 hour report, and physician orders, and care plans were reviewed in the morning Clinical Meeting to ensure any resident change of condition is addressed and appropriate interventions were implemented. 17. Review of facility audits dated 10/09/17 and 10/08/17 revealed the DON completed audits on a minimum of five (5) residents daily to ensure appropriate evaluation of pain and to validate that residents were accurately assessed, physician notification had been made as indicated, and appropriate nursing documentation was completed. 18. Review of facility audits dated 10/09/17 and 10/08/17, revealed the DON and Unit Managers conducted audit of at a minimum of five (5) residents weekly to validate physician notification, accurate assessment, care plan implementation, and appropriate medical record documentation. Interviews conducted on 10/19/17, with the DON at 1:15 PM, and the Administrator at 1:50 PM, revealed beginning 10/09/17, all resident Nursing Notes for the previous 24 hours, 24 hour reports, and new physician orders [REDACTED]. 19. Review of the 24 hour reports revealed they included an x-ray tracking form and information on how to follow up on the status of x-ray orders to ensure any required follow-up was completed. Interviews on 10/19/17 with Unit Manager #1 at 12:20 PM, Unit Manager #2 at 12:30 PM, Social Services Director at 12:50 PM, and the DON on 10/19/17 at 1:15 PM, revealed they attended the Morning Clinical Meeting Monday through Friday. Interview with the DON on 10/19/17 at 1:15 PM revealed on weekends the DON or a licensed nurse designee was conducting reviews. The DON also stated that the clinical team was conducting look-backs for weekend compliance during the Monday morning Clinical Meeting. Interviews on 10/19/17 with LPN #5 at 10:27 AM, LPN #6 at 10:37 AM, and LPN #1 at 12:15 PM, revealed they had been trained and would be responsible to conduct weekend reviews at the request of the DON. 20. Review of the QA Committee Sign-in Sheets dated 10/09/17 and 10/16/17, revealed QA meetings had been held weekly. Further review revealed a regional team member was also in attendance. The minutes revealed the status of education, audit information, and progress of the plan was reviewed.

Based on interview, record review, review of facility policy, and review of the facility's investigation it was determined the facility failed to ensure the plan of care was revised after a change in behavior was identified for one (1) of three (3) sampled residents (Resident #1). The resident was witnessed to be standing without assistance by staff. However, the facility failed to ensure this change in the resident's behavior was added to the care plan. The resident demonstrated this same behavior hours later, which resulted in a fall with multiple facial fractures and [MEDICAL CONDITION] (upper arm). The findings include: Review of the facility's policy titled Care Plan Policy Statement, date unknown, revealed any licensed nurse and/or interdisciplinary team member could update the care plan to reflect changes and that care plans were revised as information about the resident and the resident's condition changed. Record review revealed the facility admitted Resident #1 on 07/31/15, with [DIAGNOSES REDACTED]. Review of the nursing Admission Assessment dated 07/31/15, revealed the resident was assessed to be alert, confused, and to be experiencing poor short and long-term memory problems. Further review of the Nursing Admission Assessment revealed the facility assessed the resident to have mild to moderate cognitive impairment and to require assistance with mobility. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 07/31/15, revealed the resident was referred to OT due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance, reduced ADL (Activities of Daily Living) participation, increased need for assistance from others and decreased coordination placing the patient at risk for falls. Review of the resident's Plan of Care, dated 07/31/15 and revised on 08/03/15, revealed the resident was at risk for falls related to confusion and dementia and required the use of a chair alarm when using a wheelchair. Review of statements taken by the facility as part of an incident investigation, date unknown, revealed Licensed Practical Nurse (LPN) #1 stated that on 08/03/15 during second shift, Resident #1 was found to be standing without assistance in front of his/her wheelchair and the chair alarm was sounding. The LPN also stated the resident was found standing without assistance again later during the shift. Review of the facility's Resident Incident Follow-up, dated 08/04/15, revealed on 08/03/15 at 11:55 PM, Resident #1's roommate reported to staff that Resident #1 was sitting next to his/her bed on the floor. Further review revealed LPN #3 and Certified Nurse Assistant (CNA) #3 entered the resident's room and assessed the resident, finding no injuries. The resident was assisted to the bedside commode and then back to bed. Review of CNA #3's statement taken by the facility on 08/04/15, revealed after assisting the resident back to bed the resident kept trying to get up. The CNA stated he assisted the resident to the wheelchair and placed the resident at the nurses' station where LPN #3 was receiving medications with a pharmacy medication delivery person. CNA #3 stated, I went up front to get a wheelchair alarm, while getting the alarm the resident fell hitting the station. Review of the History and Physical from the hospital, dated 08/04/15, revealed Resident #1 was admitted to the hospital after the fall from his/her wheelchair which resulted in left facial fractures, as well as a left humerus (bone in the upper arm) fracture. Interview with LPN #1 on 08/10/15 at 4:45 PM revealed on two (2) occasions during the evening shift on 08/03/15, she was alerted by Resident #1's chair alarm and found the resident standing in front of his/her wheelchair without assistance. The LPN reported after finding the resident standing without assistance the second time, she placed the resident in the hallway for closer observation. Further interview revealed this was a new behavior for the resident; however, LPN #1 reported she did not update the resident's plan of care to reflect the change in behavior. Interview with LPN #3 on 08/10/15 at 5:55 PM revealed she was not aware the resident had been standing without assistance during the previous shift or required the use of a chair alarm. However, review of the resident's care plan revealed this information was on the care plan. The LPN stated she was responsible for reviewing the Plan of Care for residents who were newly admitted to the facility; however, she had only briefly reviewed the Plan of Care for Resident #1 after the resident's fall on 08/04/15. Further interview with LPN #3 on 08/11/15 at 4:20 PM, revealed the resident's recent change in behavior related to standing without assistance was not on the care plan. The LPN stated changes with residents should be on the care plan and passed on in report from shift to shift. Interview with the Unit Manager (UM) on 08/11/15 at 3:45 PM revealed a resident's Plan of Care directed nursing care; however, she was unsure how often nursing staff should be reviewing the Plan of Care. Further interview revealed any updates or changes with resident care should be noted on the care plan. Interview with the Director of Nursing (DON) on 08/11/15 at 4:50 PM revealed changes in resident behavior should be placed on the care plan; however, nursing staff was not responsible to routinely review the care plan. The DON stated that changes in resident behavior were to be reflected on the care plan. Further interview revealed the facility did not have a system to ensure information was passed from one shift to the next shift. Interview with the Administrator on 08/11/15 at 5:45 PM, revealed the change in the resident's behavior should have been passed on in report and placed on the care plan. The Administrator stated nursing staff should review the care plans daily.

Based on interview, record review, policy review, and review of facility investigation it was determined the facility failed to ensure a safety alarm was used in accordance with one (1) of three (3) sampled residents' written plan of care (Resident #1). On 08/04/15, Resident #1 experienced a fall, related to standing without assistance from his/her wheelchair, resulting in multiple facial fractures and a humerus (upper arm) fracture. Interviews with facility staff revealed the resident did not have a safety alarm in use during the time of the fall as indicated in the resident's plan of care. The findings include: Review of the facility's policy titled Care Plan Policy Statement, no date, revealed the care plan was designed to incorporate identified problem areas and aid in preventing or reducing declines in the resident's functional status and/or functional levels. Record review revealed the facility admitted Resident #1 on 07/31/15, with [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE], revealed the facility assessed the resident to be alert, confused, and to be experiencing poor short and long-term memory problems. Further review of the Admission Assessment revealed the facility assessed the resident to have mild to moderate cognitive impairment. The facility assessed the resident as requiring assistance with mobility. Interview with Licensed Practical Nurse (LPN) #2 on 08/10/15 at 5:20 PM revealed she participated in Resident #1's admission assessment on 07/31/15. Further interview revealed Resident #1's family had indicated the resident had fallen at home prior to admission to the facility. The LPN stated a chair alarm was implemented upon admission, as a fall prevention intervention. Interview with Certified Nurse Assistant (CNA) #1 on 08/10/15 at 5:37 PM revealed she had also taken part in Resident #1's admission process and confirmed a chair alarm was implemented upon admission to prevent falls. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 07/31/15, revealed the resident was referred to OT due to New onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance, reduced ADL (Activities of Daily Living) participation, increased need for assistance from others, and decreased coordination placing the patient at risk for falls. Review of the resident's Plan of Care dated 07/31/15, revealed the resident was at risk for falls related to confusion and dementia and required the use of a chair alarm when using a wheelchair. Review of the facility's investigation revealed a written statement made by CNA #3 on 08/04/15. The statement revealed CNA #3 discovered the resident on the floor of the resident's room on 08/03/15 at approximately 11:50 PM. LPN #3 and CNA #3 assessed the resident finding no injuries, assisted the resident to the bedside commode, and then assisted the resident back to bed. CNA #3 reported that the resident kept trying to get up resulting in the CNA assisting the resident to his/her wheelchair and positioning the resident by the nurses' station. Further review revealed the CNA then left the resident to obtain a wheelchair alarm during which time the resident fell from the wheelchair hitting the nurses' station. The resident was sent to the hospital for evaluation. Review of the History and Physical from the hospital dated 08/04/15, revealed the resident was admitted to the hospital on [DATE] after sustaining a fall from his/her wheelchair resulting in a left orbital floor (facial bone) fracture, left sinus fractures, left maxilla (upper jaw bone) fracture, and a left humerus (bone in the upper arm) fracture. Interview with LPN #3 on 08/10/15 at 5:55 PM revealed she was responsible for Resident #1's care on the morning of 08/04/15 when Resident #1 experienced a fall at approximately 12:20 AM. Further interview revealed at approximately 11:50 PM on 08/03/15, Resident #1's roommate alerted staff that Resident #1 was sitting on the floor beside his/her bed. The LPN stated she and CNA #3 entered the resident's room, assessed the resident, and found no injuries. They assisted the resident to the bedside commode and then back to bed. The LPN stated she was then called from the room due to the medication delivery person arriving to check in medications. Further interview revealed the LPN was told by CNA #3 the resident would not stay in bed. She stated CNA #3 placed the resident in his/her wheelchair and brought the resident to the nurses' station in order for staff to monitor the resident. LPN #3 stated an alarm was not on the resident's chair. She instructed the CNA to obtain a chair alarm for the resident at that time. Further interview revealed the LPN began checking in medications with the medication delivery person by the nurses' station and witnessed the resident stand up from his/her wheelchair without assistance and immediately fall forward to the floor at approximately 12:20 AM on 08/04/15. LPN #3 further stated she had not reviewed Resident #1's care plan and was unaware the resident was care planned for an alarm. LPN #3 stated she instructed the CNA to place an alarm on the resident's chair, because nursing staff utilized their judgment when a chair alarm was necessary and they did not have to get a physician's orders [REDACTED].>Interview with the medication delivery person on 08/11/15 at 1:19 PM, revealed he was present at the facility on 08/04/15 at 12:20 AM. The medication delivery person stated no alarm was sounding prior to the fall sustained by the resident. Interview with CNA #3 on 08/11/15 at 3:15 PM, revealed he assisted Resident #1 to his/her wheelchair and to the nurses' station on 08/04/15. CNA #3 stated a chair alarm was not in use prior to the resident's fall. Further interview with the CNA revealed he was not aware the resident required a chair alarm when in a wheelchair. The CNA stated the facility Accunurse (headset system) provided him with the resident's fall prevention interventions; however, he was unsure what interventions were in place for the resident prior to the fall on 08/04/15. The CNA stated he was not informed during the shift-to-shift report, that the resident required a chair alarm, per the Plan of Care. Interview with the Unit Manager (UM) on 08/11/15 at 3:45 PM, revealed she was unsure what Resident #1's fall prevention interventions were and she was not aware the resident did not have a chair alarm in place at the time of the fall on 08/04/15. Further interview revealed nursing staff was not required to routinely check resident care plans, even though care should be directed from the care plans. Interview with the Director of Nursing (DON) on 08/11/15 at 4:50 PM revealed she was aware that Resident #1 had been assessed upon admission to be at risk for falls and a chair alarm had been implemented as a preventive measure. The DON stated an alarm placed upon admission should be included on the care plan and the care plan should be followed. Further interview revealed care plans were always available to nursing staff; however, they were not responsible to review the care plans routinely. Interview with the Administrator on 08/11/15 at 5:45 PM, revealed nursing staff was responsible to review and follow resident care plans daily. Further interview revealed, according to the Plan of Care, Resident #1 should have had a chair alarm in place prior to the fall that occurred on 08/04/15.

Based on interview, record review, facility policy review, and review of the facility's investigation it was determined the facility failed to ensure assistance devices were provided to prevent accidents for one (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 to be at risk for falls and a care plan intervention was developed for a chair alarm while the resident was up in a wheelchair. On 08/03/15, during the evening shift, the resident was witnessed to be standing without assistance, which was a change in behavior for the resident. On 08/04/15, Resident #1 was assisted to a wheelchair and taken to the nurses' station without a chair alarm in place, which was required per plan of care. Resident #1 got up from the chair unassisted and fell , resulting in multiple facial fractures and a fracture to the humerus (bone in the upper arm). The findings include: Review of the facility's policy titled Incidents and Accidents, undated, revealed all incidents and accidents were reported using written and verbal format. Review of the Care Plan Policy Statement, undated, revealed a comprehensive care plan was developed for each resident and any licensed nurse and/or interdisciplinary team member could update the care plan to reflect changes. Record review revealed the facility admitted Resident #1 on 07/31/15, with [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment, dated 07/31/15, revealed the resident was assessed to be alert, confused, and to be experiencing poor short and long-term memory. Further review of the Admission Assessment revealed the facility assessed the resident to have mild to moderate cognitive impairment and to require assistance with mobility. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 07/31/15, revealed the resident was referred to OT due to new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced balance, reduced ADL (Activities of Daily Living) participation, increased need for assistance from others, and decreased coordination placing the patient at risk for falls. Review of the resident's Plan of Care with a revision date of 08/03/15, revealed the resident was at risk for falls related to confusion and dementia and required the use of an alarm when using a wheelchair. Review of the History and Physical revealed Resident # 1 was admitted to the hospital on [DATE] after sustaining a fall from a wheelchair resulting in left orbital floor (facial bone) fracture, left sinus fractures, left maxilla (upper jaw bone) fracture, and a left humerus (bone in the upper arm) fracture. Review of the Resident Incident Follow-up, dated 08/04/15, revealed Resident #1 was discovered on 08/03/15 at 11:55 PM on the floor next to his/her bed by Certified Nurse Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #3 after the resident's roommate notified facility staff. The staff members assisted the resident off the floor and then assisted the resident to the bedside commode for toileting. The resident was assessed at that time and found to have no injuries. CNA #3 assisted the resident back to bed; however, the resident stated he/she did not want to stay in bed. CNA #3 then assisted the resident to his/her wheelchair and took the resident to the nurses' station for close observation. The resident was witnessed to stand up from the wheelchair, grab the nurses' station, and fall to the floor on 08/04/15 at 12:20 AM. Review of witness statements taken by the facility, dated 08/04/15, revealed CNA #3 stated the resident kept trying to get up so the CNA assisted the resident to a wheelchair and took the resident to the nurses' station. CNA #3 stated he went to locate a wheelchair alarm and while he was looking for the alarm, Resident #1 fell . Further review of the statements revealed LPN #1 stated the resident was found to be standing unassisted two (2) times during the evening shift (3 PM to 11 PM) on 08/03/15. According to the statement, the resident had a working wheelchair alarm in place at the time. The LPN stated after the resident attempted to stand unassisted two (2) times, she placed the resident in the hallway for closer observation. Interview with LPN #2 on 08/10/15 at 5:20 PM revealed she was involved in the admission process for Resident #1. The LPN stated Resident #1's family had indicated the resident had fallen at home in the past. Further interview revealed the LPN placed a wheelchair alarm on the resident upon admission as a preventive measure for falls. Interview with LPN #1 on 08/10/15 at 4:45 PM revealed she was responsible for Resident #1's care on the evening of 08/03/15. The LPN stated she was alerted by the resident's wheelchair alarm on two (2) occasions during the shift. The resident was found to be standing without assistance on both occasions. Further interview revealed after the second occurrence of the resident standing without assistance, staff placed the resident in the hallway for closer observation while the LPN completed medication pass. The LPN stated she verbalized to the oncoming nurse (LPN #3) that the resident was found standing unassisted and required a wheelchair alarm. Interview with CNA #3 on 08/11/15 at 3:15 PM revealed Resident #1's roommate alerted him that the resident was on the floor on 08/03/15 at 11:55 PM. The CNA stated he found Resident #1 sitting on the floor beside the bed. He stated the resident stated he/she had scooted out of bed and needed to use the restroom. CNA #3 stated he and LPN #3 assisted the resident to the bedside commode and assessed the resident, finding no injuries. He stated LPN #3 was called from the room to check in a medication delivery. Further interview revealed CNA #3 stated he assisted the resident back to bed from the bedside commode. He stated the resident was sitting on the side of the bed and was fidgeting with his/her socks. CNA #3 reported he asked the resident if he/she wanted to get up and the resident agreed. The CNA assisted the resident to his/her wheelchair and took the resident to the nurses' station. CNA #3 stated the resident did not have a wheelchair alarm in place. Further interview revealed the CNA was instructed by LPN #3 to get an alarm for Resident #1. He stated he left the resident at the nurses' station in sight of LPN #3 and went to locate an alarm. CNA #3 stated he was not made aware during shift-to-shift report that the resident required a wheelchair alarm and did not recall if the Accunurse (headset system that directs CNAs on resident care needs) directed the use of a wheelchair alarm for Resident #1. Interview with LPN #3 on 08/10/15 at 5:55 PM, revealed after Resident #1 was discovered on the floor of his/her room on 08/04/15 at approximately 11:55 PM, she and CNA #3 assisted the resident to the bedside commode. LPN #3 stated Resident #1 was assessed and was found to have no injuries. The LPN stated she was called from the room to check in a delivery of medication at the nurses' station. The LPN stated the resident would not stay in bed so CNA #3 assisted the resident to the nurses' station in a wheelchair. Further interview with LPN #3 revealed a wheelchair alarm was not in place at that time and she felt the resident needed an alarm in place on the wheelchair. LPN #3 stated she instructed CNA #3 to locate and place an alarm on the resident's wheelchair. The LPN stated she was checking in medications with the medication delivery person when she witnessed Resident #1 stand unassisted and fall forward to the floor. LPN #3 stated she was unaware the resident required a wheelchair alarm and had not reviewed Resident #1's care plan. She stated she asked the CNA to apply an alarm per nursing judgment. The LPN also stated she was not informed that Resident #1 was standing unassisted during the previous shift on 08/03/15. Interview with the medication delivery person on 08/11/15 at 1:19 PM revealed he was at the facility on 08/04/15 at the time of the resident's fall checking in medications with LPN #3. Further interview revealed the medication delivery person and LPN #3 were approximately six to eight feet from the resident and confirmed no alarm was sounding when the resident fell . Interview with the Director of Nursing (DON) on 08/11/15 at 4:50 PM, revealed Resident #1 should have had a wheelchair alarm in place prior to the fall on 08/04/15. The DON stated alarms could be implemented by nurses using their judgment and did not require a physician's orders [REDACTED]. The DON stated that all care plan updates and interventions were reviewed during the morning administration meeting. The DON stated updates/changes that were identified in the morning meeting were placed in the Accunurse system. Interview with the Administrator on 08/11/15 at 5:45 PM revealed a wheelchair alarm should have been in place for Resident # 1 prior to the fall. The Administrator further stated that all incidents and accidents were discussed in the morning meetings, and any care plan updates and interventions were reviewed and updated in the Accunurse system.

Based on interview, record review, and a review of facility policies, it was determined the facility failed to ensure prompt efforts were taken to resolve grievances for one of three sampled residents. On 01/18/12, Resident #1's physician wrote an order to discontinue a medication the resident was taking. Registered Nurse (RN) #1 informed Resident #1's family member of the change in the resident's medications. The family member of Resident #1 informed RN #1 the resident could not be taken off the medication due to the resident's history of adverse effects as a result of not taking the medication. However, RN #1 failed to document the family member's concerns in accordance with facility policy and failed to ensure the resident's physician was informed of the family member's concern. Four days after the medication change, Resident #1 was hospitalized with a [DIAGNOSES REDACTED].) The findings include: A review of the facility policy "Concern-Resident/Family" (dated 10/09) revealed any employee could receive a grievance/concern from a resident and/or family member of a resident. According to policy, the employee was to attempt to resolve the grievance/concern and complete a "Resident Concern Report," which was then given to the Administrator. A review of Resident #1's medical record revealed the facility admitted the resident on 12/21/11. Resident #1 had [DIAGNOSES REDACTED]. A review of the medical record revealed upon admission the resident's medications included 40 meq (milliequivalents) of Potassium (electrolyte) twice a day and 40 milligrams (mg) of [MEDICATION NAME] (diuretic) twice a day. Further review of the medical record revealed on 01/18/12, the resident's physician discontinued the [MEDICATION NAME] and ordered [MEDICATION NAME] (a potassium-sparing diuretic) for the resident. Continued review of the medical record revealed Resident #1 was admitted to a hospital on [DATE], four days after the [MEDICATION NAME] had been discontinued, with a [DIAGNOSES REDACTED]. A review of the hospital record for Resident #1 revealed the resident's admitting physician consulted another physician and the consulting physician suspected the origin of Resident #1's severe [MEDICAL CONDITION] was the cessation of the [MEDICATION NAME], the addition of [MEDICATION NAME], and the very high daily potassium supplement which, according to the physician, was almost two times the daily potassium dietary intake. Interview with Resident #1's family member on 01/26/12, at 12:45 PM, revealed when the nurse informed the family member of the change in Resident #1's medication on 01/18/12, she explained to the nurse that Resident #1 could not be taken off the [MEDICATION NAME]. The family member stated she was very "adamant" in telling the nurse that Resident #1 had a history of [REDACTED]. Interview further revealed the daughter told RN #1, "I am telling you right now you can't take her off [MEDICATION NAME]." The family member stated the nurse informed the family member that the physician had requested the medication change because Resident's #1's potassium was "low." Interview with RN #1 on 01/25/12, at 3:30 PM, revealed she received the order from Resident #1's physician on 01/18/12, to discontinue the resident's [MEDICATION NAME] and to start the [MEDICATION NAME] for Resident #1. RN #1 stated she spoke with Resident #1's family member on the evening of 01/18/12, and informed the family member of the change in the resident's medications. Further interview revealed on 01/18/12, Resident #1's family member told the nurse Resident #1 could not be taken off of the [MEDICATION NAME] because previously when the medication had been stopped Resident #1 experienced a "[MEDICAL CONDITION]" and was told by a physician that the resident's [MEDICAL CONDITION] was due to the [MEDICATION NAME] being discontinued. Interview with RN #1 further revealed the family member asked RN #1 if the resident's physician was aware Resident #1 had [MEDICAL CONDITION] and RN #1 explained to the family member that she was sure the physician was aware. RN #1 stated she explained to the resident and the family member that facility staff would "watch her." In addition, RN #1 stated she thought the resident's family member was "okay" with the RN's response and stated she did not consider the family members statement regarding the physician's decision to discontinue the [MEDICATION NAME] as a concern because the family member was not "insistent" on the concern. Interview with Resident #1's physician on 01/25/12, at 6:00 PM, revealed he was not made aware by facility staff that Resident #1's daughter had voiced concerns related to the resident's [MEDICATION NAME] being discontinued on 01/18/12. The physician stated even though he assumed care of Resident #1 on 12/21/11, he was not aware of the resident's medical history. According to the physician, if facility staff had informed him of the family member's concern, it would have made a difference in his decision to discontinue the [MEDICATION NAME]. Interview with the Educator Training Director on 01/26/12, at 3:04 PM, revealed all staff was in-serviced upon employment on the facility's policy related to concerns/grievances from residents and or family members. The Director further stated that all staff also received in-service training related to what constituted a concern/grievance and the appropriate form to fill out when a resident or family member had a concern/grievance. Interview with RN #1 on 01/26/12, at 3:45 PM, revealed she did not recall if she was trained on what to do when a resident or family member voiced a concern or grievance, and was not aware where the concern/grievance forms were located. In addition, RN #1 acknowledged she had not completed a concern/grievance form as a result of the family member's concern related to the physician's decision to discontinue the resident's [MEDICATION NAME]. Facility staff could not provide documentation that RN #1 had been trained on the concern/grievance process. Interview with the Administrator on 01/26/12, at 12:15 PM, revealed she was not made aware of the incident involving Resident #1 until 01/23/12, after the resident had been sent to the hospital. The Administrator stated staff should have listened to the family member's concern and should have notified the resident's physician of the family's concern since the physician was not aware of the resident's history. She further stated that RN #1 should have filled out a grievance/concern form after the family member voiced the concern.

Based on interview, record review, and a review of facility policies, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents (Resident #1). Resident #1 was admitted to the facility 12/21/11, and had physician's orders for Potassium (electrolyte) and [MEDICATION NAME] (a diuretic). On 01/18/12, the physician discontinued Resident #1's [MEDICATION NAME] and ordered [MEDICATION NAME] (a diuretic). Resident #1's family member informed Registered Nurse (RN) #1 on 01/18/12, that the resident had experienced a "[MEDICAL CONDITION]" previously when [MEDICATION NAME] had been discontinued and informed the nurse "you can't take her off." However, facility staff failed to assess and/or plan the resident's care after information was received about the resident's medical history. In addition, RN #1 failed to inform the resident's physician of the family member's concern and on 01/22/12, four days after the change in the resident's medications, Resident #1 was admitted to the Critical Care Unit of a hospital with [DIAGNOSES REDACTED]. The findings include: A review of the facility policy "Concern-Resident/Family" (dated 10/09) revealed any employee could receive a grievance/concern from a resident and/or family member of a resident. According to policy, the employee is to attempt to resolve the grievance/concern and complete a "Resident Concern Report," which is then given to the Administrator. Review of the medical record of Resident #1 revealed the facility admitted the resident on 12/21/11, with [DIAGNOSES REDACTED]. Resident #1's medications included 40 milliequivalents (mEq) of Potassium (electrolyte) two times a day and 40 milligrams (mg) of [MEDICATION NAME] (a diuretic) twice a day. A review of the resident's labs revealed on 01/11/12, a potassium level of 3.3 milliequivalents per liter (mEq/l) (normal 3.5-5.3 mEq/l). On 01/12/12, a physician's order was received to increase the potassium to 40 mEq four times a day. Continued review of the medical record revealed on 01/18/12, a potassium level of 3.0 mEq and a physician's order to discontinue the [MEDICATION NAME] and begin [MEDICATION NAME] (a potassium-sparing diuretic) 25 mg twice a day. A review of Resident #1's Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed the resident's cognition to be intact, to require Oxygen Therapy, Diuretics, and Respiratory Therapy. Review of the resident's Comprehensive Care Plan (CCP) revealed a care plan for potential for alteration in circulation dated 01/03/12; the facility interventions included: medications/treatments as ordered, to update the physician/family as needed, labs as ordered, and for facility staff to monitor for signs and symptoms of cardiac distress. Continued review of the resident's CCP revealed a care plan for potential for/actual alteration in oxygen exchange dated 01/12/12; the facility interventions included to update the physician/family as needed, medications/treatments as ordered, and breathing treatments as ordered. An interview was conducted with Resident #1's family member on 01/26/12, at 12:45 PM. According to the family member, a nurse had informed him/her on 01/18/12, that Resident #1's physician had discontinued the resident's [MEDICATION NAME]. The family member stated he/she explained to the nurse that Resident #1 could not be taken off the [MEDICATION NAME]. The family member stated he/she informed the nurse Resident #1 had a history of [REDACTED]. (him/her) off [MEDICATION NAME]." The family member stated the nurse informed the family member that the physician had requested the medication change because Resident's #1's potassium was "low." In addition, interview with the family member revealed to his/her knowledge the nurse did not relay the information to the resident's physician. Interview with Registered Nurse (RN) #1 on 01/25/12, at 4:10 PM, revealed she worked on the evening of 01/18/12, when Resident #1's physician had been to the facility and written orders to discontinue the resident's [MEDICATION NAME] and ordered [MEDICATION NAME] for the resident. RN #1 stated at approximately 6:00 PM, after the physician left the facility, she went to Resident #1's room to speak with the resident's family member and asked the family member if the physician had informed him/her of the change in the resident's medication. According to the nurse, the resident's family member informed the nurse the physician had not informed him/her of the medication change. Interview with RN #1 revealed she explained the physician had discontinued the resident's [MEDICATION NAME] and had ordered [MEDICATION NAME]. RN #1 stated she explained to the resident's family member that both medications were diuretics and that [MEDICATION NAME] was a potassium-sparing diuretic that the physician had probably ordered because Resident #1's potassium was low. Continued interview with RN #1 revealed Resident #1's family member informed her prior to the resident's admission to the facility that the resident's [MEDICATION NAME] had been discontinued and as a result the resident experienced a [MEDICAL CONDITION]. Based on interview with RN #1, the resident's family member stated the physician felt that the resident's [MEDICAL CONDITION] was caused due to the discontinuance of the [MEDICATION NAME]. A review of a History and Physical found on the resident's chart from a hospitalization prior to admittance to the facility, revealed the resident was hypokalemic (low potassium level) and had a elevated troponin level (a blood test used to check for damage to the heart). According to the documentation the primary physician at the hospital was unsure if the elevated troponin level was related to a [MEDICAL CONDITION] or the recent reduction in the resident's [MEDICATION NAME]. RN #1 also stated the resident's family member asked if the resident's physician was aware the resident had a history of [REDACTED].#1's diagnosis. Further interview with the nurse confirmed the family member had stated that the resident was "not" to be taken off the [MEDICATION NAME]. However, RN #1 stated she had not notified the resident's physician of the family member's concerns related to the resident's history and medication change. She stated she did not feel the family member was "insistent" on the concern. Continued record review and interview with Licensed Practical Nurse (LPN) #3 on 01/25/12, at 3:47 PM, revealed on 01/22/12, at 2:00 PM, Resident #1's family member informed LPN #3 the resident felt short of breath and requested a "breathing" treatment for [REDACTED]." treatment was administered. After the administration of the breathing treatment, continued interview revealed the resident's family member was concerned the resident's assessed symptoms were the result of the change in the resident's medications. Documentation revealed LPN #2 notified the resident's physician and the physician requested for the resident to be transported to the hospital. Based on documentation in the medical record, four days after the [MEDICATION NAME] was discontinued and the [MEDICATION NAME] was initiated, Resident #1 was transferred to the hospital and admitted to the Critical Care Unit of a hospital on [DATE], with a [DIAGNOSES REDACTED]. A review of Resident #1's hospital record revealed the resident's condition was "exceptionally guarded." Continued review of the resident's hospital medical record revealed the resident's consulting physician documented "I certainly suspect" the origin of Resident #1's severe critical [MEDICAL CONDITION] was the cessation of the [MEDICATION NAME], the addition of [MEDICATION NAME], and the very high daily potassium supplement which, according to the physician, was almost two times the daily potassium dietary intake. Interview conducted on 01/25/12, at 6:00 PM, with Resident #1's physician at the facility revealed he discontinued the resident's [MEDICATION NAME] and prescribed the [MEDICATION NAME] in an effort to get the resident's potassium level within a normal range. He further stated he had previously increased the potassium medication for Resident #1; however, the potassium level had still dropped from 3.3 to 3.0 and he "thought" it was "okay" at the time to discontinue the [MEDICATION NAME]. The physician stated he was not aware the resident's family had expressed a concern related to his decision to discontinue the [MEDICATION NAME] and that if facility staff had informed him of the family member's concern, it would have made a difference in his decision to discontinue the [MEDICATION NAME]. Interview with the physician further revealed he had assumed medical care of the resident when the resident was initially admitted to the long term care facility and was not aware of the resident's past medical history. Interview with the Administrator on 01/26/12, at 12:15 PM, revealed she was not aware of the incident involving Resident #1 until 01/23/12, the day after the resident was transferred to the hospital. The Administrator stated staff should consider residents' and/or family members' concerns related to care and acknowledged facility staff should have made the physician of Resident #1 aware of the resident's family member's concerns related to his/her medical care.