Every finding on record at Hillside Nursing Center of Wake Forest

Based on observations and staff interviews, the facility failed to store medications at the refrigeration temperature specified by the manufacturer in 1 of 3 Medication Rooms observed (Unit 2 Med Room). The findings included: On 6/6/23 at 10:42 AM, an observation was made of the facility's 100 Hall Medication (Med) Room. At that time, the Med Room's refrigerator temperature was observed to be 46 degrees Fahrenheit (o F) and within the recommended range (36o - 46o F) for refrigerated medications. However, a food-related refrigerator temperature log was observed to be taped onto the Med Room refrigerator. This temperature log indicated the Med Room refrigerator temperature should be less than 41o F. Accompanied by the facility's Director of Nursing (DON), an interview was conducted on 6/6/23 at 10:45 AM with the facility's consultant pharmacist. During the interview, use of the food-related refrigerator temperature log posted on the Med Room refrigerator was discussed. The consultant pharmacist confirmed the standard temperature range for refrigerated medications was 36o - 46o F. Accompanied by Nurse #1, an observation was made of the Unit 2 Medication Room (Med Room) on 6/6/23 at 10:48 AM. A thermometer placed inside of the Med Room's compact refrigerator indicated the refrigerator's temperature was 34o F (not within the recommended range for pharmaceuticals). Nurse #1 confirmed the temperature reading of the thermometer. A food-related temperature log was also observed to be taped onto the top of the Med Room's medication refrigerator at the time of the observation. This temperature log read as follows: Refridgerator [Refrigerator] Temperatures Log 1. Acceptable refrigerator temperature is at 41 F or below. 2. If temperature is not in range adjust the thermostat and retake temp in about 30 minutes. 3. If temperature is still not in range, move items to an appropriate refrigerator and notify Maintenance. The temperature log recorded the following temperatures taken in June 2023 to date: 6/1/23 at 2:00 AM = 32o F; 6/2/23 at 7:15 AM = 34o F; 6/3/23 at 7:00 AM = 36o F; 6/4/23 at 10:00 PM = 34o F; 6/5/23 at 12:00 AM = 38o F; 6/6/23 at 12:00 AM = 34o F. Four (4) out of the 6 recorded temperatures were outside of the recommended temperature range of 36o - 46o F for refrigerated medications. The contents of the Med Room refrigerator at the time of the observation included: --One unopened box of 1.5 mg / 0.5 milliliters Trulicity (an injectable antidiabetic medication) containing 4 single-dose pens; --4 unopened Lantus insulin pens; --1 unopened vial of Lantus insulin; --1 unopened vial of Levemir insulin; --3 unopened bottles of latanoprost ophthalmic eye drops (used for the treatment of glaucoma); A review of the manufacturers' product information for the individual medications stored in the Unit 2 Med Room refrigerator included the following storage requirements: -- Unopened Lantus insulin pens may be stored in a refrigerator (36o - 46o F); Do not freeze. -- Unopened vials of Lantus insulin may be stored in a refrigerator (36o - 46o F); Do not freeze. -- Unopened vials of Levemir insulin may be stored in a refrigerator (36o - 46o F); Do not freeze. -- Unopened (intact) bottles should be stored in a refrigerator (36o - 46o F). The facility's Director of Nursing (DON) joined Nurse #1 in the Unit 2 Med Room on 6/6/23 at 11:00 AM. At that time, concern related to the current temperature of the Med Room refrigerator and the previously recorded June temperatures recorded on the log were discussed. Upon review of the temperature log, the DON stated a nurse recording the temperatures should have called Maintenance to check on the refrigerator and to ensure it was within the appropriate temperature range. The DON also reported she would need to develop a new Med Room temperature log which included the correct temperature range of 36o F - 46o F for refrigerated medications. The DON stated she would call the Maintenance Director to request that he check on the refrigerator. On 6/6/23 at 11:10 AM, the Maintenance Director came to the Med Room with a new thermometer. The Maintenance Director was observed as he placed a new thermometer in the Unit 2 Med Room refrigerator (along with the old thermometer) to check both the temperature of the refrigerator and the accuracy of the old thermometer. Additionally, the Maintenance Director checked the thermostat setting of the refrigerator and reported it was set too cold. He stated the thermostat was turned up past 6 but should have been set at 5. The Maintenance Director was observed as he adjusted the refrigerator's thermostat. Accompanied by the Maintenance Director and Nurse #1, a second observation of the Unit 2 Med Room refrigerator was made on 6/6/23 at 12:10 PM. At that time, both the old and the new thermometers read the temperature of the refrigerator as 40o F (within the recommended range of 36o F - 46o F for refrigerated medications). The Maintenance Director reported the agreement of the two thermometers confirmed the accuracy of the original thermometer placed in the refrigerator.

Based on observations and staff interviews, the facility failed to maintain sanitary conditions in the kitchen and nourishment rooms by not ensuring unsealed food items were dated and labeled and opened items not resealed in 1 of 1 walk in refrigerators in the kitchen, 2 of 3 refrigerators in the nourishment rooms, and 1 of 1 refrigerated cooler and 1 of 1 dry storage room in the kitchen. The facility also failed to maintain sanitary conditions in 1 of 1 nourishment rooms and 1 of 1 dry food storage areas by not ensuring clean ice machines and storage areas free from debris. Findings include: An observation was made of the kitchen on 8/25/19 at 12:20pm. It was observed that there were 7 small salads and a half full pitcher of red liquid not labeled or dated. In the dry storage room, an observation was made of opened individual packets of salt and pepper laying opened on a box of food items, 3 individual bags of cookies on the floor under the food shelves, cereal on the floor under and around the cereal dispenser along with in the dispenser basin, 17 individual plastic containers of cereal not dated, and an opened box of Cocoa Puff cereal opened and not dated. It was also observed that there was a bag of marshmallows opened and not dated and opened packets of individual salt, pepper, and sugar on the floor. An observation was also made of a half full gallon size container of barbeque sauce opened and not dated, a container of sweet and sour sauce one third full not dated, and a jar of peanut butter opened and not dated with peanut butter on the lid and sides of the container. An observation was made in the walk in refrigerator which revealed 24 ham and cheese sandwiches not dated, a salad not dated, an opened 5 gallon container of Cole slaw not dated, a pan with cooked bacon and meat patties covered but not dated, sliced cheese opened and not sealed nor dated, 14 hard boiled eggs in container not dated, 3 opened gallons of orange juice opened but not dated, mayonnaise container with lid half on and mayonnaise on sides of the container, not dated. It was observed in the freezer that there was debris on the floor along with a white lump approximately 4 inches by 4 inches frozen on the floor along with a brown lump of hard material in the middle of the floor. An observation was made on 8/26/19 at 10:48am of the 100-hall nourishment room. The observation revealed black material all along the bottom edge of where the ice comes out of the ice maker into the ice bin. The black material was approximately 5 inches in length and ½ inch in height and would come off on a finger when touched. It was also observed an opened not dated can of Coca Cola and can of Red Bull not dated in the freezer of the refrigerator along with a container of a resident's food in the refrigerator not dated. It was also observed that the refrigerator had a dried yellow material on the bottom shelf of the refrigerator and dried brown material on the top shelf on the door. An observation was made on 8/26/19 at 2:00pm of the 300-hall nourishment room. It was observed that the freezer had opened cake and ice cream that was not dated. An observation was made on 8/27/19 at 2:30pm with the Housekeeping supervisor, the DON (Director of Nursing) and the Administrator of the black material in the 100-hall ice maker. At this observation, the ice was piled on top of part of the black material. It was observed a housekeeping staff cleaning the 100-hall refrigerator and had disposed of the opened drink cans. The undated food was still in the refrigerator. An observation was also made of the 300-hall refrigerator which revealed the undated ice cream remained in the freezer. The DON disposed of the container during the observation. An interview was conducted with the dietary manager on 8/27/19 at 1:50pm. She reported she expected all open foods to be sealed and dated, that there should be no food or debris on the floor in the dry storage area or walk in freezer. She reported it was the responsibility of maintenance to clean and maintain the ice makers in the nourishment rooms. An interview was conducted with the Housekeeping Supervisor on 8/27/19 at 2:30pm. She reported it was the responsibility of her staff to clean the nourishment room refrigerators daily on first shift. An interview was conducted with the DON on 8/27/19 at 2:30pm. She reported it was the nursing staff responsibility for labeling and dating all food kept in the nourishment room refrigerator. An interview was conducted with the Administrator on 8/27/19 at 2:30pm. He reported he was not sure who was responsible for the cleaning of the ice machine but would find out and make sure the 100-hall maker was thoroughly cleaned. He reported it was his expectation that the nourishment rooms refrigerators and ice makers are kept well maintained and sanitary. He reported it was his expectation that all opened foods are labeled and dated in all nourishment room refrigerators. An interview was conducted with the Administrator on 8/28/19 at 12:55pm. He reported the 100-hall ice maker had been cleaned and he had a plan in place for maintenance to clean the ice makers weekly. He reported it was his expectation that the food in the kitchen should be sealed, dated and labeled, and stored properly. He reported he expected no debris should be in the storage areas of the kitchen at any time.

Based on observations, resident and staff interviews the facility failed to offer or deliver an evening snack to 3 of 3 residents who expressed they were not consistently offered an evening snack during the resident council meeting (Resident # 48, Resident #57 and Resident #20). Findings Included: A resident council meeting was held on 8/26/19 at 2:00 pm and was attended by 7 residents. Resident #48, Resident #57 and Resident #20 voiced concerns that they were not routinely offered a bedtime snack. An observation was conducted on 8/27/19 from 8:00 pm through 8:55 pm of the 100 hall where the named residents resided. No snacks were observed to be offered to the residents on the 100 hall. Resident #48 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] identified the resident ' s cognition was intact. The care plan for the resident identified bedtime snack as a scheduled task. An interview on 8/27/19 at 8:30 pm with the resident revealed she had not been offered a snack tonight. She stated the staff did not routinely bring her a bedtime snack only occasionally. Resident #57 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident ' s cognition was intact. The care plan for the resident identified a bedtime snack as a scheduled task. An interview on 8/27/19 at 8:33 pm with the resident revealed she had not received or been offered a bedtime snack. Resident #20 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] identified the resident ' s cognition was intact. The care plan for the resident identified a bedtime snack as a scheduled task. An interview on 8/27/19 at 8:35 pm with the resident revealed she had not been offered a snack tonight. An interview on 8/27/19 at 8:34 pm with Nursing Assistant (NA) #5 revealed she had not passed out any snacks. She stated she was new, but she believed the kitchen did send out some snacks for specific residents and then a few extra things if a resident requested a snack. An interview on 8/27/19 at 8:40 pm with NA #6 revealed not all residents received a labeled snack, just a few residents. She stated the kitchen usually sent a few extra snacks for other residents if they wanted one. An interview on 8/28/19 at 1:50 pm with the Dietary Manager revealed snacks were put in the nourishment rooms at 2:00 pm and at night. She stated the staff would bring back leftover snacks to the kitchen. An interview on 8/28/19 at 12:06 pm with the Director of Nursing (DON) revealed all residents should be offered a snack at bedtime and they should not have to ask for one. She stated there should be an adequate supply of snacks sent out from the kitchen to ensure there are enough available for all residents that want one.

Based on observations, record review, staff and resident interviews the facility ' s Quality Assessment and Performance Improvement Committee (QAPI) failed to maintain implemented procedures and monitor the interventions that were put in place following the annual recertification and complaint survey of 9/25/2018. This was for 3 recited deficiencies in the area of accuracy of assessments (F-641), food procurement and storage (F-812) and dumpster free of debris (F-814). These deficiencies were re-cited during the annual recertification and complaint survey of 8/28/2019. The continued failure of the facility during 2 federal surveys of record showed a pattern of the facility ' s inability to sustain an effective QAPI program. Findings included: This tag is cross referred to: 1. F-641- Based on record review and staff interview the facility failed to accurately code the Minimum Date Set (MDS) for 1 of 1 resident reviewed for skin condition (Resident #25), for 1 of 3 residents revealed for discharged (Resident #119) and 2 of 5 residents reviewed for unnecessary drug. Resident # 66 and Resident #46). During the recertification and complaint survey of 9/25/2019 the facility was cited for failure to accurately code the MDS assessment for 1 of 1 resident reviewed for elopement from the facility (Resident 81). Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) Assessment for 1 of 1 resident reviewed for elopement from the facility (Resident 81). 2. F-812 Based on observations and staff interviews, the facility failed to maintain sanitary conditions in the kitchen and nourishment rooms by not ensuring unsealed food items were dated and labeled and opened items not resealed in 1 of 1 walk in refrigerators in the kitchen, 2 of 3 refrigerators in the nourishment rooms, and 1 of 1 refrigerated cooler and 1 of 1 dry storage room in the kitchen. The facility also failed to maintain sanitary conditions in 1 of 1 nourishment rooms and 1 of 1 dry food storage areas by not ensuring clean ice machines and storage areas free from debris. During the recertification and complaint survey of 9/25/2018 the facility was cited for failure to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean the convection oven, the conventional oven, failed to clean the drink gun nozzle, failed to remove grease build up from 7 of 7 sheet pans, failed to clean the can opener and failed to store pans completely dry. 3. F-814-Based on observations and staff interviews, the facility failed to ensure garbage and debris were properly disposed of in one of one garbage container and failed to maintain area outside of kitchen free of debris. During the recertification and complaint survey of 9/25/2019 the facility was cited for failure to maintain the area surrounding the dumpster free of debris for 5 of 5 dumpsters observed. An interview on 8/28/2019 at 1:17 pm with the Administrator revealed the facilities quality assurance team consisted of himself, the Director of Nursing, Medical Director, Pharmacy Consultant and other department heads. He stated they tried to meet monthly but did meet quarterly at a minimum. He stated they utilized a schedule of data that was evaluated and if concerns were identified they developed a QA plan. He added the team also worked on enhancement goals. The Administrator stated it was his expectation the QA system translated into the outcomes that were required for compliance and hope to delete repeat tags.

Based on observations and staff interviews the facility failed to maintain 2 of 2 whirlpools in safe operating condition. Findings included: Interview with the Maintenance Director (MD) on 8/27/2019 at 8pm revealed he been here for three years and the facility had 2 whirlpool tubs. He stated he was not aware of any residents ever using the whirlpools. The MD added the whirlpool on the short hall did not work and he had recently repaired the whirlpool on 6/25/2019 for the long hall. Review of repair requisition form on 8/27/2019 at 8:15pm revealed date 6/25/2019 Location unit 2 shower room, repair needed: waterline busted on whirlpool revealed repaired on 6/25/2019 signed and approved. On 8/27/2019 at 8:18 PM, observation of the whirlpool in the unit 2 shower room revealed the whirlpool was still broken. Observation revealed water was running out of the bottom of the whirlpool onto the shower room floor. During a second interview with the MD on 8/27/2019 around 8:30pm he indicated he would have to work to fix the whirlpool and he believed it needed something to stop the water from running out. He added it would not be safe for residents to use the whirlpool. During an interview with the Administrator on 8/28/2019 at 1:30pm he indicated he expected the maintenance director/staff to maintain the equipment in good shape and safe operating conditions for the residents to use.

Based on record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) for 1 of 1 resident reviewed for Hospice (Resident #25), 1 of 3 residents reviewed for discharge (Resident #119) and 1 of 5 residents reviewed for unnecessary medications (Resident # 66). Findings included: 1. Resident #25 was admitted to the on 8/2/2017 and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of d Minimum Date Set dated 6/4/2019 Section O indicated that Resident #25 was not on hospice. Review of Minimum Date Set ((MDS) dated [DATE] Section O indicated that Resident #25 was coded for Hospice. Review of Care plan dated 6/3/2019 indicated that Resident #25 was on Hospice. Record Review revealed that Resident #25 received Hospice Services during the week of (MONTH) 28, 2019. An interview was conducted with the MDS coordinator on 8/27/19 at 12:50pm. She reported the MDS nurses were responsible for coding all MDS assessments accurately. She reported the MDS for Resident #25 should have reflected Resident's Hospice Care. An interview was conducted with the Administrator on 8/28/19 at 12:55pm. He reported it is the responsibility of the MDS nurses to correctly and accurately complete all MDS assessments. He reported it was his expectation that the MDS assessments would be coded accurately to reflect all residents status. 2. Findings included: Resident #119 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. Review of discharged Minimum Date Set on 6/21/2019 revealed on 6/21/2019 Resident #119 was discharged to chronic hospital. Review of discharge summary dated 6/21/2019 revealed that Resident # 119 was discharged to Assistant Living Facility. An interview was conducted with the MDS coordinator on 8/27/19 at 12:50pm. She reported the MDS nurses were responsible for coding all MDS assessments accurately. She reported the MDS for Resident #25 should have reflected Resident's discharged status. An interview was conducted with the Administrator on 8/28/19 at 12:55pm. He reported it is the responsibility of the MDS nurses to correctly and accurately complete all MDS assessments. He reported it was his expectation that the MDS assessments would be coded accurately to reflect all residents status. 3. Findings included: Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #66's most recent MDS (Minimum Data Set) coded as a quarterly assessment and dated 7/12/19 revealed the resident was cognitively impaired. Active [DIAGNOSES REDACTED]. The 7-day medication look back on the MDS revealed Resident #66 received an antipsychotic 7 out of 7 days, anticoagulant 7 out of 7 days, antianxiety 7 out of 7 days, antidepressant 7 out of 7 days, and a diuretic 7 out of 7 days. A review of Resident #66's most current care plan dated 5/2/19 revealed the resident was care planned for side effects from antidepressant medication use, antianxiety medication use, and antipsychotic medication use. Resident #66 was also care planned for potential fluid volume deficit related to a diuretic, and potential for bruising/bleeding due to anticoagulant therapy. A review of Resident #66's medical record revealed a physician's note dated 7/2/19 by the geriatric psychiatric nurse practitioner. She documented the resident had the following Diagnoses: [REDACTED]. An interview was conducted with the MDS coordinator on 8/27/19 at 12:50pm. She reported the MDS nurses were responsible for coding all MDS assessments accurately. She reported the MDS for Resident #66 should have reflected the [DIAGNOSES REDACTED]. An interview was conducted with the Administrator on 8/28/19 at 12:55pm. He reported it is the responsibility of the MDS nurses to correctly and accurately complete all MDS assessments. He reported it was his expectation that the MDS assessments would be coded accurately to reflect all pertinent diagnoses.

Based on observations, record review and staff interviews the facility failed to provide assistance with eating for a resident with impaired vision. This was evident for 1 of 3 residents reviewed for activities of daily living (Resident #8). Findings Included: Resident #8 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #8 identified she required supervision, oversight, encouragement or cueing with eating, had severely impaired vision and had impaired cognition. Review of a care plan with an onset date of 1/31/14 stated Resident #8 had a self-care deficit related to [MEDICAL CONDITION], weakness, [DIAGNOSES REDACTED]. Interventions included to provide set-up assistance and instructions as to food placement for meals in the dining room. Review of a care plan with an onset date of 10/17/14 stated Resident #8 was at risk for nutritional decline. Interventions included to provide all meals in Unit 1 dining room with complete set-up assistance, supervision and assistance as needed. Staff to inform the resident of food / bowl placement due to [MEDICAL CONDITION]. An observation of Resident #8 on 8/25/19 at 1:17 pm revealed she was in her room eating lunch. There were no staff present with the resident. The resident was observed to be eating with her fingers, there were 3 beverages on her tray that had lids on them and a container of ice cream that had not been opened. Resident #8 stated she could not see anything and asked if she had any coffee and ice cream on her tray. An observation of Resident #8 on 8/27/19 at 12:28 pm revealed she was eating her lunch in the dining room. There were no staff assisting the resident with her meal. She was observed to be using her fingers to feel for items and noted to have food spilled on her lap. The resident stated she didn ' t know what she had to eat except a piece of chicken. She asked if she had any coffee or ice cream on her tray. An interview on 8/27/19 at 12:31 pm with Nursing Assistant (NA) #4 revealed she did not know what staff member had served the resident her meal tray, but they should have explained what foods were served and where they were located on her meal tray. She added the resident often ate with her fingers and needed to have her meats cut up. An interview on 8/28/19 at 12:03 pm with the Director of Nursing (DON) revealed she expected all residents receive adequate assistance with eating. She stated Resident #8 should have been provided with a full tray set-up that included an explanation of the foods served and where they were located.

Based on observations, record review, nurse practitioner, and staff interviews, the facility failed to notify physician of urinalysis and urine culture abnormal results on the day received to assist in determining treatment for [REDACTED].#56 and Resident #85) reviewed for history of urinary tract infections. Findings include: A review of the facility's policy for notification of laboratory results to the physician stated the staff should 'notify the physician promptly of abnormal results.' 1.Resident #56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #56's most recent MDS (Minimum Data Set) dated 7/5/19 was coded as a quarterly assessment. The MDS coded the resident as cognitively impaired. Active [DIAGNOSES REDACTED]. The MDS coded Resident #56 as frequently incontinent of urine. A review of Resident #56's medical record revealed a nursing note dated 8/25/19 that revealed the resident was having hematuria, lower abdominal pain and tremors. The record also revealed a physician's orders [REDACTED].' The resident's medical record also revealed urine culture results received 8/26/19 that showed the culture grew out 50,000-100,00 colony forming units per milliliter of proteus mirabilis. An observation was made on 8/28/19 at 9:00am of Resident #56's urine culture results sideways in the chart and the chart was placed on top of the chart shelf for the nurse practitioner to review. There was no documentation noted that the nurse practitioner had seen or been called the results. 2. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #85's most recent MDS dated [DATE] was coded as a quarterly assessment. The MDS coded the resident as cognitively impaired. The resident was coded as having an indwelling catheter. Active [DIAGNOSES REDACTED]. A review of Resident #85's care plan dated 1/14/19 revealed the resident was care planned for potential for urinary tract infection related to the presence of an indwelling catheter due to [MEDICAL CONDITION] bladder. A review of Resident #85's medical record revealed a physician's note dated 7/3/19 which noted the resident was seen for urinary issues such as fever and foul-smelling urine. The physician ordered an antibiotic and will monitor for improvement. The resident's medical record also revealed a physician's orders [REDACTED]. Check urinalysis, culture and sensitivity (nausea, abdominal pain, odor) rule out urinary tract infection.' A nursing note dated 8/21/19 revealed a urine sample was obtained for urinalysis, culture and sensitivity. A review of Resident #85's medical record revealed a urinalysis report dated 8/21/19 that revealed white blood cells 20-40, positive leukocytes and [MEDICATION NAME], few bacteria, moderate triple [MEDICATION NAME] crystals, and hyaline cast 0-5. A urine culture report time stamped received 8/24/19 revealed the urine culture showed 50,000-100,000 colony forming units per milliliter of proteus mirabilis. An interview was conducted with Nurse #13 on 8/27/19 at 3:30pm. She reported all abnormal laboratory results are to be called to the physician as soon as the results are received. She reported the nurse then documented on the laboratory results the date and time and which provider was given the abnormal results. Nurse #13 reported if the laboratory results are normal, the staff will flag in the chart for the provider's next visit. She reported the urine culture results on Resident #85 should have been called to the physician on 8/24/19. Nurse #13 stated she would call the provider with the results. An interview was conducted with NP #5 (Nurse Practitioner) on 8/28/19 at 10:30am. She reported the providers expected all abnormal laboratory results be either called or faxed to them as soon as the facility received them and then the nurse should also flag in the chart. She reported the provider may or may not treat abnormal laboratory results, but it would be up to the provider to decide. An interview was conducted on 8/28/19 at 10:45am with the DON (Director of Nursing). The DON reported all abnormal laboratory results should be reported to the physician as soon as the nurse received it. An interview on 8/28/19 at 12:55pm was conducted with the Administrator. He reported it was his expectation that the provider be notified of all abnormal laboratory results as soon as received.

Based on observations and staff interviews, the facility failed to ensure garbage and debris was properly disposed of in one of one garbage container and failed to maintain area outside of kitchen free of debris. Findings include: An observation was made on 8/25/19 at 1:00pm with dietary aide #5 of the dumpster area and area outside of kitchen door. It was observed that there was a large garbage container on sidewalk outside kitchen door that was uncovered and overflowing with trash that included opened food containers. It was also observed that there was debris strewn on the ground and sidewalk. An interview was conducted with dietary aide #5 on 8/25/19 at 1:00pm. She reported all garbage should be placed in the dumpsters with the doors closed. She reported she did not know why someone left the garbage container on the sidewalk. An interview was conducted on 8/27/19 at 1:50pm with the dietary manager. She reported she expected all garbage and debris to be disposed of in the dumpsters. She also reported she expected the staff to pick up any/all debris/trash on the ground between the kitchen and dumpster and the staff should never leave garbage containers outside full and uncovered. An interview was conducted on 8/28/19 at 12;55pm with the Administrator. He reported that he expected garbage containers should be covered and not left out on sidewalks and that all garbage/debris should be disposed of properly, not just left on the ground.

Based on record reviews and staff interviews, the facility failed to develop and implement a comprehensive care plan to include non-pharmacological interventions on 1 out of 5 residents (Resident #66) who was reviewed for unnecessary medications. Findings include: Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #66's most recent MDS (Minimum Data Set) coded as a quarterly assessment and dated 7/12/19 revealed the resident was cognitively impaired. Active [DIAGNOSES REDACTED]. The 7-day medication look back on the MDS revealed Resident #66 received an antipsychotic 7 out of 7 days, anticoagulant 7 out of 7 days, antianxiety 7 out of 7 days, antidepressant 7 out of 7 days, and a diuretic 7 out of 7 days. A review of Resident #66's most current care plan dated 5/2/19 revealed the resident was care planned for side effects from antidepressant medication use with interventions that included: discussed potential side effects of medication with family and resident, administer medication as ordered by physician, observe for adverse side effects, document and report to physician, monitor and record target behaviors, pharmacy consult, and monitor for signs of extrapyramidal symptoms and document. Resident #66 was care planned for antianxiety medication use with interventions that included discussing potential side effects of medication with resident and family, administer medication as ordered by physician, observe for adverse side effects, document and report to physician, monitor and record target behaviors, pharmacist consult, monitor for signs or extrapyramidal symptoms and document. Resident #66 was care planned for antipsychotic medication use with interventions that included discussion of medications with family and resident, administer medications as ordered by physician, observe for adverse side effects, monitor behaviors, maintain environment free of clutter and safety hazard, and monitor for signs of tremor and document. The resident was care planned for fluid volume deficit related to a diuretic and potential for bruising/bleeding due to anticoagulant therapy. An interview was conducted with the MDS coordinator on8/27/19 at 12:50pm. She reported it was her responsibility to develop and implement care plans for all the residents. She reported Resident #66 should have had non-pharmacological interventions for his [MEDICAL CONDITION] medications. An interview was conducted on 8/28/19 at 12:55pm with the administrator. He reported it was the responsibility of the MDS nurses to develop and implement all care plans for all residents. He reported it was his expectation that the care plans include non-pharmacological interventions when the resident was on [MEDICAL CONDITION] medications.

Based on resident and staff interviews, observations and record review, the facility failed to honor a resident's choice to provide a whirlpool bath for 1 of 1 resident (Resident #94) reviewed for choices. Findings included: Resident #94 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #94 ' s cognition was severely impaired, and she required extensive physical assistance for bathing. A review of the ADL (activities of daily living) care plan dated 8/3/2019 revealed Resident #94 was resistant to daily care and refused ADL care at times. Interventions included for staff to approach the resident slowly/calmly and to strike up a conversation with the resident before starting her care. On 8/25/2019 at 4pm an interview with Resident #94 ' s family revealed the resident can be combative with staff during care. The family indicated they had asked for Resident #94 to have a whirlpool bath because they thought she would be more cooperative with that because it would be calmer for her. The family added they would come in and assist with the whirlpool bath, but the whirlpool had not been working for months. The family stated this information had been shared with the facility in the writing several months ago, but the whirlpool still didn ' t work. During an interview with Nurse #1 on 8/27/2019 at 12:00 pm she reported the resident had a shower today, however she stated the resident usually refused showers and the family would have to come in and convince her take one. A review of the medical record revealed Resident #94 refused showers for time to time. Observation on the whirlpool on 8/27/2019 at 8:20 pm revealed the whirlpool did not work. During an interview with the Director of Nursing (DON) on 8/27/2019 at 8:40 pm revealed she did not know the whirlpool was not working and she had only been at the facility for 20 days or less. During an interview with the DON on 8/28/2019 at 10am she revealed she expected the facility to honor the residents and family ' s choices.

Based on observations and staff interviews the facility failed to maintain the area surrounding the dumpster free of debris for 5 of 5 dumpsters observed. The findings included: During an observation of the dumpster area on 9/18/18 at 9:25 AM, 2 disposable gloves were observed in front of dumpster # 1, assorted papers, straws and Styrofoam cup were in front of dumpster # 3 and 3 disposable gloves were to the right of dumpster # 5. During an second observation on 9/19/18 at 8:03 AM 4 disposable gloves were in front of dumpster # 1, assorted papers, straws and Styrofoam cup were in front of dumpster # 3 and 3 disposable gloves were to the right of dumpster # 5. A third observation of the dumpster area on 9/20/18 at 8:22 AM 3 disposable gloves and ice cream cup were observed on the ground between dumpster # 1 and dumpster # 2. 3 disposable gloves were observed on the ground in front of dumpster # 4 and 4 disposable gloves were observed to the right of dumpster # 5 with assorted papers strewn about in front and behind the dumpster area. An observation of the dumpster area was conducted with the certified dietary manager (CDM) on 9/20/18 at 9:57 AM revealed the dumpster area to be in the same condition. During an interview on 9/20/18 at 10:00 AM the CDM stated that the maintenance man went out twice a day to pick up the dumpster area. On 9/20/18 at 10:01 AM the maintenance man stated he went out every morning and afternoon to rake around the dumpster area.

Based on observations, record review and staff interviews, the facility failed to accurately transcribe and follow the dosing frequency of a medication as ordered by the physician for 1 of 4 residents reviewed for unnecessary medications (Resident #29). The findings included: Resident #29 was admitted to the facility on [DATE] from the community. His cumulative [DIAGNOSES REDACTED]. A review of the resident ' s admission medication orders (dated 7/2/18) included 20 milligrams (mg) [MEDICATION NAME] (a medication used to treat acid reflux) to be given by mouth twice daily. A review of Resident #29 ' s admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had severely impaired cognitive skills for daily decision making. The resident required supervision for eating, limited assistance for walking in his room and for toileting, extensive assistance for bed mobility, locomotion on and off the unit, dressing, and personal hygiene. Section I of the MDS assessment indicated Resident #29 ' s [DIAGNOSES REDACTED]. A review of Resident #29 ' s (MONTH) (YEAR) Medication Administration Record revealed he received 20 mg [MEDICATION NAME] twice daily as prescribed from 7/3/18 to 7/31/18. The [MEDICATION NAME] was scheduled to be given at 8:00 AM and 5:00 PM every day. A review of the resident ' s monthly Physician order [REDACTED]. A review of Resident #29 ' s (MONTH) (YEAR) Medication Administration Record revealed he received 20 mg [MEDICATION NAME] only once daily at 8:00 AM from 8/1/18 to 8/21/18. The [MEDICATION NAME] was not scheduled on the MAR to be given at 5:00 PM until 8/22/18. Resident #29 received 20 mg [MEDICATION NAME] twice daily (at 8:00 AM and 5:00 PM) from 8/22/18 to 8/31/18. A review of the resident ' s monthly Physician order [REDACTED]. A review of Resident #29 ' s (MONTH) (YEAR) Medication Administration Record revealed he received 20 mg [MEDICATION NAME] only once daily at 8:00 AM from 9/1/18 up to the date of the review on 9/20/18. The [MEDICATION NAME] was not scheduled to be given at 5:00 PM on the MAR. An interview was conducted on 9/20/18 at 9:30 AM with Nurse #8. Upon request, the nurse reviewed the resident ' s (MONTH) (YEAR) MAR and confirmed the dosing of [MEDICATION NAME] was only scheduled once daily at 8:00 AM. However, she acknowledged the instructions written on the physician's order [REDACTED]. A review of the bubble pack card of [MEDICATION NAME] dispensed by the pharmacy on 9/19/18 for the resident included instructions to take one tablet by mouth twice daily for GERD. An interview was conducted on 9/20/18 at 10:11 AM with Unit Manager #1. During the interview, the Unit Manager reported, The second dose (of Resident #29 ' s [MEDICATION NAME]) fell off somehow. She stated she would complete a medication error report related to the situation. An interview was conducted on 9/20/18 at 10:19 AM with the facility ' s Director of Nursing (DON). During the interview, the DON stated it appeared there was an error during the month end changeover resulting in Resident #29 ' s [MEDICATION NAME] being given once daily instead of two times a day as ordered. The DON stated her expectation was for the nurse to read the order and administer the medication as ordered on the MAR. Upon inquiry, the DON identified the nurses who had checked the physician orders [REDACTED]. She reported one of the nurses was on leave and would not be available for an interview. An interview was conducted on 9/20/18 at 11:04 AM with the facility ' s consultant pharmacist. During the interview, the pharmacist reported she had completed a medication regimen review for Resident #29 on 8/22/18. She thought the error on the [MEDICATION NAME] ' s dosing frequency was caught and corrected when she conducted the review at that time. An interview was conducted on 9/20/18 at 3:35 PM with Nurse #9. Nurse #9 identified her hand-writing on Resident #29 ' s (MONTH) MAR as the nurse who corrected the MAR to include twice daily dosing of the [MEDICATION NAME]. She reported the pharmacist and/or the Unit Manager had requested the correction on 8/22/18. An interview was conducted on 9/20/18 at 3:45 PM with Nurse #2. Nurse #2 was identified as the nurse who completed the first check on Resident #29 ' s physician's order [REDACTED]. Upon review of the orders and the (MONTH) MAR, Nurse #2 stated, It was over looked. She reported that normally such an error should have been caught and corrected. A telephone interview was conducted on 9/20/18 at 4:00 PM with the Nurse Practitioner (NP) who helped care for Resident #29. During the interview, the NP reported she had assessed the resident earlier that morning (9/21/18) after the medication error was brought to her attention. At that time, she decided to see if the resident continued to tolerate once daily dosing of the [MEDICATION NAME] and stated she changed the order accordingly.

Based on observations, staff interviews, and consultant pharmacist interviews, the facility: 1) Failed to store medications as specified by the manufacturer in 2 of 3 medication carts (Unit 2 Med Cart 2 and Unit 1 Med Cart 2); 2) Failed to remove expired medications from 2 of 2 medication storerooms (Unit 2 Med Room and Unit 1 Med Room); and, 3) Failed to dispose of a loose, unidentified tablet observed at the bottom of a soiled compartment on 1 of 3 medication carts (Unit 2 Med Cart 1). The findings included: 1a) Accompanied by Nurse #4, an observation of the Unit 2 Medication Cart 2 was conducted on 9/19/18 at 9:30 AM. A bottle of 200 units/activation calcitonin nasal spray (a medication indicated for the treatment of [REDACTED].#4 was observed to be lying on its side in the top drawer of the medication cart. The manufacturer labeling on the bottle of the calcitonin included instructions to store the bottle in the upright position. After reviewing the medication ' s storage and labeling, Nurse #4 attempted to reposition the bottle and close the top drawer. However, the drawer would not close with the calcitonin bottle standing upright. The nurse stated, Someone moved it from where it was supposed to be. The nurse was then observed as she placed the calcitonin standing upright in another drawer of the medication cart. A review of Resident #4 ' s Physician order [REDACTED]. An interview was conducted on 9/20/18 at 7:41 AM with the facility ' s Director of Nursing (DON). During the interview, the observations of medication storage on the med carts was discussed. At that time, the DON stated her expectation for medication storage was to follow the proper procedures based on the individual medications. An interview was conducted on 9/20/18 at 11:04 AM with the facility ' s consultant pharmacist. During the interview, the observations of medication storage on the med carts and med room were discussed. The pharmacist had no questions or disagreements regarding the findings of the medication storage observations. 1b) Accompanied by Nurse #5, an observation of the Unit 1 Medication Cart 2 was conducted on 9/19/18 at 9:50 AM. A 5 milliliter (ml) bottle of 0.1% fluorometholone ophthalmic suspension (a steroid-containing eye drop) dispensed for Resident #71 was observed to be lying on its side with the other eye drops stored on the medication cart. The storage instructions on the manufacturer labeling of the fluorometholone eye drops was covered by the pharmacy label. The manufacturer recommendations for storage of the fluorometholone ophthalmic suspension indicated the bottle of eye drops should be stored in the upright position. A review of Resident #71 ' s Physician order [REDACTED]. An interview was conducted on 9/20/18 at 7:41 AM with the facility ' s Director of Nursing (DON). During the interview, the observations of medication storage on the med carts was discussed. At that time, the DON stated her expectation for medication storage was to follow the proper procedures based on the individual medications. An interview was conducted on 9/20/18 at 11:04 AM with the facility ' s consultant pharmacist. During the interview, the observations of medication storage on the med carts and med room were discussed. The pharmacist reported she was made aware of the storage concern for the fluorometholone ophthalmic suspension. She reported the resident ' s insurance would not replace the eye drops at this time. After calling the manufacturer, she reported telling the facility they could use these eye drops for Resident #71, but that the bottle needed to be stored in an upright position. The pharmacist had no questions or disagreements regarding the findings of the medication storage observations. 2a) An observation of the Unit 2 Medication Room was conducted on 9/19/18 at 4:23 PM. The observation revealed an opened vial of [MEDICATION NAME] PPD injectable medication (used for skin test in the [DIAGNOSES REDACTED]. A hand-written date indicated the [MEDICATION NAME] PPD medication was opened on 8/15/18. The manufacturer ' s product information indicated opened vials of [MEDICATION NAME] PPD injectable medication should be discarded after 30 days. An interview was conducted on 9/19/18 at 4:40 PM with the facility ' s Director of Nursing (DON). During the interview, the observations of opened vial of [MEDICATION NAME] PPD (dated 8/15/18) stored in the med room refrigerator was discussed. Upon inquiry as to how long the [MEDICATION NAME] PPD could be kept after opened, the DON answered, 30 days. During a follow-up interview conducted on 9/20/18 at 7:41 AM, the DON stated her expectation for medication storage was to follow the proper procedures based on the individual medications. An interview was conducted on 9/20/18 at 11:04 AM with the facility ' s consultant pharmacist. During the interview, the observations of medication storage were discussed, including the expired [MEDICATION NAME] PPD. The pharmacist had no questions or disagreements regarding the findings of the medication storage observations. 2b) An observation of the Unit 1 Medication Room was conducted on 9/20/18 at 9:47 AM. The observation revealed two opened vials of [MEDICATION NAME] PPD injectable medication (used for skin test in the [DIAGNOSES REDACTED]. A hand-written date indicated both of the [MEDICATION NAME] PPD vials were opened on 8/17/18. The manufacturer ' s product information indicated opened vials of [MEDICATION NAME] PPD injectable medication should be discarded after 30 days. An interview had been conducted on 9/19/18 at 4:40 PM with the facility ' s Director of Nursing (DON). During the interview, the observation of an opened vial of [MEDICATION NAME] PPD (dated 8/15/18) stored in the Unit 2 Med Room refrigerator had been discussed. This interview was conducted prior to the observation of the additional opened, expired [MEDICATION NAME] PPD vials in the Unit 1 Med Room. Upon inquiry as to how long [MEDICATION NAME] PPD could be kept after being opened, the DON answered, 30 days. During a follow-up interview conducted on 9/20/18 at 7:41 AM, the DON had stated her expectation for medication storage was to follow the proper procedures based on the individual medications. An interview was conducted on 9/20/18 at 11:04 AM with the facility ' s consultant pharmacist. During the interview, the observations of medication storage were discussed, including the expired [MEDICATION NAME] PPD. The pharmacist had no questions or disagreements regarding the findings of the medication storage observations. 3) Accompanied by Nurse #3, an observation of the Unit 2 Medication Cart 1 was conducted on 9/19/18 at 9:12 AM. The observation revealed the bottom of one compartment in top drawer of the medication cart contained a yellow, sticky substance. Two stock bottles of medication were stuck to the bottom of the drawer. Removal of the two stock bottles revealed there was one loose, unidentified tablet stuck in the yellow substance at the bottom of the compartment. Upon inquiry, Nurse #3 reported she typically didn't use these two stock meds very often so had not noticed the yellow substance at the bottom of the compartment. The nurse removed the loose, unidentified tablet from the bottom of the compartment and was observed as she discarded it. An interview was conducted on 9/20/18 at 7:41 AM with the facility ' s Director of Nursing (DON). During the interview, the observations of medication storage on the med carts was discussed. At that time, the DON stated her expectation for medication storage was to follow the proper procedures based on the individual medications.

Based on observations and staff interviews the facility failed to maintain kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean the convection oven, the conventional oven, failed to clean the drink gun nozzle, failed to remove grease build up from 7 of 7 sheet pans, failed to clean the can opener and failed to store pans completely dry. The findings included: During the initial kitchen tour on 9/18/18 at 9:18 AM the kitchen work area was observed. The bottom inside of the convection oven was observed with black charred food particles. The conventional oven door handle was greasy to touch and the bottom inside was observed to have black charred food particles. The drink gun nozzle was observed to have a dark brown residue build up inside the nozzle. 2 of 2 full size hotel pans were observed nested wet and 2 of 3 half size hotel pans were observed stored nested wet. During the meal observation on 9/18/18 at 11:18 AM the conventional oven door handle was greasy to touch and the bottom inside of the oven was observed to have black charred food particles. 7 of 7 sheet pans stacked on the drying rack, were observed to have 1/8 to ¼ inch of black dried food residue one inch wide under the rim. During an observation of the kitchen work area on 9/19/18at 3:43 PM the bottom inside of the convection oven was observed with black charred food particles. The conventional oven handle was greasy to touch and the bottom inside of the oven was observed to have black charred food particles. The drink gun nozzle was observed to have a dark brown residue build up inside the nozzle. An observation of the kitchen work area on 9/20/18 at 9:50 AM revealed the convection oven and conventional oven were in the same condition. At 9:54 AM 2 of 2 half size hotel pans were observed stacked together wet and 8 of 8 sheet pans stacked on the drying rack, were observed to have 1/8 to ¼ inch of black dried food residue one inch wide under the rim. The table mounted can opener was observed to have a greasy black residue build up above the blade and the can opener frame had a greasy black buildup of residue. The drink gun nozzle was observed with a dark colored residue build up inside the nozzle. During an interview 9/20/18 at 9:51 AM the Certified Dietary Manager (CDM) stated Wednesday was the regular cleaning day in the kitchen. However due to a call out the scheduled cleaning staff had to fill in for another dietary staff member who had called out. The CDM stated the ovens did not look thoroughly cleaned and stated staff usually cleaned according to the posted cleaning schedules. During an interview on 9/20/18 at 10:15 AM the dietary staff stated that she usually did clean the drink nozzle and can opener but had gotten busy and would clean them right away.

Based on observations, staff interviews, and record review, the facility staff failed to store residents ' glucometers (device used to measure a resident's blood glucose or blood sugar level) in a manner to prevent potential cross-contamination from contact with other glucometers on 3 of 3 medication carts observed (Unit 2 Med Cart 1, Unit 2 Med Cart 2 and the Unit 1 Med Cart 2). The findings included: A review of the facility policies entitled Obtaining a Fingerstick Glucose Level (revised (MONTH) 2011) read, in part: 18. Clean and disinfect reusable equipment between uses according to the manufacturer ' s instructions and current infection control standards of practice. The storage of the residents ' individual glucometers in a manner to prevent potential cross-contamination from contact with other glucometers was not specifically addressed in the facility policy/procedures. A review of the manufacturer ' s labeling on the wipes (towelettes) used to clean and disinfect glucometers at the facility was conducted. The Cleaning Instructions read as follows: Use one (Brand Name) towelette to completely preclean surface of all gross debris. For use as a virucide (an agent active [MEDICAL CONDITION] infections), including HIV-1 (human immunodeficiency virus type 1), HBV ([MEDICAL CONDITION] virus) and HCV ([MEDICAL CONDITION] virus) applications and effectiveness against [MEDICAL CONDITION] (a bacteria which is also known [MEDICAL CONDITION]), [MEDICATION NAME] (an antibiotic) Resistant [MEDICATION NAME] faecalis (a type of bacteria also known as VRE) and Staphylococcus aureus with Reduced Susceptibility to [MEDICATION NAME] (a type of bacteria): Use a second (Brand Name) towelette to thoroughly wet the surface. Repeated use of the product may be required to ensure that the surface remains visibly wet for 2 minutes at room temperature (68o Fahrenheit / 20o Celsius). A continuous observation was conducted on 9/19/18 at 8:15 AM as Nurse #3 checked a resident ' s blood glucose using an individual glucometer labeled with the resident ' s name. After the blood glucose check was completed, the nurse wiped the glucometer with one disinfectant wipe for 30 seconds. Nurse #3 was observed as she placed the glucometer in the medication cart (Unit 2 Med Cart 1) with 9 other meters (each labeled for an individual resident). The glucometers were in contact with one another. There was no barrier in place that separated the meters to prevent potential cross-contamination. An observation was conducted of the Unit 2 Med Cart 2 on 9/19/18 at 9:30 AM with Nurse #4. Seven glucometers (each individually labeled with a resident ' s name) were stored on the medication cart. The glucometers were stored on the med cart in contact with one another. There was no barrier in place that separated the meters to prevent potential cross-contamination. An observation was conducted of the Unit 1 Med Cart 2 on 9/19/18 at 9:50 AM with Nurse #5. Six glucometers (each individually labeled with a resident ' s name) were stored on the medication cart. The glucometers were stored on the med cart in contact with one another. There was no barrier in place that separated the meters to prevent potential cross-contamination. An interview was conducted on 9/20/18 at 1:12 PM with the facility ' s Infection Control Nurse. Upon inquiry, the nurse stated the residents ' glucometers originally came in a pink bag, but the pink bags had disappeared over time and were no longer used to separate the glucometers. An interview was conducted with the facility ' s Director of Nursing (DON) on 9/20/18 at 2:46 PM in regards to the storage of the residents ' individual glucometers on the med carts. Additionally, the observation of staff failing to clean an individual glucometer as directed by the manufacturer of the disinfectant wipes used and the related concern regarding potential cross-contamination of the glucometers was discussed. When the DON was asked if she had been aware the individual resident glucometers were stored in contact with one another, she stated she did not realize this would be a concern. Upon further discussion, the DON reported she would expect a barrier to be used for storing the individual residents ' glucometers so they would be not be in contact with one another due to the concern for potential cross-contamination.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) Assessment for 1 of 1 residents reviewed for elopement from the facility (Resident 81). The findings included: Resident #81 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The resident's Care Plan dated 3/1/18 noted the resident wandered due to cognitive impairment and to provide care for the wander guard twice a day. The Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #81 had severe cognitive impairment and ambulated independently in the corridor with supervision. Section P0200 E noted a wander guard was not used for the resident. The Quarterly MDS dated [DATE] noted a wander guard was not used for Resident #81. The Quarterly MDS dated [DATE] noted a wander guard was not used for Resident #81. On 9/21/18 at 10:38 AM an interview was conducted with MDS Nurse #1 who stated she completed the resident's MDS. The MDS Nurse stated she was instructed to not code the wander guard on the MDS. The MDS Nurse stated she did not code a wander guard on the MDS for any of their residents with a wander guard. On 9/21/18 at 11:38 AM The Director of Nursing (DON) stated in an interview the wander guard was placed on Resident #81 upon admission and understood the wander guard was not to be coded on the MDS. On 9/21/18 at 12:03 PM an interview was conducted with the DON and the MDS Coordinator. The MDS Coordinator stated she understood if they had an alarm system on all the doors in the facility where an alarm sounded if any person exited the door, a wander guard was not to be coded on the MDS.

Based on record reviews, attending physician and staff interviews the facility failed to use a mechanical lifting device during Resident #120's transfer from bed to chair and the transfer back into the bed. This was evident in 1 of 7 residents reviewed for accidents. Findings included: Resident #120 was readmitted to the facility on [DATE] with numerous [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] coded the resident with short and long-term memory loss and no behavior issues. Under functional status the MDS was coded as extensive assistance of 2 staff for transfers. Review of the written care plan (undated) revealed a problem of [MEDICAL CONDITION], and at risk for fractures with an approach to use a mechanical lift for transfers. Another identified problem was falls with the approach for total lift for transfers. Interview on 09/20/18 at 2:58 PM with Unit Manager (UM) #1 stated on 7/18/18, NA #1 was looking for a lift pad for Resident #120 and UM #1 instructed her to contact the Lead NA to obtain the lifting pad. UM #1 stated the next time on 7/18/18 she observed Resident #120 was in the dining room for breakfast. Interview on 09/20/18 at 4:36 PM with Nurse #2 stated around 6:00 PM on 7/18/18 NA #2 informed her that Resident #120 had a skin tear with dried blood and the resident's left leg was swollen, painful, and bruised. Nurse #2 notified the on-call Nurse Practitioner who ordered an x-ray of the left leg. Further interview revealed she administered [MEDICATION NAME] extra strength (2) tablets for pain. Interview on 09/20/18 at 1:31 PM with the Administrator and Director of Nurses (DON) was conducted. The Administrator and DON indicated NA #1 was should have used the mechanical lift to transfer Resident #120 into and out of bed. Interview on 09/20/18 at 4:47 PM via phone with NA #1 stated when she arrived on duty (7/18/18 during the 7 AM-3 PM shift) Resident #120 needed to be transferred out of bed for breakfast and she could not find a lifting pad so I transferred her (Resident #120) out of bed by myself. NA #1 stated I made a mistake when she transferred Resident #120 by herself and did not use a lift. Further interview with NA #1 stated she was unware of any skin tears that Resident #120 sustained on 7/18/18. Interview on 9/25/18 at 3:09 PM via phone with the attending physician revealed Resident #120 was fragile, dependent on staff for transfers and had [MEDICAL CONDITION]. During the conversation the attending physician stated she was unsure how staff handled her during transfers but that her bones could break at any time with or without associated trauma.

Based on record review and staff interviews, the facility failed to notify the family member and the Ombudsman in writing when 2 of 2 sampled residents (Residents # 126 and 113) were discharged to the hospital. The findings included: 1. Resident # 126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #126 ' s admission Minimum Data Set (MDS) identified him as having moderately impaired cognition. A review of Resident # 126 ' s medical record revealed he was sent to the hospital on [DATE] for evaluation after his Xray revealed he had [MEDICAL CONDITIONS] and pleural effusion. No written notice of transfer was documented to have been provided to the resident, his responsible party (RP) or the Ombudsman. During an interview on 9/20/18 at 1:57 AM the social worker (SW) stated that they did not notify the Ombudsman when a resident was sent out to the hospital. She stated the responsible party (RP) was called to notify them the resident had been sent to the hospital. During an interview on 9/20/18 at 2:25 PM the 100 hall nurse stated they called the RP to notify them the resident was sent to the hospital and document the call in the resident ' s medical record. During an interview with the Director of Nursing (DON) on 9/20/18 at 2:58 PM she stated they notify the family, RP via phone and document in the resident ' s medical record the reason for discharge to the hospital. She stated they did not send a letter to the family or RP as they document in the medical record the reason for discharge to the hospital. The DON stated they did not notify the Ombudsman when a resident is discharged to the hospital. During an interview on 9/20/18 at 3:39 PM the Administrator stated that they called the family or RP to inform them the resident was discharged to the hospital and document the call in the resident ' s medical record. He revealed they did not notify the Ombudsman when a resident was discharged to the hospital. 2.Resident # 113 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] coded the resident with severely impaired cognition. Record review of the departmental notes revealed Resident #113 was transferred to the hospital on [DATE] due to vomiting and abdominal discomfort. No written notice of transfer was documented to have been provided to the Ombudsman. During an interview on 9/20/18 at 1:57 AM the social worker (SW) stated that they did not notify the Ombudsman when a resident was sent out to the hospital. During an interview with the Director of Nursing (DON) on 9/20/18 at 2:58 PM she stated the facility did not notify the Ombudsman when a resident was discharged to the hospital. During an interview on 9/20/18 at 3:39 PM the Administrator stated the facility does not notify the Ombudsman when a resident was discharged to the hospital.

Based on record review and staff interviews, the facility failed to report an abuse allegation and serious injury of unknown origin to the State Agency within the required time frame for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] from a hospital. Her cumulative [DIAGNOSES REDACTED]. A review of Resident #1 ' s quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident was assessed by staff to have severely impaired cognitive skills for daily decision making. The resident required extensive assistance from staff for all of her Activities of Daily Living (ADLs). A review of an Incident Report dated 4/30/18 at 10:08 AM reported Resident #1 ' s left lower leg skin appeared blue/yellow with swelling. This was described as a non-witnessed incident. The facility ' s Nurse Practitioner was notified of the concern and an order was received to obtain a 2-view x-ray of the left lower leg and ankle. A review of the resident ' s medical record included a Radiology Report dated 4/30/18 at 2:20 PM. Significant findings from the Radiology Report revealed the resident had acute oblique, slightly displaced fractures present in the distal left tibia and fibula (the two bones of the lower leg). Oblique fractures are slanted fractures that occur when a force is applied at any angle other than a right angle to the bone. The significant findings also noted Resident #1 ' s bones were osteopenic (a bone condition characterized by bone loss that is not as severe as in [MEDICAL CONDITION]). The facility ' s Director of Nursing (DON) completed an Initial Allegation Report to the State Agency on 5/1/18. The report designated the type of allegation as Resident Abuse and reported the facility became aware of the incident/allegation at 2:00 PM on 4/30/18. Allegation details noted Resident #1 had an x-ray which showed left tibia and fibula fractures. The Transmission Verification Report was dated and timed as 5/1/18 at 8:17 PM. This report revealed the Initial Allegation Report was faxed to the State Agency approximately 30 hours after the facility became aware of the resident ' s injuries. An interview was conducted on 5/16/18 at 5:05 PM with the DON. When asked, the DON stated she would consider Resident #1 ' s tibia and fibula fractures to be serious bodily injuries. An interview was conducted on 5/17/18 at 8:45 AM with the facility ' s Administrator. During the interview, regulations for the reporting of alleged abuse and serious bodily injury were discussed. Upon review of the regulations, the Administrator stated, We should have gotten that off (referring to the Initial Allegation Report). A follow-up interview was conducted on 5/17/18 at 11:52 AM with the DON. During the interview, the DON stated she was aware of the reporting time frames required by the regulations. However, she reported her initial focus was on the investigation of what had actually happened to cause Resident #1 ' s fractures.

Based on interviews with staff and record reviews, the facility failed to develop a plan of action to correct an identified quality deficiency for 1 of 1 residents (Resident #1) who did not receive emergency medical services for a significant change in condition, failed to maintain a Quality Assessment and Assurance (QAA) Committee that met quarterly and included a physician, and failed to develop a method for identifying issues arising in the facility. The immediate jeopardy began on 8/14/13. The administrator was notified of the Immediate Jeopardy on 2/25/14 at 12:00pm. The immediate jeopardy was removed on 2/27/14 at 5:00pm. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. Findings included: Cross refer to tag F309. Based on record review, staff interviews, Medical Director (MD) interview and Nurse Practitioner (NP) interview, the facility failed to assess the need for medical intervention for a resident with a significant change of condition; and failed to provide medical intervention in an emergent life threatening situation for 1 of 1 resident's (Resident #1). During a phone interview with Medical Director #1 on 2/26/14 at 2:45 pm he stated, "The three medical directors rotate attending the facility Quality Assurance meetings, when they have them." He indicated he had not been involved in any recent activities or developments of the committee. The other two medical directors were unavailable for interview. During an interview with the DON on 2/26/14 at 3:19 pm, she indicated she was the head of QAA committee and she referenced the QAA committee notebook while answering questions during the interview. She stated, "We meet quarterly. Sometimes we will meet just because something has come up or to catch up because something comes up in building." Regarding who comprised the committee and attended the QAA meetings, the DON stated, "Unit managers, aides, and the doctor sometimes will attend the meetings. Whoever is involved in what is being discussed will attend. I do not have attendance sheets from the meetings. I have talked privately to the physician about things that will come up. A doctor does not attend all quarters. When I go over some issues, that is when I will call him." When asked if any issues have recently been spoken about with a physician she stated, "Recently the side rails have been talked about. That was on 2/6/14 or 2/4/14 that we met and then talked to the doctor a couple of days later about it. I would have to check on that. On 8/7/13 we went over overbed tables because the residents stated their tables were being borrowed. On 8/14/13 we went over (residents') personal property and what needed to go into a plastic bag with their name on there. That was the last meeting for 2013. I have not met this year, just had the impromptu meeting about the side rails." The DON indicated there was no formal method for identifying issues that may require quality assessment arising in the facility and there had been no further QAA meetings since August 2013. During an interview with the Administrator on 2/26/14 at 3:46 pm, he stated, "(The DON) basically heads up QA. We all have a role. I would have to look up documentation about any meetings. I keep a record of meetings and discussions we have. The last time I pulled a lot of the staff together to talk about changes that needed to be made. Sometimes the meetings are impromptu. We contacted the doctor. He was going to be coming in the next day or two. I don't get a signature sheet of who attends but have notes about the meetings somewhere in my office. I don't have any kind of written record I can show you." The Administrator was unable to produce additional documentation of QAA meetings or staff that attended the meetings. The administrator was notified of the Immediate Jeopardy on 2/25/14 at 12:00pm. The facility provided the following Credible Allegation on 2/27/14 at 12:15pm. For the provision of Care to Maintain the highest level of function for residents. The corrective action was accomplished for Resident #1 in the following manner. On 8/2/13 the Director of Nursing met with the 7am supervisor regarding not sending resident to the hospital following a status change. DON gave the 7am supervisor a verbal warning and educated her that if an "employee believes a resident has to be sent to hospital, employee is to send resident to hospital, based on her own assessment of residents condition". The Director of Nursing discussed with the 7am supervisor that when she does not get a timely response back from the attending physician she is to call the Medical Director for guidance and notify the Director of Nursing. Director of Nursing also met with 7pm supervisor on 8/2/13 to discuss her handling of assessing and sending the resident out. The Administrator spoke with the DON on 8/6/13 who related the events of the weekend transfer concerning Resident #1. On 8/6/13 the Administrator met with the Nurse Practitioner to discuss the circumstances surrounding the transfer of the resident. A concern was expressed about the timeliness of the return communication and some confusion as to who was on call. The Nurse Practitioner satisfied those concerns by discussing the necessary changes to the on call protocol with her company. The on call protocol for the NP's company is for the facility to call the 800 number to speak with the NP/PA on call. The facility is not to directly call the NP on the weekends, or after hours, nor is the NP to answer if she is not the designated on-call NP. See attached information regarding communication with NP and weekend on call staff. Administrator talked to her about concerns regarding the blood sugar level at the time of the transfer to the hospital. The Nurse Practitioner explained a rationale that appeared to explain the blood sugar level. After speaking with the Nurse Practitioner the Administrator communicated with the DON regarding the employee involved and was satisfied that the necessary steps were taken to correct and educate this employee regarding her responsibilities to the non responsive resident. The scenario was not discussed in the Quality Assurance Committee meeting on 8/7/2013 however, the QA committee met on 2/26/2014. Members of the team in attendance were as follows; the DON, the Administrator, the Medical Director's on-call physician, the consulting pharmacist, two unit managers, and the Staff Development Coordinator. At the meeting, the committee discussed changes made to the facility's policies and procedures for Acute Changes in Condition and Assessment of Residents. The committee reviewed and discussed findings reported by the survey team relative to F157, F309, and F490 for Resident #1. The corrective action will be accomplished for those residents having potential to be affected by the same deficient practice in the following manner. Audits were completed by the Unit Managers using a Quality Assessment tool created 2/26/2014. Unit managers used medical records, 24 hour monitoring report, resident interviews and staff interviews to complete Quality Assessment tool. The QA tool identifies residents who have had a change in condition, if the doctor was notified properly, and if the current assessment was documented in the chart. During the audit 14 residents who were previously identified with an acute change in condition, were noted. All residents noted with acute conditions were previously addressed, the physician was notified following the facility's policies and procedures, and the identified condition was documented in each resident's medical record. The QA committee met on 2/26/2014. Members of the team in attendance were as follows; the DON, the Administrator, the Medical Director's on-call physician, the consulting pharmacist, two unit managers, and the Staff Development Coordinator. At the meeting, the committee discussed changes made to the facility's policies and procedures for Acute Changes in Condition and Assessment of Residents. The Staff Development Coordinator initiated education for all licensed nurses on 2/26/2014. Information included in education was on reporting acute condition changes to doctor, and the appropriate ways to notify doctor based upon facility's policy and procedure. Any nurses, who have not completed the training by 2/26/2014, will not be allowed to work until necessary training is completed. All licensed nurses hired will also receive education on this policy during orientation. Systematic changes made include review of the facility's current plan for Quality Assurance meetings. The DON and/or Administrator will identify any areas that need to be discussed during the following QA meeting. Any issues the DON and/or Administrator deem to be an emergency will be discussed prior to the next scheduled meeting. QA meetings will occur monthly for six months, and quarterly thereafter, and the following individuals will be present; the DON, the Administrator, the consulting pharmacist, the medical director, and three members of the staff. Other members of the staff, including department heads will also be invited to attend meetings. During QA meetings, the QA committee will monitor trends in specific areas of the facility's function and medical care. Areas discussed during the QA meeting will include [MEDICAL CONDITION] drugs, falls, trends related to falls, wounds, and other trends and issues identified from the facility's Quality Improvement Report. The facility's next QA meeting's agenda was revised to include "Residents with Acute Change in Condition" as a topic of discussion. On 2/27/14 at 4:45pm, verification of the credible allegation was evidenced by interviews with the DON and Administrator related to QAA meetings. The DON and Administrator indicated QAA meetings would be held monthly for six months and then quarterly thereafter, to included acute condition changes (clinical protocol), resident examination and assessment. The DON and Administrator verified through interviews that new QAA tools had been developed and would be used for future meetings.

Based on record review, staff interviews and Nurse Practitioner (NP) interview, the facility failed to notify the physician for 1 of 3 sampled residents (Resident #1) exhibiting signs and symptoms of an acute change in condition. The immediate Jeopardy began on 7/27/13. The immediate Jeopardy was removed on 2/27/14 at 5:00pm when the facility provided an acceptable Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. The findings included: Resident #1 was originally admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. Resident #1 was admitted with cumulative [DIAGNOSES REDACTED]. New [DIAGNOSES REDACTED]. Review of the MD order dated 3/12/13, no time given, stated " Do not send to hospital for " unresponsive " episodes unless SBP (systolic blood pressure) <= (less than or equal to) 80 after 20 minutes laying in bed. If asleep - use sternal rub (making a fist and placing knuckles against the patient ' s mid-sternum, apply firm downward pressure and rub up and down across the sternum to illicit a response in a conscious/semi-conscious patient) to wake. " The Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact. Resident #1 was always incontinent of bowel and bladder. She required limited assistance with one person assist for bed mobility, locomotion on/off unit and eating. She required extensive assistance with one person assist for transfers. She was totally dependent with one person assist with toilet use, personal hygiene and bathing. The care plan most recently dated May 2013 identified the resident as being at risk for Urinary Tract Infections [MEDICAL CONDITION] and a goal that the resident would be free form UTI ' s. The approaches were listed as: encourage fluids frequently, monitor for signs/symptoms of UTI such as increased confusion and vital signs weekly/as needed (PRN) and report to MD. The Care plan dated 5/2013 also indicated resident was not to be sent to the hospital for " unresponsive " episodes unless her SBP was less than or equal to 80 after 20 minutes lying in bed. The care plan also indicated that if the resident appeared to be asleep during an unresponsive episode, staff were directed to use sternal rubs to awaken. Review of the (Medical Group) contact information was as follows: " Monday - Friday 8:00am - 5:00 pm - Contact (Medical Group) NP/PA first. If he/she has not returned your call in 10 min, REPEAT. " 1-800 phone number listed. " After Hours/Weekend/Holiday contact information - After hours/weekends/holidays, call the (Medical Group) answering service to speak to an (Medical Group) " 1-800 phone number listed. " Life threatening emergency information - If indicated in Advance Directives, dial 911 and attempt to call the (Medical Group) NP/PA. If this is an (Medical Group) patient - Call the above NP/PA with any changes in condition, questions or concerns Monday - Friday 8:00am - 5:00 pm. After hours/weekends/holidays: Call (Medical Group) answering service to speak to an (Medical Group) NP/PA. " 1-800 phone number listed. Record review of Resident #1 ' s nurses ' notes revealed the following: Nurse #6 note dated 7/26/13 at 10:00 pm stated " Resident responsive. Took meds without difficulty. Went back to sleep. No complaints. " Nurse #7 note dated 7/27/13 at 3:17 am stated " At 12am med (medication) pass for the Tylenol she opened her eyes and looked at the med in the cup then turned her head and returned to her sleep. " Review of the MAR (medication administration record) indicated the resident refused the medication. Nurse #7 note dated 7/27/13 at 6:00 am stated " Open eyes and looked around but would not open mouth for this a.m. ' s one Tylenol scheduled. " Nurse #3 note dated 7/27/13 at 8:30 am stated " Resident non responsive. Unable to take meds. Vitals as follow: temp (temperature) 95.2 (axillary), b/p (blood pressure) 100/54, resp (respirations) 16, pulse 60. (Medical group) called. No new orders. Family called. " Nurse #3 note dated 7/27/13 at 1:30 pm stated " Resident still non responsive without shortness of breath. (Medical group) contacted. No new orders given. Continuing to monitor. " Nurse # 3 note dated 7/27/13 at 5:00 pm stated " No changes in responsiveness. " Multiple attempts were made, but Nurse #3 was not available for interview during the survey. Nurse #1 note dated 7/27/13 at 6:00 pm stated " At 9am resident was in bed with decreased responsiveness. Vitals stable. No shortness of breath. Did not respond to sternal rub. +Babinski (stimulation to the sole of the foot to elicit a response). (Medical group) made aware of " unresponsiveness " . Stable vitals. Message given to let her be and monitor. Resident with little change throughout day. Vitals remained stable. No input. Patient will voluntarily move legs and arms but does not open eyes. Mouth care given and will bite on swab. Message sent to (Medical group) about 4:45 pm to give update of condition. No message received back at this time. " Nurse #1 note dated 7/27/13 at 6:45 pm stated " Returned to room. Resident remains unresponsive but continues to move lower extremities. Family present for second time today and has asked " where do we go from here? " Informed family that we were getting ready to call MD on call, but wanted to get a fresh set of vitals. (Family member #1) OK with this and wants to do whatever MD suggests. " Nurse #2 note dated 7/27/13 at 7:20 pm stated " Resident lying on back in bed with eyes closed. Respirations rapid and shallow (28). O2 (oxygen) on @ 2 liters per minute. Called resident name without response. Touched resident ' s arm with no response. Pupils fixed and dilated. Sternal rub done with no response. Babinski +. No response to painful stimuli. (Family member #3 and #1) are present. Asked family what they wanted us to do - keep her here on comfort measures or send her to emergency room . (Family member #1) stated, " Tell us what the doctor says. " Nurse #2 note dated 7/27/13 at 7:35 pm stated " This writer called MD on call. Explained situation. MD gave order to do whichever the family wanted. " Nurse #2 note dated 7/27/13 at 7:37 pm stated " Family wants resident sent to ER. Called 911 at this time. " Nurse #2 note dated 7/27/13 at 7:40 pm stated " EMS arrived. Assessment by EMS. Multiple attempts to start IV unsuccessful. v/s 180/92, 96, 24. " Nurse #2 note dated 7/27/13 at 8:10 pm stated " Resident transferred to gurney and was unresponsive with pupils fixed and dilated when she was transported out of the facility. (Family member #3 and #1) were present during this process. " The Emergency Medical Service (EMS) transport report dated 07/27/13 stated " patient has been unresponsive since 0700 (7:00am) this morning. The facility staff called the MD and were told to wait a little while and see if she came around. Night shift nurse came in and called 911 for transport as the patient was still unresponsive. Baseline is talkative and oriented. She was last seen normal at midnight. Last meal yesterday ' s lunch. " The chief complaint indicated on the report was " Unresponsive. Duration 12 hours " and the signs and symptoms were " [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. " EMS assessment on 07/27/13 at 7:38pm indicated that they arrived to an unconscious and unresponsive female, lying supine (lying on back) in bed with an oxygen saturation of 89% and a blood glucose of 25mg/dl. EMS assessment stated " Multiple IV (intravenous) attempts failed. [MEDICATION NAME] administered. O2 administered via a non-rebreather mask. Many minutes after [MEDICATION NAME] administration, patient did open her eyes but remained unresponsive and was never able to follow commands. BGL (blood glucose level) improved to 84 mg/dl. " Record review of the Hospital Discharge / Transfer Summary dated 8/9/13 at 2:08pm included the following: " Altered mental status secondary to metabolic [MEDICAL CONDITION] from profound [DIAGNOSES REDACTED] and UTI. Patient made some improvement in her mental status while in the hospital and she is currently awake but slow. She is able to say 1 or 2 words and will follow some simple commands, but has never made it back to her normal baseline. She has had 2 head CT scans which were negative for acute stroke. It was felt that the altered mental status was from prolonged profound [DIAGNOSES REDACTED] and possible UTI. It is unclear if her mentation will return to her baseline prior to this episode. We did not pursue MRI during this hospitalization as we did not feel it would change her current management. Unfortunately, due to her profound altered mental status and weakness, she did require placement of a [DEVICE] by [MEDICATION NAME] radiology for nutrition. " During an interview on 2/24/13 at 4:50pm, the Director of Nursing (DON) when the DON was asked what her expectations were in a situation such as this she stated " I would have wanted (Nurse #1) to call the MD if she was dissatisfied with what the NP said to do. Call the MD to review what (NP) was saying and send resident to hospital. When in doubt the staff knew I was on call 24/7 and they could call me anytime. We have a nursing management staff member on call every weekend to answer any nursing questions the staff may have or they can call me. " The DON indicated she would have talked to the NP about Resident #1 mental status and would have wanted the resident sent out to the hospital. During an interview on 2/25/14 at 9:32am Nurse #1 was asked to describe Resident #1 status. Nurse #1 indicated Resident #1 status fluctuated; Resident #1 communicated, could sit up in her chair, had periods of sleepiness, and if comfortable with you, have a conversation. Nurse #1 indicated on 07/27/13 Resident #1 was able to move her own extremities; however during that shift Resident #1 was unresponsive. Nurse #1 stated " My definition (of unresponsiveness) could have put it wrong, but my definition is she would not open her eyes and talk to me. If you put a swab in her mouth she would bite down on it. " Nurse #1 indicated Resident #1 was different from the previous days. During the continued interview Nurse #1 indicated she contacted the NP on 7/27/13 at 9:02am via a text message and asked what she wanted her to do when Resident #1 was having one of her episodes, and the NP stated " Let her be as long as her vitals were stable. " Nurse #1 indicated all notes for 7/27/13 were written by herself and via text messages to the NP. When asked what the usual protocol is when a resident is unresponsive, Nurse #1 stated " Call on call MD and follow their instructions. The notes were not as good as it should have been, I can ' t prove it but between (Nurse #3) and I we went in back and forth and took vitals every hour, I had a piece of paper with them on it but not in the chart. I apologize; I could have done my job better. " Nurse #1 indicated the family (Family member #1) was in to see the resident around 12 noon, left, and returned around 6pm. Nurse #1 indicated she asked the family what they wanted to do and she indicated the family wanted to do what the MD wanted. Nurse #1 indicated she explained to the family that the MD was not on call. Nurse #1 stated " I took 2 other RN ' s (Registered Nurse) in the room with me and they agreed and we were not supposed to send her out, this was between 10-11am. " Nurse #1 indicated her interpretation of the MD order written on 3/12/13 was to only give sternal rub if the resident ' s SBP was <80. " During the interview Nurse #1 was asked to clarify if she reported to the NP that Resident #1 did not respond to a sternal rub and she stated " I feel fairly certain that I did, I cannot say for a fact. In hindsight, I would talk more with the family and push a little bit more and advocate for the resident. I guess the next time I have to push the NP a little bit more. I talked to (Nurse #4) Unit two manager and (Nurse #4) stated she (resident #1) was unresponsive the previous night and (Medical Director #1) went in to assess her the day before on 7/26. " Nurse #1 was asked what stable vital signs (VS) are and she stated " To me stable VS are within normal limits. The unit does VS every Tuesday and that would list what her normal range is. " During the interview Nurse #1 indicated the NP did not answer back at 4:45pm and she did not call anyone else. Nurse #1 stated " We waited for the family to show up because he (family member #1) said he would be back and I wanted to talk with him to see what he wanted. The reality is I should have thought for myself. The only thing I can say is I had been told by (Nurse #4) and (NP) if she had stable VS then we leave her alone. I think unresponsive is the wrong word; I would say decreased responsiveness now. The resident was still moving her extremities. " Nurse #1 was asked if Resident #1 condition worsened throughout the day and she stated " I felt it stayed the same. The family being there was the difference in her going out at 7pm versus 9am. " During the interview Nurse #1 indicated she did not obtain a blood sugar for Resident #1 because there were no symptoms such as being shaky or signs of [DIAGNOSES REDACTED]. Nurse #1 stated " The resident had not had a temp (temperature) that day. She was on I&O (intake and output), they should have a sheet for that, it was not the normal amount that she had had. On 7/27 resident did not take in anything that day. I assume it (temp) was 98.2, if it was a 95 we would have changed the batteries and rechecked but this was (Nurse #3) note. " Nurse #1 revealed after Resident #1 went to the hospital, she and the DON talked about the Resident #1 ' s situation Nurse #1 indicated the DON told her for future occurrences to always take blood sugars on an unresponsive resident and to send the resident to the hospital if the MD, NP and she were not in agreement. Nurse #1 stated " I think it (report sheet) said to check blood sugar if an unresponsive episode. (MD) did not know about episodes on 7/27. I still have all of my text messages. None of our notes justify everything we did that day. I was in charge of everyone and trying to deal with this situation. " Nurse #1 indicated the only practitioner she contacted on 7/27/13 was the NP and all communication was via text messages. The text messages read as follows: 7/27/13 at 9:02am - Nurse #1 sent a text to the NP that stated " What do we do for (Resident #1 ' s) unresponsive episodes? " 7/27/13 at 9:05am - NP responded " Give her time. Are her vitals stable? " 7/27/13 at 9:06am - Nurse #1 responded " Vitals stable. " 7/27/13 at 9:06am - NP responded " Let her be and just monitor her. " 7/27/13 at 4:47pm - Nurse #1 sent a text to the NP that stated " No change in (Resident #1). " During an interview on 2/25/14 at 10:37am, Nurse #2 indicated she worked on 7/27/13 from 7pm until 7am. Nurse #2 indicated Resident #1 baseline was alert, would look at you and sometimes would say some words. Nurse #2 stated " On 7/27 when I walked into room, she had her eyes closed, she was unresponsive, resident did not look at me when I called her name, she did not open her eyes and that was different for her. When I approached her I touched her arm, she would normally turn her head to look at you but there was no response at all. She was not moving any extremities. I tried to shake her, no response; I did a sternal rub, no response, which raised a red flag to me. I did VS, babinski, her pupils were fixed. Her family came in and I explained to them that she probably needed to go to the hospital. I got report from the nurse on the hall, (Nurse #3) and she told me resident was unresponsive, she wasn ' t getting a response from her, so I said come on lets go look at her. I took her with me. I assessed her, no response, family present. I stated we should probably send her to the ER (emergency room ), called MD and got an order to send her out. The family was reluctant to send her out. It was too drastic a change for me to take care of her in this environment. I asked the nurse supervisor about the resident and she came in the resident ' s room. We discussed it with the family there and we called MD to send her out. I do not recall if the nurse supervisor stated she spoke with MD during the day. I called MD on call, if I would have talked to NP, I would have written NP. " During an interview on 2/25/14 at 10:59am the NP stated " I was not on call that day. I don ' t know who was on call, but they weren ' t called. There is an 800 # (staff is) supposed to call after 5pm and on Saturday and Sunday. It is at the nurse ' s station and in all the charts and is common standard practice for the last 2 years. Over the weekends they frequently forget that and will call or text. Out of kindness, I would respond. Now, because of this episode, all calls go to the 800 #. I was texted about 8am. The resident had been sent to the ED twice during narcoleptic episodes. Because of difficulty hearing, she sometimes would not respond during these episodes. That is why we encouraged the staff to let her sleep it off. Being that I wasn ' t on call. I did not have my phone on me. I got a call that evening about 8pm that they were sending her out. I was not as vigilant with my calls or texts as if I had been on call. They did not follow what they were supposed to do with calling. I wasn ' t aware of anything else until I got a call that evening. I do not believe the on call person was called. The resident had narcoleptic episodes and the first text indicated she was having another episode and what should they do. The response was to let her sleep it off because of what I was told. If I had been given her an accurate assessment, I only live 7 miles away, and I would have stopped by to look at her - even not being on call. (Resident #1) with her difficulty hearing and sometimes with her level of cooperativeness, I would not have been surprised if she had been in bed 2-4 hours just ignoring the staff. She would still have responded to a sternal rub even if she was ignoring them. Her narcoleptic episodes would have lasted 2-3 hours and I think that led the nurses to be hesitant to react. I don ' t believe that she was hypoglycemic the entire 11 hours. " She also said " If I had received the 1pm text, I would have been over here to assess. We would have talked to the family about end of life issues if they did not want her to be sent out. Not getting a response from me, she should have called the doctor or 800#. " During an interview on 2/25/14 at 4:05pm with Nurse #4, she indicated she had just moved into the Unit Manager position at the beginning of July 2013 and on 7/27/13 was more than likely here in the office preparing for the end of the month. Nurse #4 stated " I know it was not my admin (administration) weekend, it was changeover (changing over the MAR ' s for the upcoming month). My recollection is not of that day but the prior evening was that (MD) assessed the resident and there was a short discussion about this not being the first time the resident had presented this way. She had been sent out multiple times over the previous months. Prior to my new role, I had taken care of the resident as the primary nurse on 7-3 shift. Resident would become unresponsive, be hemodynamically stable, the MD/NP would do sternal rubs, would get facial grimaces, resident would pull foot back if you did noxious stimuli. There was an order that was written to not send resident out if she was hemodynamically stable. The longest she had stayed out I guess would be 4-6 hours, maybe overnight. My concern was how long do we leave her like this, this was my thought but I did not ask the MD. On Saturday 7/27, (Nurse #1) asked me to go in and assess resident and she showed no signs of [DIAGNOSES REDACTED], wasn ' t diaphoretic, wasn ' t cool or clammy. (Nurse #1) did speak with me a couple of times during the day but I wasn ' t in the building as admin. I could not tell you why no one called the on call MD/NP, at some point I would like to have seen her call the on call MD/NP. (NP) will from time to time ask that we communicate with her on her patients. But after this incident staff have been instructed to utilize the on-call number. All of the on-call numbers and schedule is posted at each nurses ' station. The admissions coordinator assigns the admission MD on each admission and the on call MD is on call after 5pm through 8am the next morning. Starting at 8am you can call the resident ' s assigned MD. If it is a weekend then they call the on call MD from Friday at 5p through Monday 8am. We do not have a call schedule for (Medical Group). They are supposed to call the call center number and get the NP on call. " During an interview with the administrator on 2/26/14 at 11:18am he stated " My expectations would have been the nurse that was in attendance with the resident would have called the MD or just sent her out. If they have any questions or in doubt, to have just sent her out. What I believe is if the resident was not responsive, call the MD and if you can ' t reach whoever is in authority timely then send the resident to the hospital. " The Administrator indicated he had not been aware of the texting at the time of the incident and he said " The texting has caught me off (offguard), I did not know about that at the time. To me, notifying the MD/NP means talking to them on the telephone. " During a phone interview on 2/26/14 at 1:52pm with Nurse #1 was asked to clarify why she texted the NP versus calling the MD on call and she stated " Because she and I had a previous understanding that she wanted me to text her because she knew the resident ' s better than the on call person. " Nurse #1 indicated she texted (NP) regardless of who was on call. Attempted to speak to Resident #1 ' s attending physician and he was not available for interview during the survey process. During a phone interview with (Medial Director #1) on 2/26/14 at 2:45pm he stated " She (nurse) should have contacted the on call person for (Medical group) or the MD on call. " The administrator was notified of the Immediate Jeopardy on 2/25/14 at 12:00pm. The facility provided the following Credible Allegation on 2/27/14 at 12:15pm. Credible Allegation of Compliance F-Tag 157 For the provision of Care to Maintain the highest level of function for residents. The corrective action was accomplished for Resident # 1 in the following manner. On 7/27/13 at 7:20pm the 7pm staff nurse completed a thorough nursing assessment. As part of the assessment, the 7pm staff nurse checked respirations and checked oxygen saturation. The results were as follows, respiration was 28, oxygen saturation was 24, touched arm with no response, pupils were fixed, and sternal rub provided with no response. Based upon the results of this assessment at 7:35pm the staff nurse contacted the on call physician. The resident was transported via EMS ambulance service to the hospital at 8:10pm. Family was present upon discharge to the hospital on [DATE]. On 8/2/13 the Director of Nursing met with the 7am supervisor regarding not sending resident to the hospital following a status change. DON gave the 7am supervisor a verbal warning and educated her that if an " employee believes a resident has to be sent to hospital, employee is to send resident to hospital, based on her own assessment of residents condition " . The Director of Nursing discussed with the 7am supervisor that when she does not get a timely response back from the attending physician she is to call the Medical Director for guidance and notify the Director of Nursing. Director of Nursing also met with 7pm supervisor on 8/2/13 to discuss her handling of assessing and sending the resident out. The Administrator spoke with the DON on 8/6/13 who related the events of the weekend transfer concerning Resident #1. After the Administrator ' s review and due consideration he went to speak with the Nurse Practitioner regarding this resident. On 8/6/13 the Administrator met with the Nurse Practitioner to discuss the circumstances surrounding the transfer of the resident. A concern was expressed about the timeliness of the return communication and some confusion as to who was on call. The Nurse Practitioner satisfied those concerns by discussing the necessary changes to the on call protocol with her company. The on call protocol for the NP ' s company is for the facility to call the 800 number to speak with the NP/PA on call. The facility is not to directly call the NP on the weekends, or after hours, nor is the NP to answer if she is not the designated on-call NP. See the information regarding communication with NP and weekend on call staff. Administrator talked to her about concerns regarding the blood sugar level at the time of the transfer to the hospital. The Nurse Practitioner explained a rationale that appeared to explain the blood sugar level. After speaking with the Nurse Practitioner the Administrator communicated with the DON regarding the employee involved and was satisfied that the necessary steps were taken to correct and educate this employee regarding her responsibilities to the non responsive resident. The resident returned to the facility on [DATE]. Resident returned from the hospital with a new [DEVICE]. Orders were provided to check for signs and symptoms of infection related to [DEVICE] placement, and call doctor for temperature greater than 101 degrees Fahrenheit. Resident also returned from the hospital with a Goldenrod (DNR), which was signed by the hospital doctor. If resident became unresponsive, staff would make detailed observations, assessments and collect pertinent information to report to the nurse supervisor and the Physician and/or Physician on call. The clinical record will reflect accurate documentation of the resident ' s current assessment. Phone calls to attending or on-call physicians will be made by the nurse who has collected and organized pertinent information, including the concise and relevant information related to the resident ' s current symptoms and status. The facility now prohibits the use of texting as a form of communicating with the Physician and/or Physician on call and Nurse Practitioner. The nursing staff will contact the Physician based on the results of the nurse ' s clinical assessment of the resident. The nurse will call the Physician and request a prompt response (timely response will be within approximately one-half hour or less). The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status per their policy. The Physician will help identify and authorize appropriate treatments. The Physician will continue to follow up and monitor the resident until the problem or condition has resolved or stabilized. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting. The do not hospitalize order was not in effect, after resident ' s return from the hospital, but resident did return with a Goldenrod (DNR). On 8/2/2013 the DON met with nurse-on-duty and nurse supervisor, and educated both on how to handle future episodes with resident. They verbalized understanding of when to send resident to hospital if similar scenario occurred. For all residents having the potential to be affected by the same deficient practice the corrective action was accomplished by completing a 100% audit of all residents to determine if any residents where exhibiting signs of unresponsiveness or any changes in status by 2/26/2014. The Staff Development Coordinator initiated education for all licensed nurses on 2/26/2014. Information included in education was on reporting acute condition changes to doctor/or NP, and the appropriate ways to notify doctor or NP based upon facility ' s policy and procedure. Any nurses, who have not completed the training by 2/26/2014, will not be allowed to work until necessary training is completed. Audits were completed by the Unit Managers using a Quality Assessment tool created 2/26/2014. Unit managers used medical records, 24 hour monitoring report, resident interviews and staff interviews to complete Quality Assessment tool. During the audit, 14 residents, who were previously identified with an acute change in condition, were noted. All residents noted with acute conditions were previously addressed, the physician was notified following the facility ' s policies and procedures, and the identified condition was documented in each resident ' s medical record. For any residents not responding to stimuli or experiencing a change in status, the nursing staff will make detailed observations, assessments and collect pertinent information to report to the nurse supervisor and the Physician and/or Physician on call. The clinical record will reflect accurate documentation of the resident ' s current assessment. Phone calls to attending or on-call physicians will be made by the nurse who has collected and organized pertinent information, including the concise and relevant information related to the resident ' s current symptoms and status. The facility now prohibits the use of texting as a form of communicating with the Physician and/or Physician on call and Nurse Practitioner. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, the nurse will call the Physician and request a prompt response (timely response will be within approximately one-half hour or less). The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The Physician will help identify and authorize appropriate treatments. The Physician will continue to follow up and monitor the resident until the problem or condition has resolved or stabilized. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting. The staff will notify the DON and the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. For example if the Physician calls back and says for the nurse to just monitor the resident and the nurse feels that the residents condition warrants further medical intervention (i.e.; hospitalization ) the nurse will call the DON and Medical Director. The Medical Director will help the staff identify and authorize appropriate treatments. The facility has reviewed, revised and updated effective 2/26/14 the Policy and Procedure on Resident Examination and Assessments as well as the Policy and Procedure on Acute Condition Changes in conjunction with the review and input of the Medical Director. Systematic changes made include review of the facility ' s current Acute Condition Changes protocol by the Medical Director, Director of Nursing and Administrator on 2/26/2014. The DON or designee will continue to educate appropriate nursing staff on the new protocol and will be completed on 2/26/14. If any appropriate nursing staff has not completed required training by 2/26/14, they will be removed from the schedule until appropriate training has been received. The unit managers conducted a 100% audit on 2/26/2014 to assure that all change of status have been identified and appropriate actions taken. Audits were completed by unit manager using a Quality Assessment tool created 2/26/2014. Unit managers used medical records, 24 hour monitoring report, resident interviews and staff interviews to complete Quality Assessment tool. Unit Managers will review daily current status of residen

Based on record review, staff interviews, Medical Director (MD) interview and Nurse Practitioner (NP) interview, the facility failed to assess the need for medical intervention for a resident with a significant change of condition; and failed to provide medical intervention in an emergent life threatening situation for 1 of 1 resident's (Resident #1). The immediate jeopardy began on 7/27/13. The administrator was notified of the Immediate Jeopardy on 2/25/14 at 12:00pm. The immediate jeopardy was removed on 2/27/14 at 5:00pm. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. The findings included: Resident #1 was originally admitted to the facility on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. Resident #1 was admitted with cumulative [DIAGNOSES REDACTED]. New [DIAGNOSES REDACTED]. At the time of this event (7/27/13) there was not a [DIAGNOSES REDACTED]. Review of the Doctor's order dated 3/12/13, no time noted, stated " Do not send to hospital for " unresponsive " episodes unless SBP (systolic blood pressure - the top number in the blood pressure) is less than or equal to 80 after 20 minutes laying in bed. If asleep - use sternal rub (making a fist and placing knuckles against the patient's mid-sternum, apply firm downward pressure and rub up and down across the sternum to illicit a response in a conscious/semi-conscious patient) to wake. " The most recent Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact. Resident #1 was always incontinent of bowel and bladder. She required limited assistance with one person assist for bed mobility, locomotion on/off unit and eating. She required extensive assistance with one person assist for transfers. She was totally dependent with one person assist with toilet use, personal hygiene and bathing. The care plan most recently dated May 2013 identified the resident as being at risk for Urinary Tract Infections [MEDICAL CONDITION] and a goal that the resident would be free form UTI's. The approaches were listed as: encourage fluids frequently, monitor for signs/symptoms of UTI such as increased confusion and vital signs weekly/as needed (PRN) and report to the physician (MD). Care plan dated 5/2013 also indicated resident was not to be sent to the hospital for " unresponsive " episodes unless her SBP is less than or equal to 80 after 20 minutes lying in bed. If asleep, use sternal rubs to wake Record review of the nurses' notes revealed the following: Nurse #6 note dated 7/26/13 at 10:00pm stated " Resident responsive. Took meds without difficulty. Went back to sleep. No complaints. " Nurse #7 note dated 7/27/13 at 3:17am stated " At 12 a.m. med pass for the Tylenol she opened her eyes and looked at the med in the cup then turned her head and returned to her sleep." Nurse #7 note dated 7/27/13 at 6:00am stated " Open eyes and looked around but would not open mouth for this a.m. ' s one Tylenol scheduled. " Nurse #3 note dated 7/27/13 at 8:30 am stated " Resident non responsive. Unable to take meds. Vitals as follow: temp 95.2 (axillary), b/p 100/54, resp 16, pulse 60. (Medical group) called. No new orders. Family called. " Nurse #3 note dated 7/27/13 at 1:30 pm stated " Resident still non responsive without shortness of breath. (Medical group) contacted. No new orders given. Continuing to monitor. " Nurse # 3 note dated 7/27/13 at 5:00 pm stated " No changes in responsiveness. " Nurse #1 note dated 7/27/13 at 6:00 pm stated " At 9am resident was in bed with decreased responsiveness. Vitals stable. No shortness of breath. Did not respond to sternal rub. +Babinski (+ sign indicates when there is stimulation to the sole of the foot a response may indicate neurological damage). (Medical group) made aware of " unresponsiveness " . Stable vitals. Message given to let her be and monitor. Resident with little change throughout day. Vitals remained stable. no input. Patient will voluntarily move legs and arms but does not open eyes. Mouth care given and will bite on swab. Message sent to (Medical group) about 4:45 pm to give update of condition. No message received back at this time." Nurse #1 note dated 7/27/13 at 6:45 pm stated " Returned to room. Resident remains unresponsive but continues to move lower extremities. Family present for second time today and has asked " where do we go from here? " Informed family that we were getting ready to call MD on call, but wanted to get a fresh set of vitals. (Family member #1) OK with this and wants to do whatever MD suggests. " Nurse #2 note dated 7/27/13 at 7:20 pm stated " Resident lying on back in bed with eyes closed. Respirations rapid and shallow (28). O2 on @ 2l/minute. Called resident name without response. Touched resident ' s arm with no response. Pupils fixed and dilated. Sternal rub done with no response. Babinski +. No response to painful stimuli. (Family member # 1 and #3) are present. Asked family what they wanted us to do - keep her here on comfort measures or send her to emergency room . (Family member #1) stated, " Tell us what the doctor says. " Nurse #2 note dated 7/27/13 at 7:35 pm stated " This writer called MD on call. Explained situation. MD gave order to do whichever the family wanted. " Nurse #2 note dated 7/27/13 at 7:37 pm stated " Family wants resident sent to ER. Called 911 at this time. " Nurse #2 note dated 7/27/13 at 7:40 pm stated " EMS (Emergency Medical Services) arrived. Assessment by EMS. Multiple attempts to start IV (intravenous access) unsuccessful. v/s 180/92, 96, 24. " Nurse #2 note dated 7/27/13 at 8:10 pm stated " Resident transferred to gurney and was unresponsive with pupils fixed and dilated when she was transported out of the facility. (Family member #1 and #3) were present during this process. " The EMS transport report dated 07/27/13 stated "patient has been unresponsive since 7:00am this morning. The facility staff called the MD and were told to wait a little while and see if she came around. Night shift nurse came in and called 911 for transport as the patient was still unresponsive. Baseline is talkative and oriented. She was last seen normal at midnight. Last meal yesterday ' s lunch. " The chief complaint indicated on the report was " Unresponsive. Duration 12 hours " and the signs and symptoms were " [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. " EMS assessment on 07/27/13 at 7:38pm indicated that they arrived to an unconscious and unresponsive female, lying supine (lying on back) in bed with an oxygen saturation of 89% and a blood glucose of 25. EMS assessment stated " Multiple IV attempts failed. [MEDICATION NAME] administered. O2 administered via a non-rebreather mask. Many minutes after [MEDICATION NAME] administration, patient did open her eyes but remained unresponsive and was never able to follow commands. BGL (blood glucose level) improved to 84." Record review of the Hospital Discharge / Transfer Summary dated 8/9/13 at 2:08pm stated the following: Reason for admission: The patient is a [AGE] year old female, who is brought in from a nursing facility secondary to altered mental status. Patient apparently was nonverbal at presentation. Apparently she was found unresponsive at her nursing home with very low blood sugars. Her blood sugar was found to be 25. She was given [MEDICATION NAME] by EMS and brought to the hospital. She also had a low grade fever. Hospital course: Altered mental status secondary to metabolic [MEDICAL CONDITION] from profound [DIAGNOSES REDACTED] and UTI. Patient made some improvement in her mental status while in the hospital and she is currently awake but slow. She is able to say 1 or 2 words and will follow some simple commands, but has never made it back to her normal baseline. She has had 2 head CT (Computerized tomography - x-ray) scans which were negative for acute stroke. It was felt that the altered mental status was from prolonged profound [DIAGNOSES REDACTED] and possible UTI. It is unclear if her mentation will return to her baseline prior to this episode. We did not pursue MRI (Magnetic Resonance Imaging - takes pictures of organs inside the body) during this hospitalization as we did not feel it would change her current management. Unfortunately, due to her profound altered mental status and weakness, she did require placement of a [DEVICE] by [MEDICATION NAME] radiology for nutrition. Final [DIAGNOSES REDACTED]. 1. Altered mental status secondary to metabolic [MEDICAL CONDITION] from profound [DIAGNOSES REDACTED] and UTI. 2. Oral dysphagia status [REDACTED]. 3. [MEDICAL CONDITION] Fibrillation 4. Pulmonary fibrosis 5. Hypertension 6. Code status: Do not resuscitate During an interview on 2/24/13 at 4:50pm, the Director of Nursing (DON) stated " I questioned (nurse#1) at the time. I questioned (nurse #1) about what the NP and MD said. (Nurse #1) was going by what the NP said. (Nurse #2) went on to assess her when she got here and send her out to the hospital. I cannot remember who was on call that day. (NP) was on call. (NP) texted with (Nurse #1) all day. She could not get out here. I believe they were talking on the phone and texting. When I spoke with (Nurse #1) she stated she was going by (NP) order. When I spoke to (Nurse #1) after the fact she felt like she should have sent the resident out. " When the DON was asked what her expectations are in a situation such as this she stated " I would have wanted (Nurse #1) to call the MD if she was dissatisfied with what the NP said to do. Call the MD to review what (NP) was saying and send resident to hospital. When in doubt the staff knew I was on call 24/7 and they could call me anytime. We have a nursing management staff member on call every weekend to answer any nursing questions the staff may have or they can call me. " The DON indicated she would have talked to the NP about Resident #1 mental status and would have wanted the resident sent out to the hospital. The DON was asked what measures were put in place after the incident and she indicated she spoke with the nurse, NP and individuals involved. On 2/24/14 at 5:15pm, a call was placed to Nurse #3 with no answer. During an interview on 2/25/14 at 9:32am Nurse #1 was asked to describe Resident #1 status. Nurse #1 indicated Resident #1 status fluctuated; Resident #1 communicated, could sit up in her chair, had periods of sleepiness, and if comfortable with you, have a conversation. Nurse #1 indicated on 07/27/13 Resident #1 was able to move her own extremities; however during that shift Resident #1 was unresponsive. Nurse #1 stated " My definition (of unresponsiveness) could have put it wrong, but my definition is she would not open her eyes and talk to me. If you put a swab in her mouth she would bite down on it. " Nurse #1 indicated Resident #1 was different from the previous days. Nurse #1 indicated she contacted the NP and asked what she wanted her to do when Resident #1 was having one of her episodes, and the NP stated " Let her be as long as her vitals were stable. " Nurse #1 indicated all notes for 7/27/13 were written by herself and via text messages to the NP. When asked what the usual protocol is when a resident is unresponsive, Nurse #1 stated " Call on call MD and follow their instructions. The notes were not as good as it should have been, I can't prove it but between (Nurse #3) and I we went in back and forth and took vitals every hour, I had a piece of paper with them on it but not in the chart. I apologize; I could have done my job better. The family was in around 12 and Family member #1) was present and came back around 6, asked what they wanted to do and they wanted to do what the MD wanted to do, explained her MD was not on call. I took 2 other RN's (Registered Nurse) in the room with me and they agreed and we were not supposed to send her out, this was between 10-11am. I read order to only give sternal rub if her SBP was <80." Nurse #1 was asked to clarify if she reported to the NP that Resident #1 did not respond to a sternal rub and she stated " I feel fairly certain that I did, I cannot say for a fact. In hindsight, I would talk more with the family and push a little bit more and advocate for the resident. I guess the next time I have to push the NP a little bit more. I talked to (Nurse #4) Unit two manager and (Nurse #4) stated she (resident #1) was unresponsive the previous night and (Medical Director #1) went in to assess her the day before on 7/26. " Nurse #1 was asked what stable vital signs (VS) are and she stated " To me stable VS are within normal limits. The unit does VS every Tuesday and that would list what her normal range is." Nurse #1 indicated the NP did not answer back at 4:45pm and she did not call anyone else. Nurse #1 stated " We waited for the family to show up because he (family member #1) said he would be back and I wanted to talk with him to see what he wanted. The reality is I should have thought for myself. The only thing I can say is I had been told by (Nurse #4) and (NP) if she had stable VS then we leave her alone. I think unresponsive is the wrong word; I would say decreased responsiveness now. The resident was still moving her extremities. " Nurse #1 was asked if Resident #1 condition worsened throughout the day and she stated " I felt it stayed the same. The family being there was the difference in her going out at 7pm versus 9am." Nurse #1 indicated she did not obtain a blood sugar for Resident #1 because there were no symptoms such as being shaky or signs of [DIAGNOSES REDACTED]. Nurse #1 stated " The resident had not had a temp that day. She was on I&O (intake and output), they should have a sheet for that, it was not the normal amount that she had had. On 7/27 resident did not take in anything that day. I assume it (temp) was 98.2, if it was a 95 we would have changed the batteries and rechecked but this was (Nurse #3) note. " Nurse #1 revealed after Resident #1 went to the hospital, she and the DON talked about the situation with Resident #1. Nurse #1 indicated the DON told her for future occurrences to always take blood sugars on an unresponsive resident and to send the resident to the hospital if the MD, NP and she were not in agreement. Nurse #1 stated " I think it (report sheet) said to check blood sugar if an unresponsive episode. (MD) did not know about episodes on 7/27. I still have all of my text messages. None of our notes justify everything we did that day. I was in charge of everyone and trying to deal with this situation. " Nurse #1 offered the text messages between herself and the NP for 7/27/13. The text messages read as follows: 7/27/13 at 9:02am - Nurse #1 sent a text to the NP that stated " What do we do for (Resident #1 ' s) unresponsive episodes? " 7/27/13 at 9:05am - NP responded " Give her time. Are her vitals stable? " 7/27/13 at 9:06am - Nurse #1 responded " Vitals stable. " 7/27/13 at 9:06am - NP responded " Let her be and just monitor her. " 7/27/13 at 4:47pm - Nurse #1 sent a text to the NP that stated " No change in (Resident #1). " During an interview on 2/25/14 at 10:37am with Nurse #2 she indicated she worked on 7/27/13 from 7pm until 7am. Nurse #2 indicated Resident #1 baseline was alert, would look at you and sometimes would say some words. Nurse #2 stated " On 7/27 when I walked into room, she had her eyes closed, she was unresponsive, resident did not look at me when I called her name, she did not open her eyes and that was different for her. When I approached her I touched her arm, she would normally turn her head to look at you but there was no response at all. She was not moving any extremities. I tried to shake her, no response; I did a sternal rub, no response, which raised a red flag to me. I did VS, babinski, her pupils were fixed. Her family came in and I explained to them that she probably needed to go to the hospital. I got report from the nurse on the hall, (Nurse #3) and she told me resident was unresponsive, she wasn ' t getting a response from her, so I said come on lets go look at her. I took her with me. I assessed her, no response, family present. I stated we should probably send her to the ER (emergency room ), called MD and got an order to send her out. The family was reluctant to send her out. It was too drastic a change for me to take care of her in this environment. I asked the nurse supervisor about the resident and she came in the resident ' s room. We discussed it with the family there and we called MD to send her out. I do not recall if the nurse supervisor stated she spoke with MD during the day. I called MD on call, if I would have talked to NP, I would have written NP. " During an interview on 2/25/14 at 10:59am the NP stated " I was not on call that day. I don't know who was on call, but they weren't called. There is an 800 # (staff is) supposed to call after 5pm and on Sat and Sun. It is at the nurse's station and in all the charts and is common standard practice for the last 2 years. Over the weekends they frequently forget that and will call or text. Out of kindness, I would respond. Now, because of this episode, all calls go to the 800 #. I was texted about 8am. The resident had been sent to the ED twice during narcoleptic episodes. Because of difficulty hearing, she sometimes would not respond during these episodes. That is why we encouraged the staff to let her sleep it off. Being that I wasn ' t on call. I did not have my phone on me. I got a call that evening about 8pm that they were sending her out. I was not as vigilant with my calls or texts as if I had been on call. They did not follow what they were supposed to do with calling. I wasn ' t aware of anything else until I got a call that evening. I do not believe the on call person was called. The resident had narcoleptic episodes and the first text indicated she was having another episode and what should they do. The response was to let her sleep it off because of what I was told. If I had been given her an accurate assessment, (referencing text messages) I only live 7 miles away, and I would have stopped by to look at her - even not being on call. (Resident #1) with her difficulty hearing and sometimes with her level of cooperativeness, I would not have been surprised if she had been in bed 2-4 hours just ignoring the staff. She would still have responded to a sternal rub even if she was ignoring them. Her narcoleptic episodes would have lasted 2-3 hours and I think that led the nurses to be hesitant to react. I don ' t believe that she was hypoglycemic the entire 11 hours. I believe she had a TIA (transient ischenmic attack - stroke). There was a strong family dynamic. There was a conversation that needed to occur with the family about her end of life. If I had received the 1pm text, I would have been over here to assess. We would have talked to the family about end of life issues if they did not want her to be sent out. Not getting a response from me, she should have called the doctor or 800#. " On 2/25/14 at 3:49pm, a call was placed to Nurse #3 with no answer. On 2/25/14 at 3:54pm a call was placed to aide #1 that worked 7/27/13 7a-3p, number disconnected. During an interview on 2/25/14 at 4:05pm with Nurse #4, she indicated she had just moved into the Unit Manager Position at the beginning of July 2013 and on 7/27/13 was more than likely here in the office preparing for the end of the month. Nurse #4 stated " I know it was not my administration weekend, it was changeover. My recollection is not of that day but the prior evening was that (MD) assessed resident and there was a short discussion about this not being the first time the resident had presented this way. She had been sent out multiple times over the previous months. Prior to my new role, I had taken care of the resident as the primary nurse on 7-3 shift. Resident would become unresponsive, be hemodynamically stable, the MD/NP would do sternal rubs, would get facial grimaces, resident would pull foot back if you did noxious stimuli. There was an order that was written to not send resident out if she was hemodynamically stable. The longest she had stayed out I guess would be 4-6 hours, maybe overnight. My concern was how long do we leave her like this, this was my thought but I did not ask the MD. On Saturday 7/27, (Nurse #1) asked me to go in and assess resident and she showed no signs of [DIAGNOSES REDACTED], wasn ' t diaphoretic, wasn ' t cool or clammy. " Nurse # 4 was unable to indicate a time frame of when she assessed the resident. During a phone interview with aide #3 on 2/25/13 at 5:51pm she stated " On 7/27 she (Resident #1) was nonresponsive. I had went in to get her VS. They wasn ' t high or low, she wasn ' t talking to me or opening her eyes. Usually she will talk to me but I didn ' t get any of that that day. I notified my nurse that (Resident #1) was still not herself and I asked the nurse had she been like that all day and they said yes. Aide #3 indicated on 07/26/13 Resident #1 was sleepy. Aide #3 stated " I thought she was taking her afternoon nap. Around 4:30pm-4:45pm I went in to get her up for supper to go to the dining room, as her usual routine, she was just laying there. She did not talk to me she, was not herself. So I went to get the nurse and she was busy so I went to the nurse supervisor and she got her VS. When the resident came in (admitted to facility) she had these spells, so everybody was thinking she was having one of her spells. At this time, the nurse supervisor, nurse, and the SW came in and a nurse (Nurse #4) came in and stated she was having one of her spells. I was use to her spells, but this was kind of different. Usually she was out of her spells in 1-2 hours and definitely by 3 hours. The nurse supervisor rubbed her skin and the resident opened her eyes and she closed them right back. The nurse supervisor said go ahead and get her up and put her in her chair. Once I got her in the chair she was limp, her arms just hanging. I got the nurse again and told her this was not her. Nurse stated to lay her back down. So I laid her back down and changed her clothes and got her ready for bed. After supper I checked on her and nurse said she took her meds and I checked on her again before I left, changed her and she opened her eyes. On Saturday (07/27/13) I asked the aide how she was, she said the same and nurse stated to not get her up. I was concerned; this was not like the resident. She was active, wheeled self around. For her to lay around and sleep this long, it was concerning. I asked nurse again to check on her. Her VS were low. Around 6 or 7pm they called the ambulance to come and get her because she was not opening her eyes or responding. " During an interview with the administrator on 2/26/14 at 11:18am he stated " My expectations would have been the nurse that was in attendance with the resident would have called the MD or just sent her out. If they have any questions or in doubt, to have just sent her out. What I believe is if the resident was not responsive, call the MD and if you can ' t reach whoever is in authority timely then send the resident to the hospital. The texting has caught me off, I did not know about that at the time. To me, notifying the MD/NP means talking to them on the telephone. " During a phone interview on 2/26/14 at 1:52pm with Nurse #1 was asked to clarify why she texted the NP versus calling the MD on call and she stated " Because she and I had a previous understanding that she wanted me to text her because she knew the resident ' s better than the on call person. " Nurse #1 indicated she texted (NP) regardless of who was on call. Attempted to speak to Resident #1 attending physician and he was not available for interview during the survey process. The AIT (administrator in training) indicated he was out of town at a conference and was not available. During a phone interview with (Medical Director #1) on 2/26/14 at 2:45pm he stated " She (nurse) should have contacted the on call person for the (medical group) or the MD on call. " The administrator was notified of the Immediate Jeopardy on 2/25/14 at 12:00pm. The facility provided the following Credible Allegation on 2/27/14 at 12:15pm. Credible Allegation of Compliance F-Tag 309 For the provision of Care to Maintain the highest level of function for residents. The corrective action was accomplished for Resident # 1 in the following manner. On 7/27/13 at 7:20pm the 7pm staff nurse completed a thorough nursing assessment. As part of the assessment, the 7pm staff nurse checked respirations and checked oxygen saturation. The results were as follows, respiration was 28, oxygen saturation was 24, touched arm with no response, pupils were fixed, and sternal rub provided with no response. Based upon the results of this assessment at 7:35pm the staff nurse contacted the on call physician. The resident was transported via EMS ambulance service to the hospital at 8:10pm. Family was present upon discharge to the hospital on [DATE]. On 8/2/13 the Director of Nursing met with the 7am supervisor regarding not sending resident to the hospital following a status change. DON gave the 7am supervisor a verbal warning and educated her that if an " employee believes a resident has to be sent to hospital; employee is to send resident to hospital, based on her own assessment of residents condition " . The Director of Nursing discussed with the 7am supervisor that when she does not get a timely response back from the attending physician she is to call the Medical Director for guidance and notify the Director of Nursing. Director of Nursing also met with 7pm supervisor on 8/2/13 to discuss her handling of assessing and sending the resident out. The Administrator spoke with the DON on 8/6/13 who related the events of the weekend transfer concerning Resident #1. After the Administrator ' s review and due consideration he went to speak with the Nurse Practitioner regarding this resident. On 8/6/13 the Administrator met with the Nurse Practitioner to discuss the circumstances surrounding the transfer of the resident. A concern was expressed about the timeliness of the return communication and some confusion as to who was on call. The Nurse Practitioner satisfied those concerns by discussing the necessary changes to the on call protocol with her company. The on call protocol for the NP ' s company is for the facility to call the 800 number to speak with the NP/PA on call. The facility is not to directly call the NP on the weekends, or after hours, nor is the NP to answer if she is not the designated on-call NP. Administrator talked to her about concerns regarding the blood sugar level at the time of the transfer to the hospital. The Nurse Practitioner explained a rationale that appeared to explain the blood sugar level. After speaking with the Nurse Practitioner the Administrator communicated with the DON regarding the employee involved and was satisfied that the necessary steps were taken to correct and educate this employee regarding her responsibilities to the non responsive resident. The resident returned to the facility on [DATE]. Resident returned from the hospital with a new [DEVICE]. Orders were provided to check for signs and symptoms of infection related to [DEVICE] placement, and call doctor for temperature greater than 101 degrees Fahrenheit. Resident also returned from the hospital with a Goldenrod (DNR), which was signed by the hospital doctor. If resident became unresponsive, staff would make detailed observations, assessments and collect pertinent information to report to the nurse supervisor and the Physician and/or Physician on call. The clinical record will reflect accurate documentation of the resident ' s current assessment Phone calls to attending or on-call physicians will be made by the nurse who has collected and organized pertinent information, including the concise and relevant information related to the resident ' s current symptoms and status. The facility now prohibits the use of texting as a form of communicating with the Physician and/or Physician on call and Nurse Practitioner. The nursing staff will contact the Physician based on the results of the nurse ' s clinical assessment of the resident. The nurse will call the Physician and request a prompt response (timely response will be within approximately one-half hour or less). The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status per their policy. The Physician will help identify and authorize appropriate treatments. The Physician will continue to follow up and monitor the resident until the problem or condition has resolved or stabilized. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting. The do not hospitalize order was not in effect, after resident ' s return from the hospital, but resident did return with a Goldenrod (DNR). On 8/2/2013 the DON met with nurse-on-duty and nurse supervisor, and educated both on how to handle future episodes with resident. They verbalized understanding of when to send resident to hospital if similar scenario occurred. For all residents having the potential to be affected by the same deficient practice the corrective action was accomplished by completing a 100% audit of all residents to determine if any residents were exhibiting signs of unresponsiveness or any changes in status by 2/26/2014. Audits were completed by the Unit Managers using a Quality Assessment tool created 2/26/2014. Unit managers used medical records, 24 hour monitoring report, resident interviews and staff interviews to complete Quality Assessment tool. During the audit 14 residents who were previously identified with an acute change in condition, were noted. All residents noted with acute conditions were previously addressed, the physician was notified following the facility ' s policies and procedures, and the identified condition was documented in each resident ' s medical record. For any residents not responding to stimuli or experiencing a change in status, the nursing staff will make detailed observations, assessments and collect pertinent information to report to the nurse supervisor and the Physician and/or Physician on call. The clinical record will reflect accurate documentation of the resident ' s current assessment. Phone calls to attending or on-call physicians will be made by the nurse who has collected and organized pertinent information, including the concise and relevant information related to the resident ' s current symptoms and status. The facility now prohibits the use of texting as a form of communicating with the Physician and/or Physician on call and Nurse Practitioner. The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, the nurse will call the Physician and request a prompt response (timely response will be within approximately one-half hour or less). The Attending Physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. The Physician will help identify and authorize appropriate treatments. The Physician will continue to follow up and monitor the resident until the problem or condition has resolved or stabilized. The Nurse will repeat any verbal orders to the physician to ensure accurate transcription. If it is decided, after sufficient review, that care or observation cannot reasonably be provided in the facility, the Attending Physician will authorize transfer to an acute hospital, emergency room , or another appropriate setting. The staff will notify the DON and the Medical Director for additional guidance and consultation if they do not receive a timely or appropria