Every finding on record at Ignite Medical Resort Sugar Land, LLC

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan area for Resident #1's use of a midline to receive IV antibiotics. This failure placed residents at risk for inconsistent care, complications related to midline catheter, and a decline in health status.Findings included: Record review of Resident #1's facesheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included Type II diabetes (chronic condition where your body either resists the effects of insulin or doesn't produce enough of it), tracheostomy status (presence of an artificial opening in the neck into the trachea), osteomyelitis (an infection and inflammation of the bone), chronic respiratory failure (a long-term condition where the lungs cannot adequately pull oxygen into the blood or remove carbon dioxide from it), infection and inflammatory reaction due to indwelling urethral catheter. Record review of Resident #1's admission MDS dated [DATE] revealed a staff assessment for mental status indicating short term and long-term memory problems and cognitive skills for daily decision making were severely impaired. Record review of Resident #1's Care Plan initiated on 5/20/2026 revealed no mention of placement/use of midline catheter (a long, thin, flexible tube inserted into a vein in the upper arm to deliver intravenous (IV) fluids, medications, or blood) to administer IV antibiotics. Record review of Resident #1's progress note dated 6/12/2026 at 6:54am revealed, The doctor gave a new order for a midline for IV antibiotics for bacterial infection in the sacral wound (skin and tissue damage over the tailbone). The nurse received verbal consent from the guests' [family member]. Record review of Resident #1's progress note dated 6/12/2026 at 11:20am revealed, .Guest to start antibiotic Imipenem-Cilastatin-Relebactam Intravenous Solution Reconstituted 1.25 GM give 1 gram intravenously every 8 hours for infected sacral wound for 14 days until 6/25/2026, Daptomycin 500 mg intravenously at bedtime for infected sacral wound for 14 days until 6/26/2026, remains on Fosfomycin 3 gm every 48 hours till 6/16/2026, await midline insertion, Midline placement staff aware. Record review of Resident #1's progress note dated 6/12/2026 at 5:19pm revealed, Midline inserted to left upper arm 15cm, patent and flushable (access route that is open, unobstructed, and functioning properly to allow fluid or medication to flow freely into a vein). Record review of Resident #1's Informed Consent for PICC/Midline Insertion signed on 6/12/2026 revealed was given for a midline placement for new indication and it was placed in the left basilic vein (a major superficial vein on the inner side of your arm and forearm). Record review of Resident #1's June 2026 MAR revealed: DAPTOmycin Intravenous Solution Reconstituted 500 MG (Daptomycin) Use 500 mg intravenously at bedtime for infected sacral wound for 14 Days started on 6/12/2026 and ended on 6/25/2026 was marked as administered on all days except for 6/15/2026 where the medication was marked as hold/see nurse notes.DAPTOmycin Intravenous Solution Reconstituted 500 MG (Daptomycin) Use 500 mg intravenously at bedtime for Sacral Wound for 4 Weeks starting on 6/27/2026 was marked as administered on 6/28/2026 and 6/29/2026.Check IV dressing each shift and PRN every shift starting on 6/15/2026 was marked completed from 6/16/2026 - 6/30/2026.IV PICC: Monitor site and dressing. Document in progress note any signs and symptoms of infection, notify provider of signs and symptoms of infection every shift per protocol started on 6/15/2026 and marked completed for day and night shift from 6/16/2026 - 6/30/2026.Normal Saline Flush Solution (Sodium Chloride Flush) Use 10 ml intravenously every shift for PICC Line Patency as well as before and after each infusion starting on 6/15/2026 and was marked completed from 6/15/2026 - 6/30/2026.Imipenem-Cilastatin-Relebactam Intravenous Solution Reconstituted 1.25 GM (Imipenem-Cilastatin-Relebactam) Use 1 gram intravenously every 8 hours for infected sacral wound for 14 Days starting on 6/12/2026, medication marked as administered from 6/12/2026 - 6/26/2026.Imipenem-Cilastatin-Relebactam Intravenous Solution Reconstituted 1.25 GM (Imipenem-Cilastatin-Relebactam) Use 1 gram intravenously every 8 hours for Sacral Wound for 4 Weeks starting on 6/28/2026 and was marked as administered from 6/28/2026 - 6/30/2026. Record review of Resident #1's progress note dated 6/22/2026 at 6:38pm by LVN A revealed, .Writer flushed PICC Line noted to residents left arm post antibiotic completion and noticed leakage from line. Contacted PICC line/midline placement team to replace line and was informed that she would be out to replace it this later this evening. Record review of Resident #1's progress note dated 6/23/3036 at 5:28am revealed in part, .The Midline was replaced and started the AM med. Record review of Resident #1's progress note dated 6/25/2026 at 7:46pm revealed in part, .During routine incontinent care, resident's midline catheter was noted to have a break at the catheter hub/medication access end, rendering the line unusable. IV therapy team was notified, and the midline catheter was reinserted without complication. Record review of Resident #1's progress note dated 6/27/2026 at 4:38pm revealed in part, .New order given to extend antibiotic regimen X 4 Weeks. Imipenem 1.25gm via IV every 8 hours for sacral wound for 4 weeks. Daptomycin 500mg via IV at bedtime for sacral wound for 4 weeks. Observation on 6/30/2026 at 3:30pm, Resident #1 was lying in bed resting. Midline was observed to her right upper arm with a green cap on the port. No medication lines connected or medication infusing at the time of observation. Dressing was observed intact and no swelling or redness observed to the area. Interview on 6/30/2026 at 3:53pm, LVN B said Resident #1 was a total care resident and she had a midline to her right upper arm due to her receiving IV antibiotics for a wound infection. LVN B denied there being any current issues with the midline but stated she was aware in the past it had to be replaced. LVN B said the nurses inspect the midline every shift and also before, during, and after they administer IV infusions to check for signs of infection and to ensure the midline is working properly. Interview on 6/30/2026 at 6:13pm, the MDS Coordinator said Resident #1 does have a midline used to administer IV antibiotics for a wound infection. The MDS Coordinator reviewed Resident #1's care plan and stated there was not a care plan area included for the midline and IV antibiotics. The MDS Coordinator stated this was typically something she would include in a resident's care plan and stated anything new going on with residents is usually reviewed in morning meetings and she would update the care plan. The MDS Coordinator was not sure how the information regarding Resident #1's midline was missed and stated she may have been out the day it was discussed. The MDS Coordinator stated during the meeting they would also discuss interventions, and they would likely include information about monitoring the IV site and lines, monitoring for fluid overload, and checking for signs of infection. Interview on 6/30/2026 at 7:04pm, the DON said Resident #1 was receiving IV antibiotics for a wound infection. Resident #1 was admitted with the wounds and since admission the wounds have greatly improved. The DON said there were two occasions she knows of where Resident #1's midline needed to be replaced and they are contracted with a company that manages all of their IVs. On both occasions the team was immediately notified about the issues regarding the midline and they came out to replace the line and there were no missed doses of medication or adverse reactions from midline needing to be replaced. The DON said the midline and use of IV antibiotics was something that should be included in Resident #1's care plan. The DON stated the MDS Coordinator was typically the person to update and complete care plans and she had just spoken to the MDS Coordinator about the missing care plan area for Resident #1. The DON said she just went and added the area to Resident #1's care plan with appropriate interventions to prevent complications associated with the use of a midline and IV antibiotics. Record review of the facility Care Plan policy last reviewed 04/2024 revealed in part, .the care plans are updated at least every 90 days or with a significant change of the resident by the team member initiating the care plan. The care plan consists of the following: Problems as identified by reviewing the medical record and discussion with the resident and /or significant others. b. Goals are set in conjunction with the family and resident. Goals are realistic, measurable, behaviorally stated and may be long or short term. Goals should prevent decline or maintain resident function is realistic and appropriate based on the diagnosis. c. Interventions are actions taken to achieve the goal. These interventions should build on the resident's strengths, be realistic and identify those responsible for the interventions.

Based on interviews, observations, and record reviews, the facility failed to provide reasonable accommodations to meet the needs of 2 (Residents #1 and #2) out of 8 residents reviewed for call lights.The facility failed to ensure a call light system was available for Resident #1.The facility failed to ensure a call light was within reach for Resident #2. This failure has the potential to put residents at risk of not having their needs met when they are unable to contact staff. Findings include:Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. She had diagnoses of respiratory failure with hypoxia (a critical condition where the lungs fail to oxygenate the blood adequately, leading to dangerously low blood oxygen levels, even if carbon dioxide levels are normal or low), abnormalities of gait and mobility (changes in normal walking pattern, resulting from issues in nervous, musculoskeletal, or sensory systems, causing symptoms like limping, shuffling, stiff posture, or uncoordinated steps), muscle weakness (a lack of strength in muscles, making movement difficult), and Restless Leg Syndrome (a neurological disorder causing an irresistible urge to move your legs, often with unpleasant creeping, tingling, or crawling sensations, especially when resting or at night, relieved by movement like walking or stretching, impacting sleep and daily life).Record review of Resident #1's care plan dated 11/4/2025 revealed the resident required assistance with eating set up and clean up, oral hygiene, toileting hygiene, dressing, rolling left to right, and was wheelchair dependent. Observation and interview on 12/8/2025 at 10:21 a.m., Resident #1 was in bed alert, clean and well groomed. Observation of the room did not reveal a call light. Resident #1 said she is a fall risk and said the facility was aware of her being a fall risk when she was admitted . She said she needed help going to the restroom and would fall if she got up on her own. She said she did not know where her call light was. Observation and interview on 12/8/2025 at 10:33 a.m., the Wound Care LVN assisted Resident #3 from her bed to stand and use her walker. Wound Care LVN checked the resident's bed for the resident's call light. Wound Care LVN said she did not know how long Resident #1's call light had been missing. Wound Care LVN said the call light stand was on the wall behind the resident's bed. She said the call light could be taken off the wall and clipped to the resident's gown. She said she believed the resident's call light was in another location in the facility. Wound Care LVN requested a new call light be sent to Resident #1's room. Surveyor observed new call light brought to Resident #1's room at 10:35 a.m., the call light was working and alarming.During observation and interview on 12/9/2025 at 6:12 p.m., Resident #1 was seen in bed with oxygen in use with 2 manual bells at bedside table. She said she did not know what happened to her call light. She said staff had placed bells on her bedside table to use when she needed help to use the restroom and get her walker. She said the staff came when she rang the bells, but they still took a long time to come. Observation of Resident #3 ringing her manual bells revealed bells could not be heard past 2-3 feet from Resident #3's door. RN A passed by Resident #1's door and did not hear the resident ringing the bells. Interview with RN A on 12/9/2025 at 6:17 p.m., she said she did not know where Resident #1's call light was located and stated Resident #3 was using manual bells .Observation on 12/9/2025 at 6:41 p.m., revealed Resident #1 was lying in bed with a call light clipped to her walker not in reach of the resident who was lying in bedResident #2 Record review of Resident #2's face sheet revealed she was [AGE] year-old female admitted the facility on 4/19/2024. She had diagnoses of hemiplegia and hemiparesis affecting right dominant side (damage occurred in the left side of the brain, as the left hemisphere controls the body's right side and language), contractures right elbow, right shoulder, right hand, and right wrist (a permanent tightening and shortening of muscles, tendons, skin, or other tissues that restricts normal movement), aphasia (weakness/paralysis on the right, potential speech/language issues).Record review of Resident #2's care plan dated 6/2/2025 indicated she was a fall risk, interventions read in part call light within reach at all times. The resident also required assistance with toilet, bathing, eating, dressing, transfer and bed mobility.Observation on 12/8/2025 at 9:27 a.m., Resident #2 was sitting in her wheelchair with her breakfast in front of her on the bedside table. She attempted to put a straw through the foil top of a sealed juice cup. The resident's call light was observed in a basket on her nightstand and not within her reach.In an interview on 12/8/2025 at 4:40 p.m., with CNA A, she said the policy was that call lights must be in the resident's reach. She said once the call light was on staff must go and attend to what the resident needed. She said staff do not leave the light on unattended for a long time. She said it takes 2-3 minutes to respond to a call light unless you are busy. She said even if staff were busy someone else should be available to answer the call light. Said if the call light was not working, she would inform the nurse and maintenance would repair or replace the call light. She said there was no log book for call light repairs and she would call maintenance to the hall.Record review of an Email correspondence on 12/8/2025 at 4:38 p.m., with General Manager read in part We don't have the capacity (to review nurse call light log response time) with our call light system. We are anticipating a system upgrade in 2026Interview on 12/9/2025 at 7:03 p.m., CNA B said she was the only one on her hallway for 6pm shift. She said she moved around to the different resident rooms and responded to call lights as soon as possible. She said if there are 3 call lights at a time the priority will be for the person to be changed than a person that was needing a remote picked up or something minor. She said if she can complete the task for the resident she will turn off the call light once she was done. She said when she responded to the call light, but could not complete the task at that moment, she would tell the resident she would be right back but does not turn off call light. She said she will return to assist the resident as soon as she could to complete the task.Interview on 12/9/2025 at 5:39 p.m., the General Manager said she conducted the in service for call light, customer service and neglect. She said she went over expectations of reporting broken call lights. She said the expectation was for staff to answer call lights in a reasonable time. She said a reasonable time was immediately if the staff can, if not staff needed to let the resident know they were coming. She said staff signed the in service for call light and complete orientation for call light and other items.Interview on 12/10/2025 at 2:41 p.m., the DON said when there was call light concerns staff was in-serviced. She said if there was an isolated event with staff there would be a one-on-one reeducation and a complete write up. She said when the facility got complaints about call lights the facility would go into resident rooms at all times to see if call lights were available and working. She said in the evenings CNAs give showers and it can take longer to respond to call lights. She said when a resident complained about call light responses overnight, she came and observed the overnight shift. She said she did not document the overnight observation, what was completed or seen. She said the risk of not answering call lights could be a fall risk or some type of hazard for the resident.Record review of facility in service dated 11/26/2025 revealed a training on facility policy CALL LIGHT - ABILITY TO USE revised on 01/2024. Record review of facility policy CALL LIGHT - ABILITY TO USE revised on 01/2024 read in part 5.Staff members will ensure that call lights are within reach of a resident who is able to cognitively use a call light each time they leave the room. 6.Staff members will acknowledge and respond to the call light by entering the resident's room and determining and assisting with the resident's needs.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and contained. B. Ensure general cleanliness was maintained. C. Ensure substitution list, cleaning list and temperature logs were utilized. These failures could place all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: Observations on 9/23/24 at 09:33 am, during initial kitchen rounds of the freezer by the stove revealed: 1. Hash brown in a box not labeled and not dated 2. 5-way mixed vegetable, not labeled or dated, and not in the original box. 3. Vegetable egg rolls in original container 3 pounds box open not dated 4. Beyond chicken tenders 2.5 pounds in box not dated in original package 5. Vegetable egg rolls in original container 3 pounds box open not dated Observations on 9/23/24 at 09:33 am, during initial kitchen rounds of the standing oven the grill revealed: 1. Standing oven by the grill had dry food particles, sticky and grime. In an interview with the DM on 9/23/ 24 at 10:00AM, he said he normally scheduled employee to clean the oven, he was not sure when it was last cleaned. He said did not have a cleaning log. He thought it was last cleaned a week before. DM said he would start keeping a cleaning log. Interview on 9/27/2024 at 1:39pm with the Administrator, she said she was informed that the food was not labeled. She said her expectations for her staff was to have the food dated, labeled including discard date to be thrown out if the dates have passed on the item. She said she was told inside the oven it was brown. She said her expectations moving forward for the staff was to have the oven cleaned after every use. She said by having her staff clean the oven after each use it would guarantee that the oven will not have any particles left over. Record Review of the (Revised date November 2022 ) facility policy titled ' Food Receiving and storage . Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded, food items that remain sealed from the supplier may be held until the expiration date if unopened. Food returning to storage after Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) -(G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.

Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident #7) of four received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices reviewed for wound care . -Resident #7's order for a wound dressing to be changed daily was not completed on 01/04/25, 01/05/25, and 01/06/25. The failure could place residents at risk for delayed healing or worsening of the wound. Findings Included: Record review of the admission Record for Resident #7 revealed she was [AGE] years old and was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, cutaneous abscess (collection of pus under the skin) of abdominal wall, unspecified wound of the abdominal wall, and sepsis (a condition in which the body responds improperly to an infection that may cause organ damage and possibly death). Record review of the Entry MDS dated [DATE] for Resident #7 revealed she was transferred from a short-term general hospital. The Entry MDS did not contain clinical health information. Record review of Resident #7's Care Plan , dated 01/06/25, revealed the resident had skin impairment. One Intervention read, in part, .Administer treatments as ordered and monitor for effectiveness . Record review of Resident #7's Physician Order (effective 01/04/25 to 01/08/25) revealed the abdominal wound was to be treated daily by cleansing with wound cleaner, with medihoney and then covered with a hydrofera blue and a foam dressing. Record review of Resident #7's TAR revealed the treatments were not documented as being provided on 01/04/25, 01/05/25, or 01/06/25. Record review of Resident #7's Physician Order dated 01/08/25 revealed the same treatment was changed to every two days, with a treatment scheduled for 01/09/25. Record review of Resident #7's January 2025 TAR revealed the treatment was not signed as been provided on 01/09/25. Observation on 01/10/25 at 10:21 a.m. revealed Resident #7 was lying in bed. Observation of the abdominal dressing revealed a date of 01/07/25. In an interview on 01/10/25 at 11:15 a.m., the DON said she was unaware the dressing on Resident #7's abdomen had not been changed since 01/07/25. She said the order dated 01/08/25 reflected the dressing was to be changed every other day. She said each nurse was responsible for making sure the wound care was provided as ordered. She said she or the ADON were responsible for supervising the nurses. Record review of the facility policy on Wound Care (revised October 2010) revealed no guidance to report outdated wound dressings. The policy reflected the nurse was to verify there was a physician's order for the treatment, and to document the date and time the treatment was provided.

incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #18) reviewed for incontinent care. 1. The facility failed to ensure CNA A separated Resident #18's labia, cleaned the foley catheter insertion site and performed proper hand hygiene during foley care for Resident #18. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #18's face sheet, dated 09/21/2024, revealed an admitted [DATE], with diagnoses That included: encephalopathy tracheostomy, respiratory failure with hypoxia (low levels of oxygen in your tissues) or hypercapnia ( high levels of carbon dioxde in your blood), osteomyelitis of vertebra ( a bone infection that causes inflammation and swelling in the bone and its surrounding tissues), sacral and sacrococcygeal region stage 4( a full -thickness skin loss that extends into the deep tissues, including muscle, tendons, ligaments cartilage or bone), cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, right lower leg, cerebral aneurysm ( a bulge in a weakened artery wall in the brain that can fill with blood), not ruptured. Record review of Resident #18's quarterly MDS assessment, dated 09/18/2024, revealed Resident #18 BIMS score was blank which indicated cognitive impairment. Resident #18 required limited to extensive assistance with all ADLs and was continent of bladder with indwelling catheter and frequently incontinent of bowel. Record review of Resident #18 's care plan, dated 6/21/24, reflected, . The resident has an ADL self-care deficit .Interventions .Personal hygiene and Toilet use- Resident is totally dependent An observation on 09/24/24 at 2:22 p.m., revealed CNA A and CNA C entered Resident #18's room preparing to provide incontinence care. CNA A put on clean gloves and unfastened Resident #18's brief soaked with urine and serous fluid. CNA A said the indwelling catheter was leaking and she would let the nurse know . CNA A took a peri-wipe and cleaned resident's perineal area; she did not open the labia to wipe, did not clean indwelling catheter from the insertion. CNA C assisted to roll Resident #18 on her left side. CNA A took a peri-wipe and wiped in-between residents' rectal area and did not wipe around the buttocks. Interview with CNA A on 09/24/24 at 5:12 p.m. she stated she was supposed to open the labia to clean and around the buttocks. CN.A A said she was nervous. She stated she knew the importance of properly cleaning a resident and by not doing so, placed them at risk of infections and she had been working with the facility for about 2 months Interview with the DON on 09/27/24 at 02:00 p.m., she stated staff were to open labia and clean around residents' buttocks. She stated by not following proper peri care it placed residents at risk of urinary tract infections and she would be over seeing and monitoring incontinent care. Review of CNA A's skill checks dated 07/30/24 reflected she was competent in performing peri-care. Record review of the facility's policy titled, Perineal care, revised March 2017, reflected, .Wash and dry hands thoroughly .put on gloves .wash perineal are , wiping from front to back .Separate labia and wash area downward from front to back . Assist the resident to turn on her side .Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks .Rinse and dry thoroughly

Based on observations, interviews, and record reviews, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 5 residents (Resident #18) reviewed for infection control, in that: CNA A did not change her gloves or wash her hands after providing incontinent care to Resident #18. RN R did not change her gloves or wash her hands during pressure ulcer treatment and after providing treatment to Resident #18 RN R did not change her gloves or wash her hands and used sterile technique during tracheotomy care and suctioning for Resident #5. These failures could place residents at-risk for infection due to improper care practices. The findings included: Record review of Resident #18's face sheet, dated 09/21/2024, revealed an admitted [DATE], with diagnoses that included: encephalopathy tracheostomy, respiratory failure with hypoxia or hypercapnia, osteomyelitis of vertebra, sacral and sacrococcygeal region stage 4 pressure ulcer, cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, right lower leg, cerebral aneurysm, not ruptured. Record review of Resident #18's quarterly MDS assessment, dated 09/18/2024, revealed Resident #18 BIMS score was blank which indicated cognitive impairment. Resident #18 required limited to extensive assistance with all ADLs and was continent of bladder with indwelling catheter and frequently incontinent of bowel. Review of Resident #18's care plan dated 06/23/2024, revealed a problem of The resident has Urinary Tract Infection, with an intervention of Provide incontinence care as needed. Record review of the physician order dated 9/23/24 revealed Physician's order for Resident #18 Fosfomycin Tromethamine Oral Packet 3 GM (Fosfomycin Tromethamine) Give 3 gram via G-Tube every 72 hours for UTI until 10/03/2024. Observation on 09/24/24 at 1:06 p.m. while RN R was providing pressure ulcer treatment to Resident #18, RN R did not wash her hands before donning gloves, she removed the old dressing to left ear that was bleeding, without changing gloves she picked up clean 4 X4 gauzes , and placed 4 x4 gauzes in a clean cup then poured in normal saline, then picked the wet gauzes and cleaned the wound about 4 times to left [NAME], she then used the same gloves, picked up a scissor cut the Xerofoam dressing and applied to left ear and boarder dressing. Observation on 09/24/24 at 2:22 p.m., revealed, while providing incontinent care for Resident #18, CNA A did not wash her hands when she entered Resident #18's room to provide incontinent care, don clean gloves. C.NA A did not change her gloves or wash her hands after providing incontinent care for Resident #18 and before touching and fastening the clean brief to Resident #18. During an interview on 9/24/2024 at 5:12 p.m. CNA A confirmed she did not change her gloves or wash her hands prior to touching the clean brief. She said she was nervous. She confirmed she received infection control training 1 month ago when she was hired. Record review of Resident #5's face sheet dated 09/27/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old male. Resident #5 had diagnosis of Acute Respiratory Failure with Hypoxia (occurs when the body doesn't have enough oxygen in its tissues). Record review of Resident #5's MDS dated [DATE] revealed the BIMS assessment was not done. Further review revealed that the staff assessed Resident #5 on mental status and found he has short-term and long-term memory/recall ability problems; and severely cognitively impaired. Observation on 09/24/2024 at 4:00pm revealed Resident #5 was in bed with audible moist breath sounds. RN R set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. RN R did not remove dirty gloves, used the same gloves, and picked up Trach Care Kit. RN R opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, placed sterile gloves on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doff gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #5's bed side, poured it in the tray. RN R picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #5's bed side. RN R, using the same gloves, removed tracheostomy inner canula, then re-inserted it to trach site. Cleaned the surrounding area of trach using the sterile 4x4 gauze and dipped the gauze in the normal saline three different times without changing gloves and preforming hand hygiene during the cleaning and changing of tracheostomy tubes. Interview on 09/25/2024 at 1:30 PM, RN R stated she did not wash her hands during trach care or do suctioning. She stated she should have used sterile technique throughout, and she was recently in-serviced on tracheostomy care but could not recall the date of in service. RN R did not disclose why she failed to use sterile technique. She stated she worked with Resident #5 often. RN R stated that using the technique she used placed the resident at risk for a respiratory infection. Interview on 09/25/2024 at 5:00 PM, the DON stated that staff had been in-serviced on tracheostomy in September 2024. The DON stated that RN R should have used sterile technique during tracheostomy care. The DON stated that using the technique RN R used could have placed the resident at risk for an infection. The DON stated that the facility's scheduled respiratory therapist is usually responsible be providing respiratory care, but the nurses are trained in the event that the respiratory therapy staff is not available. The DON stated that the respiratory therapy department primarily oversees the trach care, but she would be working with the respiratory therapy to ensure that nursing staff was held accountable as well. During an interview with the DON on 09/26/2024 at 3:15 p.m., the DON confirmed gloves must be changed after cleaning and before touching clean brief to prevent cross contamination. The DON revealed she was training the staff for infection control. DON just started working one week and would be monitoring the staffs. Interview on 9/27/24 at 1:39 PM with the Administrator, she said she expected for Incontinent care and Foley care done by the staffs to prevent infection. She said she was informed by DON about peri care the foley insertion site was not cleaned properly. She said her expectations was for the staff to clean all the areas including the foley insertion area thoroughly. She said the staff should be using multiple cleansing wipes. She said she was informed staff was cleaning from the outside in which causes contamination. She said her expectation was for the staff to clean inside out and not to re-wipe areas that have already been cleaned. She said it was important to determine which hand will be clean and which hand will be dirty. She said infection control hands on competencies in a classroom setting referencing trach and wound care with verbal and return demonstrations. She said they will perform weekly trach care and wound care audits x 8 (2 months) and re-evaluate staff after all training was completed. Review of the facility policy, titled Fundamental of infection control precautions, dated 2019, revealed [ .] the following is a list of some situations that require hand hygiene: [ .] Before and after direct resident contacts (for which hand hygiene is indicated by acceptable professional practice) [ .] after contact with a resident's mucous membranes and body fluids or excretions.

Based on observation, interview and record review, the facility failed to ensure garbage and refuse was disposed properly for 1 of 1 dumpster reviewed for garbage disposal. -The facility failed to ensure the dumpster floor were free of debris. This failure could place residents at risk of infection from improperly disposed garbage. Findings include: Observation and Interview on 9/24/24 at 12:20 PM with Housekeeper A, revealed around the dumpster, behind and the side of the dumpster had lots of debris of paper, diaper, leaves, woods, and a broken dresser. Housekeeper A asked the surveyor Is the company the picks up the dumpster supposed to swipe the debris around the dumpster or the facility? Surveyor advised her to check with her supervisor. Interview on 9/24/24 at 2:06 PM with the Director of housekeeping, he said he has been working in the facility since March 2024. He said he was not aware of the debris behind the dumpster and by the side. He said he had not check around the dumpster. He said he was told by the housekeeping staff and the dumpster was picked up 3 times a week on Tuesdays, Thursday, and Saturday. He said the company just picked the dumpster up earlier today, he was not aware the dumpster had all that trash behind. He stated that he did not expect the debris around the dumpster because it can bring critters, rodents and rats. He said he was going sweep around dumpster and he would be checking on it often. Interview on 9/24/24 at 5:30 PM with the Administrator, she said she expected the dumpster, to be closed and the surrounding to be free of debris and trash. Administrator said she would be monitoring it every other day. Record review of the facility policy and procedure dated (revision October 2017) Food-Related Garbage and refuse Disposal . 5.Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests.6. Storage areas will be kept clean at all times and shall not constitute a nuisance.7. Outside dumpster provided by garbage pick up services will be kept closed and free of surrounding litter.

Based on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of five percent (%) or greater. The facility had a medication error rate of 26% based on 8 errors out of 30 opportunities, which involved 1 of 5 residents (Resident #177) reviewed for medication errors. LVN A administered Lacosamide (medicine used to treat seizures), and Hydralazine (medicine used to lower blood pressure); to Resident #177 at 9:08am instead of 7:00am as ordered by the physician. LVN A administered the wrong dose of Hydralazine and Carvedilol (medicines used to lower blood pressure); Baclofen (medicine used as skeletal muscle relaxants); Glycopyrrolate (treats chronic obstructive pulmonary disease); Doxycycline (medicine used bacterial infections); and Isosorbide (medicine used to treat uncontrolled arterial hypertension) to Resident #177 as ordered by the physician. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Record review of Resident #177's face sheet dated 09/27/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old male. Resident #177 had diagnoses of Parkinson's Disease (a progressive neurodegenerative disease); Epilepsy (a chronic brain disorder that causes people to have repeated seizures); Muscle Generalized Weakness (a feeling of weakness in most areas of the body); Dysarthria and Anarthria (both speech disorders that affect the ability to coordinate and control the muscles used for speaking); Tracheostomy Status (a medical classification that refers to an artificial opening in the windpipe (trachea) created to help with breathing); Presence of Cardiac Pacemaker (small device that's implanted in the chest to regulate a slow heart rate); Muscle Wasting and Atrophy (the thinning or loss of muscle tissue); Cognitive Communication Deficit (a difficulty with communication that's caused by a disruption in cognition); Dysphagia Oropharyngeal Phase (a condition that occurs when there is a delay in the movement of food or liquid during the phase is when food or liquid is moved from the mouth to the upper esophageal sphincter); Contracture of the Right Elbow, Left Elbow Right Wrist, Left Wrist, Right Hand, Left Hand, Right Knee, and Left Knee, Contracture (a permanent or temporary tightening of muscles, tendons, skin, and nearby tissues that limits the normal movement of a joint or body part); Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause); and Cellulitis (a bacterial infection that affects the skin). Record review of Resident# 177's quarterly MDS dated [DATE] revealed a BIMS score of 03 which indicated severely impaired cognition. It also revealed the resident needed total care assist with ADL with two to three staff assistance. Further review revealed resident had gastrostomy tube (also called a G-tube) for feeding. Record review of rResident #1's physician's order summary report revealed the following order: order dated 07/16/2024, Lacosamide solution 10 mg/ml give 10 ml via g-tube two times a day (7:00am and 7:00pm) for anticonvulsants. order dated 09/11/2024, Hydralazine tablet 25 mg Give 2 tablet via g-tube three times a day (7:00am, 2:00pm, and 9:00pm) for hypertension related to essential (primary) hypertension order dated 07/16/2024, Baclofen tablet 5 mg Give 1 tablet by mouth three times a day (9:00am, 2:00pm, and 9:00pm) for musculoskeletal order dated 07/16/2024, glycopyrrolate tablet 1 mg Give 1 tablet via g-tube three times a day (9:00am, 2:00pm and 9:00pm) for antiasthmatic and bronchodilator agents order dated 07/16/2024, Isosorbide Dinitrate tablet 10 mg Give 1 tablet via g-tube three times a day a day (9:00am, 2:00pm, and 9:00pm) for hypertension order dated 09/12/2024, Doxycycline tablet 100 mg Give 1 tablet via g-tube every 12 hours (9:00am and 9:00pm) related to cellulitis, unspecified Observation on 09/25/2024 at 9:08am revealed G-Tube medication administration with LVN A for Resident # 177. LVN A prepared to administer Resident # 177 as she added Lacosamide solution 10 mg to a 30ml cup and mixed with water to dilute. LVN A crushed two Hydralazine tablet 25 mg, Baclofen tablet 5 mg, glycopyrrolate tablet 1 mg, Isosorbide Dinitrate tablet 10 mg, Doxycycline oral tablet 100 mg. Each medication was crushed separately and diluted with water in individual 30ml cups. LVN A did not administer the whole amount of the crushed medication leaving a significant amount medication in each of the five cups. As LVN A was leaving Resident #177's room the surveyor asked LVN A if she had completed the medication pass. LVN A confirmed that she had completed the medication pass. The surveyor showed the medication cups with medication to LVN A and the DON. LVN A stated that medication should be administered. LVN A returned to Resident #177 to correct the errors by adding additional water to each medication cup to ensure that Resident #177 received the remainder of the medications as ordered by the physician. LVN A did not disclose why the medications were administered late. LVN A stated that the physician was notified of the medications that were administered late and was instructed by the physician to continue to monitor Resident #177. Interview on 09/25/2024 at 12:05pm The DON stated that she recently started work at the facility, but she would be the individual responsible for overseeing and auditing if medication were administered timely. The DON stated that medications were to be checked for the correct dosage and route with each medication pass. The DON stated that medication should be administered at the ordered time, allowing staff an hour before and hour after. The DON stated that when medications was administered in error at the wrong time and wrong dose that it can cause serious, sometimes long-term effects to the resident. The DON stated that it was a safety concern, and she was able to follow up with LVN A related to G-tube medication administration. The DON stated that all nurses and MA staff have been trained and were knowledgeable of the medication administration policy. The DON stated that additional training will be provided. Interview on 09/25/2024 at 2:00pm with LVN A, she stated that Lacosamide and Hydralazine were given later than scheduled time of 7:00am to Resident #177. LVN A also verbally acknowledged she initially failed to administer the ordered dose of five medications (Hydralazine, Baclofen, glycopyrrolate, Isosorbide Dinitrate, Isosorbide Dinitrate). LVN A stated that she would usually give all medications as ordered and did not disclose why she failed to administer the medications at the time of the medication pass observation. She stated that if the residents did not get the medications as ordered, then the resident will not have the desired effect of the medication, and it can have a negative effect on the resident. She stated she had been trained on G-Tube medication administration. LVN A stated that medication should be administered at the ordered time, giving staff an hour before and hour after. Record review of education/training record for LVN A related to g-tube care and medication administration was verified by the surveyor team. The last documented medication administration training was September 2024. Review of the facility's policy titled Medication and Treatment orders dated November 2014, read Medications shall be administered only upon the written order . The was not additional mention of to address administering meds timely and administering all the meds correctly.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 5 residents (Resident #177) reviewed for pharmacy services. LVN A failed to administer Lacosamide (medicine used to treat seizures), and Hydralazine (medicine used to lower blood pressure); to Resident #177 at 7:00am as ordered by the physician. LVN A failed to administer the whole dose of Hydralazine and Carvedilol (medicines used to lower blood pressure); Baclofen (medicine used as skeletal muscle relaxants); Glycopyrrolate (treats chronic obstructive pulmonary disease); Doxycycline (medicine used bacterial infections); and Isosorbide (medicine used to treat uncontrolled arterial hypertension) to Resident #177 as ordered by the physician. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Record review of Resident #177's face sheet dated 09/27/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old male. Resident #177 had diagnoses of Parkinson's Disease (a progressive neurodegenerative disease); Epilepsy (a chronic brain disorder that causes people to have repeated seizures); Muscle Generalized Weakness (a feeling of weakness in most areas of the body); Dysarthria and Anarthria (both speech disorders that affect the ability to coordinate and control the muscles used for speaking); Tracheostomy Status (a medical classification that refers to an artificial opening in the windpipe (trachea) created to help with breathing); Presence of Cardiac Pacemaker (small device that's implanted in the chest to regulate a slow heart rate); Muscle Wasting and Atrophy (the thinning or loss of muscle tissue); Cognitive Communication Deficit (a difficulty with communication that's caused by a disruption in cognition); Dysphagia Oropharyngeal Phase (a condition that occurs when there is a delay in the movement of food or liquid during the phase is when food or liquid is moved from the mouth to the upper esophageal sphincter); Contracture of the Right Elbow, Left Elbow Right Wrist, Left Wrist, Right Hand, Left Hand, Right Knee, and Left Knee, Contracture (a permanent or temporary tightening of muscles, tendons, skin, and nearby tissues that limits the normal movement of a joint or body part); Essential (Primary) Hypertension (high blood pressure that is multi-factorial and doesn't have one distinct cause); and Cellulitis (a bacterial infection that affects the skin). Record review of Resident# 177's quarterly MDS dated [DATE] revealed a BIMS score of 03 which indicated severely impaired cognition. It also revealed the resident needed total care assist with ADL with two to three staff assistance. Further review revealed resident had gastrostomy tube (also called a G-tube) for feeding. Record review of Resident #1's physician's order summary report revealed the following order: order dated 07/16/2024, Lacosamide solution 10 mg/ml give 10 ml via g-tube two times a day (7:00am and 7:00pm) for anticonvulsants. order dated 09/11/2024, Hydralazine tablet 25 mg Give 2 tablet via g-tube three times a day (7:00am, 2:00pm, and 9:00pm) for hypertension related to essential (primary) hypertension order dated 07/16/2024, Baclofen tablet 5 mg Give 1 tablet by mouth three times a day (9:00am, 2:00pm, and 9:00pm) for musculoskeletal order dated 07/16/2024, glycopyrrolate tablet 1 mg Give 1 tablet via g-tube three times a day (9:00am, 2:00pm and 9:00pm) for antiasthmatic and bronchodilator agents order dated 07/16/2024, Isosorbide Dinitrate tablet 10 mg Give 1 tablet via g-tube three times a day a day (9:00am, 2:00pm, and 9:00pm) for hypertension order dated 09/12/2024, Doxycycline tablet 100 mg Give 1 tablet via g-tube every 12 hours (9:00am and 9:00pm) related to cellulitis, unspecified Observation on 09/25/2024 at 9:08am revealed G-Tube medication administration with LVN A for Resident # 177. LVN A prepared to administer Resident # 177 as she added Lacosamide solution 10 mg to a 30ml cup and mixed with water to dilute. LVN A crushed two Hydralazine tablet 25 mg, Baclofen tablet 5 mg, glycopyrrolate tablet 1 mg, Isosorbide Dinitrate tablet 10 mg, Doxycycline oral tablet 100 mg. Each medication was crushed separately and diluted with water in individual 30ml cups. LVN A did not administer the whole amount of the crushed medication leaving a significant amount medication in each of the five cups. As LVN A was leaving Resident #177's room the surveyor asked LVN A if she had completed the medication pass. LVN A confirmed that she had completed the medication pass. The surveyor showed the medication cups with medication to LVN A and the DON. LVN A stated that medication should be administered. LVN A returned to Resident #177 to correct the errors by adding additional water to each medication cup to ensure that Resident #177 received the remainder of the medications as ordered by the physician. LVN A did not disclose why the medications were administered late. LVN A stated that the physician was notified of the medications that were administered late and was instructed by the physician to continue to monitor Resident #177. Interview on 09/25/2024 at 12:05pm The DON stated that she recently started work at the facility, but she would be the individual responsible for overseeing and auditing if medication were administered timely. The DON stated that medications were to be checked for the correct dosage and route with each medication pass. The DON stated that medication should be administered at the ordered time, allowing staff an hour before and hour after. The DON stated that when medications was administered in error at the wrong time and wrong dose that it can cause serious, sometimes long-term effects to the resident. The DON stated that it was a safety concern, and she was able to follow up with LVN A related to G-tube medication administration. The DON stated that all nurses and MA staff have been trained and were knowledgeable of the medication administration policy. The DON stated that additional training will be provided. Interview on 09/25/2024 at 2:00pm with LVN A, she stated that Lacosamide and Hydralazine were given later than scheduled time of 7:00am to Resident #177. LVN A also verbally acknowledged she initially failed to administer the ordered dose of five medications (Hydralazine, Baclofen, glycopyrrolate, Isosorbide Dinitrate, Isosorbide Dinitrate). LVN A stated that she would usually give all medications as ordered and did not disclose why she failed to administer the medications at the time of the medication pass observation. She stated that if the residents did not get the medications as ordered, then the resident will not have the desired effect of the medication, and it can have a negative effect on the resident. She stated she had been trained on G-Tube medication administration. LVN A stated that medication should be administered at the ordered time, giving staff an hour before and hour after. Record review of education/training record for LVN A related to g-tube care and medication administration was verified by the surveyor team. The last documented medication administration training was September 2024. Review of the facility's policy titled Medication and Treatment orders dated November 2014, read Medications shall be administered only upon the written order . The was not additional mention of to address administering meds timely and administering all the meds correctly.

Based on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #18) for pressure ulcers. 1. The facility failed to ensure Resident #18 received services and treatment orders to prevent sacral pressure ulcers from healing. These failures could place residents at risk for worsening of existing wounds or development of new pressure ulcers. The findings were: Record review of Resident #18's face sheet, dated 09/21/2024, revealed an admitted [DATE], with diagnoses That included: encephalopathy tracheostomy, respiratory failure with hypoxia (low levels of oxygen in your tissues) or hypercapnia ( high levels of carbon dioxde in your blood), osteomyelitis of vertebra ( a bone infection that causes inflammation and swelling in the bone and its surrounding tissues), sacral and sacrococcygeal region stage 4( a full -thickness skin loss that extends into the deep tissues, including muscle, tendons, ligaments cartilage or bone), cognitive communication deficit, muscle wasting and atrophy, not elsewhere classified, right lower leg, cerebral aneurysm ( a bulge in a weakened artery wall in the brain that can fill with blood), not ruptured. Record review of Resident #18's quarterly MDS assessment, dated 09/18/2024, revealed Resident #18 BIMS score was blank which indicated cognitive impairment. Resident #18 required limited to extensive assistance with all ADL and pressure ulcer Record review of Resident #18 wound assessment form dated reflected 9/27/24 had, ;Cleanse Sacral With Ns, Pat Dried, Wound Care Md Apply Helicoil (Stem Cells, Adaptic, Tape And Cal Alginate With Dry Dressing To Be In Place Until 10/3/2024. Do Not Remove Stem Cells/Adaptic.Change Cal Alginateevery othe day and nd Prn, Dressing Changes Only If Soiled. Every Day Shift Every Other Day For Wound. Record review wound care dated 9/26/24 revealed the physician did measurement of sacral pressure ulcer which reflected length 6.9 CM, width 9.0 CM and depth 5.3cm . Observation at 2:45PM on 9/24/24 revealed RN R performing Sacral wound treatment to Resident #18. RN R poured NS ( Normal Saline) on 4 X4 gauze, cleaned the wound bed from outside in with wet gauze repeated it 3 times with moderate serous fluid, without changing gloves she picked up dry 4 x4 gauze, she pat and dry the sacral wound, picked up a sheet of calcium Alginate placed it on the dressing and placed a foam heel dressing on the dressing and taped it. Interview with RN R on 9/24/24 at 1:16 PM regarding wound care she just completed, RN R said she did a good job. She wanted the surveyor to tell her what she did wrong. Interview on 9/25/24at 3:35 PM with the DON via telephone and RN R, RN R said she admitted to the facility 2 weeks and she did not have any training on wound care. She said the facility did not have all the treatment stuff for the resident and she did talk to the DON, before using the heel foam dressing. RN R said the treatment was for every other day and it was not due yet that was why she was taking her time. When asked why she was cleaning the wound bed outside in she did not have any explanation and she knew it can cause infection. Interview with the treatment Physician on 9/26/24 at 2:00 p.m., hhe said he surgically debrided the sacral weekly and calcium alginate should be packed inside the wound. He said the facility needs nursing education on wound dressing. He said foam heel should not be used on sacral dressing. In an interview on 09/26/2024 at 4:20 PM the DON stated her expectation was for the nurses to follow Dr's orders. She stated not following orders could potentially affect the resident's health. She would have in-service and monitor the license staff. No policy and procedure regarding following Physician orders was provided by the DON at the time of exit from the facility.

Based on observation, interview and record review, the facility failed to ensure that residents who needs respiratory care, including tracheotomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of two residents reviewed for tracheotomy care (Resident #5). The facility failed to ensure RN R used sterile technique during tracheotomy care and suctioning for Resident #5. These failures could place residents with a tracheotomy requiring suctioning at risk for respiratory infections, hospitalization s, and a decline in their quality of life. Findings included: Record review of Resident #5's face sheet dated 09/27/2024 revealed resident was admitted to the facility on [DATE], age [AGE] years old male. Resident #5 had diagnosis of Acute Respiratory Failure with Hypoxia (occurs when the body doesn't have enough oxygen in its tissues). Record review of Resident #5's MDS dated [DATE] revealed the BIMS assessment was not done. Further review revealed that the staff assessed Resident #5 on mental status and found he has short-term and long-term memory/recall ability problems; and severely cognitively impaired. Record review of Resident #5's Physician Orders reviewed 08/13/2024 revealed the following: Tracheostomy Care cuffed flex Shiley 6 with disposable inner cannula) as indicated every 12 hours and PRN. Observation on 09/24/2024 at 4:00pm revealed Resident #5 was in bed with audible moist breath sounds. RN R set up a clean field on the bedside table, checked oxygen saturation checked and it was 96%. RN R did not remove dirty gloves, used the same gloves, and picked up Trach Care Kit. RN R opened the sterile Trach Care Kit, using the same gloves picked up sterile 4x4 gauze, placed sterile gloves on the bedside table. She changed gloves without washing hands or using hand sanitizer, grabbed the sterile suction catheter kit tray, opened it, then doff gloves without washing hands, picked up the sterile gloves, don sterile gloves then picked up normal saline at Resident #5's bed side, poured it in the tray. RN R picked up the suction tubing from the sterile suction kit connected it to the suction machine at Resident #5's bed side. RN R, using the same gloves, removed tracheostomy inner canula, then re-inserted it to trach site. Cleaned the surrounding area of trach using the sterile 4x4 gauze and dipped the gauze in the normal saline three different times without changing gloves and preforming hand hygiene during the cleaning and changing of tracheostomy tubes. Interview on 09/25/2024 at 1:30 PM, RN R stated she did not wash her hands during trach care or do suctioning. She stated she should have used sterile technique throughout, and she was recently in-serviced on tracheostomy care but could not recall the date of in service. RN R did not disclose why she failed to use sterile technique. She stated she worked with Resident #5 often. RN R stated that using the technique she used placed the resident at risk for a respiratory infection. Interview on 09/25/2024 at 5:00 PM, the DON stated that staff had been in-serviced on tracheostomy in September 2024. The DON stated that RN R should have used sterile technique during tracheostomy care. The DON stated that using the technique RN R used could have placed the resident at risk for an infection. The DON stated that the facility's scheduled respiratory therapist is usually responsible be providing respiratory care, but the nurses are trained in the event that the respiratory therapy staff is not available. The DON stated that the respiratory therapy department primarily oversees the trach care, but she would be working with the respiratory therapy to ensure that nursing staff was held accountable as well. Review of the facility's policy titled Tracheostomy Care dated August 2013, read Aseptic technique must be used: during cleaning and sterilization of reusable tracheostomy tubes; during all dressing changes until the tracheostomy wound has granulated (healed); and during tracheostomy tube changes, either reusable or disposable. Gloves must be used on both hands during any or all manipulation of the tracheostomy. Sterile gloves must be used during aseptic procedures.

Based on observation, record review and interview, the facility failed to ensure that residents who needs respiratory care is provided such care consistent with professional standards, the comprehensive care plan, the residents goals, and preferences for 1 of 5 (CR#1) residents reviewed for respiratory and tracheostomy care in that: -The facility failed to ensure that CR#1 who needed respiratory care, including tracheotomy care circuit was attached appropriately causing it to become dislodged resulting in agonal breathing, cardiac arrest, and death. -The facility failed to have emergency tracheostomy equipment at CR#1's bedside when CR#1 trach dislodged. An Immediate Jeopardy (IJ) was identified on [DATE] at 05:42pm . The IJ template was provided to the facility on [DATE] at 5:42pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained on [DATE]. This failure had the potential to place residents with tracheostomies as well as other residents requiring respiratory care at risk of not receiving the necessary care and services needed to meet their medical goals resulting in a decline in health or harm. Findings Included: Record review of facility census dated [DATE] revealed there were 24 residents. Record review of the facility's CMS form 672 revealed there were 7 residents that had a tracheostomy out of 24 residents. Record review of CR#1's face sheet dated [DATE] revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (a condition where the body has low levels of oxygen in the blood), Type 2 Diabetes Mellitus without complications (a condition in which the body has trouble controlling blood sugar), anoxic brain damage(condition caused by a lack of oxygen which could lead to brain death), pulmonary hypertension A type of high blood pressure that affects arteries in the lungs and in the heart), dependence on ventilator, tracheostomy. CR#1 was designated as full code. Record review of CR#1's MDS dated [DATE] revealed Section B0100- Comatose (Persistent vegetative state/no discernible consciousness was documented as 1-(Yes). Section C500- BIMS summary score was left blank. GG0115- Functional Limitations was coded 2 (which meant impairment on both sides) for both upper and lower extremities which included: shoulder, elbow, wrist, hand and hip knee, ankle and foot. Section GG0120- Mobility devices were coded Z. (none of the above), which meant she did not use a cane, walker, wheelchair, limb prosthesis in the last 7 days. Mobility revealed A. Roll left and right was coded as 01- which meant CR#1 was dependent- helper does all of the effort. B. Sit to lying, C. Lying to sitting on side of the bed; D. Sit to stand; E. Chair/bed-to-chair transfer and walk 10 feet were all coded as 88, which meant not attempted due to medical or safety concern. Section H0300- Urinary Incontinence and Bowel incontinence were both coded as 3. Which meant she was always incontinent. Section O. Special treatment, Procedures, and programs performed revealed respiratory treatment (C1) oxygen therapy; (D1) Suctioning and (E1) Tracheostomy care was all coded as B. While a resident. Record review of CR#1's care plan dated [DATE] and revised/cancelled on [DATE] revealed the following care areas: CR#1 required supplemental oxygen for respiratory status hypoxemia, respiratory illness. Goal: Resident will tolerate use of oxygen and oxygen saturations will remain within normal ranges through the next review. Interventions was: Monitor for complications r/t oxygen use (ears, nose, dry mucous membranes) follow up with MD and preventative measures. CR#1 had potential for impaired gas exchange, CHF, shortness of breath, tracheostomy status, vent dependent. Goal: CR#1's respiratory function will WNL as evidence by: normal rate, rhythm and depth of respirations, no dyspnea and oxygen states WNL. Interventions: Monitor for signs and symptoms of shallow rapid respirations, diminished or absent breath sounds, hypoxia, elevate head of bed. All interventions were to be done by LVN or RN and assess and report signs and symptoms of impaired respiratory functions were assigned to nursing department. Record review of CR#1's nursing progress notes for [DATE] revealed the following: Effective date: [DATE] at 6:48 a.m. Note Text: Author: LVN A - Writer assessed and monitor resident q2 hour and prn, no distress noted, writer checked on about 0500, feeding is running good, around 05:15, two assigned staff changed resident on the last round, pt was ok per staff members. Around 0530, RT went to the room and came back and called this writer to resident's room, Writer asked to call 911 because resident was in distress. EMS team called by this writer at 0537 am. Writer was able to palpate residents' pulse and CPR was started, AED was used and 911 arrived at 0540 and took over. Resident was pronounced at 06:14am. Effective Date: [DATE] at 7:30 a.m. Note Text: Author: LVN A -Writer called emergency contact FM and notified her that resident in distress, CPR was initiated, and EMS was called, and resident was pronounced death. Will notify MD. Record review of physician order summary revealed the following orders: [DATE]- Trach care as needed. [DATE]- Tracheal suction every 4 hours and as needed. [DATE]- Change Shiley 4 inner cannula as needed. [DATE]- Enteral feedings every shift. [DATE]- Change bedside respiratory Therapy supplies; neb kit, oxygen tubing, suction set-up with tubing, canister, oral yank [NAME], oxygen concentrator air filter, in-line suction ballad, HME filters, corrugated tubing, bacterial filters. [DATE]- Trach cuff pressure checks every shift and as needed [DATE] AC 16, 350, +5, 5L every shift Record review of EMS incident report for CR#1 revealed they were called to the facility on [DATE] at 5:37 a.m. for CR#1 in cardiac arrest and arrived at the facility at 5:47 a.m CR#1 was observed to be lying in a bed unresponsive and severely swollen. Patient was pulseless and apneic. Nursing staff was forcibly bagging the patient and no compressions were being performed at this time. The nurse was adamant that the patient had a pulse and that the bagging was difficult but effective. Patient pulses were checked and absent. CPR was started at this time. Manual compressions were continued throughout the CPR. Patient's trach tube was confirmed to not be in a correct position (or false pathway) and was not oxygenating the patient. Patient facial anatomy due to swelling was too distorted to control her airway by any other means. CR#1 had severe subcutaneous emphysema and skin was cold. CR#1 had swelling to the face, neck, chest and her whole arms (both left and right). Trach tube was removed and a [NAME] bag was used to locate her tracheotomy. An ET tube was placed, and CPR continued. The nurse stated that CR#1 was alert just 8 minutes before the 911 call. EPI was administered per guidelines. Patient was moved to the floor to facilitate higher quality CPR. CPR was continued per department guidelines. It was noted that CR#1 was in asystole and remained in asystole condition (where the heart stops beating due to complete failure of the heart's electrical system) for the duration of the call. EMS called medical doctor C via phone for an order to terminate CPR efforts after 20 minutes. Medical doctor C agreed, and ultrasound was utilized to confirm no heart wall movement but due to emphysema there was no view of the heart. CPR was discontinued. The scene was turned over to local police department. An in-field pronouncement was done. CR#1 was determined expired at 6:13a.m. Record review of handwritten and signed statement submitted to the Administrator by LVN A on [DATE], she wrote Respiratory Therapist A called her to CR#1's room around 5:25am. CR#1 was unresponsive with palpable pulse. LVN A activated 911 call at 5:37am and EMS arrived at 5:40am. CR#1 was pronounced death at 6:14am. Record review of CR#1's ADL record dated [DATE] revealed CNAs were responsible for incontinent care. The record shows that CR#1 had her briefs changed: [DATE]- 00:57 (12:57am) 17:59 (5:59pm) 23:57 (11:57pm) There was no documentation that CNAs entered CR#1's room for incontinent care since just before midnight. CR#1's incident occurred on [DATE] at or about 5:25am. Record review of the facility's CMS form 672 revealed there were 7 residents had a tracheostomy out of 24 residents. Record review of tracheostomy competency revealed RT Director skills were checked off by RT A on [DATE]. RT Director became employed at the facility on [DATE]. Record review of RT A employment record revealed she became employed at the facility on [DATE] and all her competencies were checked by RT Director. An interview with the DON on [DATE] at 10:29am, she said she had been employed here since [DATE]st, 2024. She stated LVN A called her and said RT yelled for her to come to CR#1's room after finding her unresponsive. She said CR#1 was in respiratory distress when RT A discovered the circuit had become dislodged. CR#1 was on a mechanical ventilator and G-tube. She said CR#1 was admitted with chronic conditions. She said CR#1 was diabetic and had hypertension and heart condition. Investigator asked what could have caused her respiratory distress, she said she was told by LVN A that the circuit was dislodged and, on the floor, but CR#1 had co-morbidities that could have caused her distress. She said LVN A said when she was solicited to the room, the resident had agonal breathing and she was not sure why RT A was trying to get supplies to intubate the resident. When asked how the staff knew CR#1 was full code she said staff are aware of how to find whether patients are full code or DNR. She said it was in PCC on under CR#1's profile and it is also on the crash cart. CR#1 was pronounced deceased at the facility by EMS. Her expectation is for staff to immediately provide emergency care for all residents. She said trach care is the responsibility of the RT's. However, she expects CNAs and all other staff to let someone know if they hear the alarm sounding. In a telephone interview on [DATE] at 12:46pm, FM #1 stated she was called early in the morning around 7:15am on [DATE]. She said she was told staff discovered CR#1 was not breathing and that they could not revive her. She said the DON stated CR#1 was not breathing and went into cardiac arrest. She said she immediately called FM#2 as she was the RP. She said when she arrived EMS and the police was there. She said the facility did not call them immediately when she was in distress, and she wish they would have called her and FM#2 after calling EMS. She said CR#1 was not capable of turning her head. She was basically comatose. She said staff had to do everything for her. She said this was heartbreaking. In a telephone interview with FM #2 on [DATE] at 1:01p.m. she stated she had a missed call from the facility at 7:14am, due to her phone being on silent. She said FM#1 notified her on the morning of CR#1's death. She said CR#1 had only been at the facility since [DATE]. She said she came from a local L-TAC. She said she arrived at the facility by 8am and they were cleaning her and preparing her for the medical examiner she believed. She said the police had arrived. She said she was not called when CR#1 had a change in condition, she said staff said it was because when they found her, she was not breathing. She was in cardiac arrest. She asked if we could speak later, she was distraught. She said she just did not understand why they could not save her. The call ended. In an interview on [DATE] at 3:19 p.m., LVN A revealed she worked the 6p-6am shift and had been employed with the facility since [DATE]. She said she did rounds at or about 8pm on [DATE] and provided G-tube medications for CR#1. She said CR#1 did not have any medications after 8pm. She said at that time, CR#1's ventilator alarm was not beeping. She said she saw RT A go into CR#1's room and figured she was doing rounds. She said she went to assist another resident down the hall. Then, she heard Respiratory Therapist A (RT) yelling for her to come to CR#1's room to be a witness on [DATE] at or about 5:25am. She said RT A did not immediately disclose what she wanted her to witness. She said RT A began to gather trachea supplies but said she did not have another circuit. RT A left out of the room, and this is when she noticed the circuit on the floor near where she was standing. The circuit was not connected to the ventilator. She said RT A was attempting to re-insert CR#1's inner cannula but was unsuccessful. She said she took CR#1's pulse because she was having agonal breathing. She had a palpable pulse. But, no air was coming from the bag. She ran to get the crash cart and began giving her air. She said she used the AED. She said she called 911 from her cell phone at 5:37am and she and RT A began CPR. She said a backboard was placed behind her back as they provided CPR with CR#1 in bed. She said EMS arrived and took over CPR. CR#1 expired while they were performing CPR. She stated she was the only nurse on the shift, and there were two CNAs and RT A. She said there is usually only (1) nurse on the overnight shift. She said she was not responsible for suctioning CR#1. She said RT's have 12-hour shifts and are there around the clock. She said RTs are responsible for suctioning and all related trach care. She said she was CPR certified. She said she was not sure how long the ventilator was alarming. An interview with CNA A on [DATE] at 4:22 p.m. revealed he and CNA B changed CR#1's brief at approximately 5am. Then, they changed her roommates' brief. He stated CR#1 was not gasping for air nor was her ventilator alarming. He said CR#1 eyes were opened. She was not in respiratory distress while they were in her room. He stated he heard yelling when he was going to put trash out and LVN A said they needed the crash cart. He stated he went to get the crash cart for her and when he came back EMS was there. An interview with RT Director on [DATE] at 11:39 a.m., she stated she normally work 12-hour shift from 7a-7pm three times per week. She said RT A worked the overnight shift. She stated CR#1 was a vent, and trach dependent patient. She said tubing was to be changed every 7 days and prn. Vent circuit every 30 days and PRN. She stated as RT A's supervisor she did not notify her of the situation. She learned about it the next day or later that day she could not recall. RT A told her the following: RT A said she was in the room with patient two or three doors down from CR#1 when she heard the vent alarm go off. She said she went in the room and said the vent circuit was on the floor and her trach was dislodged. RT A could see the balloon. RT A said she tried to push the trach back in but patient was in respiratory distress with agonal breathing. She said she had verbally reprimanded RT A twice concerning the trach tie being too loose. She said you should only be able to stick two fingers under the tie. She said when she worked behind RT A she found loose ties. She said she told her the ties were so loose she could stick her whole hand underneath. She did not have documentation of these incidents. She stated she trained the RT's how to look for signs and symptoms of respiratory distress but had a couple of RTs she would immediate train once they came in for their shift. An interview with Respiratory Therapist A (RT A) on [DATE] at 12:59 p.m stated she had been employed at the facility since [DATE]. She normally worked the 6p-6a shift. She said there is a RT in the facility 24-hours a day. She stated on the early morning of [DATE], She said at or about 4:37am she provided trach care and brushed CR#1's teeth and then did the same for her roommate. She said then she proceeded to provide trach care for a resident two doors down from CR#1's room. She said she thought she heard a vent alarming when she turned the suctioning machine off. She said she heard the vent alarm coming from CR#1's room. She said she did not see the nurse at the nursing station and finished the care for the resident. She said about 3 minutes she finished and went to CR#1's room which was at the time in approximately 3 minutes. Then, she entered CR#1's room at approximately 5:20am. She added that before she returned to the CR#1 room for the alarming vent she saw the CNAs coming from the room after she left CR#1's room. She said she discovered the vent circuit was on the floor but still attached. She said she noticed CR#1's trach was out, so she pushed it back in and it was still attached to the trach tie. She said she took off the vent and started bagging her to give her deeper breaths because she was having agonal breathing. She said she called in the LVN A to come to witness because the resident had an extra airway on the wall. She said she tried to inflate air into her cuff and continue to bag her, but it still was not inflating. She tried to inflate again but the cuff would not stay. She said that is when she realized the cuff was blown. She said they took the one off the wall, put it in her, inflated it and begin to bag her again. Her rate was 12 she kept it there while she was bagging her the rate on the machine was 16. She said she knew CR#1 was going into cardiac arrest when she found her. She said she told LVN A to call 911 because she did not have an inner trachea tube and was told she was not allowed to intubate in a SNF. So, there was nothing she could do but put the lateral trach in her that was a size 4. She said so that was done. She said what she and LVN was doing was not helping with the AED, so they started CPR because her pulse was low (she thinks about 40). LVN A checked pulse while she was bagging. CNA A bought in the crash cart while LVN A was doing chest compressions. She said the cardiac board was placed behind her back as she was still in the bed. LVN called 911. She called from her cell phone and kept on speaker while listening to 911 operator. EMS arrived quickly. She said she was unsure about the time they arrived. She said they took the trach out and they intubate her. The local fire department told her she could not intubate at a nursing home. She said she had been licensed as a Registered Therapist for [AGE] years. She said she hold heartedly believe that the CNAs must have caused the circuit to dislodge because they were in the room after her. She denied that the RT Director reprimanded her for loose trach ties. She said she had not been written up or no verbal reprimand from RT Director. In an interview with the Administrator on [DATE] at 5:22 p.m., she said she had been employed at the facility almost 2 weeks. She said she called in the incident because it was an unusual death. When asked why it was considered an unusual death, she said because the circuit was found on the floor, her trach became dislodged, and no one seemed to know what happened. She said she believed while the CNAs were repositioning and changing CR#1 her trach might have been dislodged. She said CNA B clocked out at 5:16 a.m. and CNA A was still there when the incident occurred. She said she spoke to both CNAs, and they stated the ventilator was not alarming after they changed her. She said there was 1 nurse, two CNAs and the RT in the building. She said she would be adding another nurse to work the night shift. She said from her understanding, CR#1 was found unresponsive. RT A and LVN A started CPR when she was unable to get the trach back inserted. She was pronounced deceased at the facility. She said the MD and family had been notified. In an interview on [DATE] at 6:06 p.m., CNA B stated she had been employed at the facility about 1 year. She stated her normal shift is 6p-6a. She said she and CNA B went into CR#1's room right at about 5am, her brief was changed no bed bath. Then, she was repositioned she was left on her right side. Went to her roommate and changed her brief. She said the vent alarm was not beeping. She said if it would have started alarming, they must call the RT or the nurse on duty. Resident eyes were opened. She said the circuit was still attached. She said she did not see RT A go into the room because after they changed CR#1 and her roommate she left. She said CNA A was still there until 6am. She said CR#1 tubing was on the pillow and was not detached. She said the vent machine would alarm if the circuit was dislodged. She said CNAs are responsible for taking vitals when they first start the shift. No vitals the taken when they were in her room changing her. She said CR#1's breathing was normal nothing different. She said CR#1 could not move her head. She is stiff when they turn her everything turned with her. She said someone must lift her head if it needed to be moved. In a subsequent interview with on [DATE] at 6:25 p.m. RT A, she said LVN A was not conducting CPR correctly. She said she had to correct her because she had her fist bald up and her other hand on top. She should have had hand over hand, laced and heel of the hand in the center of the chest when doing compressions. She said she was concerned about her and other nurses being able to conduct CPR adequately. In addition, she said there was no way she could have left the other resident she was with when she heard the alarm. She said a nurse should be available at the nursing station or the facility should have some other means for being able to call staff for help. She said they did not use any radios nor intercom. She said tracheostomy supplies were kept in bins in the RT office. She said she did not have a circuit and that is why she went to the office. She said also staff do not respond to the vent alarms timely. She said they have alarm fatigue. She added CR#1 was getting air underneath her skin from the ventilator every time she bagged her, causing her to swell. She said CR#1 was really trying to breath on her own obviously with a size 4 trach. She said she voiced these concerns with the RT Director. She denied being reprimanded by the RT Director for having trach ties too loose. She denied having an in-service at the facility on [DATE] - [DATE]. She said training consist of signing pre-printed training forms. There was not any hands-on even when she first started working at the facility. She said in fact she trained the RT Director. Record review of payroll sheet provided on [DATE] revealed RT A worked on [DATE], [DATE], and [DATE]. Record review of tracheostomy policy dated [DATE] revealed the purpose of this procedure is to guide tracheostomy care and the cleaning of reusable trach cannulations. Procedure guidelines-Preparation and assessment: check physician orders, explain procedures to resident, wash hands, put gloves, remove oxygen mask for tracheostomy and inspect skin for signs and symptoms of infection, leakage, crepitus or dislodged, and assess resident for distress. An IJ was identified on [DATE] at 5:42 p.m. The IJ template and Plan of removal were provided to the DON and later to the Administrator via email at 5:42pm. The following Plan of Removal was submitted by the facility and was accepted on [DATE] at 11:57 a.m. and indicated the following: F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure that CR#1 who needed respiratory care, including tracheotomy care circuit was attached appropriately causing it to become dislodged resulting in agonal breathing, cardiac arrest and death. Immediate action: Respiratory Therapist Director completed sweep of all Ventilator/Tracheostomy residents to validate Tracheostomies were in place and attached/secured appropriately on [DATE]. No residents identified to have any respiratory distress. Administrator/designee completed a sweep of all residents requiring ventilator and tracheostomy care to validate that tracheostomy supplies were available and set up at all residents bedside on [DATE]. No issues identified. Facilities Plan to ensure compliance quickly: Respiratory Therapy Director completed education with all nursing and respiratory staff on [DATE]. Education conducted by Respiratory Therapy Director included an in-service and competency check, with return demonstration, to cover Tracheostomy Care and placement, and Ventilator Functionality/Processes, this included identifying S/S of respiratory distress and how to respond appropriately when identified. The RT involved in the incident will be termed on [DATE] due to attendance issues and the LVN was educated by the Respiratory Therapy Director. Any New or Interim staff will be educated on procedures and policies on tracheostomy care and equipment availability check off list, prior to working the floor or accepting assignment. Respiratory Therapy Director validated that a procedure is in place on [DATE], to track all tracheostomy and ventilator supplies at resident bedside. Respiratory therapist to track and sign off on the availability of these supplies at the beginning of each shift. Ad Hoc QAPI meeting held with medical director on [DATE] at 1900 (7 p.m.) to review issuance of Immediate jeopardy and Policy and procedures pertaining to Ventilator and Tracheostomy cares. Monitoring of the plan of removal included the following: Record review of education in-service training dated [DATE] revealed the RT Director conducted in-services for and competency check, with return demonstration to cover trach care placement, and Ventilator Functionality/Processes and signs and symptoms of distress with all RT's. Record review of termination notice for RT A dated [DATE] stated she was termed due to failure to report to work as scheduled without notice. Excessive absenteeism or tardiness was unacceptable. Record review of Ad hoc QAPI sign-in sheet for identification of fragmented system dated [DATE] revealed the facility reviewed the facility's need for training and re-education of staff to ensure they were educated on Trach care, ventilator care and CPR. IDT, DON/MDS and Administrator initiated an action plan includes the concern, corrective actions, identification of concerns, systemic changes, monitoring and Physicians. MD participated via telephone, DON, HR, MDS, Admissions Coordinator, BOM and Administrator were in attendance. Record review of in-service of re-education conducted by the RT Director was ,d+[DATE] with LVN A on [DATE] and covered signs and symptoms of respiratory distress. Record review of audit sheet revealed an audit check list of trach supplies to ensure all residents rooms were equipped with all supplies. Observation on [DATE] revealed of code sheets were located on the crash cart located near the nursing station across the hall from the RT office. All residents were listed as either being full code or DNR. Observation on [DATE] of bags hanging on the walls of residents with trachs/vents. Observation on [DATE] of clear containers in the RT office containing vent circuits, trach ties, oxygen tubing, nasal cannulas, cuffs, suction kit, suction tubing, suction machine, back board, C-collar, and gloves. gloves, Interviews ensued on [DATE]-[DATE] with staff on both shifts (6a.m.-6 p.m.) and (6p.m. to 6a.m.) for CNAs and 6 a.m.-6 p.m. for the CNAs including the DON and Administrator, LVN B, LVN D, LVN C- and LVN C agency nurse all on dayshift (6 a.m.-6 p.m.), Respiratory Therapist Director, Respiratory Therapist B, Housekeeping A and Housekeeping Ball from the 6 a.m.-6p.m. shift. LVN A, Respiratory Therapist C to verify in-services and to validate their understanding of the information presented. They were able identify what was neglect and examples, what are some signs and symptoms of respiratory distress, the new code for emergency (CODE BLUE) used. CNAs were able to tell me that they were in-services on calling the nurse when there is an emergency and re-positioning residents with airway. LVN's were able to explain the importance of calling a codes, prompt response to emergencies, and checking the code status either in PCC or the crash cart. An interview with Pulmonology physician on [DATE] at 10:45 a.m., took place after the exit of this facility and re-entry due to another complaint. While investigator was investigating allegations for Resident #8, facility pulmonary doctor revealed him to state CR#1 had a poor prognosis which he had discussed with the family prior to the incident. Investigator asked what would cause CR#1 to swell. He stated she was not getting any oxygen. He said it was his understanding that the trachea came out. He said CR#1 was vent dependent so as soon as ,d+[DATE] seconds she could have become deceased . He said trachs are very difficult to just put back in. He said most physicians have difficulties with tracheostomiesy. The skin around the area creates the problem with pushing it back in. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 3:08 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation interview and record reviews the facility failed to provide pharmaceutical services including procedure that assure accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 (Resident #8) residents reviewed for pharmaceutical services. -Facility failed to implement effective pharmaceutical procedures when RN A incorrectly added an order to Resident #8 to administer 12 units of Lispro insulin subcutaneously every 8 hours. Resident #8 who was not diabetic caused himcaused him to sweat and become lethargic and had to be sent to the emergency room due to hypoglycemia (low blood sugar). -The facility failed to prevent Resident #8 from receiving 48 units of insulin within 24-hours. On 8/8/2024 at 8AM (12 units of insulin) and 4PM (12 units of insulin) were administered by LVN A and on 8/9/2024 RN A administered 12 units of insulin at 8AM and 4PM totaling 24 units each day. -The facility failed to ensure there was a sliding scale order for Resident #8 and was administered 48 units of insulin within 24-hours. This failure could place residents at risk of being given inaccurate amounts of insulin or the wrong medication and placed them at risk for hypoglycemia, hospitalization s and death. An Immediate Jeopardy (IJ) was identified on 8/26/2024 at 5:32 p.m The IJ template was provided to the facility on [DATE] at 5:32pm. While the IJ was removed on 8/27/2024, the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy, because all staff had not been trained on 8/26/2024. Findings Included: Record review of Resident #8's face sheet dated 8/21/2024 revealed he was an [AGE] year-old male that was admitted to the facility on [DATE] with acute and chronic respiratory failure with hypoxia (when the lungs have a difficulty exchanging oxygen and carbon dioxide with the blood), cognitive communication deficit (difficulty with communication that is caused by a cognitive impairment), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), dysphagia (difficulty swallowing) and presence of prosthetic heart valve (a one-way valve that replaces a damaged heart). Record review of Resident #8's MDS dated [DATE] revealed Section C- BIMS Summary was left blank. Section GG0103- Functional Abilities and Goals revealed eating was coded as 88 (which meant not attempted). Oral hygiene, toileting, shower, upper body dressing, lower body dressing, put on and take off footwear were all coded as 03, which meant partial/moderate assistance. Section I-Active diagnoses in last 7 days Metabolic had no X in the boxes for Diabetes Mellitus, hyponatremia, hyperkalemia, or Thyroid disorder. Section N0300- Injections had 0 for record of number of days that injections of any type were received during the last 7 days. Section N0350-Insulin the boxes had no entry which meant he was not currently taking insulin injections nor were there any orders during the last 7 days. Record review revealed no other MDS was available after 6/6/2024. Record review of Resident#8's care plan initiated on 8/12/2024 revealed: It did not have a focus, goal or interventions for Diabetes Mellitus nor was Insulin address for CR#8. Record review of Resident #8's MAR provided on 8/21/2024 revealed: -Insulin Lispro Injection Solution 100 units/ML (Insulin Lispro) Inject 12 units subcutaneously every 8 hours for Diabetes and inject 0-12 under the skin before meals. Start date:8/8/2024 and discontinued on 8/10/2024. Nursing progress notes for August 2024 revealed: -8/8/2024 at 5:53 a.m. RN A documented a verbal order from MD for Resident#8 to receive 12 units of Lispro solution 100 unit/ML (Insulin Lispro) Inject 12 unit subcutaneous every 8 hours for Diabetes inject 0-12 under the skin before meal. -8/9/2024- LVN G documented that Resident#8 was sweating and lethargic. FM voiced concerns. Nurse checked BS it was 24. Administered Glucagon and continue to flush sugar water into Resident #8's g-tube. BS slowly raised to 101. FM #2 was in room. -8/10/2024- Note Text : Spoke with ER Nurse [NAME] regarding resident stated and paperwork, per ER nurse [NAME] who stated that medication list and face sheet was received from 911 crew and requesting to speak with supervisor regarding medication administration from past 2 days. Writer informed ER nurse that the phone number will be given to supervisor. Writer gave report and ER nurses' number to the supervisor. Authored by LVN B -8/10/2024- Note text: Approximately 12:30pm, spoke with NP to get order to discontinued, report also patients' change in condition from PM shift as per nurses' notes. Author e-signed by RN C. Record review of local pharmacy delivery sheet revealed RN A order for Humalog (insulin Lispro) 100 units. Further, the Humalog (insulin Lispro) was electronically signed for by RN A on 8/9/2024 at 9:17AM. Record review of Physician orders for the month of July 2024 revealed: Blood sugar check one time a day for Accucheck. Start date: 7/25/2024 and discontinued 8/5/2024. Record review of documented blood sugar checks revealed: Blood sugars documented between 7/27/2024 and 8/1/2024 revealed: 7/27- 146 7/28- 134 7/29- 120 7/30- 138 7/31- 134 8/1 - 141 8/9 - 24 No blood sugar documentation was available between 8/2-8/8/2024. Blood sugars checked between 6/26/2024-8/9/2024 revealed no blood sugars that were under 97.0 (7/27/2024); except on 8/9/2024 when it was documented as 24.0. Record review of physician order recap report for August 2024 revealed: Fingerstick blood sugar every shift call MD if less than 60 or greater than 400 repeat BS in 15 mins until above 100 or lower than physician stated measure/result two times a day related to dysphasia, unspecified order date 8/11/2024 and start date 8/11/2024. Glucagon Hypoglycemia kit, inject 1 mg PRN for blood sugar less than 60. Ordered by NP on 8/9/2024. Insulin Lispro sliding scale if 151-200= 2 units; 201-250= 4 units; 300 or more =6 units; 301-450 call physician was ordered on 8/10/2024 and discontinued on 8/11/2024 Record review of Resident #8's hospital record dated 8/10/2024 revealed admission nurses' notes: Resident#8 was admitted to the local hospital on 8/10/2024 at 1:37 pm due to a call to local EMS that Resident#8 was unconscious then story changed to AMS. Resident arrived and admitting nurse stated she was told his BS was 24 and staff rushed in to fix. Upon reading Resident#8 information that was sent from the facility. This RN found an order for 12 units of insulin that was discontinued on 8/10/2024. Admitting nurse telephoned the facility for nurse report and medication log. She spoke with LVN B. LVN B told the hospital admitting nurse that Resident#8 had been given 12 units of insulin on 8/8 and 8/9/2024. An interview on 8/22/2024 at 5:06 p.m. revealed FM said someone in his family is at the facility with Resident #8 almost 24 hours a day. He said Resident Resident#8's siblings and mother are always there. He stated on 8on 8/9/2024 he was in Resident #8's room when RN A came in and said she had to provide him with insulin. He said he questioned why Resident #8 needed insulin. RN A told him that the doctor called it in for his dysphagia. He said he moved the opening of his gown and RN A gave him a shot of insulin in his stomach about 4:00 p.m. or so. He said Resident # 8 seemed to be different after the insulin shot. He said on 8/9/2024 he thinks on or about midnight when he was supposed to get another dosage of insulin, he called LVN G because Resident #8 was sweating and lethargic. She took his blood sugar and said it was 24 so she held the insulin. He said LVN G called someone and came back and gave him something to bring his BS up. down. He said this was perhaps after midnight or early morning of 8/10/2024. He said after the nurse assured him that the blood sugar was better, he said he was not convinced because Resident #8 still was not himself. He said he was still lethargic after a few hours, so, he requested for Resident #8 to be sent to the local hospital. He said he was very concerned and spoke with the DON about his concerns. He said she was hesitant to provide him with Resident #8's medication log and even asked, why did he need it. He said he wanted to see what they had documented as the reason for the insulin. He said his family had never been told he was diabetic. He said he had dysphagia, but never heard of treating dysphagia with insulin. An interview with LVN E on 8/21/2024 at 1:03 p.m., revealed him to state he had been employed at the facility for 1 1/2 years. He stated today the DON asked him if he had provided insulin for Resident #8. He stated he did not give Resident #8 insulin. He said he saw it on the MAR but did not administer 24 units of insulin to Resident #8. He stated that he had a lot going on with different residents so he might have placed a check by the insulin but did not give it. He stated only nurses can take a verbal order over the phone and it is then entered into PCC. He stated he did not take a verbal order for insulin. He said that he had in the past taken verbal orders but not for Resident #8. He stated he questioned the insulin medication because he did not know he was diabetic or what it was being used for. He said it was several weeks ago so he thinks he brought it to the DONs attention if he was not mistaken. He said the DON called him about it on 8/11/2024 he can recall asking him to write a statement. He said he completed a statement on 8/16/2024 and told her he did not give insulin. In an interview with the DON on 8/23/2024 at 12:41 p.m. the DON said LVN E and RN A both denied they administered the medication when she spoke to them over the phone. She said she understood Resident #8 had a change in condition with shortness of breath. She said the weekend supervisor (RN C) was asked whether he had given insulin. RN C reported to her that LVN E and RN A documented that they had given him insulin but she was not sure who ordered it because the doctor said he did not order insulin and especially not 12 units. She stated the following after verifying in her computer: Lispro order entered with sliding scale on 8/11/2024. She said it would be a short acting insulin based on his blood sugar. Diagnosis: She stated he had a g-tube feedings, but no diabetes diagnosis. When he came from the hospital on (8/7) it was in the hospital paperwork for the facility to check his blood sugars and an insulin order for sliding scale insulin. Visit from 8/7 had orders to give insulin. Weekend supervision RN C reached out the doctor over weekend and he said did not order the insulin. She said staff put orders verbal directly into PCC. She said blood sugars were to be check every shift. She said Resident #8's FM told her about the insulin, and she talked to the nurses. Found out the nurses signed that they gave but said both said they did not give it. She said the nursing staff knows that there is a code in the MAR if a medication is not given and checked off by accident. Neither used the code, nor did they solicit another nurse to verify the error. DON and Investigator walked to the nursing station where the DON stated the hospital paperwork could be found. Observation revealed on 8/23/2024 at 1:27 p.m., a clear container with papers placed both horizontally and vertically. The DON started going through this container for Resident #8's paperwork. She stacked papers on the side of the container as she viewed them. Investigator took some of the stack from inside of the container and helped review. The paperwork inside this container was for multiple residents and contained faxed orders, handwritten notes, hospital paperwork for other residents but we were unable to find hospital paperwork for Resident #8. Investigator asked the DON, if Resident #8's blood sugar had ever dropped as low as 24 in the past, is it likely someone gave him insulin despite what they are stating? She said, I guess they both did not tell me the truth. Interview with LVN G on 8/23/2024 at 4:12 p.m., stated she was an agency nurse that had only been to the facility on [DATE]. She said she worked 6a-6pm shift. She said she had not worked at the facility since 8/9/2024. She said LVN B was called into the room when FM had concerns about Resident #8 sweating, lethargic and he bottomed out. She said she spoke with the DON about it and said she was on her way to the facility. She said she gave him sugar water in his G-tube. She said LVN B showed her around and she was the only nurse as LVN B left around 11pm and she was there 6p-6a. She said she documented the incident in PCC. An interview with FM #2 on 8/26/24 at 10:23 a.m., she stated Resident #8 was sent to the ER 8/10/2024 after an overdose of insulin on 8/9/2024. She stated that LVN G seemed surprised that he was supposed to get more insulin dosage and took his blood sugar and said it was too low to give. She said FM #1 saw RN A give the insulin in fact held his gown up so she could give it to him in his stomach. She said the weekend nurse (RN C) told her when she called the hospital had ordered it. She said LVN G said he had been given 12 units of insulin according to PCC. She said LVN G and she was not going to give the 3rd based on his BS being 24. In a telephone interview with the MD on 8/26/2024 at 11:39 a.m., he stated that nobody called him about a verbal order for insulin. He stated there is sometimes a need for insulin for example stress induced hyperglycemia, g-tube and if they have an infection,all of which could it can cause the patient's sugar to increase. Also, steroids would cause sugars to increase. He said a sliding scale order is standard for residents that are on G-tube continuously. He said he spoke with the NP. She told him she learned that Resident#8 had accidentally been given insulin and was lethargic over the weekend of 8/10/2024. He said he had been the MD at the facility a few months and was getting used to the way they do things. He had another call and said he would call back. An interview with RN A on 8/26/2024 at 2:16 p.m., revealed she had been employed at the facility since July 2024. She said she work both morning and overnight shifts it depends on the need of the facility. She said she did not administer insulin to Resident #8. When asked why it was documented as given with her initials in PCC, she said she must have checked it off by accident. She said she had a lot of residents to take care of and just do not remember giving him insulin. She said she recalled the order for 12 units in the system, but thought it was for sliding scale and his blood sugar was low, so she held it and did not give it. She stated she put in the order after reviewing hospital paperwork that had orders for sliding scale insulin. She stated that the facility staff are supposed to verify orders with physician before entry into PCC. She was asked if she spoke with the MD and received a verbal order from him, she said if she documented a verbal order from him then she either spoke to him or his NP. Investigator asked her if any other staff must verify along with nurses when the orders are verbal. She said once they received the order it is verified with the MD then it is entered into PCC, not another nurse. Record review of payroll provided on 8/21/2024 revealed RN A worked: -8/7-8/8/2024 from 6:46 PM to 10:07 AM -8/9/2024- 6:11AM- 7:23PM Record review of verbal orders policy dated February 2014 read in part 1. Verbal orders shall only be given in emergency or when the attening physician is not immediate available to sign the order. 2. Verbal orders will [NAME] be based on verbal ecxchange with the prescribing practitioner or on approved written protocols. 3. Verbal orders are those given by an authorized practitioner directly to a person authorized to receive and transcribe orders on his or her behalf. 4. Text messaging is not an acceptable method of communicatiing. 6. Anyone writing an unauthorized verbal order will be subject to discipliary action. An interview with the Administrator on 8/26/2024 at 4:10 p.m., revealed her to state she was made aware of the insulin situation on or about 8/10/2024 but did not know Resident #8 was not a diabetic, nor could she understand why he would have been given insulin with a Dysphagia diagnosis. She stated the nurses currently input orders directly into PCC. She stated all nurses have their own logins for PCC. She said the only people that can login remotely is the DON and the Regional Nurse. An IJ was identified on 8/26/2024 at 5:32 p.m. The IJ template and plan of removal were provided to the DON and later to the Administrator via email at 5:32pm. The following Plan of Removal submitted by the facility was accepted on 8/27/2024 at 11:32 a.m. Summary of Details which lead to outcomes On 08/26/2024 an abbreviated survey was initiated at Medical Resort Sugarland. A surveyor provided an IJ Template notification that the Survey Agency has determined that the conditions at the center constitute immediate jeopardy to resident health. The notification of the immediate jeopardy states as follows: F755 - Pharmacy Services/Procedures/Pharmacist/Records The facility failed to implement effective pharmaceutical procedures when the facility added an order to Resident #8's medical chart to administer insulin when Resident #8 is not diabetic, causing him to become lethargic and had to be sent to the emergency room for hypoglycemia. Immediate Corrective Action The Corporate Clinical Consultant provided education to the Director of Nursing on 8/26/2023 regarding monitoring new orders received. Director of Nursing/Designee/Weekend Supervisor will print the order listing reporting and check the new orders for accuracy of diagnosis and monitoring in PCC daily. This includes weekends, holidays and afterhours. Any orders entered where the communication method is telephone, or verbal will prompt the user to acknowledge the order was read back to the prescribing practitioner. Without completing this acknowledgement, the order will be saved to the Resident's chart in Pending Confirmation status. As a result, the order will not be sent to pharmacy or available for documentation in eMAR (if applicable). The order will require confirmation by a security permitted user at which time they will be required to acknowledge the order has been read back to the prescribing practitioner. Initiated in-service for all licensed nurses on Practitioner Readback for Telephone and Verbal orders on 8/27/24, ongoing. Nurses will be in-serviced prior to working their next shift. Director of Nursing assessed resident #8 to validate no s/s of hyper/hypoglycemia were noted and no adverse side effects noted related to alleged deficiency. No adverse effects were noted. Assessed on 8/26/24. Director of Nursing completed review of medication orders to validate all insulin orders were entered correctly with proper parameters and dosing per physician orders. All orders for resident #8 had been updated to reflect appropriate parameters and orders per physician. 8/10/24; Physician was notified and reviewed orders on 8/10/24 Initiated in-service for all licensed nurses on accurate transcribing of orders on 8/26/24, ongoing. Nurses will be in-serviced prior to working their next shift, new nursing staff will be in-serviced during their orientation process. The 2 nurses who allegedly administered the insulin have been educated on ensuring parameters are monitor when administering insulin. Identification of Others The Director of Nursing/Designee completed an audit of all residents with orders for insulin, diabetic medication, and any diagnosis of diabetes on 8/26/2024 to validate that orders are in place with blood sugar monitoring in place to reflect parameters per physician. No discrepancies were identified and blood sugar monitoring in place per physician for all residents. Care plans updated as needed. Director of Nursing completed audit on 8/26/24; physician reviewed resident medications 8/26/24, no errors found. Systemic Changes Director of Nursing/Designee initiated education with all licensed nursing staff on 8/26/24 regarding accurately transcribing orders when received and put into PCC. All licensed nurses will be in service prior to their next scheduled shift. Facility used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated. New staff will be in-serviced during orientation period prior to working a shift. Nursing staff will not be permitted to perform direct nursing care until training has been completed. The Corporate Clinical Consultant completed education with Director of Nursing and Administrator on process of reviewing all orders daily in daily clinical meeting through running Order Listing Report in electronic health record system, reviewing all orders with team to validate orders are entered correctly, with proper parameters being monitored, including blood sugars with Insulin administration, diabetic residents monitoring and when to notify physician, initiated on 8/26/2024. Monitoring The Director of Nursing/designee will conduct monitoring of new medication orders daily in daily clinical meeting to validate appropriateness of orders, parameters in place, and directions of when to notify physician. Monitoring will occur, starting on 8/27/2024, 7 days a week for 4 weeks then Monday through Friday ongoing in daily clinical meeting. Weekend Supervisor/designee will validate appropriateness of orders, parameters in place, and directions of when to notify physician ongoing. Any trends identified will be reported to the QAPI Committee monthly and as needed until a lessor frequency until substantial compliance is achieved. Ad Hoc QAPI meeting was held on 8/26/2024 with the Medical Director, Administrator, Director of Nursing, and Nurse Management to review Immediate Jeopardy issued and plan of removal for correction going forward. The Administrator will be responsible for the implementation of ensuring the adequate process regarding Medication Administration. The new processes/system were initiated, and all licensed nursing staff had initiated education on 8/26/2024. All licensed nurses and medication aides were in-serviced. DON/designee used a staff roster meeting with all available staff in person and contacting each PRN and Agency staff member via phone to ensure all required staff were educated, completed on 8/26/2024. Monitoring of the plan of removal included the following: In- services conducted by DON, Regional Nurse were: Accuracy in Transcribing in PCC (8 LVN's and RN's signed) Audit review form with a list of diabetics (all residents on the list were said to not have any adverse effects Monitoring of proper diagnosis Practitioner Readback for telephone or verbal orders. It will place a hold on the order until verified by DON or designee (a tool use to valid orders) Monitoring for new medication orders that had been signed off by the DON that orders were verified, Parameters in place, concerns, if concerns was the doctor notified were in columns and no concerns (9 residents were checked for new orders).Morning meeting notes dated 8/27/2024 listed 8 nursing staff. with all nurses included In-service attendance form for all nursing staff covered putting orders in PCC and when the DON, family and MD should be notified. Interviews with 4 LVN's, and 3 RN's on both morning and overnight shifts were conducted between 8/26-8/29/2024 revealed them to be able to communicate the new system of monitoring new orders, importance of re-verifying orders before placing in PCC and the new Readback feature. The Administrator was informed the Immediate Jeopardy was removed on 8/29/2024 at 1:48 p.m. The facility remained out of compliance at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview, and record review the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel for 1 to 7 residents (CR#1) reviewed for CPR. -RT A and LVN A failed to initiate life-saving measures (CPR) when CR#1 who had a full code (meaning all resuscitation procedures provided if their heart stops beating or stop breathing) immediately when she was found unresponsive and died . -The facility failed to ensure that CR #1 received Cardio-pulmonary resuscitation (CPR) in accordance with professional standards of practice. -The facility failed to immediately initiate CPR when CR#1 was found unresponsive at or about 5:25 a.m. EMS was called at 5:37 a.m. A delay of 12 minutes initiating CPR. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:42 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the severity level at a potential for more than minimal harm that is not immediate jeopardy. These failures placed residents at risk of experiencing worsening of condition, pain and death from possible delays in the initiation of an emergency response and improper implementation of CPR. Findings Included: Record review of facility census dated [DATE] revealed there were 24 residents. Record review of the facility's CMS form 672 revealed there were 7 residents that had a tracheostomy and ventilator out of 24 residents. Record review of CR#1's face sheet dated [DATE] revealed she was an [AGE] year-old female that was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure with hypoxia (a condition where the body has low levels of oxygen in the blood), Type 2 Diabetes Mellitus without complications (a condition in which the body has trouble controlling blood sugar), anoxic brain damage(condition caused by a lack of oxygen which could lead to brain death), pulmonary hypertension A type of high blood pressure that affects arteries in the lungs and in the heart), dependence on ventilator, tracheostomy. CR#1 was designated as full code. Record review of CR#1's MDS dated [DATE] revealed Section B0100- Comatose (Persistent vegetative state/no discernible consciousness was documented as 1-(Yes). Section C500- BIMS summary score was left blank. GG0115- Functional Limitations was coded 2 (which meant impairment on both sides) for both upper and lower extremities which included: shoulder, elbow, wrist, hand and hip knee, ankle and foot. Section GG0120- Mobility devices were coded Z. (none of the above), which meant she did not use a cane, walker, wheelchair, limb prosthesis in the last 7 days. Section GG0130 revealed A. Eating was coded as 88 (not attempted due to medical condition or safety concern) and eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing were coded as 01 (which meant CR#1 was dependent- helper does all of the effort. Section GG0170- Mobility revealed A. Roll left and right was coded as 01- which meant CR#1 was dependent- helper does all of the effort. B. Sit to lying, C. Lying to sitting on side of the bed; D. Sit to stand; E. Chair/bed-to-chair transfer and walk 10 feet were all coded as 88, which meant not attempted due to medical or safety concern. Section H0300- Urinary Incontinence and Bowel incontinence were both coded as 3. Which meant she was always incontinent. Section O. Special treatment, Procedures, and programs performed revealed respiratory treatment (C1) oxygen therapy; (D1) Suctioning and (E1) Tracheostomy care were all coded as B. While a resident. Record review of CR#1's care plan dated [DATE] and revised/cancelled on [DATE] revealed the following care areas: CR#1 required supplemental oxygen for respiratory status hypoxemia, respiratory illness. Goal: Resident will tolerate use of oxygen and oxygen saturations will remain within normal ranges through the next review and interventions were: Monitor for complications r/t oxygen use (ears, nose, dry mucous membranes) follow up with MD and preventative measures. CR#1 had potential for impaired gas exchange, CHF, shortness of breath, tracheostomy status, vent dependent. Goal: CR#1's respiratory function will WNL as evidence by: normal rate, rhythm and depth of respirations, no dyspnea and oxygen states WNL. Interventions: Monitor for signs and symptoms of shallow rapid respirations, diminished or absent breath sounds, hypoxia, elevate head of bed. All interventions were to be done by LVN or RN and assess and report signs and symptoms of impaired respiratory functions were assigned to nursing department. CR#1 had an advanced directive evidence by: Full Code. Goals included: CR#1's wishes would be honored. Interventions: CPR will be performed as ordered, follow facility protocol for identification of code status and keep family informed of change in condition. Record review of CR#1's nursing progress notes for [DATE] revealed the following: Effective date: [DATE] at 6:48 a.m. Note Text: Author: LVN A - Writer assessed and monitor resident q 2 hour and prn , no distress noted, writer checked on about 0500, feeding is running well, around 05:15, two assigned staff changed resident on the last round, pt was ok per staff members. Around 0530, RT went to the room and came back and called this writer to resident's room, Writer asked to call 911 because resident was in distress. EMS team called by this writer at 0537 am. Writer was able to palpate residents' pulse and CPR was started, AED was used and 911 arrived at 0540 and took over. Resident was pronounced at 06:14am. Effective Date: [DATE] at 7:30 a.m. Note Text: Author: LVN A -Writer called emergency contact FM and notified her that resident in distress, CPR was initiated, and EMS was called, and resident was pronounced death. Will notify MD. Record review of EMS incident report for CR#1 revealed they were called to the facility on [DATE] at 5:37 a.m. for CR#1 in cardiac arrest and arrived at the facility at 5:47 a.m. CR#1 was observed to be lying in a bed unresponsive and severely swollen. Patient was pulseless and apneic. Nursing staff was forcibly bagging the patient and no compressions were being performed at this time. The nurse was adamant that the patient had a pulse and that the bagging was difficult but effective. Patient pulses were checked and absent. CPR was started at this time. Manual compressions were continued throughout the CPR. Patient's trach tube was confirmed to not be in a correct position (or false pathway) and was not oxygenating the patient. Patient facial anatomy due to swelling was too distorted to control her airway by any other means. CR#1 had severe subcutaneous emphysema and skin was cold. CR#1 had swelling to the face, neck, chest and her whole arms (both left and right). Trach tube was removed and a [NAME] bag was used to locate her tracheotomy. An ET tube was placed, and CPR continued. The nurse stated that CR#1 was alert just 8 minutes before the 911 call. EPI was administered per guidelines. Patient was moved to the floor to facilitate higher quality CPR. CPR was continued per department guidelines. It was noted that CR#1 was in asystole and remained in asystole for the duration of the call. EMS called medical doctor C via phone for an order to terminate CPR efforts after 20 minutes. Medical doctor C agreed, and ultrasound was utilized to confirm no heart wall movement but due to emphysema there was no view of the heart. CPR was discontinued. The scene was turned over to local police department. An in-field pronouncement was done. CR#1 was determined expired at 6:13 a.m. Record review of handwritten statement submitted to the Administrator by LVN A on [DATE], she wrote Respiratory Therapist A called her to CR#1's room around 5:25 a.m. CR#1 was unresponsive with palpable pulse. LVN A activated 911 call at 5:37 a.m. and EMS arrived at 5:40 a.m. CR#1 was pronounced deceased at 6:14 a.m. Record review of CR#1's ADL record dated [DATE] revealed CNAs were responsible for incontinent care. The record shows that CR#1 had her brief changed: [DATE]- 00:57 (12:57am) 17:59 (5:59pm) 23:57 (11:57pm). There was no documentation that CNAs entered CR#1's room for incontinent care since before midnight. CR#1's incident occurred on [DATE] at or about 5:25 a.m. An interview with the DON on [DATE] at 10:29 a.m., she said she had been employed at the facility since [DATE]st, 2024. She stated LVN A called her on ([DATE]) and said RT yelled for her to come to CR#1's room after finding her unresponsive. She said CR#1 was in respiratory distress when RT A discovered the circuit had become dislodged. She said CR#1 was a full code so both LVN A and RT A knew to immediate start CPR. CR#1 was on a mechanical ventilator and G-tube. She said she was admitted with chronic conditions. She said CR#1 was diabetic and had hypertension and heart condition. Investigator asked what could have caused her respiratory distress, she said she was told by LVN A that the circuit was dislodged and, on the floor, but CR#1 had co-morbidities that could have caused her distress. She said LVN A said when she was solicited to the room, the resident had agonal breathing and she was not sure why RT A was trying to get supplies to intubate the resident. She said LVN A told her she could not intubate in a SNF. When asked how the staff knew CR#1 was full code she said staff are aware of how to find whether patients are full code or DNR. She said it was in PCC under CR#1's profile and it is also on the crash cart. CR#1 was pronounced deceased at the facility by EMS. In a telephone interview on [DATE] at 12:46pm, FM #1 states she was called early in the morning around 7:15am on [DATE]. She said she was told staff discovered CR#1 was not breathing and that they could not revive her. She said the DON stated CR#1 was not breathing and went into cardiac arrest. She said she immediately called FM#2 as she was the RP. She said when she arrived EMS and the police were there. She said the facility did not call them immediately when she was in distress, and she wish they would have called her and FM#2 after calling EMS. She said CR#1 was not capable of turning her head. She was comatose. She said staff had to do everything for her. She said this was heartbreaking. In a telephone interview with FM #2 on [DATE] at 1:01p.m. she stated she had a missed call from the facility at 7:14am, due to her phone being on silent. She said FM#1 notified her on the morning of CR#1's death. She said CR#1 had only been at the facility since [DATE]. She said she came from a local L-TAC. She said she arrived at the facility by 8am and they were cleaning her and preparing her for the medical examiner she believed. She said the police had arrived. She said she was not called when CR#1 had a change in condition, she said staff said it was because when they found her, she was not breathing. She was in cardiac arrest. She asked if we could speak later, she was distraught. She said she just did not understand why they could not save her. The call ended. In an interview on [DATE] at 3:19 p.m. LVN A revealed she worked the 6p-6am shift and had been employed with the facility since [DATE]. She said she did rounds at or about 8pm on [DATE] and provided G-tube medications for CR#1. She said CR#1 did not have any medications after 8pm. She said at that time, CR#1's ventilator alarm was not beeping. She said she saw RT A go into CR#1's room and figured she was doing rounds. She said she went to assist another resident down the hall. Then, she heard Respiratory Therapist A (RT) yelling for her to come to CR#1's room to be a witness on [DATE] at or about 5:25am. She said RT A did not immediately disclose what she wanted her to witness. She said RT A began to gather trachea supplies but said she did not have another circuit. RT A left out of the room, and this is when she noticed the circuit on the floor near where she was standing. The circuit was not connected to the ventilator. She said RT A was attempting to re-insert CR#1's inner cannula but was unsuccessful. She said she took CR#1's pulse because she was having agonal breathing. She had a palpable pulse. But, no air was coming from the bag. She ran to get the crash cart and began giving her air. She said she used the AED. She said she called 911 from her cell phone at 5:37am and she and RT A began CPR. She said a backboard was placed behind her back as they provided CPR with CR#1 in bed. She said EMS arrived and took over CPR. CR#1 expired while they were performing CPR. She stated she was the only nurse on the shift, and there were two CNAs and RT A. She said there is usually only (1) nurse on the overnight shift. She said she was not responsible for suctioning CR#1. She said RT's have 12-hour shifts and are there around the clock. She said RT's are responsible for suctioning and all related trach care. She said she was CPR certified. She said she was not sure how long the ventilator was alarming. An interview with CNA A on [DATE] at 4:22 p.m., revealed he and can B changed CR#1's brief at approximately 5:00 a.m. Then, they changed her roommates' brief. He stated CR#1 was not gasping for air nor was her ventilator alarming. He said CR#1 eyes were opened. She was not in respiratory distress while they were in her room. He stated he heard yelling when he was going to put trash out and LVN A said they needed the crash cart. He stated he went to get the crash cart for her and when he came back EMS was already there. An interview with RT A on [DATE] at 12:59 p.m., stated she had been employed at the facility since [DATE]. She normally worked the 6p-6a shift. She said there is a RT in the facility 24-hours a day. She stated on the early morning of [DATE], She said at or about 4:37 a.m. she provided trach care and brushed CR#1's teeth and then did the same for her roommate. She said then she proceeded to provide trach care for a resident two doors down from CR#1's room. She said she thought she heard a vent alarming when she turned the suctioning machine off. She said she heard the vent alarm coming from CR#1's room. She said she did not see the nurse at the nursing station and finished the care for the resident. She said about 3 minutes she finished and went to CR#1's room which was at the time in approximately 3 minutes. Then, she entered CR#1's room at approximately 5:20 a.m. She added that before she returned to the CR#1 room for the alarming vent she saw the CNAs coming from the room after she left CR#1's room. She said she discovered the vent circuit was on the floor but still attached. She said she noticed CR#1's trach was out, so she pushed it back in and it was still attached to the trach tie. She said she took off the vent and started bagging her to give her deeper breaths because she was having agonal breathing. She said she called in LVN A to come to witness because the resident had an extra airway on the wall. She said she tried to inflate air into her cuff and continue to bag her but it still was not inflating. She tried to inflate again but the cuff would not stay. She said she knew the cuff was blown. She said they took the one off the wall, put it in her, inflated it and begin the bag her again. Her rate was 12 she kept it there while she was bagging her the rate on the machine was 16. She said she knew CR#1 was going into cardiac arrest when she found her. She said she told LVN A to call 911 because she did not have an inner trachea tube and was told she was not allowed to intubate in a SNF. So, there was nothing she could do but put the lateral trach in her that was a size 4. She said that is what she did. She said what they were doing was not helping with the AED, so they started CPR because her pulse was low. LVN A checked pulse while she was bagging. CNA A got the crash cart while LVN A was doing chest compressions. She said the cardiac board was placed behind her back as she was still in the bed. LVN A called 911. She called from her cell phone and kept on speaker while listening to 911 operator. EMS arrived quickly. She was unsure about the time they arrived. She said they took the trach out and they intubated her. Fire department told her she could not she could not intubate at a nursing home. In an interview with the Administrator on [DATE] at 5:22 p.m., she said she had been employed at the facility almost 2 weeks. She said she called in the incident because it was an unusual death. When asked why it was considered an unusual death, she said because the circuit was found on the floor, her trach became dislodged, and [NAME] seemed to know what happened. She said she believed while the CNAs were repositioning and changing CR#1's brief her trach might have come dislodged. She said CNA B clocked out at 5:16 a.m. and CNA A was still there when the incident occurred. She said she spoke to both CNAs, and they stated the ventilator was not alarming after they changed her. She said all nurses were CPR certified. She said at the time, there was 1 nurse, two CNAs and the RT in the building. She said she would be adding another nurse to work the night shift. She said from her understanding, CR#1 was found unresponsive, and RT A took some time to try to get the trach in and they started CPR when she was unable to get the trach back inserted. EMS arrived quickly and took over CPR. She was pronounced deceased at the facility. She said the MD and family had been notified. In an interview on [DATE] at 6:06 p.m., CNA B stated she had been employed at the facility about 1 year. She stated her normal shift is 6p-6a. She said she and CNA B went into CR#1's room right at about 5:00 a.m., her brief was changed no bed bath. Then, she was repositioned she was left on her right side. Went to her roommate and changed her brief. She said the vent alarm was not beeping. She said if it would have started alarming, they have to call the RT or the nurse on duty. Resident eyes were opened. She said the circuit was still attached. She said she did not see RT A go into the room because after they changed CR#1 and her roommate she left. She said CNA A was still there until 6am. She said CR#1's tubing was on the pillow and was not detached. She said the vent machine would alarm if the circuit was dislodged. She said CNAs are responsible for taking vitals when they first start the shift. No vitals the taken when they were in her room changing her. She said CR#1's breathing was normal nothing different. She said CR#1 could not move her head. She is stiff when they turn her everything turned with her. She said someone must lift her head if it needed to be moved. Record review of LVN A's certification card revealed she had taken CPR on ,d+[DATE] and was valid until ,d+[DATE]. It was an e-card that she printed from a website. Record review of RT A's CPR certification card revealed it was not legible. The date and where it was taken was hazy. No other copy was available. In a subsequent interview with RT A on [DATE] at 6:35pm, she said LVN A was not conducting CPR correctly. She said she had to correct her because she had her fist bald up and her other hand on top. She should have had hand over hand, laced and heel of the hand in the center of the chest when doing compressions. She said she was concerned about LVN A and other nurses being able to conduct CPR effectively. In addition, she said there was no way she could have left the resident in the other room because she was suctioning her when she heard the alarm. She said a nurse should be available at the nursing station or the facility should have some other means for being able to call staff for help in an emergency. She said the facility staff did not use any radios nor intercom. She said tracheostomy supplies were kept in bins in the RT office. She said she did not have a circuit and that is why she went to the office. All supplies should have been kept in the residents' room. She said also staff do not respond to the vent alarms timely. She added CR#1 was getting air underneath her skin from the ventilator every time she bagged her, causing her to swell. She said CR#1 was really trying to breath on her own obviously with a size 4 trach. She said she voiced these concerns with the RT Director. Record review of cardio-pulmonary resuscitation policy dated ,d+[DATE] revealed: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines: 1. Sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms (arrhythmias). Cardiac arrest occurs soon after symptoms appear. 5. Early delivery of a shock with a defibrillator plus CPR within ,d+[DATE] minutes of collapse csn further increase chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS shall initiate CPR. Preparation for cardio-pulmonary resuscitation: Obtain and maintain American Red Cross or American heart Association certification in Basic Life Support (BLS)/Cardiopulmonary (CPR) for key clinical staff members who will direct resuscitative efforts including non-licensed personnel. 3. Provide mock codes (simulations of an actual cardiac arrest) for training purposes. 4. Select and identify a CPR team for each shift in the case of an actual cardia arrest. Record review of in-services provided on [DATE]: [DATE]- Resident transfer and oral care [DATE]- Elopement [DATE]- Abuse and neglect (staff signed ,d+[DATE]-,d+[DATE]) [DATE]-ongoing Enhanced Barrier Precaution [DATE]-ongoing-Turning/Providing Care for vent residents (no sign in sheet was provided) An IJ was identified on [DATE] at 5:42 p.m. The IJ template was provided to the DON and later to the Administrator via email at 5:42 p.m. Record review of the facility's emergency Procedure- Cardiopulmonary Resuscitation stated in part: . personnel have completed training on the initiation of cardio-pulmonary (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. General Guidelines: 1. 5. Early delivery of a shock with defibrillator plus CPR within ,d+[DATE] minutes of collapse can further increase chances of survival. 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally a licensed staff member who is certified in CPR/BLS shall initiate CPR Preparation for cardio-pulmonary resuscitation: 1. Obtain and maintain American Red Cross or American heart Association certification in Basic Life Support (BLS)/Cardiopulmonary (CPR) for key clinical staff members who will direct resuscitative efforts including non-licensed personnel. 3. Provide mock codes (simulations of an actual cardiac arrest) for training purposes. 4. Select and identify a CPR team for each shift in the case of an actual cardia arrest. Record review of DON job description: Summary: The primary purpose of the position is to ensure the highest quality of resident care available, support staff and establish a positive reputation in the community while delivering on the company values of wellness, compassion, customer experience. DON will plan, organize, develop, and direct the overall operation of the nursing services department. Record review of an article on Web MD website, titled What to know about agonal breathing that was medically reviewed by [NAME] MD on [DATE]. The article stated agonal breathing is when someone who is not getting enough oxygen is gasping for air. It is usually due to cardiac arrest or stroke. It is not true breathing. It is a natural reflex that happens when your brain is not getting the oxygen it needs to survive. Agonal breathing is a sign that a person is near death. People who have agonal breathing and are given cardiopulmonary resuscitation (CPR) are more likely to survive cardiac arrest than people without agonal breathing. The following Plan of Removal submitted by the facility was accepted on [DATE] at 11:57 a.m. The Immediate Jeopardy findings were identified in the following areas: F678 Cardio-Pulmonary Resuscitation: The facility failed to ensure that a resident received Cardio-Pulmonary Resuscitation (CPR) in accordance with professional standards of practice. The facility failed to immediately initiate CPR at or about 5:20am when CR #1 was found unresponsive. Immediate action: The facility identified residents who require Cardio-Pulmonary Resuscitation [DATE]. Facility did an audit of residents with an active Do Not Resuscitate order on [DATE]. Facility ensured a book to identify residents who are a Do Not Resuscitate was accurate and up to date [DATE]. DON/Designee will update book with new admission or change in code status as indicated. On [DATE], Administrator/DON in-serviced staff on how to locate the code status of residents in the event of an emergency code situation. Nursing Staff were trained to call CODE Blue so they can remain with the residents. The staff that stays with the residents notifies other staff members to grab the code status book and crash cart if Resident is found to not have a DNR, then CPR certified staff will initiate CPR. Staff members that have not been in-serviced will not be allowed to work their shift until they are in-serviced. On [DATE], the facility Administrator and DON began to gather the CPR certifications of staff to ensure that every shift has a CPR team per revised policy. This was completed on [DATE]. The CPR policy was evaluated by corporate chief nursing officer and amended on [DATE], to state that the CPR team will comprise of the nurse on shift and the respiratory therapist and CNAs to assist as able. Policy amendment reviewed with Ad Hoc QAPI team on [DATE]. Facilities Plan to ensure compliance quickly: Director of Nursing/Designee completed education with all nursing and respiratory staff on [DATE]. Education included RT Director started an in-service/competency with return demonstration under CPR and Trach Care and Ventilator Functionality/Process, included S/S of respiratory distress and appropriate initiation of CPR. The RT was termed on [DATE] due to attendance issues and the LVN was reeducated by the RT Director. DON/Designee will update book with new admission or change in code status as indicated. New staff will be educated in the process of identifying the code status of residents. All new staff will be trained on these policies prior to working the floor. Ad Hoc QAPI meeting held with medical director on [DATE] at 1900 (7p.m.) to review issuance of Immediate jeopardy and Policy and procedures pertaining to Cardio-Pulmonary Resuscitation. Monitoring of the plan of removal included the following: Record review of education in-service training dated [DATE] revealed the RT Director conducted in-services for and competency check, with return demonstration to cover trach care placement, and Ventilator Functionality/Processes and signs and symptoms of distress. Record review of termination notice for RT A dated [DATE] stated she was termed due to failure to report to work as scheduled without notice. Excessive absenteeism or tardiness was unacceptable. Record review of Ad hoc QAPI sign-in sheet for identification of fragmented system dated [DATE] revealed the facility reviewed the facility's need for training and re-education of staff to ensure they were educated on Trach care, ventilator care and CPR. IDT, DON/MDS and Administrator initiated an action plan includes the concern, corrective actions, identification of concerns, systemic changes, monitoring and Physicians. MD participated via telephone, DON, HR, MDS, Admissions Coordinator, BOM and Administrator were in attendance. Record review of in-service of re-education conducted by the RT Director was ,d+[DATE] with LVN A on [DATE] and covered CPR and signs and symptoms of respiratory distress. Record review of audit sheet of residents that were full code and list that were DNR. Record review of amended CPR policy revealed that the CPR team would consist of a nurse on shift and respiratory therapist and CNAs to assist as able. Record review of Ad Hoc QAPI sign in sheet dated [DATE] revealed: MD participated via telephone, the Administrator, HR, DON and Business Office manager attended in person. Observation on [DATE] revealed the code sheets located on the crash cart dated [DATE] near the nursing station across the hall from the RT office. All residents were listed as either being full code or DNR. Interviews ensued on [DATE]-[DATE] with staff on both shifts (6a.m.-6 p.m.) and (6p.m. to 6a.m.) for CNAs and 6 a.m.-6 p.m. for the CNAs including the DON and Administrator, LVN B, LVN C, and LVN D all on dayshift (6 a.m.-6 p.m.), Respiratory Therapist Director, Respiratory Therapist B, Housekeeping A and Housekeeping B all from the 6 a.m.-6 p.m. shift. LVN A, Respiratory Therapist C to verify in-services and to validate their understanding of the information presented. They were able identify what was neglect and example, what are some signs and symptoms of respiratory distress, the new code for emergency (CODE BLUE) used. CNAs were able to explain they were in-serviced on calling the nurse when there is an emergency and extra caution needed when re-positioning residents. LVN's were able to explain the importance of calling a code, prompt response to emergencies/vent alarms, checking the code status either in PCC or the crash cart to ensure they were able to conduct CPR. The Administrator was informed the Immediate Jeopardy was removed on [DATE] at 3:08 p.m. The facility remained out of compliance with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put in place.

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (Resident #7) reviewed for medications received the appropriate treatment and services to prevent complications of enteral feeding/medication administration including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities. -The nurse failed to verify placement of Resident #7's G-tube prior to administering medications. This failure could place residents at risk for complications from medications not entering the stomach. Findings include: Record review of the Admission Record for Resident #7 revealed a [AGE] year-old-female. She was admitted to the facility on [DATE]. Resident #7 had diagnoses which included, but were not limited to, hydrocephalus (accumulation of cerebrospinal fluid which causes pressure inside the skull), acute and chronic respiratory failure (difficult breathing), dysphagia (inability to swallow), and gastrostomy status (has a G-tube for nutrition). Record review of Resident #7's Care Plan (target date 11/17/23) revealed she had a feeding tube (G-tube) due to dysphagia. One intervention read, in part, .Check for tube placement and gastric contents/residual volume per facility protocol and record. Observation on 08/08/23 at 9:45 a.m. revealed LVN A prepared medications for Resident #7. The medications were dispensed at the medication cart in the hallway. There were 2 liquid medications and 6 tablets. Each tablet was crushed individually and placed in 30-cc medication cups. The medications were taken into the room and placed on the overbed table. LVN A washed her hands and donned gloves. LVN A placed the enteral nutrition pump on 'hold' and drew back the resident's gown to permit access to the G-tube. She then added a small amount of water (approximately 10 cc) each 30-cc cup that contained crushed medications. LVN A used a stethoscope to listen for bowel sounds of each quadrant of Resident #7's abdomen. She did not verify placement of the G-tube by placing the stethoscope on the abdomen and pushing air through the G-tube to listen for air delivery into the stomach. LVN A then used a 60-cc syringe to check for residual by connecting it to the tubing and drawing the plunger back. There was less than 5 cc residual. LVN A then flushed the G-tube with approximately 50 cc of water. LVN A administered Resident #7's medications via the G-tube, alternating between medications and small amounts of water. The medication administration concluded with a flush of approximately 50 cc of water. Interview on 08/09/23 at 2:20 p.m. with LVN A revealed she had not verified placement of the G-tube that morning when administering medications to Resident #7. She said she listened for the four quadrants to hear for gastric contents, but she did not push air through the syringe to check for placement. Interview on 08/09/23 at 2:54 p.m. with the DON revealed the placement of the G-tube with a stethoscope was to be verified prior to administering medications. She said verifying placement was obtained by placing a stethoscope on the abdomen. A 60-cc syringe was then used to push air through the G-tube. The stethoscope was then used to listen for the air to determine the G-tube was in the correct place. She said if the G-tube was not in the correct place, the medications would not work, and the resident could become sick. Record review of the facility policy, Enteral Tubes (2017), read in part: .8. Verify tube placement. a. Unclamp tube and use the following procedures: Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds

Based on interview and record review, the facility failed to conduct a comprehensive and accurate assessment within 14 days after admission for 2 of 4 residents (Resident #1 and #2) reviewed for assessments. -The facility failed to ensure admission MDS Assessments for Residents #1 and #2 were completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings included: Resident#1 Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), morbid (severe) obesity due to excess calories (a chronic disease in which a person has a body mass index (BMI) of 40) and acute kidney failure (is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). Record review of Resident #1's electronic medical record revealed as of 06/26/2023 no Admission assessment MDS had been completed. Further review of Resident #1's electronic medical record revealed an alert in red under the MDS tab, ARD: 3/27/2023 , 91 days overdue. Resident#2 Record review of Resident #2's, undated, face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), anemia (a condition in which the body does not have enough healthy red blood cells) and hypertension (A condition in which the force of the blood against the artery walls is too high). Record review of Resident #2's electronic medical record revealed as of 06/26/2023 no Admission assessment MDS had been completed. In a telephone interview on 06/26/23 at 3:57 p.m., with the MDS Nurse, she said she helped part time at this facility because the facility did not have a full time MDS nurse. She said she reviewed Resident #1 and Resident #2's records today and noticed they were missing the admission MDS assessments. She said the time frame for an admission MDS to be completed was 14 days from admission. She said Resident #1 and Resident #2 were admitted in March 2023. She said in March 2023 the facility had an MDS nurse and that MDS nurse should have completed the assessments. She said, I didn't go back and check the previous MDS nurse's work. Now that it has been brought to my attention, I will look at all the residents MDS. She said not completing an MDS assessment in a timely manner could affect a resident's care plan and receiving services needed . In an interview on 06/26/23 at 4:46p.m., with the VP of clinical operations, she said the DON was on leave and she was the interim. Surveyor asked when the admission MDS was completed and who was responsible for checking the accuracy and submission of MDS. The VP of clinical operations said, this would be a question for the Administrator. I don't know their procedure. I could be wrong. In an interview on 06/26/23 at 4:52p.m., with the Administrator, BOM, and the VP of Clinical operations. when asked how often the MDS assessments were completed and the importance for completing and submitting the assessments timely. The BOM said I don't know. The Administrator said, I don't know when the MDS were submitted. I am not sure what could happen if MDS assessments were not completed in a timely manner. This is a nursing task. The VP of Clinical Operations said the Administrator was not a nurse. The VP of Clinical Operations said, I don't know. Will find out. The Administrator asked this Surveyor, Can you tell us what's the importance of MDS and when its submitted?. The VP of clinical Operations said, we have a MDS nurse we can call her and find out. At this time the Surveyor asked VP of clinical operations if she would like to call the MDS nurse to provide them with clarity. The VP of Clinical Operations said, we will call her later. Go on. Record review of the mds-3.0-rai-manual-v1.17.1_October_2019 revealed in part: .The Admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: -this is the resident' s first time in this facility, OR -the resident has been admitted to this facility and was discharged return not anticipated, OR -the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge .

Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 4 residents (Resident #1 and #2) reviewed for care plan revisions, in that: -Resident #1's comprehensive care plan did not address the resident's code status, allergies, antidepressants, anticoagulant therapy, antihypertensive medications, oxygen therapy, falls, bowel and bladder incontinence, pain, diuretic therapy, yeast infection and ADLs . -Resident #2's comprehensive care plan did not address the resident's code status, antidepressants, antihypertensive medications, and ADLs. These deficient practice could place residents at risk of receiving inappropriate care. Findings included: Resident#1 Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), morbid (severe) obesity due to excess calories (a chronic disease in which a person has a body mass index (BMI) of 40) and acute kidney failure (is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). Record review of Resident#1's Care plan initiated 3/14/2023 revealed the following read in part: .Focus: Alteration in skin integrity. Goal: Wounds will not develop a secondary infection. Target Date: 07/19/2023. Intervention/Tasks: Monitor skin and report red/discolored or broken skin. Notify physician PRN. Skin assessment as per protocol. Treatments as ordered . Further review of care plan did not address resident's code status, allergies, antidepressants, anticoagulant therapy, antihypertensive medications, oxygen therapy, falls, bowel and bladder incontinence, pain, diuretic therapy, yeast infection and ADLs. Record review of Resident#1's consolidated physician orders dated 3/14/23 revealed the following: -Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day related to OTHER PULMONARY EMBOLISM WITHOUT ACUTE CORPULMONALE Monitor for abnormal bruising/bleeding and notify MD/NP if occurs -acetaZOLAMIDE Oral Tablet 250 MG (Acetazolamide) Give 1 tablet by mouth two times a day related to UNSPECIFIED COMBINED SYSTOLIC (CONGESTIVE) AND DIASTOLIC (CONGESTIVE) HEART FAILURE -Amiodarone HCl Oral Tablet 200 MG (Amiodarone HCl)Give 1 tablet by mouth two times a day for Arrhythmias related to UNSPECIFIED COMBINED SYSTOLIC (CONGESTIVE)AND DIASTOLIC (CONGESTIVE) HEART FAILURE HOLD FOR HR <60 -Sertraline HCl Oral Tablet 50 MG (Sertraline HCl) Give 1 tablet by mouth one time a day related to MAJOR DEPRESSIVE DISORDER, RECURRENT,UNSPECIFIED -Vitamin C Oral Tablet 500 MG (Ascorbic Acid) Give 1 tablet by mouth one time a day for wound healing -Zinc Sulfate Oral Tablet 220 (50 Zn) MG (Zinc Sulfate) Give 1 tablet by mouth one time a day for supplement -Potassium Chloride ER Oral Tablet Extended Release 20 MEQ (Potassium Chloride) Give 1 tablet by mouth one time a day for low potassium to be given with lasix -Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 100 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION Hold for SBP<110 or HR <60 -Nystatin Powder (Nystatin (Bulk)) Apply to Groin topically one time a day for yeast infection -Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for Congestive Heart Failure -Flonase Allergy Relief Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal))1 spray in both nostrils at bedtime for Allergy Relief -Famotidine Oral Tablet 20 MG (Famotidine) Give 1 tablet by mouth one time a day for acid reflux -Cetirizine HCl Oral Tablet 10 MG (Cetirizine HCl) Give 1 tablet by mouth one time a day for allergies -02: 3LPM via NC continuous- Monitor 02 Sats q shift. -Apply Bipap every night at bedtime for breathing support and remove per schedule. Resident#2 Record review of Resident #2's, undated, face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included type 2 diabetes mellitus (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), anemia (a condition in which the body does not have enough healthy red blood cells) and hypertension (A condition in which the force of the blood against the artery walls is too high). Record review of Resident #2's Care plan initiated 3/24/2023 revealed Resident was care planned for only one care area, which read in part: .Focus: At risk for cerebrovascular complications. Goal: Will not develop complications. Target Date: 07/19/2023. Interventions: Observe for weakness, headache . Resident #2's care plan did not address code status, antidepressants, antihypertensive medications, or ADLs Record review of Resident#2's consolidated physician orders dated 3/24/23 revealed the following: -Atenolol Oral Tablet 100 MG (Atenolol) Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP <110 AND HR <60 -NIFEdipine ER Oral Tablet Extended Release 24 Hour 60 MG (Nifedipine) Give 1 tablet by mouth one time a day for HTN HOLD FOR SBP <110 -Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth one time a day for GERD -PROzac Oral Capsule 40 MG (Fluoxetine HCl) Give 1 capsule by mouth one time a day for CVA, depression In an interview on 6/26/23 at 11:10a.m., with LVN BB, she said the DON was responsible for updating resident's care plans. She said the DON was not in the facility today. In a telephone interview on 06/26/23 at 3:57 p.m., with the MDS Nurse, she said the care plan was completed within 7 days after the comprehensive MDS assessment was completed. She said care plans were important for informing the team about the resident's needs and how the resident was to be cared for. She said the MDS nurse was responsible for the comprehensive care plans that correlated with the admission MDS assessments. She said she was reviewing the care plans today to ensure all areas were addressed when she realized that Resident #1's didn't really have a care plan. She said Resident#1 had a set of care plans from back in 2019 when the resident was first admitted to the facility. The MDS nurse said, so I re-activated that cancelled care plan today. Resident cannot be in the facility without a care plan. She said the previous MDS Nurse initiated Resident #1 and Resident #2's care plans. But, they were not completed because both residents did not have the admission MDS. She said the MDS triggered certain categories that were incorporated into the Resident's care plan. She said the importance for incorporating the triggers from the MDS was so that they could meet the resident's needs and deliver the appropriate treatment to residents. In an interview on 06/26/23 at 4:52p.m., with the Administrator, BOM, and the VP of Clinical operations, the Administrator was asked who was responsible for updating the care plans. The Administrator said the IDT consisted of the DON, ADON, Director of rehabilitation, MDS nurse, social service, Dietary manager and BOM were involve with care plan . He said, it's done initially. Then, the Receptionist would set up a care plan meeting. The VP of Clinical operations said base line care plan was completed on admission and the comprehensive care plan kicks in day 15. The BOM said the facility did not have a MDS nurse. The new MDS nurse started working 4 to 6 weeks ago. Record review of facility's Care planning-Interdisciplinary Team policy (Revised February 2014) read in part: .Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Policy Interpretation and Implementation: 1. A comprehensive care plan for each resident is developed within seven (7) days of complication of the resident assessment (MDS ) .

Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents (Resident #1) received reasonable accommodation of needs. -The facility failed to ensure Resident #1 had properly fitting bariatric briefs available for incontinent episodes to meet the needs of the resident This failure could place residents at risk of not receiving care or attention needed. Findings Included: Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), morbid (severe) obesity due to excess calories (a chronic disease in which a person has a body mass index (BMI) of 40) and acute kidney failure (is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). Record review of Resident #1's Medicare-5 days MDS assessment dated [DATE] revealed her BIMS score was 15 out of 15, which indicated the resident was cognitively intact. Resident #1 required total dependence from one person physical assist from staff with bed mobility, transfer and toilet use. Further review of Section H0300. Urinary Continence was coded- 3. Always incontinent. H0400. Bowel Continence was coded- 3. Always incontinent . Record review of Resident#1's Care plan initiated 3/14/2023 revealed the following: Focus: Alteration in skin integrity. Goal: Wounds will not develop a secondary infection. Target Date: 07/19/2023. Intervention/Tasks: Monitor skin and report red/discolored or broken skin. Notify physician PRN. Skin assessment as per protocol. Treatments as ordered. Record review of Resident #1's physician order dated 5/23/2023 revealed an order for Nystatin Powder apply to groin topically one time a day for yeast infection. Record review of the email dated 5/17/23 provided by the VP of Clinical Operations between VP of Clinical Operations and Resident#1's family member read in part: . is there a possibility that you could purchase the briefs for [Resident #1] Or any of her personal care items ? This will help ease up some of the financial burden from the facility . Observation and interview on 6/26/23 at 9:12a.m, revealed Resident #1 was observed lying in her bed. She stated, Can you help me get bariatric brief. The facility stopped ordering bariatric brief after they handed me 30-day discharge notice. She stated the facility had asked her family member to provide brief for the resident. She stated the family member sent a box this week, but it was not the correct size. She stated, I don't think it's fair for them to be asking my [family member] to provide briefs for me In an interview on 6/26/23 at 10:24a.m., with CNA A, she stated Resident#1 was a total assist (hands-on activity where the person is incapable of participating in the activity and the provider must perform all services). Resident was incontinent of bowel and bladder. She stated Resident #1 required 3XL brief (white ones). She stated the facility had been out of the 3XL briefs for a while. She stated she could not recall the exact date. She stated she changed Resident#1 this morning and had to place two briefs on the resident so it would not leak. She stated the family member did bring the resident briefs, but they were not the correct size. Observation and interview on 6/26/23 at 10:26a.m., with CNA A of the supplies closet in Hall 500-600. Observation revealed there were no 3XL briefs. CNA A stated, we have been out of white briefs for a while. In an interview on 6/26/23 at 10:31a.m., with LVN BB, she stated she was not aware Resident #1 was out of briefs. She stated the facility had a contract with Resident#1's family member to purchase briefs for the resident. She stated she would call the resident's family member to bring some briefs. In a telephone interview on 6/26/23 at 10:47a.m., with Resident #1's family member, she stated the VP of Clinical Operations emailed her on May 17, 2023, requesting her to purchase briefs for Resident#1. She stated she replied in agreement to assist with purchasing the briefs because I didn't want them to treat [Resident #1] bad. She stated since that request, she had purchased and sent two big boxes with packets of briefs to the facility. She stated, Resident#1 was still residing in the facility and was under their care. I don't think that was fair for the facility to be asking family members to purchase supplies which was necessity for the resident. In an interview on 6/26/23 at 11:43a.m., with the BOM, she stated, Resident#1 was still in the facility and receiving services, food, care, activities even though she has not made any payments She stated the facility requested the family member to bring the briefs for the resident to help the facility and Resident. She stated the resident had briefs because the family member sent a box with uber . In an interview on 6/26/23 at 12:30p.m., with the Administrator, he stated the facility continued to provide everything, food and supplies to Resident#1. He stated, we asked family's help to provide brief. Told them here is what you owe us. We have done evidently everything to please her. In an interview on 6/26/23 at 12:38p.m., with the VP of Clinical Operations, she stated she was responsible for ordering supplies for the facility. She stated Resident#1 had not made payments. She stated she emailed Resident#1's family member to provide briefs for the resident to help the facility. She stated she was not aware that the family member did not deliver the briefs. At this time the Surveyor shared Resident#1's interview from earlier with the VP of Clinical Operations. The VP of Clinical Operation stated it was not brought to her attention that Resident #1 did not have briefs. She stated Central Supply made rounds and prepared a list for her to place an order. Observation on 6/26/23 at 1:08p.m., revealed LVN BB and CNA A provided incontinent care to Resident#1. Observation revealed Resident had two briefs on. LVN BB stated the draw sheet and the fitted sheet were wet and needed to be changed. LVN BB asked CNA A to bring the sheets to change resident's bed. In an interview on 6/26/23 at 1:57p.m., with Central Supply, she stated her responsibility was to make rounds and ask nurses and CNAs what supplies they needed. She stated she asked CNAs the brief sizes that needed to be ordered. Then, she would make a list and gave that list to the VP of Clinical Operations to place an order. She stated when the truck came, she would disperse supplies that staff needed. She stated the facility stopped ordering 3XL size briefs for Resident#1. She stated Resident#1 was the only one that required that size. She stated she was told by the VP of Clinical Operations that resident's family member was responsible for purchasing her briefs. In an interview on 6/26/23 at 4:52pm with the Administrator, VP of Clinical Operations and the BOM, the Surveyor explained while making her initial rounds during this visit Resident#1 requested the Surveyor to assist her get bariatric brief. The VP of Clinical Operations stated she was the interim DON and happened to be in the building when the Administrator asked if she could request the family member to assist financially. So, she sent an email on May 17, 2023 asking the family member to assist with purchasing briefs. I don't see anything wrong. It's a business. She has not made payments. Record review of facility's Resident Rights policy (Revised August 2009) read in part: 3.our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity .

Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman, the location to which the resident is transferred or discharged ; the name, address (mailing and email) and telephone number of the Office of the State Long Term Care Ombudsman for 1 (Resident #1) of 2 residents reviewed for discharge. -The facility gave Resident #1 a 30-day written notice which failed to include the location to which the resident would be transferred. -The facility failed to send a copy of 30-day written notice to the Ombudsman as soon as practicable for Resident #1. These failures could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes. Findings included: Record review of Resident #1's, undated, face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute respiratory failure with hypoxia (a condition where there's not enough oxygen or too much carbon dioxide in your body), morbid (severe) obesity due to excess calories (a chronic disease in which a person has a body mass index (BMI) of 40) and acute kidney failure (is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days). Record review of Resident #1's Medicare-5 days MDS assessment dated [DATE] revealed her BIMS score was 15 out of 15, which indicated the resident was cognitively intact. Resident #1 required total dependence from one person physical assist from staff with bed mobility, transfer and toilet use. Record review of Resident #1's Care plan initiated on 3/13/23 and revised 6/26/23 revealed the following: Focus: (Resident#1) family wishes for her to return home. Goal: Their desire to discharge to their home will be honored through next review Target date: 08/01/2023. Intervention/Tasks: Assist with arranging outside services (home health) as ordered. Prior to discharge educate the family about treatments and medications in terms they can understand. Record review of Resident#1's 30-day written notice undated read in part: .Notice: 30-day discharge Dear (Resident #1), pursuant to Federal and State regulations, this Notice is being provided as formal notification that you are being transferred or discharged from [Facility name] for the following reason(s) that are marked: Your bill for services at the facility has not been paid after reasonable and appropriate notice to pay (Medicare or Medicaid) your stay at this facility . The letter was signed by Resident #1 and the Administrator dated 4/27/23. The notice mentioned 3 different locations to which the resident could be transferred. Record review of Resident#1's nurse notes/progress notes for the month of June 2023 provided by the VP of Clinical Operations revealed there were no notes regarding discharge planning/care plan meeting held with the interdisciplinary team, Resident #1, or the Responsible party after the 30-day discharge was given to the Resident. Record review of the email dated 5/17/23 between the VP of Clinical Operations and Resident#1's family member received from the family member read in part: .If there was a certain question or certain questions that should be asked to the facilities, recommendations are absolutely accepted. The accusations are absolutely unwarranted as we all navigate the unfamiliar process. Lastly, If there are any facilities that you've worked with that accept Medicaid pending, please advise. When researching the facilities, this information is oftentimes not clearly noted . In an interview on 6/26/23 at 9:12a.m. Resident #1 stated she was given a 30-day notice to leave the facility. She stated she required extensive assistance from staff with bathing, dressing and changing briefs. She stated she was glad the ombudsman came to find out about the discharge notice and was assisting her with fair hearing. She stated the Administrator handed her the discharge notice and asked her to sign the letter. She said the facility had not discussed having a discharge planning meeting with her or her family member. She stated her family member was assisting her with filling out the Medicaid application. She said the facility did not offer to help with filling out the Medicaid application. She said the facility wanted to send her to a personal care home. The facility set up the transport without her approval. She stated she refused to go to the personal care home when the transport arrived. She stated, I did not feel it was a safe place for me to go. They wanted me out of here. In a telephone interview on 6/26/22 at 11:21 a.m., the Ombudsman stated the facility had issued Resident #1 a 30-day discharge notice on 4/27/23. He stated he filed a complaint on behalf of Resident#1. The reason was for non-payment. He stated there was no IDT care plan meeting for the discharge after the notice was issued. There were 3 different facilities listed on the discharge notice. He stated, the Administrator was making threats of putting the resident in a cab to send her home. He stated the facility was not contracted with a social worker. The facility failed to send the discharge letter for Resident #1 to the Ombudsman Office. He stated the facility violated the following, .F623 of the SOM clearly stated Notice before discharge 483.15c5 Contents of the notice. The written notice specified in paragraph (c) (3)of this section must including the following. The location to which the resident is transferred or discharged . The 30-day discharge notice had 3 different facilities names and address listed. Which facility was the resident going to . He stated the facility wanted to send Resident #1 to a personal care home. He stated that would be an unsafe discharge because the resident required total assistance even with transfer from bed to wheelchair. He stated, clearly the facility is in violation for the above mentioned regulations. Record review and interview on 6/26/23 at 11:43a.m., with the Business Office Manager, she stated the 30-day discharge notice was issued to Resident #1 for nonpayment. She said it was a generic notice that came from corporate. She said, all I do is add the resident's name and address if the letter needed to be mailed. Print the letter and give it to the Administrator. The Administrator needed to give the letter to the resident. She stated she was not involved in the discharge planning. The BOM reviewed Resident#1's 30-discharge notice with the Surveyor. The BOM said, 3 facilities mentioned on the letter came from corporate. I am assuming they are Medicaid pending facilities. When asked which facility was the resident transferring to after her 30 days were over. The BOM stated, her [family member] needs to tell us. In a telephone interview on 6/26/23 at 2:08p.m., with Resident#1's family member, she said she received a call from someone at the facility saying, [Resident #1's] coverage for Medicare is ending. You can apply for Medicaid. She said there was no communication on discharge planning. The facility management kept saying you need to find a place for [Resident #1] to go. She said there was no clear instructions given by the facility. She said she was searching for nursing facilities online and calling those facilities if they were accepting new residents. She said she gave a list of facilities to the BOM that were accepting new residents. She stated the BOM then guided her that she also needed to ask if those facilities were accepting residents with Medicaid pending. She said [facility name] did not assist at all with the discharge planning. She said the facility did not have a social worker. A community SW got involved. She said the facility wanted to send the resident to a personal care home to get rid of her. She said she came to find out about the Ombudsman and asked for his assistance with the appeal process while she applied for resident's Medicaid application. In an interview on 6/26/23 at 2:34p.m., with the Administrator and the VP of Clinical Operations, the VP of Clinical Operations stated it was not a safe discharge for Resident #1 to go home. She stated with the help of a community social worker the facility found a personal care home. She stated at first the resident agreed to go to the personal care home. The facility set up the transportation for transfer. When the transportation came with the stretcher to pick up the resident for transfer, Resident#1 stated, don't touch me. Therefore, the facility had to give the 30-day notice to the resident. Record review and interview on 6/26/23 at 3:40p.m., the Surveyor reviewed Resident#1's 30-day discharge notice with the Administrator and the VP of clinical operations. The Administrator said, 3 facilities listed on the letter was letting the resident know here are some choices. Can't say whether or not they will accept. They are just options; we were trying to help. The Administrator said the facility had not made contact with the 3 facilities mentioned in the letter. The VP of clinical operations said there was no documentation an IDT care plan meeting/discharge planning was held after the notice was given on 4/27/23 because we are waiting on the [family member] to give the name of a facility to transfer the resident. At this time policies on Transfer or Discharge Notice were requested. No policies on Transfer or Discharge Notice were provided on exit.

Based on interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, for 1 (CR#1) of 5 residents reviewed for quality of care. The facility failed to call 911 for three hours after finding CR#1 vomiting up blood and blood in her urine and feces on [DATE]. CR #1 later expired at the hospital because of her condition and lack of 911 being called. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:45p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure could put all residents at this facility at risk for not being provided adequate care and treatment and not contacting emergency services in a timely manner resulting in clinical complications, injuries and/or death. Findings Include: Record Review CR #1 a [AGE] year-old female who was admitted to the NF on [DATE] with the following diagnoses that included Partial intestinal Obstruction, chronic respiratory failure with hypercapnia, candida esophagitis, sickle-cell trait, demyelinating disease of central nervous system, chronic inflammatory demyelinating polyneuritis, Chronic combined systolic and diastolic congestive heart failure. Record review of CR#1's Physician Orders revealed the following: [DATE] Albuterol Sulfate HFC Inhalation Aerosol Solution 108 (90 Base) MCG/ACT 2 puffs inhale orally every 6 hours for Chronic resp failure **Give while awake** Record Review of LVN A's Progress note dated [DATE] at 10:47p.m., LVN A wrote a note that she found CR #1 in blood vomit and stool of blood CR #1 was taken to hospital. Record review of LVN A's late entry note on [DATE] indicated CR#1 was alert and talking expressing pain as she was being cleaned for transfer to the hospital. Record review of LVN A's second late entry on [DATE] indicated s she observed CR # 1 at 8:00p.m. vomiting blood and blood in her urine and stool. Record review [DATE] 1:00p.m. of SBAR completed by LVN A revealed the CR#1 had symptoms of bleeding, GI bleeding and abdominal pain. Vitals signs were taken after the change in condition occurred. BP taken at 8:23 pm, and Pulse was taken at 8:23 pm, and respirations were taken at 8:51 pm and temp was taken at 8:52 p.m. Record review on [DATE] of EMS report revealed on [DATE] they were dispatched to the facility after 911 call was made at 10:18 p.m. Upon arriving at the facility there was found with a significant amount blood in garbage bags, on linens, and covering CR#1. The onset of symptoms was [DATE] at 7:00 p.m. per the staff at the facility. Facility staff was advised that the situation was critical. The facility staff was in the way and delaying scene time. CR #1 was showing signs of clinical worsening. Interview [DATE] 12:15p.m. with LVN A, she said she was the nurse who was with CR#1 the night she went to the hospital. She come in at 6p.m. on [DATE], she made her rounds and check all her patients. At about 7:00pm she normally does her breathing treatments. CR#1 is one of the patients she gave the breathing treatment to. Then she went back to the nurse's station and at about 7:45pm. CNA B came to tell her CR#1 was vomiting blood and had blood in her stool and urine. CNA B said it was a lot of blood gushing out in clots and she was vomiting. When CNA B and LVN A turned her, the bed was covered in blood coming from CR#1's brief. LVN A stated she went to the room and saw CR#1 vomiting blood, there was a substantial amount of blood on the bed and on the resident. LVN A said she stepped out of the room and immediately called EMS. Then she went back into the room took her vitals and help to make sure she was ok until EMS arrived. LVN A said that she must have documented the incorrect time because she said for sure CR#1 had change of condition at around 7:45pm and not 10:45pm. LVN A said she called EMS at about 7:45 then she called the family member, then she called the physician. This process happened very rapidly, and she did her documentation of the SBAR when she returned to work on [DATE]. In another interview LVN A stated she made a mistake and documented the wrong times. She completed breathing treatments around 7pm for CR#1, and then stated that she called EMS at 10:18 pm. LVN A was asked about the delay in calling EMS. LVN A said she had made a mistake with the time. LVN A did not find CR#1 at 740p.m., it was at 10:17p.m Interview [DATE] at 10:47a.m. with CNA B she said she worked with CR#1, on [DATE] and she did not want anybody to touch her. She had to have help to change her most of the time. CR#1 always complained of pain in her lower back. CNA B said she is the one who alerted LVN A the nurse for CR#1 's change of condition. CNA B said it was a lot of blood gushing out in clots and she was vomiting. When LVN A and CNA B turned her, the bed was covered in blood coming from CR#1's brief. CNA B said CR#1 was vomiting blood and urinating and stool with blood she reported this to the nurse on duty. The nurse called EMS and she believes LVN A reported the change of condition to her doctor and family. She does not remember the exact time; she said it was evening. Interview with CR#1's Family member on [DATE] 7:45am, he said he visited CR#1 on [DATE], and she was doing just fine. CR #1 was talking and had been experiencing pain in her back and hip. CR#1 complaining that the facility was not giving her the pain medications she needed. CR#1 left the facility at about 3:00pm and she was just fine. On [DATE] at 1:33a.m. he got a call from the facility that CR#1 was being rushed to the hospital. CR#1's relative got a call from the hospital that she was suffering from internal bleeding and was on life support. He rushed to the hospital and CR #1 never woke up again. Interview [DATE] at 1:56p.m. with the VP of Clinical operations explained that LVN A made an error in documentation. VP of Clinical operations says LVN A called her at 10:18p.m. and advised her of CR#1 Change of Condition and EMS was going to be called. The VP of Clinical operations stated that LVN A was not made aware of CR #1's change of condition prior to this time. She explained that LVN A made an honest mistake in her documentation of the time. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:45p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal. Plan of Removal The Medical Resort Sugarland [DATE] Immediate Actions taken By Medical Resort Sugarland. Immediate Jeopardy was identified to The Medical Resort Sugarland on [DATE] @ 12:45pm: Quality of Care, F-684. The Medical Resort Sugarland Immediate Jeopardy was called: The Facility failed to ensure that CR #1 received treatment and care in accordance with professional standards of practice. c 100% of all patients admitted to The Medical Resort Sugarland were assessed by Charge Nurses for change in conditions. This assessment was documented and completed on [DATE]. On [DATE] one family member out of 22 current residents stated that she was a little concerned about her husband's appetite and wanted him checked out. [NAME] President of Clinical Services and charge nurses assessed patient and sent out to hospital per family request. Change in condition and transfer form completed. Observed charge nurse give report to EMS, accurate detailed report given by Medical Resort Sugarland Charge Nurse. c LVN A was educated on how to recognize a change in condition, when to notify the physician and the family. LVN A was also educated on the importance of documenting the correct date and time when making a Late Entry. LVN A was also educated on the importance of giving EMS an accurate report on a patient when being transferred to the hospital. Training was provided by the [NAME] President of Clinical Operations on [DATE]. c Change in Condition Policy and Procedure was reviewed by The [NAME] President of Clinical Operations on [DATE]. No revisions to the policy were warranted at this time. c Training on Change in Condition (SBAR) documentation was given to Charge Nurses. Charge Nurses and floor nurses were educated on the importance of documenting real time and also how to document a late entry, with emphasis placed on the importance of documenting the correct date and time of the actual event. Training was provided by the [NAME] President of Clinical Operations on [DATE]. c On [DATE] The [NAME] President of Clinical Operations rounded with both the Medical Resort Sugarland ADON and the Charge Nurses and received a verbal report on 100% of all residents admitted to The Medical Resort Sugarland. In addition to [NAME] President rounding with charge nurses, [NAME] President of Clinical Operations delegated to ADON to call 100% of all patient's responsible parties and informed them that when visiting their loved one, please notify the charge nurse immediately if they noticed any changes in the physical or mental status. On [DATE] one family member out of 22 current residents stated that she was a little concerned about her husband's appetite and wanted him checked out. [NAME] President of Clinical Services and charge nurses assessed patient and sent out to hospital per family request. Change in condition and transfer form completed. Observed charge nurse give report to EMS, accurate detailed report given by Medical Resort Sugarland Charge Nurse. Resident was transferred out on [DATE]. c [NAME] President of Clinical Operations delegated to ADON call 100% of all families to educate them on changes in condition. Informed them that when visiting their loved one, if they noticed a change in their mental or physical status, to please immediately let the charge nurse know so that immediate actions could be taken by the nurse doing an immediate assessment and notifying the physician for further orders. Initiated and completed on [DATE]. c 100% of all Medical Resort Sugarland Staff, including all nursing and non-nursing staff, were in-service on how to recognize a change in condition by [NAME] President of Clinical Operations. For non-nursing staff, [NAME] President of Clinical Operations verbally went over what to do in the event they noticed a resident with a change and gave examples of what a change could reflect to them. All staff were asked questions and were able to verbalize the answers to the group in real time. [NAME] President of Clinical Operations initiated facility wide campaign Change in Condition is Everyone's Responsibility! Campaign will be continued by [NAME] President of Clinical Service and designee to walk the halls in real time and ask questions to all staff, both clinical and non-clinical while observing current patients under the care of The Medical Resort Sugarland. Non-clinical staff were able to verbalize some examples of changes, and what and who to report those changes to. All Medical Staff were re-educated on how to recognize a change in condition and what steps are actively taken when a change in condition is identified such as performing an assessment, notifying the physician and follow up. This was initiated and completed on [DATE]. Training and observation will be ongoing. All clinical staff will be required to complete this in-service before they are able to work in their designated positions. Facilities Plan to Ensure Compliance Quickly c Impromptu QAPI was held [DATE] with the Medical Director and informed him of the two immediate jeopardies that The Medical Resort Sugarland obtained for Quality of Care, F-684 and Notify Physician of Change in Condition, F-580. Informed the Medical Director that training on Changes in Conditions, SBAR documentation, Late Entry Documentation was given to all clinical and non-clinical staff. Notifications to the families about recognizing and reporting any mental or physical changes noted to their loved ones. No additional guidance at this time. c An in-service was provided to all clinical staff by the [NAME] President of Clinical Operations regarding Change in Condition and Physician/Family notification. The attending physician should be notified as soon as safely possible when a resident change of condition occurs. In the event the resident experiences a medical emergency which requires activation of emergency medical services the attending physician and family would be notified immediately after the transfer of care has been made to emergency medical services personnel. In a non-emergent change of condition, the nurse would initiate an SBAR (as appropriate) and contact the attending physician for further guidance as the condition/situation warrants. The family would be notified within 24 hours of a non-emergent change in condition. The nurse would complete the SBAR documentation, document all events, physician guidance and include information in the shift-to-shift report for continuity of care/follow up. The in-service was initiated and completed on [DATE]. c All Staff will be educated on Policy for Changes in Condition, by the [NAME] President of Clinical Operations and/or designee, which includes when to notify the physician and/or a nurse, BEFORE they are able to work in their designated positions. Monitoring of the plan of removal included: The IJ was called on [DATE] at 12:26p.m. Facility was monitored from [DATE] through [DATE]. The plan of removal was accepted on [DATE]. The IJ was lowered [DATE] at 9:04a.m. with the ED of the facility. Record review of Employee Discipline Notice dated [DATE] revealed LVN A was disciplined for failure to report to the physician the change of condition and failure to call 911 upon seeing the change of condition of CR #1 on [DATE]. Record Review of In-service conducted dated [DATE] The VP and ADON conducted training of all staff on change of condition and reporting of change of condition. The training also included SBAR, physician notification and late entries in the nurses' notes. Interviews were conducted on [DATE] through [DATE] on all shifts with the VP, ADON, LVN A, LVN K, CNA B, CNA C, CNA D, CNA F, and CNA G to verify the in-services had been conducted and to validate the staff understanding of the information presented to them. No concerns were found regarding understanding of requirements, training material and expectations. Record Review QAPI was held [DATE] with the Medical Director and informed him of the two immediate jeopardies that The Medical Resort Sugarland obtained for Quality of Care, F-684 and Notify Physician of Change in Condition, F-580. Informed the Medical Director that training on Changes in Conditions, SBAR documentation, Late Entry Documentation was given to all clinical and non-clinical staff. Notifications to the families about recognizing and reporting any mental or physical changes noted to their loved ones. No additional guidance currently. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:45p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that is not an Immediate Jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on interview and record review, the facility failed to ensure residents the right to be free from any physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms for 1 (CR #134) of 1 resident reviewed for restraints. Staff applied socks on both of CR #134's hands to restrict her movement during the night and did not remove the socks until family's intervention. This failure could place residents at risk of a decline in the ability to participate in activities of daily living (ADLs). Findings Included: Record review of CR #134's undated Face Sheet reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CR #134 was discharged from the facility on 05/21/2022. Record review of CR #134's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed she had short and long term memory problems, and she was severely impaired that never/rarely made decisions. She displayed 1 to 3 days of other behaviors symptoms not directly toward others such as hitting or scratching self. CR #134 required total dependence with 2+ persons assistance for bed mobility, and one person assistance for eating and toilet use. She also required extensive assistance with 1 person assistance for transfer, dressing and personal hygiene. Restraints was coded as not used and did not trigger a care plan. Record review of CR #134's undated Care Plan did not address restraints or socks or any behavioral issues. Record review of CR #134's Physician Consolidated Orders revealed no order for socks or any other forms of restraints. Record review of CR #134's progress notes dated 05/21/2022, created by RN O revealed in parts RN received resident at the start of the AM shift with no private sitter at her side, had socks on both hands; received report resident was attempting to pull out her [CONDITION(S)], and other tubes connected to her during the night shift, socks removed, right hand observed to be swollen slightly, left hand observed with 2+ pitting [CONDITION(S)], resident is not in any distress, on assessment, resident acknowledges (with nod) mild pain on the left wrist, resident is non-verbal, could not rate pain. Resident repositioned in bed, hands elevated on pillows, cold compress applied to both hands swelling on both hands alleviated, hands remain elevated on pillows, resident able to move all extremities, tolerated all medications and care very well, not in any distress. Incoming nurse advised to monitor. Telephone interview on 06/23/22 at 02:32 PM with RN O revealed she was the morning nurse on 05/21/2022. She said when she got to the facility, the socks were removed from the resident's hand already. She said she observed swelling and documented her observation and assessment in the progress note. RN O said she reported this incident to the administrator at that time, and she considered the socks as restraints and it was concerning, as it was restricting the resident's movement. Telephone interview with RN M on 06/20/22 02:24 PM, she said she was the RN that worked night shifts of 05/20/2022, and she recalled CR #134 had socks on her hands. She further said the family that put the socks on her hands so that the resident did not pull her tubes off. The surveyor asked if resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked what RN M considered restraints, she said something that could prevent the resident from grabbing things. Then surveyor asked if the socks were considered restraints as it was in place to prevent the resident from pulling her tubes out, she said no again as it was just merely a sock. Surveyor asked if she has assessed the resident's hands while she was working that day, she said yes. and Surveyor asked if she removed the socks to assess CR #134's hands, RN M said no, because there were no needs to remove the socks, she could assess the resident's hand by assessing with the socks on. Surveyor asked if she found any swollen or reddish on the resident's hands, she said no. Surveyor asked how can she do an accurate assessment of the resident's hands without actually looking at her hands, RN M said she could assess the hands by touching them, and she did not find anything, so she did not document anything. Interview on 06/20/2022 at 3:45 PM with the DON, she said the nurses would be responsible to assess residents overall well being on their shifts. They are looking at vital signs, resident's eyes/pupils, and their reaction to lights, they look at residents' skin, speech, pulse and how they are cognitively like. They would document what they found and if there's anything alarming, they would file a change of condition report. Interview on 06/20/2022 at 04:04 PM with the Administrator, revealed she started at the facility about 3 weeks ago and she was still trying to build rapport at the facility. After reading CR #134's progress notes, she said the socks were restraints and the night nurse should definitely document what she found during the night shift, but there was no documentation from the night nurse RN M. The Administrator also said this incident should be a reportable incident to the state and now that it was brought to her attention, she will report it to the State and do an investigation about it to rule out abuse. Interview on 06/21/2022 at 11:59 AM with the Administrator revealed she reported the incident to the State, and started an investigation. She said she had an interview with the Respiratory Therapist, because she had some information on the incident with CR # 134. She also mentioned that she spoke with the night nurse, RN M, and they let her go. Interview on 06/21/22 at 12:29 PM interview with Respiratory Therapist revealed she remembered that she had just arrived at the facility around 10 minutes before 6am for that morning shift, and a family member of CR #134 was looking for the nurse. She said she went to the resident's room with the family member, witnessed that CR #134's hands were covered with socks and white ties that were holding both of the resident's hands. She stated she did not know what the ties were made of She said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . When she came back to the resident's room again, the ties and socks were removed, and she saw the resident's hands were red and swollen. She performed respiratory care and apologized for the resident's sitter that she had to deal with that. She did not report this incident to anyone. Telephone interview on 06/21/22 at 04:11 PM with CNA A revealed she remembers CR #134, and it was her first day working at the facility on 5/20/22, so she recalled seeing CR #134 with socks on her hands. She said she did not observe any ties on her hands, she said the socks were on her because she was trying to get out of the bed and was pulling the tubes out. CNA A said she did not observe anything out of the norm. Telephone interview with CR #134's family member on 6/20/2022 at 12:40 PM via a Spanish speaking surveyor revealed CR #134 was abused and neglected by the facility staff because CR #134 was tied. The family member said it was unclear about what exactly happened to CR# 134 because there were never any answers that made sense. The family member said they would never expect that anyone would tie up elderly people or mistreat them like they did at the facility and felt badly for allowing CR #134 to be there. The family member found CR #134 on a Saturday morning in May 2022 (the family member was unsure of the exact date said it was a Saturday morning) with her hands tied with yellow socks on. The family member asked the nurse on duty what that was, and the nurse said she did not know anything about it, and it must have been the night, overnight nurse/staff. The family member said CR #134's hands were bound and that both of CR #134's hands were swollen when they removed the socks. The family member said CR #134's hands were very very swollen and yellowish discolored and she had reddish/purplish marks on her wrists, and she could not make a fist. The family member did not report this to the Administrator or DON at the time, because it was a Saturday, and was told by the workers that they would not be back until Monday. Family member said that very same day, later on, around 5 pm a nurse called and said CR #134 had fallen and was being sent to hospital. The family member said CR #134 had not even been there long when all of this happened, and the family member was concerned for all the older resident's safety and for what happened to CR #134. The family member clarified that the names of the day shift nurse and the night shift nurse and the exact date and times of when this happened were written down somewhere and just had to find it. The family member said that it was horrible and unacceptable what happened to CR #134 and there were pictures from that morning that are sent over to surveyor. Record review of photographic evidence provided by family member dated 05/21/2022, at 7:16am revealed CR #134 lying in bed with right hand placed on top of her left hand, visible swelling of left hand and indentation on left wrist, right hand covered with yellow sock. Record review of the policy Use of Restraints revised date April 2014 revealed in parts Restraints shall only be used upon the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls .the definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position or place, that device is considered a restraint Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (Sponsor)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment including the use of PPE and following CDC guidelines for COVID-19 for 5 of 6 residents (Resident #1, #2, #3, #4 and #5) reviewed for infection control. -The facility failed to inform staff and identify resident rooms that required quarantine. -The facility failed to protect current residents by placing new admissions in the same room as residents who were not on quarantine and who had a [MEDICAL CONDITION]. - The facility failed to have PPE stations at the entrance of each of the quarantine room for staff to don prior to entering the rooms. -The facility failed to ensure staff, who were providing care wore appropriate PPE when caring for quarantined residents. Staff did not wear eye protection and were observed wearing homemade cloth masks while caring for residents in quarantine and in patient care areas. An Immediate Jeopardy (IJ) was identified on 6/19/2020. While the IJ was lowered on 6/20/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern while they continued to monitor their plan of removal. These failures placed all residents at risk of contracting an infectious disease, COVID-19, cross-contamination, and hospitalization . Findings Include: Record review of the CDC website at cdc.gov revealed, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown read in part, .Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Record review of CDC.gov website read in part, .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: · Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Put on an N95 respirator (or higher level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or [MEDICATION NAME] respirators. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. If reusable respirators (e.g., powered air-purifying respirators (PAPRs)) are used, they must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. *When the supply chain is restored, facilities with a respiratory protection program should return to use of respirators for patients with known or suspected COVID-19. Those that do not currently have a respiratory protection program, but care for patients with pathogens for which a respirator is recommended, should implement a respiratory protection program. · Eye Protection- *Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. Remove eye protection before leaving the patient room or care area. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse. .Gowns -Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. .3. Patient Placement ·For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization . If hospitalization is not medically necessary, home care is preferable if the individual ' s situation allows. ·If admitted , place a patient with known or suspected COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom. Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section) ·As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. Interview on 06/15/20 at 9:03 a.m. with the DON she said the NF was admitting residents. The DON said the NF required the resident to have a negative COVID-19 test result. The new admissions were monitored for 14 days for any signs and symptoms of the COVID-19. The DON said the staff PPE when caring for residents being monitored for COVID-19 consisted of N95 respirator. The DON said the facility did not have designated staffing. The DON said and Hall-300 would be used for the NF COVID-19 positive residents (Isolation Hall). The DON said Hall-300 allowed the staff to enter and exit without having to enter the NF main entrance. Further interview with the DON regarding new admissions said she would quarantine a resident if the resident was symptomatic (fever, loss of appetite, and flu like symptoms). The DON said at that time the staff should be donning with the following PPE: N95 respirator, disposable gown, show covers, and goggles to prevent cross contamination. Interview on 06/15/20 at 10:35 a.m. with LVN-A on Hall-100 said when a resident is admitted from the hospital, the resident is placed on quarantine for two weeks. The resident is not allowed to come out of the room. LVN-A said the PPE that was used to care for residents on quarantine consisted of an N95 mask. LVN-A said no residents on Hall-100 were in quarantine. Interview on 06/15/20 at 10:43 a.m. with RN-B said she was working Hall-300 and there were no residents on quarantine. RN-B said when the NF received a new admission, the resident is placed in quarantine for 2 weeks on droplet precautions. RN-B said a resident could leave their room to go for PT/OT wearing a surgical mask. Interview on 06/15/20 at 11:23 a.m. with RN-C said she was working on Hall-400 to room [ROOM NUMBER]. RN-C said none of the residents were on quarantine or isolation. RN-C said any new admissions or readmits she would ask the sending facility, during report, of the resident's COVID-19 status. RN-C said if the resident had a negative test, the NF would place the resident on droplet precautions. RN-C said the PPE that would be used was an N-95 and gloves. She did not mention any eye protection or gown. RN-C said the resident would be monitored for any changes in condition such as a fever, cough, and shortness of breath. RN-C said if the resident was showing these symptoms, she would notify the doctor. Interview on 06/15/20 at 12:00 p.m. with the DON said the guidelines she was following regarding COVID-19 was from the Vice President of Clinical Services. The DON said the Vice President of Clinical Services also e-mailed webinars that the state conducted. Observation during tour on 6/17/2020 at 9:10 am of Halls 100, 200 and 300 revealed some of the Resident's doors were opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the Residents' room doors to indicate whether the resident was on quarantine or isolation precautions. Observation during the tour on 6/17/2020 at 9:31 am of Halls 400, 500 and 600 revealed some of the Residents' doors were opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the Resident's room door which indicated the resident was on isolation precautions. Resident #1 Record review of the admission sheet for Resident #1 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's Hospital to Post-Acute Care Facility Transfer-COVID -19 Assessment admitted [DATE] 12:21 pm (date of service: 6/12/20 1:04pm), read in part: .has patient been laboratory tested for COVID-19? NO, test not performed because patient did not meet the CDC testing criteria. MAY TRANSFER . Record review of Resident #1's physician's orders [REDACTED]. Record review of Resident #1's Admission MDS assessment dated [DATE] revealed the document was incomplete due to the resident being a new admission. Record review of Resident #1's Care Plan initiated 6/12/20 revealed the following care plan: Focus: Resident has had potential exposure to COVID-19. Goal: Measures would be taken to reduce the risk of contracting COVID-19 through the review date. Interventions/Tasks: Staff will maintain appropriate PPE per current guidelines and availability in facility. Record review of Resident #1's nurses notes for the month of June 2020 revealed there was no documentation that the Resident was on Droplet precautions. Observation on 6/17/2020 at 9:45 am revealed Resident #1 was in her room lying in bed. Resident #1's door was opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the Resident's room door to indicate the resident was on precautions to monitor for COVID-19. Resident #2 Record review of the admission sheet for Resident #2 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's Admission MDS assessment dated [DATE] revealed the assessment was incomplete due to the resident was a new admission. Record review of Resident #2's Care Plan initiated 6/12/20 revealed the following care plan: Focus: Resident has had potential exposure to COVID-19. Goal: Measures would be taken to reduce the risk of contracting COVID-19 through the review date. Interventions/Tasks: Staff will maintain appropriate PPE per current guidelines and availability in facility. Record review of Resident #2's Hospital to Post-Acute Care Facility Transfer-COVID -19 assessment dated and signed by the hospital staff on 6/11/20, read in part: .has patient been laboratory tested for COVID-19? NO, test not performed because patient did not meet the CDC testing criteria. MAY TRANSFER . which was one day prior to the admission. Record review of Resident #2's physician's orders [REDACTED]. Record review of Resident #2's nurses notes for the month of June 2020 revealed there was no documentation that the Resident was on Droplet precautions. Observation on 6/17/2020 at 9:52 am revealed Resident #2's door was opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the Resident's room door which indicated the resident was on isolation precautions. Resident #2 was lying in bed. Resident #3 Record review of the admission sheet for Resident #3 revealed a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3's Admission MDS assessment dated [DATE] revealed it was not yet complete due to the resident was a new admission. Record review of Resident #3's physician's orders [REDACTED]. Record review of Resident #3's Hospital to Post-Acute Care Facility Transfer-COVID -19 Assessment (YES, Test performed for COVID-19 Date of test (not dated) signed and dated by the hospital staff on 6/12/20 revealed it was marked Negative test. Record review of Resident #3's physician's orders [REDACTED]. Record review of Resident #3's physician's orders [REDACTED]. Record review of Resident #3's Care Plan initiated 6/12/20 revealed the following care plan: Focus: Resident has had potential exposure to COVID-19. Goal: Measures would be taken to reduce the risk of contracting COVID-19 through the review date. Interventions/Tasks: Staff will maintain appropriate PPE per current guidelines and availability in facility. Observation on 6/17/2020 at 9:59 am reveled Resident #3's door was opened to the hallway with no PPE cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the Resident's room door to indicate the resident was on quarantine or precautions. Resident #3 was lying in bed and was on a ventilator. Further observation revealed Resident #3 was sharing the room with Resident #4 who also had a [MEDICAL CONDITION]. Resident #4 was not a new admit or a re-admit. Observation and interview on 6/17/20 at 10:15 am revealed CNA A was observed entering Resident #3's room wearing a cloth mask, which is not PPE. Interview with the CNA A, she said she provided incontinent care to Resident #3. She said she did not know the resident was on droplet precautions. She said she started working 2 weeks ago at this facility. She said she worked full time during 6-2pm shift. She said staff could wear homemade masks or facility provided masks to care for the quarantined residents. She said she had on her own cloth mask because it was comfortable to breathe in. She did not mention eye protection, gown, or gloves. She said she was provided an N95 mask from the DON but, my family member got into it. She said she did not ask the DON for another mask. She said she did not know which residents were quarantined or on droplet precautions because no one told her. She said there were no residents on isolation because there were no signs posted on the residents' doors or PPE setup outside of any of the rooms. Resident #4 Record review of the admission sheet for Resident #4 revealed a [AGE] year-old male admitted to the facility on re-admitted on [DATE] and re-admitted on [DATE] . His [DIAGNOSES REDACTED]. Record review of Resident #4's physician's orders [REDACTED]. Record review of Resident #4's physician's orders [REDACTED].> 90% every shift. Record review of the care plan initiated on 4/9/20 revealed the following care plan: Focus- Resident has [MEDICAL CONDITION] r/t Impaired breathing mechanics Goals-Measures would be taken to clear and equal breath sounds bilaterally through the review date. Interventions/Tasks- Ensure [MEDICAL CONDITION] are secured at all times, Monitor/document for restlessness, agitation, confusion, increased heart rate ([MEDICAL CONDITION], and [MEDICAL CONDITION], Suction as necessary. Resident #5 Record review of the admission sheet for Resident #5 revealed an [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's Admission MDS assessment dated [DATE] revealed the MDS was not yet complete due to the resident was a new admission. Record review of Resident #5's Hospital to Post-Acute Care Facility Transfer-COVID -19 Assessment (YES, Test performed for COVID-19 Date of test: 6/3/20 it was marked Negative test. Which was 10 days prior to the admission. Record review of Resident #5's Care Plan initiated 6/13/20 revealed the Resident was not cared planned for COVID exposure/droplet precaution. Record review of Resident #5's consolidated order for the month of June 2020 revealed there was no order to place Resident on Droplet precautions for 14 days. Observation on 6/17/2020 at 10:23 am revealed Resident #5's door was opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was no sign posted on the Resident's room door which indicated the resident was on isolation precautions. Resident #5 was lying in bed. In an interview on 6/17/20 at 10:10 am with RN A, she said when a resident is admitted from the hospital, the resident is placed on droplet precautions for 14 days. She said the PPE used to care for residents in quarantine consists of an N95 mask. She said no residents on Hall 500 were in quarantine. She did not mention eye protection, gown, or gloves. In an interview on 6/17/20 at 10:21 am with RN D, she said she was assigned to work rooms 507 to 612. She said when a resident is admitted from the hospital, the resident is placed on droplet precautions for 14 days. When asked which residents were on droplet precautions she said she would have to look at the resident's orders. She said the admitting nurse enters the orders in the electronic medical records. She said an N95 and gloves were required to care for all residents. She said if the resident started showing s/s of COVID such as coughing or SOB then staff could get gowns from central supply. She said no face shield or goggles were worn. In an interview and observation on 6/17/20 at 10:23 am with Central Supply Aide, she had a KN95 mask on. She said gloves and masks were required to care for the residents. She did not mention eye protection or gown. She said there were no residents in isolation in the facility. She said she would know the resident was in isolation after seeing a sign posted on the door and PPE set up outside the room. She said she did not know which residents were in quarantine. In an interview and observation on 6/17/20 at 10:27 am with CNA B, she had a KN95 mask on. She said gloves and masks were required to care for these residents. She did not mention eye protection or gowns. She said there were no residents in isolation on Hall 400, 500, or 600. She said she would know the resident was in isolation after seeing the sign posted on the door and PPE set up outside the room. She said she did not know which residents were on quarantine. In an interview and observation on 6/17/20 at 10:45 am with MA A, she had a KN95 mask on. She said gloves and masks were required to care for all the residents. She said there were no residents in isolation in Hall 400, 500 and 600. She said she would know the resident was in isolation after seeing the sign posted on the door and PPE set up outside the room. She did not mention any eye protection or gown as part of the PPE that would be needed to care for a resident on quarantine. She said she did not know which residents were in quarantine. She said nurses were in charge of screening the residents. In an interview on 6/17/20 at 10:58 am with the DON, she said all new admissions were monitored for 14 days for any signs and symptoms of COVID-19. She said these residents were also placed on droplet precaution. The DON said PPE, including N95 and gloves, were required when caring for residents being monitored for COVID-19. The DON said most of their rooms were private rooms. She said she was not aware that CNA A had on a cloth mask. She said a mask and face shield were provided to the Respiratory Therapists. She said staff could wear gowns if they wanted. She said the facility was not isolating any residents. She said she supplied N95 masks every day to staff but they could wear their own masks as well. She said some staff complained that they could not breathe. She said the facility had a sufficient supply of PPE on hand in case they had a positive case. The DON was asked how the staff knew if a resident was on droplet precautions if there is no sign on the door or PPE available for the staff to don prior to entering a room. The DON said the nurses could look at the physician's orders [REDACTED]. In an interview on 6/17/20 at 11:40 am with the ADON, she said Hall 500 had fifteen residents with trachs and vents that required suctioning by a Respiratory Therapist. There were six residents that required oral suctioning by the nurses. She said only an N95 mask and gloves were required to perform these tasks. She said all new admits and re-admits were placed in Hall 400, 500 or 600. She said they were placed on droplet precautions for 14 days. She said the nurses would know when the resident was placed on droplet precautions by looking at the physician's orders [REDACTED]. In an interview on 6/17/20 at 11:55 am with Respiratory Therapist A, he said there were some new admits and re-admits in Hall 500 (trach/vent residents). He said twelve residents required suctioning. He said he wore a KN95 mask and face shield while suctioning/providing oral care to the trach/vent residents due to COVID precautions. He said he did not know if there were any residents on isolation/droplet precautions because the nurses did not communicate that with him. He also said there were no identifiers on the resident's rooms and no PPE set up outside to indicate any precautions. He said he used standard precautions to care for all the residents. Observation and interview on 6/17/2020 at 12:00 pm revealed CNA A was wearing a KN95 mask. In the interview she said the DON asked her to remove her cloth mask and handed her a KN95 mask. In an interview on 6/17/20 at 12:55 pm with MA B and LVN B, MA B had a KN95 mask on. MA B said both gloves and masks were required to care for the residents. She said there were no residents on isolation in Hall 100, 200 or 300. She said she would know if the resident was in isolation after seeing the sign posted on the door and PPE set up outside the room. She said she did not know which residents were in quarantine. LVN B said all new admits were placed on droplet precaution for 14 days in Hall 400, 500 and 600. Record review of facility's Droplet precaution policy (dated 2020) revealed read in part: .a. examples of infections requiring Droplet Precaution include, but are not limited to: (7) Covid 19. B. Resident placement (2). When the private room is not available, residents with the same infection with the same microorganism but with no other infection may cohorted. C. Mask (1) in additional to standard precautions, put on a mask when entering the room or cubicle. F. signs- the facility will implement a system to alert staff and visitors to the type of precaution the resident require. G. The facility will also ensure that the residents care plan and care specialist communication system indicates the type of precautions implemented for the resident . Record review of facility's Isolation Protocols policy (dated June 2015) revealed read in part: .purpose to facilitate safe care to all guests presenting with a known or suspected communicable disease. 2. A physician's orders [REDACTED]. 3. Isolation equipment and supplies may be obtained from Central supply coordinator. And placed in the guest's room or designated area. 4. Isolation signs and labels may be obtained from nurses' station. 6. The guest's door should display the appropriate isolation sign. 7. Nursing will notify the environment services staff regarding equipment that needs sanitizing after use in the care of an individual with isolation precautions. 9. Central Supply will frequently monitor and replenish the isolation equipment as needed. Contact Precautions: 1. Used for guest's that have an infection that can be spread by contact with he person's skin, mucous membranes. 3. In addition to standard precautions: a. wear a gown and gloves upon room entry of a guest on contact precautions. Droplet Precautions: 1. Used for guest's that have an infection that can be spread through close respiratory or mucous membrane contact with respiratory secretions. 3. In addition to standard precautions: a. wear a mask upon room entry of a guest on droplet precautions . Record review of facility's Infection Control Guidelines for All Nursing Procedures policy (Revised April 2013) revealed read in part: .Purpose: to provide guidelines for general infection control while caring for residents. Preparation: 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on general infection and exposure control issues, including: a. The facility protocols for isolation (standard and transmission-based precautions; b. The location of all personal protective gear; c. The location of medical waste disposal containers; d. The facility exposure control plan; and e. The facility protocol for occupational exposures to bloodborne pathogens . These failures resulted in an Immediate Jeopardy (IJ). The Administrator and the DON were notified of the IJ on 6/19/20 at 10:17 am and a plan of removal (POR) was requested at that time. The IJ template was left with the DON. After two revisions, the POR was accepted on 6/19/2020 7:44 PM. The POR read in part, .The Medical Resort at Sugar Land IJ Plan of Removal 6/19/2020 1. New Admits and Readmits were not quarantined. Facility residents admitted within the last 14 days are now without roommates in rooms. New and readmit residents will be placed in quarantined, in designated unit/area, x 14 days or past 14 days if patient is showing any signs and symptoms of needing to remain in isolation per CDC guidelines. Dietary was instructed on using paper products on quarantine residents. 6/19/2020 2. Signs not posted/PPE Setup not outside of rooms. Precaution Signs (See Nurse Before Entering) are now placed on resident room doors where patients are in quarantine. Isolation PPE Carts are now setup in the quarantine area for staff to don prior to entering the room. Appropriate trash and laundry biohazard bags are placed in the quarantine area. Face shields, gowns, N95 Masks, and gloves are in each PPE bin in the quarantined area for staff to use. 6/19/2020 3. Wear of Proper PPE Facility staff, including dietary, housekeeping, and laundry were re-educated on 6/19/2020 by the DON, VP of Clinical Services, and nurse managers on wearing proper PPE per CDC guidelines. Staff will not be able to return to work until completion of Infection Control inservice. Staff caring for quarantined residents will be required to wear a face shield, gown, N95 Mask, and gloves. 4. Staff Facility now has consistent staff assigned to the designated unit/area for patients who are admitted /readmitted to the facility. The above education, procedures, and policies were added to the facility's COVID/Outbreak Response Plan. 6/19/2020 . Monitoring Following acceptance of the facility's Plan of Removal, the facility was monitored on 6/20/2020. In an interview on 6/20/20 at 12:55 pm with the DON, she said the facility rearranged the residents so that the quarantined residents were on one side. PPE was available outside their rooms for the staff to don prior to entering. She said in-services were provided to the staff regarding PPE. She said there were designated staff for the quarantined residents. She said staff needed to have N95 and face shield at all times. When going into resident's room staff needed have gown, gloves, mask and face shield. Observation on 6/20/20 at 1:09 pm revealed Hall 400, 500 and 600 were designated as quarantine halls. The following rooms were with isolation precautions 608, 609, 606, 604, 607, 605, 602, 603, 601, 511, 404, 500, 411, 410, 408, 409, 407, 404, 405, 401, 400, 402, 403. There were stop signs that said Stop see the nurse before entering. these rooms had PPE station sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. In an interview on 6/20/20 at 1:23 pm with Housekeeper A, he said he had been in-serviced to wear the N95 mask, gown, face shield and gloves when cleaning resident rooms on isolation/quarantine, hand hygiene, changing mop heads and water after every third room cleaning. Housekeeping said he used the sweeper mops instead of the brooms to prevent the spread of infection. Housekeeping said he cleaned the surfaces of resident rooms with certain disinfectants that were all [MEDICAL CONDITION]. Observation on 6/20/20 at 2:18 pm revealed CNA B going into room [ROOM NUMBER], which had a stop please see nurse before entering sign on the door. She donned full PPE. There were no concerns noted regarding technique. Observation on 6/20/20 at 2:34 pm on Hall 400, 500, 600 with a total of 23 residents confirmed on quarantined with PPE available (N95 mask, gowns, gloves, and face shields). The staff were wearing the N95 mask and face shield. The doors to the resident rooms were closed. There were designated staff that consisted of three CNA's and two nurses. Observations conducted on 6/20/20 revealed all staff fully donned in PPE. The quarantined unit was stocked with PPE and staff were wearing N95 and face shield. Record review was conducted of the facility's in-services

Based on observation, interview, and record review, the facility failed to ensure residents rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one of four residents (CR#1) reviewed for resident call system, in that: -CR #1's room did not have a properly functioning call system during an emergent change in condition. This failure could affect all residents and place them at risk of lack of staff assistance and help in the event of an emergency. Findings include: CR #1 Record review of the admission sheet for CR# 1 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of CR #1's physician orders [REDACTED].VENTILATOR ORDERS: MODE: [MEDICAL CONDITION] ,[DATE] FiO2 @ 35% TO KEEP SPO2 ABOVE 92 at bedtime. Record review of CR #1's care plan dated [DATE] revealed: -The resident was at risk for falls r/t Deconditioning. Goals: Measures would be taken to reduce the risk of falls through the review date Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Follow facility fall protocol: bed at low level, call bell within reach, keep area clutter free and well lit. All patient belongings within reach as patient wishes. -Focus: CR #1 admitted with Tracheotomy Goals: Measures would be taken to maintain clear and equal breath sounds bilaterally through the review date Interventions: Ensure [MEDICAL CONDITION] are secured at all times Give humidified oxygen as prescribed. Monitor/document for restlessness, agitation, confusion, increased heart rate ([MEDICAL CONDITION], and [MEDICAL CONDITION]. Monitor/document level of consciousness, mental status, and lethargy PRN. Monitor/document respiratory rate, depth and quality. Check and document q shift/as ordered. Provide good oral care daily and PRN Suction as necessary. -Focus: CR #1 requires Ventilator at night Goal: Measures would be taken to reduce the risk of complications related to ventilator dependence, including upper respiratory infection, pneumonia, atelectasis, decreased cardiac output, pneumothorax, subcutaneous [MEDICAL CONDITION], decreased renal perfusion, increased ICP, hepatic congestion through the review date Interventions: Administer aerosol treatments using an in-line nebulizer Assess for s/sx of [MEDICAL CONDITION]: altered level of consciousness, irritability, listlessness, cyanosis. Keep call bell within reach. Keep head of bed elevated above 30 degrees unless providing care or resident request. Labs as ordered by MD. Monitor for changes in respiratory rate or depth. Observe/document for use of accessory muscles. Notify MD of significant changes Monitor for tube misplacement at least every 2 hours and PRN - document cm markings for placement. Mark at lip/teeth/nares after x-ray confirmation. Monitor oxygen saturation while resident is on mechanical ventilatory support and/or during weaning process every shift Monitor residents respiratory rate,quality of respiratory pattern, use of accessory musculature, breath sounds per shift and prn Monitor/document/report to MD PRN any s/sx of: upper respiratory infection, pneumonia, atelectasis, decreased cardiac output, pneumothorax, SIADH, decreased renal perfusion, increased intracranial pressure, hepatic congestion. Observe skin color and capillary refill. Notify MD of significant abnormalities or changes from baseline. Obtain and monitor lab/diagnostic work as ordered by MD. Report results to MD and follow up as indicated. Provide good oral care 2x/shift. Reposition patient at least every 2 hours. [MEDICAL CONDITION] by respiratory care. Trach care twice in a 24-hour period. Change inner cannula one time in a 24-hour period or more as necessary. Use in-line suction catheter for suctioning. Record review of CR #1's Admissions MDS assessment dated [DATE] revealed a BI[CONDITION] score of 13 out of 15 indicating the resident was cognitively intact. He was continent of bowel and occasionally incontinent of bladder. CR #1 needed the extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. Record review of CR #1's Respiratory Therapy progress note dated [DATE] at 6:27 am read in part, .patient was found sitting on the floor next to bed unresponsive disconnected from vent, patient had a pulse but not breathing, patient was connected to Ambu bag and bagged (assisted breathing using positive pressure), after stabilizing patient, patient was put back into bed and continued to bag patient EMT arrived and did EKG, CO2 check on patient started to come around and open eyes when his name was called, patient was sent out to hospital . Record review of CR #1's Nurse's Note dated [DATE] at 7:05 am read in part, . Around 0545 (5:45 a.m.); resident vent was alarming; the Respiratory therapy staff went to the room and found resident in sitting position on the floor next to bed. RT called for help; the writer with other co-staffs went to the resident room. the (sic) writer observed resident on sitting position, breathing but unresponsive. RT discontinue the vent and start Ambu bagged the resident. 911 was called and resident was transferred in the bed; Vital signs obtained was ,[DATE], [AGE], [AGE]%, [AGE].8, 16. 0557 (5:57 a.m.); 911 arrived and took over from the writer. Resident was still breathing with eye opening and was transfer (sic) to hospital ER for further Eval & TX . Record review of CR #1's Change in Condition dated [DATE] read in part, .CR #1 noted to be experiencing a potential change in condition, the following areas of concern noted: Unresponsiveness . Record review of CR #1's physician's orders [REDACTED]. Record review of the facility's incident report presented by the DON on [DATE] at 4:11 pm revealed CR#1 had a unwitnessed fall from bed on [DATE] at 5:35 am. Record review of CR#1's hospital ED records dated [DATE] read in part, .staff states patient was found unresponsive on the floor at 5AM. E[CONDITION] brought him to the ED, and he was stable on arrival. States that his O2 came loose and that is the last thing he remember . In a phone interview on [DATE] at 11:10 am with the family member, she said facility notified her that they had discovered CR#1 unconscious on the floor in his room. He was transported to the hospital ICU where he currently remains. She said CR#1 explained that the oxygen machine stopped working and the staff failed to respond to his call light. He had fallen out of bed and passed out in an attempt to assess what was going on with the machine. Observation and interview on [DATE] at 1:15 pm revealed CR#1 was in the hospital ICU. He was alert and oriented to name, place, and time. He was resting in bed, eating lunch and appeared to have right above the knee amputation. He said last Wednesday on [DATE] he had trouble breathing and he needed to be suctioned. He said around 8:30 pm he pushed the call light button, but nobody responded to his call light. He said he usually waited 20 to 30 minutes depending on how restricted he was. He said he waited 6 and a half hours that day, but nobody answered his call light. He said he was worn out when they cleared (suctioned) him at shift change. He said during the day staff checked on him quite often but at night barely anybody came into his room. He said the respiratory therapist that usually worked nights barely spoke to him and closed the door behind him, so nobody could see or hear what was going on in the resident's room. He said between 5am to 6am going into Friday morning his main line popped out of the ventilator and he could not reach it. He said he pushed the call light button 5 to 6 times. He said the next thing he remembered was waking up on the way to the hospital. He said when the line came out after so long he did not have any oxygen, he said he lowered the bed and slide down to get to the machine. He said, I only have one leg, I could not go far. I never made it to the machine. I was quite disappointed. He said he struggled to breathe, but hospital staff were working on it. Record review of the facility's Maintenance Work Order binder located at the Hall 500 nurse's station revealed no documentation/record of CR#1's room call light malfunction. In an interview on [DATE] at 3:43 pm with the DON, she said Respiratory Therapy was responsible for administering breathing treatments, suctioning, and care of trach/vents. She said vent alarms triggered staff with room number on the hall way. She said she received a call on Friday ([DATE]) around 6:00 am that CR#1 was transferred to the hospital. She said the nurse notified her CR#1 had a [MEDICAL CONDITION] pill administration scheduled for 5:30 am. She said she came out of the room and the alarm beeped. She said the RT went in the room CR#1 was sitting in front of the bed. He had a pulse, so no CPR was performed. She said CR #1 was not responding. She said Respiratory Therapy bagged CR #1, and he opened his eyes. She said any fall observed on the floor was considered a unwitnessed fall. She said CR #1's plan was to be discharged on [DATE] with hospice services. In a telephone interview on [DATE] at 4:06 pm with Respiratory Therapist A, he said he worked full time during 6:00 pm-6:00 am at the facility. He said CR#1 was found unresponsive sitting on the side of the bed disconnected from the ventilator. He said he had last checked on CR#1 45 minutes prior to the incident. He said CR#1 usually slept on and off during the night. He said CR#1 mostly called when he needed to be suctioned during his shift. He said CR#1 was on a ventilator at night. He said when he heard the vent alarm he went in the room to assess the resident. He said CR#1 had a pulse so he bagged and suctioned the resident. He said with assistance from staff, CR#1 was transferred back to bed. He said he charted/documented treatments, assessments, and suctioning performed in the MAR/TAR. In a telephone interview on [DATE] at 4:19 pm with LVN A, she said she worked full time during 6:00 pm-6:00 am shift at the facility. She said most of the time CR#1 called to be suctioned. She said she was at the nurse's station charting when she heard the vent alarm. She said Respiratory Therapy was in CR #1's room. She said CR#1 was found on the floor unresponsive. She said he had a pulse. She said Respiratory Therapy removed him from the vent and bagged him. She said around 5:00 am she had given CR#1 his morning medication via [DEVICE]. She said CR#1 could communicate and he did not make any requests at that time of medication administration. Observation and interview on [DATE] at 4:40 pm with RN A, RN A tested CR #1's call light by hitting the call button. Neither the light on the wall inside or outside the room lit up after she hit the button. The surveyor also pressed on the button and no light turned on. RN A said something was wrong with the call light. She said she was unaware if the aides reported it maintenance or administration. She said CR#1 was in the room by himself on bed B close to the window. She said CR #1 had a push button call light but also had access to bed A's touch pad call light because of the way trach/vent machines were set up. RN A said if the resident was on the floor he would not be able to reach or use bed A's call light. She said bed b's call light was within his reach. In an interview on [DATE] at 4:56 pm with the DON, when asked how often call light system was checked, the DON said maintenance did random checks or if a CNA caught it when they went in the room and the resident complained that he/she had been calling them. She said she usually got a text. She said she received a text today that room [ROOM NUMBER]'s call light was not working. She said she was unaware CR#1's call light was not functioning. She said Respiratory Therapy and maintenance checked the vent alarms. She said the vent itself has an alarm which would beep inside the room and outside with room number. She said during the night shift if there was a call light malfunction staff could call maintenance or the ADON. She said there was no log system. She said maybe staff took CR#1's call light because nobody was in the room. She said nobody had notified her if they switched the call light. She said CR#1 was on bed b close to the window so he was using bed b's push call light. Observation and interview on [DATE] at 5:07 pm, the DON tested CR #1's room bed b call light by hitting the call button. Neither the light on the wall inside or outside the room lit up after she pressed the button. She confirmed the call light was not working. She said CR#1 was able to press the button so he had a push button call light. When asked if CR#1 was using bed A's touch pad call light, the DON said the touch pad call light was used for residents with contractures or immobility. She said CR#1 was alert and able to use the push button call light located above bed b which was close to the window. In an interview on [DATE] at 5:26 am with CNA A, he said he worked full time on Hall 500. He said CR#1 had a push button call light. He said CR#1 could verbalize his needs. He said he was unaware CR#1's call light was not working. When asked what the CNAs would do when a call light was not working, he said the protocol was to inform the manager by writing it in the maintenance log book. He said the staff usually tried to trouble shoot the problem before calling maintenance. He said he had seen the maintenance director also come at night to fix an issue. In an interview on [DATE] at 5:23 pm with Respiratory Therapist B, he said he worked with CR#1 last Thursday [DATE] during the day shift. He said CR#1 had the push button call light. He said he checked on CR#1 often. He said he was unaware CR #1's call light was not functioning. In an interview on [DATE] at 5:38 pm with ADON A, she said CR#1 was in bed B of the room. She said he was very alert could verbalize his needs. She said if the call light was not working staff needed to notify the charge nurse or herself. She said nurses were to write concerns in the maintenance log or 24 hour report for follow up by herself or the DON. She said Halls 4, 5, and 6 had one maintenance book located at the nurse's station. She said only maintenance could remove/switch out the call light from the resident's room. She said protocol was to write in the maintenance book, so maintenance could fix it. She said she was not aware that CR#1's call light was not functioning. In an interview on [DATE] at 5:45 pm with the DON and the Regional nurse, the Regional nurse said they were in the process of fixing the call light in CR #1's room. In an interview on [DATE] at 5:06 am with CNA C, she said she worked full time during night shift. She said CR#1 used a urinal. He was incontinent of bowel. She said he would call during the night mostly for the Respiratory Therapist. She said CR#1 required total assistance with mobility and transfers. In an interview on [DATE] at 5:40 am with Respiratory Therapist A, he said the vent was set to alarm after 5 seconds if disconnected. He said it would not alarm outside the room. He said vent alarm was different from call light systems. He said vent alarms beeped continuously. He said he had a list of residents that were on a ventilator, so he knew which rooms the noise was coming from. In an interview on [DATE] at 5:50 am with LVN A, she said when the vent alarm beeped, the outside alarm guided to the room number where the vent was beeping. She said a call light system was different and would beep at the nursing station. She said CR#1 did not call for anything that night. She said she gave him his morning meds that were scheduled for 5:30 am an hour early. She said nurses were allowed to pass their medications an hour early. In an interview on [DATE] at 8:30 am with the Maintenance Director, he said he checked the call lights once a month and during deep cleaning of rooms. He said CR #1's room was last checked on [DATE] and 20, 2020. He said he was short staffed and he had not gotten a chance to deep clean after CR #1 discharged . He said during deep cleaning, all the equipment was cleaned and checked to make it ready for a new resident. He said the nursing staff had not notified him that the call light in CR #1's room was not functioning. He also said the maintenance log book did not have the resident listed as having problems with his call light. He said he received a message from the ADON and the front desk yesterday afternoon that the call light in room [ROOM NUMBER], CR #1's room, was not working. He said he came to the facility last night and replaced the cord. He said it was not communicating with wall unit. In an interview on [DATE] at 9:12 am with the Administrator, she said the DON and the ADON notified her yesterday that CR#1's call light was not working, and maintenance fixed it last night. She said maintenance check the call light system monthly. In a telephone interview on [DATE] at 9:59 am with CNA B, she said she worked full time during night shift. She said CR#1 called 2 to 3 times at night mostly for Respiratory Therapy. She said CR#1 used a urinal. She said she was assisting another resident when someone told her that her patient was on the floor. She said she did not recall when was the last time she checked on CR#1 as she had Hall 400 and half of Hall 500. Record review and interview on [DATE] at 10:35 am with the DON, she said during her investigation, CNA B told her that she went in the CR#1's room around 1:00 am to provide care and then, when she made hourly rounds at 3:00 am, the resident was sleeping. She said the [MEDICAL CONDITION] medication was scheduled for 5:30 am and nurses could give medications an hour early. She said LVN A told her when she started giving medication CR #1 was fine. Record review of facility's Maintenance Service policy revised [DATE] read in part, .1. The maintenance department is responsible for maintain the buildings, grounds, and equipment in a safe and operable manner at all times.H. Maintaining call light system in working order. If not functional during work hours staff should attempt to trouble shoot and or move patient to another location . Record review of facility's Answering the call light policy revised [DATE] read in part: .the purpose of this procedure is to respond to the resident's requests and needs.4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or candied to a chair be sure the call light is within easy reach of the resident. 6. Some residents may not be able to use their call light. Be sure you check those residents frequently. 7. Report all defective call lights to the nurse supervisor promptly. 8. Answer the resident's call as soon as possible.Documentation: 1. Requests or complaints made the residents. 2 how the request or complaint was satisfied . Record review of facility's Mechanical Ventilation: Setup and Monitoring policy revised [DATE] read in part, .the purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute and chronic respiratory insufficiency. Assessment: while the resident is on mechanical ventilation, assess for the following: 1. Signs and symptoms of [MEDICAL CONDITION]. Alarm Monitoring: 1. Response to alarm immediately when it goes off. Steps in the procedure: .3. Check for proper functioning of lights, alarms, filters, fittings, and the humidifier.10. Adjust the remote and ventilator alarms so that they can be heard by staff responsible for monitoring the resident.16. Place the call light within easy reach of the resident. 17. If the resident desires, return the door and curtains to the open position. 18. Review and document the resident's status and ventilator settings at least every 4 hours or as indicated by the resident's condition .

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 8 of 18 residents reviewed for quaity of life (Resident #44, 48, 54, 124, 50, 11, 16 and 25) - Resident #44 was not provided the physician ordered lab tests used to regulate her anticoagulant medication. Resident #44 was transferred to the hospital and diagnosed with [REDACTED]. - Resident #48's lab for PT/INR was not done as ordered by the physician. - Resident #54's lab order for BMP and CBC from [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #124's lab order for Hemoglobin A1C was not done as ordered by the physician. - Resident #50's lab order for CBC, BMP, and Ammonia level was not done as ordered by the physician. - Resident #11's lab order for CBC and BMP for [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #16's lab order for PT/INR was not done as ordered by the physician. - Resident #25's lab order for TSH, B12, B9 and Vitamin D level were not done as ordered by the physician. Labs were reordered and TSH, B9 and Vitamin D were still not done. These failures resulted in an IJ on 5/18/18. While the IJ was lowered on 5/22/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 8 residents and placed an additional 63 residents who require laboratory services at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, quality of life, hospitalization and possible death. Findings included: Resident #44: Record Review of Resident #44's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting right dominant side, [MEDICAL CONDITION], type 2 diabetes mellitus with unspecified complications, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION] of unspecified iliac vein, [MEDICAL CONDITIONS], disease of esophagus, constipation, and systemic lupus [DIAGNOSES REDACTED]tosus. Record review of Resident #44's Admission MDS assessment dated [DATE] revealed Resident #44 had a BIMS score of 11/15, indicating moderately impaired decision-making skills and required extensive assistance with one person for bed mobility, transfer, walking in room or corridor and toileting ADLs. Further record review of Resident#44's admission MDS dated [DATE] revealed she required limited assistance with 1 person for locomotion, dressing, eating and personal hygiene ADLs. The MDS was marked that she received anticoagulant medication every day. Record review of Resident #44's undated care plan revealed Resident #44 had complications with anticoagulant therapy. Resident #44's Care plan read: Focus: At risk for complication of anticoagulant therapy Goal: Medication will remain within therapeutic range as determined by physician during review period. Intervention/Tasks: Anticoagulant medication as ordered, do not give vitamin K, lab as ordered. Observe for signs/symptoms of abnormal bleeding such as bruising or black, tarry stools. Report findings to physician. Report any critical values to physician. Patient noted with bruising to rt arm due to blood drawn on 04/16/2018. Monitor site closely and any additional bruising. Report any critical values to physician. Intervention/Tasks: Labs as ordered. Report abnormal lab results to the MD. Weekly skin inspection. Medication as ordered, Dose changes based on labs. Record review of admission orders [REDACTED]. Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the PT/INR lab results between the dates of 3-26-18 to 4-19-18 for Resident #44 provided by ADON-A revealed that labs were not done on 04/05/18, 04/12/18, and 04/16/18. Record review of physician order [REDACTED]. Record review of an additional order dated 03/24/18 revealed to administer [MEDICATION NAME] sodium 7.5 mg one time per day until 3/25/18. Record review of Resident #44's PT/INR lab results dated 3/29/18 revealed PT of 20.1 (PT expected range was 9.1 - 10.9) and an INR of 2.10 (INR expected range was 0.93-1.11) Record review of Resident #44's PT/INR lab results dated 4/2/18 revealed PT of 26.3 (PT expected range was 9.1 - 10.9) and an INR of 2.76 (INR expected range was 0.93-1.11) Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 continued to receive [MEDICATION NAME] sodium 3mg every evening from 4/1/18 to 4/10/18. Record review of Resident #44's PT/INR lab results dated 4-9-18 revealed PT of 10.5 (PT expected range was 9.1 - 10.9) and an INR of 1.08 (INR expected range was 0.93-1.11) Further record review of Resident #44's MARs for (MONTH) (YEAR) revealed an order for [REDACTED]. The order was discontinued on 4/12/2018 with new orders to start [MEDICATION NAME] sodium 3mg every evening on 4/13/18. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a new physician order [REDACTED]. Record review of Resident #44's nursing notes dated 4-14-18 revealed Resident #44's family had concerns that patient had blood tinge mucus when she blew her nose. The NP for Resident#44's MD was called and received new order for [MEDICATION NAME] sodium to be given 7.5mg 2 days, then 5mg [MEDICATION NAME] sodium thereafter. PT/INR to be drawn on Monday. Nursing noted entered by LVN-LL. In an interview on 05/17/2018 at 04:17p.m. with LVN-LL revealed she did call Resident #44's MD to notify him of the blood in mucus noted in nursing notes on 4-14-18. Continued interview with LVN-LL revealed she did receive new physician's orders [REDACTED].#44's physician and it should be in the nurses' notes. Record review of Resident #44's nursing notes dated 4-15-18 revealed Family member of Resident #44 reported slight tinge of blood in mucus doctor was notified. New order of [MEDICATION NAME] sodium received, Resident #44 was alert and oriented with episodes of confusion. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a physician's orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-17-18 revealed ADON-A was called to Resident #44's room due to large bruise to right inner arm. Upon assessment Resident noted with 23 cm x 17cm purple/black bruise, dressing removed, no bleeding noted. The notes revealed that a pressure dressing was applied on 4-16-18 after blood was drawn due to increased bleeding. The resident was currently taking 7.5mg [MEDICATION NAME] sodium for the past two days. No redness, warmth, hematoma/knot felt, pt denied pain or discomfort. NP A notified. Record review of Resident #44's nursing notes dated 4-18-18 revealed large bruise of unknow origin noted to right hand covering the brachium and the antecubital area. Further review of nursing notes dated 4-18-18 revealed Resident #44 had confusion and weakness noted. Resident #44 stated, I'm crying happy tears because I'm going to the Lord today. Resident #44 noted to be alert and oriented verbally responsive with periods of forgetfulness/confusion. Record review of Resident #44's PT/INR lab results dated (MONTH) 19, (YEAR) revealed PT of 170.9 (PT expected range was 9.1 - 10.9) and an INR of 8.66 (INR expected range was 0.93-1.11) Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-19-18 revealed in part: . Resident was admitted for [MEDICAL CONDITIONS] and GERD. She is on [MEDICATION NAME] sodium therapy which is currently on hold due to critical labs value of INR greater than 18.66 and PT greater than 170.0 NP notified of the result and directed to send her to (hospital) for [MEDICATION NAME] sodium toxicity .Resident was transferred to hospital emergency room for [MEDICATION NAME] sodium toxicity. Record review of Resident #44's nursing notes dated 4/25/18 revealed Resident #44 arrived via stretcher in no distress, no sob, denies any pain or discomfort, skin warm, dry, and intact, soft and non-tender, bruising noted to BUE, no [MEDICAL CONDITION] noted, no active bleeding . continue to monitor. Record review of Resident #44's physician's orders [REDACTED]. Record review of the labs produced by the facility revealed that the labs for 5-10-18 and 05-14-18 were not done as ordered. Labs were done instead on 5/08/18 and 05/16/18. Recorded review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of nurses' note for Resident #44 dated 5/1/18 revealed that a PT/INR critical lab with values of 78.4 for PT and 8.43 of INR was received and NP was informed. The NP gave orders for vitamin K 10 mg one time, hold the [MEDICATION NAME] sodium, repeat PT/INR in the morning, and to monitor for bleeding .lab requisition made. Record review of lab result dated 05/02/18 revealed the PT was 29.2 and the INR was 3.08. lab result dated 05/03/18 had results of 12.6 for PT and 1.31 for INR. In an interview 05/14/18 at 10:34 a.m. with Resident #44's Family member she said the resident went out to the hospital due to too much [MEDICATION NAME] sodium in her system on 4-19-18. She said the new doctor increased the resident's [MEDICATION NAME] sodium from 2.5mg to 7.5mg causing her to PT/INR to go up. The Family member stated the resident just came back to facility two weeks ago. The Family member said she was concerned that the facility did labs to check the PT/INR but not as many labs as they should have done. The family member said that the resident had never been on a [MEDICATION NAME] sodium dosage higher than 3mg because it was too much for Resident #44. In an interview on 05/17/2018 at 10:35a.m. with ADON-A she said that orders for labs were written in the lab book by nurses at least two weeks in advance because things changed so quickly. She said that she was not aware that some labs were missing. In an interview with NP A on 05/17/18 11:54 AM, she said she worked M-F in the facility and coordinates with all physicians that serve the facility. She said Resident #44 has a [MEDICATION NAME] sodium sensitivity and the medication is adjusted often. She said she was usually on 2-3 mg. She said the dose was adjusted by NP B. She said she adjusted the dose based on lab results from 4/9/18, where the value was 1.6. and it was the last lab available. She said Resident #44 was also on antibiotics which can have an effect on the [MEDICATION NAME] sodium levels. She said she was made aware of the bruising to the arm but felt it was a result of the blood draw. She said they did compression to stop the bleeding. She said they gave a dose of Vitamin K and sent her to the hospital where she was given 8 units of frozen plasma. She said she was not aware that there were labs missing. She said labs were important to understand how to adjust the dose of [MEDICATION NAME]. Observation on 05/17/2018 at 12:15p.m. of Resident #44 revealed Resident in bed with some bruising midway to left arm. Resident appeared confused, unable to find call light that was next to her in bed. In an interview with NP B on 05/17/18 03:15 PM, he said he was responsible for changing the dose of the [MEDICATION NAME] sodium. He said Resident #44 had a [MEDICATION NAME] sodium sensitivity and had a history of [REDACTED].#44 usually had a PT/INR levels between 2-3 often but would present with PT/INR lab values between 1-1.6. He said she received bolus doses of 7.5mg of [MEDICATION NAME] sodium due to low lab values. He said Resident #44 was usually on a low dose of [MEDICATION NAME] sodium (2.5mg). He said the attending physician spoke with the family regarding long term goals due to instability of [MEDICATION NAME] sodium levels. He said they considered palliative care or hospice because the levels were difficult to control. He said Resident #44 was also on Bactrim for 2 days and [MEDICATION NAME], which can have an effect on [MEDICATION NAME] sodium levels. He said he wrote the standing order for PT/INR drawn on Mondays and Thursdays. He said he was aware that there were labs missing. He said he wrote a note on 5/2/18 regarding missing labs. He said he was not aware that labs were missing between 4/9- 4/19. He said nurses report results to him or to NP A who was at the facility M-F. He said she coordinates care with physicians that come to the facility. He said it was important to draw labs because the results help the physician determine how to adjust the dose. He said the facility has an issue with labs and have failed to make sure the standing orders are completed. He said he has talked to the facility regarding failure to complete lab orders. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they agreed there were labs that were not done. Resident #48: Record review of Resident # 48's face sheet revealed an admission date of [DATE] with the following diagnoses; acute hematogenous osteo[DIAGNOSES REDACTED], non-pressure chronic ulcer of leg, acute embolism and [MEDICAL CONDITION] of lower extremity, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], gastrostomy, [MEDICAL CONDITION] and [MEDICAL CONDITIONS] disease, chronic pain, [MEDICAL CONDITION], and long- term use of anticoagulants. Record review of Resident #48 Care Plan dated 04/26/18 revealed that resident was being care planned for anticoagulant therapy with one of the interventions to draw labs as ordered. Record review of Resident #48 Physician order [REDACTED]. Record review of Resident #48 MAR indicated [REDACTED]. Further review revealed that Resident #48 was administered [MEDICATION NAME] sodium 3.5mg via Gastrostomy Tube starting 04/30/18 and held on 5/9 and 5/14. Record review of Resident #48 lab results revealed that Resident #48 lab for PT/INR was not done for 5/7 (Monday) and 5/11 (Friday), and 5/16 (Monday). In an interview with DON on 05/21/18 at 10:00 a.m. copies of labs for Resident #48 were requested. The DON submitted the following dates of labs: 4/27, 4/30,5/2, 5/3, 5/4, 5/9, 5/14, and last lab drawn 5/18. The DON confirmed these were all labs drawn with results on Resident #48. Record review of the last lab drawn for Resident #48 revealed the results were PT-12.0 and INR- 1.25. indicating high levels (expected range was PT- 9.1-10.9 and INR- 0.93-1.11) Resident #54: Record review of Resident #54's Face Sheet revealed an [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #54's physician's orders [REDACTED].#54 on [MEDICAL TREATMENT] days Monday, Wednesday and Friday revealed in part: .please obtain lab results from [MEDICAL TREATMENT] and in house: On 4/27/18- CBC, BMP from [MEDICAL TREATMENT] On 4/29/18- CBC with differential and BMP On 4/30/18- CBC, and BMP every week from [MEDICAL TREATMENT] center stat. Record review of Resident # 54's record revealed no documentation indicating above lab from [MEDICAL TREATMENT] were done. The last lab on the computer was dated 3/8/18. In an interview on 5/17/18 at 11:00 a.m. charge nurse LVN X said all licensed nurses were responsible to check the lab results and call the doctor for any abnormal lab. She said she was not aware about Resident #54's labs from the [MEDICAL TREATMENT] center were not done. In an interview on 5/18/18 at 10:30 AM the DON said she checked Resident #54's lab from [MEDICAL TREATMENT] center and they were not in the chart. The DON said, This was not being done. The DON said that the in-house [MEDICAL TREATMENT] company does the labs. Resident #124: Record review of Resident #124's Face Sheet revealed a [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #124's physician's orders [REDACTED]. Record review of the Resident #124's record revealed no record that the lab was done on 5-7-18. In an interview on 5/18/18 at 10:30 AM the DON stated she was going to check Resident #124's lab results and call the lab company. The DON came back and said the lab was not done and that the facility was having problems with the current lab company. Resident #50: Record review of the Admission Record for Resident #50, dated 04/03/18, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #50's NP progress note dated 04/16/18 revealed .CURRENT LABS: CBC, BMP, magnesium if not already done .hemoglobin A1c 10.6 . Record review of a physician order [REDACTED]. Record review of the NP progress note dated 04/23/18 revealed CBC, BMP magnesium, and BNP (B-Type Natriuretic Peptide) on 4/26/18. CBC, BMP, every Thursdays. Record review of the lab results revealed the labs were drawn on 04/24/18 and not on 04/23/18. The lab results page reflected a Magnesium level was drawn and was within normal limits. There was no Ammonia level on the lab result. Record review of the lab results for Resident #50 revealed no labs were drawn on 05/03/18 (Thursday) as ordered. Interview on 05/15/18 at 11:30 a.m. ADON B said the lab reports were placed either in the paper chart medical record or downloaded onto the computer. Observation and interview at that time revealed ADON B printed the labs for 04/26/18, and then searched the paper chart medical record and confirmed the lab results for 05/03/18 were not located in the computer or the paper chart. Interview on 05/15/18 at 11:36 a.m. with the Medical Records Director revealed she searched her documentation and did not locate a lab result for 05/03/18. She said, Whatever they sent me has been uploaded. I double checked. Resident #11: Record review of the Admission Record for Resident #11 revealed a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Care Plan (no date) for Resident #11 revealed _____ (Resident #11) needs [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) r/t (related to) [MEDICAL CONDITION]. An Intervention/Task was reflected as Monitor labs and report to doctor as needed. Record review of the computerized orders for Resident #11 revealed CBC and BMP with [MEDICAL TREATMENT], ask the [MEDICAL TREATMENT] nurse to fax results. The 'start date' was 04/14/18, a Saturday. Record review of the lab results page for Resident #11 revealed the labs were not conducted on the next [MEDICAL TREATMENT] session on 04/16/18 (Monday). The page reflected there was a CBC and BMP lab processed on 04/18/18. There were no other lab results, except for a Sputum Culture, located in the paper chart or the computer chart. Record review of a physician's orders [REDACTED]. Record review of the lab results page for Resident #46 revealed no lab results for the order dated 4/24/18. Observation on 05/14/18 at 9:15 a.m. revealed Resident #11 to be in her room. She was receiving a [MEDICAL TREATMENT] treatment. A nurse was in the room, and she stated she was with the [MEDICAL TREATMENT] contract service. She said the resident received [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Resident #11 did not respond to a verbal greeting. Interview on 05/16/18 at 9:01 a.m. with the same [MEDICAL TREATMENT] nurse revealed she said she did everything regarding the [MEDICAL TREATMENT] process. She said she was filling in for the week and was not sure what the lab schedule was. Resident #16 Record review of the face sheet for Resident #16 revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]. Record review of the NP Progress Note dated 4/24/18 revealed the following documentation: AFIB- ON [MEDICATION NAME] PLAN TO CONTINUE 4-6 WEEKS. discharged ,[DATE] FROM THE HOSPITAL. Will continue [MEDICATION NAME] per neurosurgeon until follow up with cardiologist. Transition oral anticoagulation- will repeat labs works for cardiology appointment on Thursday 4/26. Record review of the lab results revealed the sample was collected on 4/29/18 and did not include results or an indication that Resident #16 had test collected for PT/INR. In an interview on 05/17/18 12:16 PM the DON, said she did not have the lab results for Resident #16 because the resident does not require PT/INR. After explaining that the resident had an order for [REDACTED]. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 1:01 PM they agreed the lab for Resident #16 should have been done but they were unable to provide any results or evidence that it was drawn. Resident #25: Record Review of Resident #25's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's [DIAGNOSES REDACTED]. Record review of Resident #25's Admission MDS dated [DATE] revealed Resident #25 had a BIMS of 12/15, indicating moderately impaired decision skills and required extensive assistance with one person for bed mobility, transfer, locomotion, dressing, toileting and personal hygiene ADLs. Further record review of Resident#25's admission MDS dated [DATE] revealed she required supervision setup assistance with eating ADL. Record review of Resident #25's file revealed a physician's orders [REDACTED]. Further record review of Resident #25 physician's orders [REDACTED]. Record review of Resident #25's record revealed documentation dated 04/22/2018 at 5:49p.m. indicating a Family member stated that psychiatrist previously ordered a B12, B level lab to be done but the lab had not been done. The family member stated the psychiatrist needed those results to determine next step in medication therapy, order was resubmitted stat. Record review of the labs provided by ADON A revealed: 4-23-18 Vitamin B12 Results 1971.0 with an expected range [PHONE NUMBER]. Continued review of lab results dated 04/23/2018 indicated TSH, B9 and Vitamin D were not completed. In an interview on 05/14/18 10:08 am Resident #25's Family member complained that Resident #25 was assessed by a Psychologist to determine cognitive loss. The family member said the facility does not do labs as ordered, and facility was not paying attention when Resident #25 was showing signs of confusion. The Family member stated a lab for B12 was order on 04/12/2018 and when she followed up on the order the facility had not done the labs. The facility then reordered the lab stat on 04/22/2018. Family member further stated the Psychiatrist needed the B12 lab results before being able to treat Resident #25. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they all agreed that they have an issue with the labs and the current lab company. They said the lab company was new and sometimes they responded late or do not send results timely. They also said they identified results errors and had to get labs retested . They said that they were aware of issues since April. When asked if they have called the lab company to discuss the issues, they said no. They said they were trying to get lab service with another lab and an application was sent last week to acquire new lab services. They said they were trying to get their own lab services here at the facility. When asked who was responsible for ensuring labs were done, they said all charge nurses and ADON's were responsible for ensuring labs were done. They said nurses were also responsible for ensuring lab results were communicated to NP A, who makes recommendations based on test results. During an interview with the Lab Supervisor on 5/18/18 at 2:33 PM, she stated ADON B left a message last week and Reported every once in a while the facility says they do not get lab results, that they were using the wrong fax number and requested results be sent to an alternative fax number. She said she had not discussed the message left with the facility because she had not been able to get in contact with them. The Supervisor said that the facility had not requested a meeting with them to report concerns about accuracy or timeliness of lab results.Record review of the lab service policy dated 5/19/18 provided by the facility revealed in part: .all requests for diagnostic services will be ordered by the physician .lab requisition log will be filled out by the Nurse receiving the orders .physician or extender will be notified upon facility receiving lab results . Record review of the service agreement between the facility and the laboratory service company revealed in part: .provider responsibilities .provider will perform only those tests order by the facility's and residents' attending physician .provider will notify facility of all critical/STAT results on residents in the best possible mode of correspondence and as required as quickly as the test results are completed and verified .results of all routine tests shall be provided to the facility by fax within 24 hours from the time the specimen is drawn .facility responsibilities .facility assures provider that all tests ordered are supported by a physician's orders [REDACTED].should any question arise over results, the provider should be notified immediately and given all pertinent information regarding specifics so that quality control procedures and polices be instituted immediately in order to maintain integrity of specimen and also provide proper quality or care to the resident . The Administrator and DON were notified on 5/18/18 at 11:52 am of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 5/21/18 at 9:22 am. POR included in part: .A complete audit of all the residents' orders was completed on 5/18/2018 to ensure that all ordered labs were completed. . residents were assessed for any changes in condition and the physicians were notified of the missing labs. The facility is changing to Quest Labs with a projected start date of 5/22/2018. The nursing staff will be in-serviced on the new lab protocol on 5/21/2018 . The Administrator and DON were immediately reeducated by the VP of Clinical Services regarding Resident Rights on 5/18/2018. The residents have the right to all care necessary for them to have the highest possible level of health. This includes the right to be free from abuse and neglect. It also includes the right to have labs completed timely and accurately and to have the system monitored. An in-service was immediately started with staff regarding Resident Rights. The in-service was completed by the Administrator and designees on 5/18/2018. This will be monitored by the Administrator. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. o The nurse will input all lab orders received by the physician in the electronic medical record. Stat orders should be entered as soon as they are received by the nurse, and regular orders need to be entered by the end of the shift. o The lab needs to be recorded on a requisitions (TRUNCATED)

- Resident #44 was not provided the physician ordered lab tests used to regulate her anticoagulant medication. Resident #44 was transferred to the hospital and diagnosed with [REDACTED]. - Resident #48's lab for PT/INR was not done as ordered by the physician. - Resident #54's lab order for BMP and CBC from [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #124's lab order for Hemoglobin A1C was not done as ordered by the physician. - Resident #50's lab order for CBC, BMP, and Ammonia level was not done as ordered by the physician. - Resident #11's lab order for CBC and BMP for [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #16's lab order for PT/INR was not done as ordered by the physician. - Resident #25's lab order for TSH, B12, B9 and Vitamin D level were not done as ordered by the physician. Labs were reordered and TSH, B9 and Vitamin D were still not done. These failures resulted in an IJ on 5/18/18. While the IJ was lowered on 5/22/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 8 residents and placed an additional 63 residents who require laboratory services at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, quality of life, hospitalization and possible death. Findings included: Resident #44: Record Review of Resident #44's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting right dominant side, [MEDICAL CONDITION], type 2 diabetes mellitus with unspecified complications, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION] of unspecified iliac vein, [MEDICAL CONDITIONS], disease of esophagus, constipation, and systemic lupus [DIAGNOSES REDACTED]tosus. Record review of Resident #44's Admission MDS assessment dated [DATE] revealed Resident #44 had a BIMS score of 11/15, indicating moderately impaired decision-making skills and required extensive assistance with one person for bed mobility, transfer, walking in room or corridor and toileting ADLs. Further record review of Resident#44's admission MDS dated [DATE] revealed she required limited assistance with 1 person for locomotion, dressing, eating and personal hygiene ADLs. The MDS was marked that she received anticoagulant medication every day. Record review of Resident #44's undated care plan revealed Resident #44 had complications with anticoagulant therapy. Resident #44's Care plan read: Focus: At risk for complication of anticoagulant therapy Goal: Medication will remain within therapeutic range as determined by physician during review period. Intervention/Tasks: Anticoagulant medication as ordered, do not give vitamin K, lab as ordered. Observe for signs/symptoms of abnormal bleeding such as bruising or black, tarry stools. Report findings to physician. Report any critical values to physician. Patient noted with bruising to rt arm due to blood drawn on 04/16/2018. Monitor site closely and any additional bruising. Report any critical values to physician. Intervention/Tasks: Labs as ordered. Report abnormal lab results to the MD. Weekly skin inspection. Medication as ordered, Dose changes based on labs. Record review of admission orders [REDACTED]. Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the PT/INR lab results between the dates of 3-26-18 to 4-19-18 for Resident #44 provided by ADON-A revealed that labs were not done on 04/05/18, 04/12/18, and 04/16/18. Record review of physician order [REDACTED]. Record review of an additional order dated 03/24/18 revealed to administer [MEDICATION NAME] sodium 7.5 mg one time per day until 3/25/18. Record review of Resident #44's PT/INR lab results dated 3/29/18 revealed PT of 20.1 (PT expected range was 9.1 - 10.9) and an INR of 2.10 (INR expected range was 0.93-1.11) Record review of Resident #44's PT/INR lab results dated 4/2/18 revealed PT of 26.3 (PT expected range was 9.1 - 10.9) and an INR of 2.76 (INR expected range was 0.93-1.11) Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 continued to receive [MEDICATION NAME] sodium 3mg every evening from 4/1/18 to 4/10/18. Record review of Resident #44's PT/INR lab results dated 4-9-18 revealed PT of 10.5 (PT expected range was 9.1 - 10.9) and an INR of 1.08 (INR expected range was 0.93-1.11) Further record review of Resident #44's MARs for (MONTH) (YEAR) revealed an order for [REDACTED]. The order was discontinued on 4/12/2018 with new orders to start [MEDICATION NAME] sodium 3mg every evening on 4/13/18. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a new physician order [REDACTED]. Record review of Resident #44's nursing notes dated 4-14-18 revealed Resident #44's family had concerns that patient had blood tinge mucus when she blew her nose. The NP for Resident#44's MD was called and received new order for [MEDICATION NAME] sodium to be given 7.5mg 2 days, then 5mg [MEDICATION NAME] sodium thereafter. PT/INR to be drawn on Monday. Nursing noted entered by LVN-LL. In an interview on 05/17/2018 at 04:17p.m. with LVN-LL revealed she did call Resident #44's MD to notify him of the blood in mucus noted in nursing notes on 4-14-18. Continued interview with LVN-LL revealed she did receive new physician's orders [REDACTED].#44's physician and it should be in the nurses' notes. Record review of Resident #44's nursing notes dated 4-15-18 revealed Family member of Resident #44 reported slight tinge of blood in mucus doctor was notified. New order of [MEDICATION NAME] sodium received, Resident #44 was alert and oriented with episodes of confusion. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a physician's orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-17-18 revealed ADON-A was called to Resident #44's room due to large bruise to right inner arm. Upon assessment Resident noted with 23 cm x 17cm purple/black bruise, dressing removed, no bleeding noted. The notes revealed that a pressure dressing was applied on 4-16-18 after blood was drawn due to increased bleeding. The resident was currently taking 7.5mg [MEDICATION NAME] sodium for the past two days. No redness, warmth, hematoma/knot felt, pt denied pain or discomfort. NP A notified. Record review of Resident #44's nursing notes dated 4-18-18 revealed large bruise of unknow origin noted to right hand covering the brachium and the antecubital area. Further review of nursing notes dated 4-18-18 revealed Resident #44 had confusion and weakness noted. Resident #44 stated, I'm crying happy tears because I'm going to the Lord today. Resident #44 noted to be alert and oriented verbally responsive with periods of forgetfulness/confusion. Record review of Resident #44's PT/INR lab results dated (MONTH) 19, (YEAR) revealed PT of 170.9 (PT expected range was 9.1 - 10.9) and an INR of 8.66 (INR expected range was 0.93-1.11) Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-19-18 revealed in part: . Resident was admitted for [MEDICAL CONDITIONS] and GERD. She is on [MEDICATION NAME] sodium therapy which is currently on hold due to critical labs value of INR greater than 18.66 and PT greater than 170.0 NP notified of the result and directed to send her to (hospital) for [MEDICATION NAME] sodium toxicity .Resident was transferred to hospital emergency room for [MEDICATION NAME] sodium toxicity. Record review of Resident #44's nursing notes dated 4/25/18 revealed Resident #44 arrived via stretcher in no distress, no sob, denies any pain or discomfort, skin warm, dry, and intact, soft and non-tender, bruising noted to BUE, no [MEDICAL CONDITION] noted, no active bleeding . continue to monitor. Record review of Resident #44's physician's orders [REDACTED]. Record review of the labs produced by the facility revealed that the labs for 5-10-18 and 05-14-18 were not done as ordered. Labs were done instead on 5/08/18 and 05/16/18. Recorded review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of nurses' note for Resident #44 dated 5/1/18 revealed that a PT/INR critical lab with values of 78.4 for PT and 8.43 of INR was received and NP was informed. The NP gave orders for vitamin K 10 mg one time, hold the [MEDICATION NAME] sodium, repeat PT/INR in the morning, and to monitor for bleeding .lab requisition made. Record review of lab result dated 05/02/18 revealed the PT was 29.2 and the INR was 3.08. lab result dated 05/03/18 had results of 12.6 for PT and 1.31 for INR. In an interview 05/14/18 at 10:34 a.m. with Resident #44's Family member she said the resident went out to the hospital due to too much [MEDICATION NAME] sodium in her system on 4-19-18. She said the new doctor increased the resident's [MEDICATION NAME] sodium from 2.5mg to 7.5mg causing her to PT/INR to go up. The Family member stated the resident just came back to facility two weeks ago. The Family member said she was concerned that the facility did labs to check the PT/INR but not as many labs as they should have done. The family member said that the resident had never been on a [MEDICATION NAME] sodium dosage higher than 3mg because it was too much for Resident #44. In an interview on 05/17/2018 at 10:35a.m. with ADON-A she said that orders for labs were written in the lab book by nurses at least two weeks in advance because things changed so quickly. She said that she was not aware that some labs were missing. In an interview with NP A on 05/17/18 11:54 AM, she said she worked M-F in the facility and coordinates with all physicians that serve the facility. She said Resident #44 has a [MEDICATION NAME] sodium sensitivity and the medication is adjusted often. She said she was usually on 2-3 mg. She said the dose was adjusted by NP B. She said she adjusted the dose based on lab results from 4/9/18, where the value was 1.6. and it was the last lab available. She said Resident #44 was also on antibiotics which can have an effect on the [MEDICATION NAME] sodium levels. She said she was made aware of the bruising to the arm but felt it was a result of the blood draw. She said they did compression to stop the bleeding. She said they gave a dose of Vitamin K and sent her to the hospital where she was given 8 units of frozen plasma. She said she was not aware that there were labs missing. She said labs were important to understand how to adjust the dose of [MEDICATION NAME]. Observation on 05/17/2018 at 12:15p.m. of Resident #44 revealed Resident in bed with some bruising midway to left arm. Resident appeared confused, unable to find call light that was next to her in bed. In an interview with NP B on 05/17/18 03:15 PM, he said he was responsible for changing the dose of the [MEDICATION NAME] sodium. He said Resident #44 had a [MEDICATION NAME] sodium sensitivity and had a history of [REDACTED].#44 usually had a PT/INR levels between 2-3 often but would present with PT/INR lab values between 1-1.6. He said she received bolus doses of 7.5mg of [MEDICATION NAME] sodium due to low lab values. He said Resident #44 was usually on a low dose of [MEDICATION NAME] sodium (2.5mg). He said the attending physician spoke with the family regarding long term goals due to instability of [MEDICATION NAME] sodium levels. He said they considered palliative care or hospice because the levels were difficult to control. He said Resident #44 was also on Bactrim for 2 days and [MEDICATION NAME], which can have an effect on [MEDICATION NAME] sodium levels. He said he wrote the standing order for PT/INR drawn on Mondays and Thursdays. He said he was aware that there were labs missing. He said he wrote a note on 5/2/18 regarding missing labs. He said he was not aware that labs were missing between 4/9- 4/19. He said nurses report results to him or to NP A who was at the facility M-F. He said she coordinates care with physicians that come to the facility. He said it was important to draw labs because the results help the physician determine how to adjust the dose. He said the facility has an issue with labs and have failed to make sure the standing orders are completed. He said he has talked to the facility regarding failure to complete lab orders. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they agreed there were labs that were not done. Resident #48: Record review of Resident # 48's face sheet revealed an admission date of [DATE] with the following diagnoses; acute hematogenous osteo[DIAGNOSES REDACTED], non-pressure chronic ulcer of leg, acute embolism and [MEDICAL CONDITION] of lower extremity, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], gastrostomy, [MEDICAL CONDITION] and [MEDICAL CONDITIONS] disease, chronic pain, [MEDICAL CONDITION], and long- term use of anticoagulants. Record review of Resident #48 Care Plan dated 04/26/18 revealed that resident was being care planned for anticoagulant therapy with one of the interventions to draw labs as ordered. Record review of Resident #48 Physician order [REDACTED]. Record review of Resident #48 MAR indicated [REDACTED]. Further review revealed that Resident #48 was administered [MEDICATION NAME] sodium 3.5mg via Gastrostomy Tube starting 04/30/18 and held on 5/9 and 5/14. Record review of Resident #48 lab results revealed that Resident #48 lab for PT/INR was not done for 5/7 (Monday) and 5/11 (Friday), and 5/16 (Monday). In an interview with DON on 05/21/18 at 10:00 a.m. copies of labs for Resident #48 were requested. The DON submitted the following dates of labs: 4/27, 4/30,5/2, 5/3, 5/4, 5/9, 5/14, and last lab drawn 5/18. The DON confirmed these were all labs drawn with results on Resident #48. Record review of the last lab drawn for Resident #48 revealed the results were PT-12.0 and INR- 1.25. indicating high levels (expected range was PT- 9.1-10.9 and INR- 0.93-1.11) Resident #54: Record review of Resident #54's Face Sheet revealed an [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #54's physician's orders [REDACTED].#54 on [MEDICAL TREATMENT] days Monday, Wednesday and Friday revealed in part: .please obtain lab results from [MEDICAL TREATMENT] and in house: On 4/27/18- CBC, BMP from [MEDICAL TREATMENT] On 4/29/18- CBC with differential and BMP On 4/30/18- CBC, and BMP every week from [MEDICAL TREATMENT] center stat. Record review of Resident # 54's record revealed no documentation indicating above lab from [MEDICAL TREATMENT] were done. The last lab on the computer was dated 3/8/18. In an interview on 5/17/18 at 11:00 a.m. charge nurse LVN X said all licensed nurses were responsible to check the lab results and call the doctor for any abnormal lab. She said she was not aware about Resident #54's labs from the [MEDICAL TREATMENT] center were not done. In an interview on 5/18/18 at 10:30 AM the DON said she checked Resident #54's lab from [MEDICAL TREATMENT] center and they were not in the chart. The DON said, This was not being done. The DON said that the in-house [MEDICAL TREATMENT] company does the labs. Resident #124: Record review of Resident #124's Face Sheet revealed a [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #124's physician's orders [REDACTED]. Record review of the Resident #124's record revealed no record that the lab was done on 5-7-18. In an interview on 5/18/18 at 10:30 AM the DON stated she was going to check Resident #124's lab results and call the lab company. The DON came back and said the lab was not done and that the facility was having problems with the current lab company. Resident #50: Record review of the Admission Record for Resident #50, dated 04/03/18, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #50's NP progress note dated 04/16/18 revealed .CURRENT LABS: CBC, BMP, magnesium if not already done .hemoglobin A1c 10.6 . Record review of a physician order [REDACTED]. Record review of the NP progress note dated 04/23/18 revealed CBC, BMP magnesium, and BNP (B-Type Natriuretic Peptide) on 4/26/18. CBC, BMP, every Thursdays. Record review of the lab results revealed the labs were drawn on 04/24/18 and not on 04/23/18. The lab results page reflected a Magnesium level was drawn and was within normal limits. There was no Ammonia level on the lab result. Record review of the lab results for Resident #50 revealed no labs were drawn on 05/03/18 (Thursday) as ordered. Interview on 05/15/18 at 11:30 a.m. ADON B said the lab reports were placed either in the paper chart medical record or downloaded onto the computer. Observation and interview at that time revealed ADON B printed the labs for 04/26/18, and then searched the paper chart medical record and confirmed the lab results for 05/03/18 were not located in the computer or the paper chart. Interview on 05/15/18 at 11:36 a.m. with the Medical Records Director revealed she searched her documentation and did not locate a lab result for 05/03/18. She said, Whatever they sent me has been uploaded. I double checked. Resident #11: Record review of the Admission Record for Resident #11 revealed a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Care Plan (no date) for Resident #11 revealed _____ (Resident #11) needs [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) r/t (related to) [MEDICAL CONDITION]. An Intervention/Task was reflected as Monitor labs and report to doctor as needed. Record review of the computerized orders for Resident #11 revealed CBC and BMP with [MEDICAL TREATMENT], ask the [MEDICAL TREATMENT] nurse to fax results. The 'start date' was 04/14/18, a Saturday. Record review of the lab results page for Resident #11 revealed the labs were not conducted on the next [MEDICAL TREATMENT] session on 04/16/18 (Monday). The page reflected there was a CBC and BMP lab processed on 04/18/18. There were no other lab results, except for a Sputum Culture, located in the paper chart or the computer chart. Record review of a physician's orders [REDACTED]. Record review of the lab results page for Resident #46 revealed no lab results for the order dated 4/24/18. Observation on 05/14/18 at 9:15 a.m. revealed Resident #11 to be in her room. She was receiving a [MEDICAL TREATMENT] treatment. A nurse was in the room, and she stated she was with the [MEDICAL TREATMENT] contract service. She said the resident received [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Resident #11 did not respond to a verbal greeting. Interview on 05/16/18 at 9:01 a.m. with the same [MEDICAL TREATMENT] nurse revealed she said she did everything regarding the [MEDICAL TREATMENT] process. She said she was filling in for the week and was not sure what the lab schedule was. Resident #16 Record review of the face sheet for Resident #16 revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]. Record review of the NP Progress Note dated 4/24/18 revealed the following documentation: AFIB- ON [MEDICATION NAME] PLAN TO CONTINUE 4-6 WEEKS. discharged ,[DATE] FROM THE HOSPITAL. Will continue [MEDICATION NAME] per neurosurgeon until follow up with cardiologist. Transition oral anticoagulation- will repeat labs works for cardiology appointment on Thursday 4/26. Record review of the lab results revealed the sample was collected on 4/29/18 and did not include results or an indication that Resident #16 had test collected for PT/INR. In an interview on 05/17/18 12:16 PM the DON, said she did not have the lab results for Resident #16 because the resident does not require PT/INR. After explaining that the resident had an order for [REDACTED]. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 1:01 PM they agreed the lab for Resident #16 should have been done but they were unable to provide any results or evidence that it was drawn. Resident #25: Record Review of Resident #25's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's [DIAGNOSES REDACTED]. Record review of Resident #25's Admission MDS dated [DATE] revealed Resident #25 had a BIMS of 12/15, indicating moderately impaired decision skills and required extensive assistance with one person for bed mobility, transfer, locomotion, dressing, toileting and personal hygiene ADLs. Further record review of Resident#25's admission MDS dated [DATE] revealed she required supervision setup assistance with eating ADL. Record review of Resident #25's file revealed a physician's orders [REDACTED]. Further record review of Resident #25 physician's orders [REDACTED]. Record review of Resident #25's record revealed documentation dated 04/22/2018 at 5:49p.m. indicating a Family member stated that psychiatrist previously ordered a B12, B level lab to be done but the lab had not been done. The family member stated the psychiatrist needed those results to determine next step in medication therapy, order was resubmitted stat. Record review of the labs provided by ADON A revealed: 4-23-18 Vitamin B12 Results 1971.0 with an expected range [PHONE NUMBER]. Continued review of lab results dated 04/23/2018 indicated TSH, B9 and Vitamin D were not completed. In an interview on 05/14/18 10:08 am Resident #25's Family member complained that Resident #25 was assessed by a Psychologist to determine cognitive loss. The family member said the facility does not do labs as ordered, and facility was not paying attention when Resident #25 was showing signs of confusion. The Family member stated a lab for B12 was order on 04/12/2018 and when she followed up on the order the facility had not done the labs. The facility then reordered the lab stat on 04/22/2018. Family member further stated the Psychiatrist needed the B12 lab results before being able to treat Resident #25. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they all agreed that they have an issue with the labs and the current lab company. They said the lab company was new and sometimes they responded late or do not send results timely. They also said they identified results errors and had to get labs retested . They said that they were aware of issues since April. When asked if they have called the lab company to discuss the issues, they said no. They said they were trying to get lab service with another lab and an application was sent last week to acquire new lab services. They said they were trying to get their own lab services here at the facility. When asked who was responsible for ensuring labs were done, they said all charge nurses and ADON's were responsible for ensuring labs were done. They said nurses were also responsible for ensuring lab results were communicated to NP A, who makes recommendations based on test results. During an interview with the Lab Supervisor on 5/18/18 at 2:33 PM, she stated ADON B left a message last week and Reported every once in a while the facility says they do not get lab results, that they were using the wrong fax number and requested results be sent to an alternative fax number. She said she had not discussed the message left with the facility because she had not been able to get in contact with them. The Supervisor said that the facility had not requested a meeting with them to report concerns about accuracy or timeliness of lab results. Record review of the lab service policy dated 5/19/18 provided by the facility revealed in part: .all requests for diagnostic services will be ordered by the physician .lab requisition log will be filled out by the Nurse receiving the orders .physician or extender will be notified upon facility receiving lab results . Record review of the service agreement between the facility and the laboratory service company revealed in part: .provider responsibilities .provider will perform only those tests order by the facility's and residents' attending physician .provider will notify facility of all critical/STAT results on residents in the best possible mode of correspondence and as required as quickly as the test results are completed and verified .results of all routine tests shall be provided to the facility by fax within 24 hours from the time the specimen is drawn .facility responsibilities .facility assures provider that all tests ordered are supported by a physician's orders [REDACTED].should any question arise over results, the provider should be notified immediately and given all pertinent information regarding specifics so that quality control procedures and polices be instituted immediately in order to maintain integrity of specimen and also provide proper quality or care to the resident . The Administrator and DON were notified on 5/18/18 at 11:52 am of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 5/21/18 at 9:22 am. POR included in part: .A complete audit of all the residents' orders was completed on 5/18/2018 to ensure that all ordered labs were completed. . residents were assessed for any changes in condition and the physicians were notified of the missing labs. The facility is changing to Quest Labs with a projected start date of 5/22/2018. The nursing staff will be in-serviced on the new lab protocol on 5/21/2018 . The Administrator and DON were immediately reeducated by the VP of Clinical Services regarding Resident Rights on 5/18/2018. The residents have the right to all care necessary for them to have the highest possible level of health. This includes the right to be free from abuse and neglect. It also includes the right to have labs completed timely and accurately and to have the system monitored. An in-service was immediately started with staff regarding Resident Rights. The in-service was completed by the Administrator and designees on 5/18/2018. This will be monitored by the Administrator. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. o The nurse will input all lab orders received by the physician in the electronic medical record. Stat orders should be entered as soon as they are received by the nurse, and regular orders need to be entered by the end of the shift. o The lab needs to be recorded on a requisitions form and the form needs to be placed in the lab binder under the date it needs to be collected. o The lab needs documented on the daily lab orders form in the lab binder. o Each morning the ADONs will review the labs order from the previous day and record them on the lab tracking log. o The ADONs will review the requisition binder to ensure that a requisition form has been completed for all ord (TRUNCATED)

Based on observation, interview and record review, the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 8 of 24 residents reviewed for Administration (Resident #44, #48, #54, #124, #50, #11, #16 and #25) in that The Administrator failed to: - Intervene and implement corrective measures when the contracted laboratory services were not completing labs as ordered by the physician. -To supervise the DON and the ADON to ensure nursing staff were receiving timely and accurate labs. The DON failed to: -To supervise and monitor the nursing staff to ensure they were receiving timely and accurate labs and that labs were done as ordered. These failures resulted in an IJ on 5/18/18. While the IJ was lowered on 5/22/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 8 residents and placed an additional 63 residents who require laboratory services at risk of not being provided with appropriate and timely medical intervention resulting in decline in their quality of care, quality of life, hospitalization and cause possible death. Findings include: In an interview with the Administrator on 5/21/18 at 9:30 am, he said he thought the Immediate Jeopardy came about because the facility failed to monitor labs as closely as they should. He said clearly there were several labs that were missed. The Administrator said he was aware of the issue but not the pervasiveness of the issues with labs. The Administrator said they started in-services and planned to put new policies in place as a corrective action. He said the facility has policies and procedures, corporate consultants, the Medical Director and other facilities as resources available to himself and staff. In an interview with the DON on 5/21/18 at 9:45 am, she said she thought the Immediate Jeopardy came about because the facility failed to monitor labs. She said she started to train nurses on laboratory procedures to ensure all labs were drawn and results were communicated to the physician. She said she was training nurses on laboratory procedures. The DON said the facility has policies and procedures, corporate consultants, the Medical Director and other facilities as resources available to herself and nursing staff. She also said that laboratory services had a consultant who was available for in-services. The DON provided an in service conducted on 5/4/18 with nurses with the topic to include how to completely fill out the lab requisition form and the daily lab order log. No other in-service on laboratory issues were done until monitoring of the POR. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they all agreed that they have an issue with the labs and the current lab company. They said the lab company was new and sometimes they responded late or do not send results timely. They also said they identified results errors and had to get labs retested . They said that they were aware of issues since April. When asked if they have called the lab company to discuss the issues, they said no. They said they were trying to get lab service with another lab and an application was sent last week to acquire new lab services. They said they were trying to get their own lab services here at the facility. When asked who was responsible for ensuring labs were done, they said all charge nurses and ADON's were responsible for ensuring labs were done. They said nurses were also responsible for ensuring lab results were communicated to NP A, who makes recommendations based on test results. During an interview with the Lab Supervisor on 5/18/18 at 2:33 PM, she stated ADON B left a message last week and Reported every once in a while the facility says they do not get lab results, that they were using the wrong fax number and requested results be sent to an alternative fax number. She said she had not discussed the message left with the facility because she had not been able to get in contact with them. The Supervisor said that the facility had not requested a meeting with them to report concerns about accuracy or timeliness of lab results. Resident #44: Record Review of Resident #44's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting right dominant side, [MEDICAL CONDITION], type 2 diabetes mellitus with unspecified complications, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION] of unspecified iliac vein, [MEDICAL CONDITIONS], disease of esophagus, constipation, and systemic lupus [DIAGNOSES REDACTED]tosus. Record review of Resident #44's Admission MDS assessment dated [DATE] revealed Resident #44 had a BIMS score of 11/15, indicating moderately impaired decision-making skills and required extensive assistance with one person for bed mobility, transfer, walking in room or corridor and toileting ADLs. Further record review of Resident#44's admission MDS dated [DATE] revealed she required limited assistance with 1 person for locomotion, dressing, eating and personal hygiene ADLs. The MDS was marked that she received anticoagulants every day. Record review of Resident #44's care plan dated initiated unknown with a target date of 6-22-18 revealed Resident #44 had complications with anticoagulant therapy. Resident #44's Care plan read: Focus: At risk for complication of anticoagulant therapy Goal: Medication will remain within therapeutic range as determined by physician during review period. Intervention/Tasks: Anticoagulant medication as ordered. Do not give vitamin K. Lab as ordered. Observe for signs/symptoms of abnormal bleeding such as bruising or black, tarry stools. Report findings to physician. Report any critical values to physician. Patient noted with bruising to rt arm due to blood drawn on 04/16/2018. Monitor site closely and any additional bruising. Report any critical values to physician. Record review of Resident #44's care plan dated initiated unknown with a target date of 6-22-18 revealed Resident #44 is on anticoagulant therapy. Resident #44's Care plan read: Focus: Resident is on Anticoagulant therapy [MEDICATION NAME] sodium r/t: [MEDICAL CONDITION]. Goal: Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Intervention/Tasks: Labs as ordered. Report abnormal lab results to the MD. Weekly skin inspection. Medication as ordered, Dose changes based on labs. Record review of admission orders [REDACTED]. Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the PT/INR lab results between the dates of 3-26-18 to 4-19-18 for Resident #44 provided by ADON-A revealed that labs were not done on 04/05/18, 04/12/18, and 04/16/18. Record review of Resident #44's PT/INR lab results dated (MONTH) 19, (YEAR) revealed PT of 170.9 (PT expected range was 9.1 - 10.9) and an INR of 8.66 (INR expected range was 0.93-1.11) Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-19-18 revealed in part: . Resident was admitted for [MEDICAL CONDITIONS] and GERD. She is on [MEDICATION NAME] sodium therapy which is currently on hold due to critical labs value of INR greater than 18.66 and PT greater than 170.0 NP notified of the result and directed to send her to (hospital) for [MEDICATION NAME] sodium toxicity .Resident was transferred to hospital emergency room for [MEDICATION NAME] sodium toxicity. In an interview 05/14/18 at 10:34 a.m. with Resident #44's Family member she said the resident went out to the hospital due to too much [MEDICATION NAME] sodium in her system on 4-19-18. She said the new doctor increased the resident's [MEDICATION NAME] sodium from 2.5mg to 7.5mg causing her to PT/INR to go up. The Family member stated she just came back to facility two weeks ago. The Family member was concerned saying that the facility did labs to check the PT/INR but not as many labs as they should have done. The family member said that the resident had never been on a [MEDICATION NAME] sodium dosage higher than 3mg because it was too much for Resident #44. In an interview with NP A on 05/17/18 11:54 AM, she said she worked M-F in the facility and coordinates with all physicians that serve the facility. She said Resident #44 has a [MEDICATION NAME] sodium sensitivity and the medication is adjusted often. She said she was usually on 2-3 mg. She said the dose was adjusted by NP B. She said she adjusted the dose based on lab results from 4/9/18, where the value was 1.6. and it was the last lab available. She said Resident #44 was also on antibiotics which can have an effect on the [MEDICATION NAME] sodium levels. She said she was made aware of the bruising to the arm but felt it was a result of the blood draw. She said they did compression to stop the bleeding. She said they gave a dose of Vit K and sent her to the hospital where she was given 8 units of frozen plasma. She said she was not aware that there were labs missing. She said labs were important to understand how to adjust the dose of [MEDICATION NAME]. In an interview with NP B on 05/17/18 03:15 PM, he said he was responsible for changing the dose of the [MEDICATION NAME] sodium. He said Resident #44 had a [MEDICATION NAME] sodium sensitivity and had a history of [REDACTED].#44 usually had a level of 2-3 often but would present with lab values between 1-1.6. He said she received bolus doses of 7.5 due to low lab values. He said Resident #44 was usually on a low dose (2.5mg). He said the attending physician spoke with the family regarding long term goals due to instability of [MEDICATION NAME] sodium levels. He said they considered palliative care or hospice because the levels were difficult to control. He said Resident Miller was also on Bactrim for 2 days and [MEDICATION NAME], which can have an effect on [MEDICATION NAME] sodium levels. He said he wrote the standing order for PT/INR drawn on Mondays and Thursdays. He said he was aware that there were labs missing. He said he wrote a note on 5/2/18 in regard to missing labs. He said he was not aware that labs were missing between 4/9- 4/19. He said nurses report results to him or to NP A who was at the facility M-F. He said she coordinates care with physicians that come to the facility. He said it was important to draw labs because the results help the physician determine how to adjust the dose. He said the facility has an issue with labs and have failed to make sure the standing orders are completed. He said he has talked to the facility regarding failure to complete lab orders. Resident #48: Record review of Resident # 48's face sheet revealed an admission date of [DATE] with the following diagnoses; acute hematogenous osteo[DIAGNOSES REDACTED], non-pressure chronic ulcer of leg, acute embolism and [MEDICAL CONDITION] of lower extremity, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], gastrostomy, [MEDICAL CONDITION] and [MEDICAL CONDITIONS] disease, chronic pain, [MEDICAL CONDITION], and long- term use of anticoagulants. Record review of Resident #48 Physician order [REDACTED]. Record review of Resident #48 Medication Administration Record [REDACTED]. Further review revealed that Resident #48 was administered [MEDICATION NAME] sodium 3.5mg via Gastrostomy Tube starting 04/30/18 and held on 5/9 and 5/14. Record review of Resident #48 lab results revealed that Resident #48 lab for PT/INR was not done for 5/7 (Monday) and 5/11 (Friday), and 5/16 (Monday). Resident #54: Record review of Resident #54's Face Sheet revealed an [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #54's physician's orders [REDACTED].#54 on [MEDICAL TREATMENT] days Monday, Wednesday and Friday revealed in part: .please obtain lab results from [MEDICAL TREATMENT] and in house: On 4/27/18 had CBC, BMP from [MEDICAL TREATMENT] On 4/29/18 Had CBC with differential and BMP On 4/30/18 had CBC, and BMP every week from [MEDICAL TREATMENT] center stat. Record review of Resident # 54's record revealed no documentation indicating above lab from [MEDICAL TREATMENT] recommendation were obtained. The last lab on the computer was dated 3/8/18. Resident #124: Record review of Resident #124's Face Sheet revealed a [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #124's physician's orders [REDACTED]. Record review of the resident's record revealed no record that the lab was done. Resident #50: Record review of the Admission Record for Resident #50, dated 04/03/18, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of an NP progress note dated 04/16/18 revealed CURRENT LABS: CBC, BMP, magnesium if not already done .hemoglobin A1c 10.6 . Record review of a physician order [REDACTED]. Record review of the NP progress note dated 04/23/18 revealed CBC, BMP magnesium, and BNP (B-Type Natriuretic Peptide) on 4/26/18. CBC, BMP, every Thursdays. Record review of the lab results revealed the labs were drawn on 04/24/18 and not on 04/23/18. The lab results page reflected a Magnesium level was drawn and was within normal limits. There was no Ammonia level on the lab result. Resident #11: Record review of the Admission Record for Resident #11 revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the computerized orders for Resident #11 revealed CBC and BMP with [MEDICAL TREATMENT], ask the [MEDICAL TREATMENT] nurse to fax results. The 'start date' was 04/14/18, a Saturday. Record review of the lab results page for Resident #11 revealed the labs were not conducted on the next [MEDICAL TREATMENT] session on 04/16/18 (Monday). The page reflected there was a CBC and BMP lab processed on 04/18/18. There were no other lab results, with the exception of a Sputum Culture, located in the paper chart or the computer chart Resident #16: Record review of the face sheet for Resident #16 revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]. Record review of the lab results revealed the sample was collected on 4/29/18 and did not include results or an indication that Resident #16 had test collected for PT/INR. In an interview on 05/17/18 12:16 PM the DON, said she did not have the results for Resident #16 because the resident does not require PT/INR. After explaining that the resident had an order for [REDACTED]. Resident #25: Record Review of Resident #25's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's [DIAGNOSES REDACTED]. Record review of Resident #25's file revealed a physician's orders [REDACTED]. Further record review of Resident #25 physician's orders [REDACTED]. Record review of Resident #25's record revealed documentation dated 04/22/2018 at 5:49p.m. indicating a Family member stated that psychiatrist previously ordered a B12, B level lab to be done but the lab had not been done. The family member stated the psychiatrist needed those results to determine next step in medication therapy, order was resubmitted stat. Record review of the labs provided by ADON A revealed: 4-23-18 Vitamin B12 Results 1971.0 with an expected range [PHONE NUMBER]. Continued review of lab results dated 04/23/2018 indicated TSH, B9 and Vitamin D were not completed. The Administrator and DON were notified on 5/18/18 at 11:52 am of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 5/21/18 at 9:22 am. POR included in part: .A complete audit of all the residents' orders was completed on 5/18/2018 to ensure that all ordered labs were completed. . residents were assessed for any changes in condition and the physicians were notified of the missing labs. The facility is changing to Quest Labs with a projected start date of 5/22/2018. The nursing staff will be in-serviced on the new lab protocol on 5/21/2018 . The Administrator and DON were immediately reeducated by the VP of Clinical Services regarding Resident Rights on 5/18/2018. The residents have the right to all care necessary for them to have the highest possible level of health. This includes the right to be free from abuse and neglect. It also includes the right to have labs completed timely and accurately and to have the system monitored. An in-service was immediately started with staff regarding Resident Rights. The in-service was completed by the Administrator and designees on 5/18/2018. This will be monitored by the Administrator. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. o The nurse will input all lab orders received by the physician in the electronic medical record. Stat orders should be entered as soon as they are received by the nurse, and regular orders need to be entered by the end of the shift. o The lab needs to be recorded on a requisitions form and the form needs to be placed in the lab binder under the date it needs to be collected. o The lab needs documented on the daily lab orders form in the lab binder. o Each morning the ADONs will review the labs order from the previous day and record them on the lab tracking log. o The ADONs will review the requisition binder to ensure that a requisition form has been completed for all ordered labs. o The DON/ADONs will bring the lab tracking log to the morning meeting. They will review the charts to ensure that the lab results have been received, the physician has been notified of abnormal labs, and new orders have been received if applicable. o Any unfinished labs or missing components identified in the morning meeting will be reviewed during stand down. o All medications that require monitoring will be care planned within 48 hours of the order being received. This system will be monitored and maintained by the DON starting 5/18/2018 . The Administrator and DON were immediately reeducated on 5/18/2018 by the VP of Clinical Services regarding abuse, neglect, and exploitation and reporting according to TX DADS Provider Letter 17-18. An in-service was immediately started with staff on 5/18/2018 regarding abuse, neglect, and exploitation and reporting according to TX DADS Provider Letter 17-18. The in-service will be completed by the Administrator and designees. This will be monitored by the Administrator . The Administrator, DON, and ADONs were immediately in-serviced by the VP of Clinical Services regarding the laboratory system and monitoring. The DON and ADONs immediately in-serviced the nurses regarding the lab process. The process will be monitored by the DON and ADONs during the daily clinical meeting. This monitoring started on 5/18/2018. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. No nurse will work a shift after 5/19/2018 without first being in-serviced . The facility was monitored between 5-18-18 and 05-22-18 with the following results: Record review of the forms revealed that in-services were conducted on all three shifts with the nursing staff attending. As of 5/22/18 most of the staff had been in-serviced. During the monitoring phase, interviews were conducted by the surveyors on different shifts with the nursing staff, nurse management, and CNA's. All interviewed staff verbalized up to date knowledge on new laboratory procedures, abuse and neglect, and resident rights. Observations were conducted during the monitoring phase of the eight residents that were identified with concerns related to laboratory services and no concerns were noted. According to the CMS 672 the census was 71 residents.

Based on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 8 of 18 residents reviewed for quaity of life (Resident #44, 48, 54, 124, 50, 11, 16 and 25) - Resident #44 was not provided the physician ordered lab tests used to regulate her anticoagulant medication. Resident #44 was transferred to the hospital and diagnosed with [REDACTED]. - Resident #48's lab for PT/INR was not done as ordered by the physician. - Resident #54's lab order for BMP and CBC from [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #124's lab order for Hemoglobin A1C was not done as ordered by the physician. - Resident #50's lab order for CBC, BMP, and Ammonia level was not done as ordered by the physician. - Resident #11's lab order for CBC and BMP for [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #16's lab order for PT/INR was not done as ordered by the physician. - Resident #25's lab order for TSH, B12, B9 and Vitamin D level were not done as ordered by the physician. Labs were reordered and TSH, B9 and Vitamin D were still not done. These failures resulted in an IJ on 5/18/18. While the IJ was lowered on 5/22/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 8 residents and placed an additional 63 residents who require laboratory services at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, quality of life, hospitalization and possible death. Findings included: Resident #44: Record Review of Resident #44's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting right dominant side, [MEDICAL CONDITION], type 2 diabetes mellitus with unspecified complications, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION] of unspecified iliac vein, [MEDICAL CONDITIONS], disease of esophagus, constipation, and systemic lupus [DIAGNOSES REDACTED]tosus. Record review of Resident #44's Admission MDS assessment dated [DATE] revealed Resident #44 had a BIMS score of 11/15, indicating moderately impaired decision-making skills and required extensive assistance with one person for bed mobility, transfer, walking in room or corridor and toileting ADLs. Further record review of Resident#44's admission MDS dated [DATE] revealed she required limited assistance with 1 person for locomotion, dressing, eating and personal hygiene ADLs. The MDS was marked that she received anticoagulant medication every day. Record review of Resident #44's undated care plan revealed Resident #44 had complications with anticoagulant therapy. Resident #44's Care plan read: Focus: At risk for complication of anticoagulant therapy Goal: Medication will remain within therapeutic range as determined by physician during review period. Intervention/Tasks: Anticoagulant medication as ordered, do not give vitamin K, lab as ordered. Observe for signs/symptoms of abnormal bleeding such as bruising or black, tarry stools. Report findings to physician. Report any critical values to physician. Patient noted with bruising to rt arm due to blood drawn on 04/16/2018. Monitor site closely and any additional bruising. Report any critical values to physician. Intervention/Tasks: Labs as ordered. Report abnormal lab results to the MD. Weekly skin inspection. Medication as ordered, Dose changes based on labs. Record review of admission orders [REDACTED]. Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the PT/INR lab results between the dates of 3-26-18 to 4-19-18 for Resident #44 provided by ADON-A revealed that labs were not done on 04/05/18, 04/12/18, and 04/16/18. Record review of physician order [REDACTED]. Record review of an additional order dated 03/24/18 revealed to administer [MEDICATION NAME] sodium 7.5 mg one time per day until 3/25/18. Record review of Resident #44's PT/INR lab results dated 3/29/18 revealed PT of 20.1 (PT expected range was 9.1 - 10.9) and an INR of 2.10 (INR expected range was 0.93-1.11) Record review of Resident #44's PT/INR lab results dated 4/2/18 revealed PT of 26.3 (PT expected range was 9.1 - 10.9) and an INR of 2.76 (INR expected range was 0.93-1.11) Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 continued to receive [MEDICATION NAME] sodium 3mg every evening from 4/1/18 to 4/10/18. Record review of Resident #44's PT/INR lab results dated 4-9-18 revealed PT of 10.5 (PT expected range was 9.1 - 10.9) and an INR of 1.08 (INR expected range was 0.93-1.11) Further record review of Resident #44's MARs for (MONTH) (YEAR) revealed an order for [REDACTED]. The order was discontinued on 4/12/2018 with new orders to start [MEDICATION NAME] sodium 3mg every evening on 4/13/18. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a new physician order [REDACTED]. Record review of Resident #44's nursing notes dated 4-14-18 revealed Resident #44's family had concerns that patient had blood tinge mucus when she blew her nose. The NP for Resident#44's MD was called and received new order for [MEDICATION NAME] sodium to be given 7.5mg 2 days, then 5mg [MEDICATION NAME] sodium thereafter. PT/INR to be drawn on Monday. Nursing noted entered by LVN-LL. In an interview on 05/17/2018 at 04:17p.m. with LVN-LL revealed she did call Resident #44's MD to notify him of the blood in mucus noted in nursing notes on 4-14-18. Continued interview with LVN-LL revealed she did receive new physician's orders [REDACTED].#44's physician and it should be in the nurses' notes. Record review of Resident #44's nursing notes dated 4-15-18 revealed Family member of Resident #44 reported slight tinge of blood in mucus doctor was notified. New order of [MEDICATION NAME] sodium received, Resident #44 was alert and oriented with episodes of confusion. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a physician's orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-17-18 revealed ADON-A was called to Resident #44's room due to large bruise to right inner arm. Upon assessment Resident noted with 23 cm x 17cm purple/black bruise, dressing removed, no bleeding noted. The notes revealed that a pressure dressing was applied on 4-16-18 after blood was drawn due to increased bleeding. The resident was currently taking 7.5mg [MEDICATION NAME] sodium for the past two days. No redness, warmth, hematoma/knot felt, pt denied pain or discomfort. NP A notified. Record review of Resident #44's nursing notes dated 4-18-18 revealed large bruise of unknow origin noted to right hand covering the brachium and the antecubital area. Further review of nursing notes dated 4-18-18 revealed Resident #44 had confusion and weakness noted. Resident #44 stated, I'm crying happy tears because I'm going to the Lord today. Resident #44 noted to be alert and oriented verbally responsive with periods of forgetfulness/confusion. Record review of Resident #44's PT/INR lab results dated (MONTH) 19, (YEAR) revealed PT of 170.9 (PT expected range was 9.1 - 10.9) and an INR of 8.66 (INR expected range was 0.93-1.11) Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-19-18 revealed in part: . Resident was admitted for [MEDICAL CONDITIONS] and GERD. She is on [MEDICATION NAME] sodium therapy which is currently on hold due to critical labs value of INR greater than 18.66 and PT greater than 170.0 NP notified of the result and directed to send her to (hospital) for [MEDICATION NAME] sodium toxicity .Resident was transferred to hospital emergency room for [MEDICATION NAME] sodium toxicity. Record review of Resident #44's nursing notes dated 4/25/18 revealed Resident #44 arrived via stretcher in no distress, no sob, denies any pain or discomfort, skin warm, dry, and intact, soft and non-tender, bruising noted to BUE, no [MEDICAL CONDITION] noted, no active bleeding . continue to monitor. Record review of Resident #44's physician's orders [REDACTED]. Record review of the labs produced by the facility revealed that the labs for 5-10-18 and 05-14-18 were not done as ordered. Labs were done instead on 5/08/18 and 05/16/18. Recorded review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of nurses' note for Resident #44 dated 5/1/18 revealed that a PT/INR critical lab with values of 78.4 for PT and 8.43 of INR was received and NP was informed. The NP gave orders for vitamin K 10 mg one time, hold the [MEDICATION NAME] sodium, repeat PT/INR in the morning, and to monitor for bleeding .lab requisition made. Record review of lab result dated 05/02/18 revealed the PT was 29.2 and the INR was 3.08. lab result dated 05/03/18 had results of 12.6 for PT and 1.31 for INR. In an interview 05/14/18 at 10:34 a.m. with Resident #44's Family member she said the resident went out to the hospital due to too much [MEDICATION NAME] sodium in her system on 4-19-18. She said the new doctor increased the resident's [MEDICATION NAME] sodium from 2.5mg to 7.5mg causing her to PT/INR to go up. The Family member stated the resident just came back to facility two weeks ago. The Family member said she was concerned that the facility did labs to check the PT/INR but not as many labs as they should have done. The family member said that the resident had never been on a [MEDICATION NAME] sodium dosage higher than 3mg because it was too much for Resident #44. In an interview on 05/17/2018 at 10:35a.m. with ADON-A she said that orders for labs were written in the lab book by nurses at least two weeks in advance because things changed so quickly. She said that she was not aware that some labs were missing. In an interview with NP A on 05/17/18 11:54 AM, she said she worked M-F in the facility and coordinates with all physicians that serve the facility. She said Resident #44 has a [MEDICATION NAME] sodium sensitivity and the medication is adjusted often. She said she was usually on 2-3 mg. She said the dose was adjusted by NP B. She said she adjusted the dose based on lab results from 4/9/18, where the value was 1.6. and it was the last lab available. She said Resident #44 was also on antibiotics which can have an effect on the [MEDICATION NAME] sodium levels. She said she was made aware of the bruising to the arm but felt it was a result of the blood draw. She said they did compression to stop the bleeding. She said they gave a dose of Vitamin K and sent her to the hospital where she was given 8 units of frozen plasma. She said she was not aware that there were labs missing. She said labs were important to understand how to adjust the dose of [MEDICATION NAME]. Observation on 05/17/2018 at 12:15p.m. of Resident #44 revealed Resident in bed with some bruising midway to left arm. Resident appeared confused, unable to find call light that was next to her in bed. In an interview with NP B on 05/17/18 03:15 PM, he said he was responsible for changing the dose of the [MEDICATION NAME] sodium. He said Resident #44 had a [MEDICATION NAME] sodium sensitivity and had a history of [REDACTED].#44 usually had a PT/INR levels between 2-3 often but would present with PT/INR lab values between 1-1.6. He said she received bolus doses of 7.5mg of [MEDICATION NAME] sodium due to low lab values. He said Resident #44 was usually on a low dose of [MEDICATION NAME] sodium (2.5mg). He said the attending physician spoke with the family regarding long term goals due to instability of [MEDICATION NAME] sodium levels. He said they considered palliative care or hospice because the levels were difficult to control. He said Resident #44 was also on Bactrim for 2 days and [MEDICATION NAME], which can have an effect on [MEDICATION NAME] sodium levels. He said he wrote the standing order for PT/INR drawn on Mondays and Thursdays. He said he was aware that there were labs missing. He said he wrote a note on 5/2/18 regarding missing labs. He said he was not aware that labs were missing between 4/9- 4/19. He said nurses report results to him or to NP A who was at the facility M-F. He said she coordinates care with physicians that come to the facility. He said it was important to draw labs because the results help the physician determine how to adjust the dose. He said the facility has an issue with labs and have failed to make sure the standing orders are completed. He said he has talked to the facility regarding failure to complete lab orders. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they agreed there were labs that were not done. Resident #48: Record review of Resident # 48's face sheet revealed an admission date of [DATE] with the following diagnoses; acute hematogenous osteo[DIAGNOSES REDACTED], non-pressure chronic ulcer of leg, acute embolism and [MEDICAL CONDITION] of lower extremity, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], gastrostomy, [MEDICAL CONDITION] and [MEDICAL CONDITIONS] disease, chronic pain, [MEDICAL CONDITION], and long- term use of anticoagulants. Record review of Resident #48 Care Plan dated 04/26/18 revealed that resident was being care planned for anticoagulant therapy with one of the interventions to draw labs as ordered. Record review of Resident #48 Physician order [REDACTED]. Record review of Resident #48 MAR indicated [REDACTED]. Further review revealed that Resident #48 was administered [MEDICATION NAME] sodium 3.5mg via Gastrostomy Tube starting 04/30/18 and held on 5/9 and 5/14. Record review of Resident #48 lab results revealed that Resident #48 lab for PT/INR was not done for 5/7 (Monday) and 5/11 (Friday), and 5/16 (Monday). In an interview with DON on 05/21/18 at 10:00 a.m. copies of labs for Resident #48 were requested. The DON submitted the following dates of labs: 4/27, 4/30,5/2, 5/3, 5/4, 5/9, 5/14, and last lab drawn 5/18. The DON confirmed these were all labs drawn with results on Resident #48. Record review of the last lab drawn for Resident #48 revealed the results were PT-12.0 and INR- 1.25. indicating high levels (expected range was PT- 9.1-10.9 and INR- 0.93-1.11) Resident #54: Record review of Resident #54's Face Sheet revealed an [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #54's physician's orders [REDACTED].#54 on [MEDICAL TREATMENT] days Monday, Wednesday and Friday revealed in part: .please obtain lab results from [MEDICAL TREATMENT] and in house: On 4/27/18- CBC, BMP from [MEDICAL TREATMENT] On 4/29/18- CBC with differential and BMP On 4/30/18- CBC, and BMP every week from [MEDICAL TREATMENT] center stat. Record review of Resident # 54's record revealed no documentation indicating above lab from [MEDICAL TREATMENT] were done. The last lab on the computer was dated 3/8/18. In an interview on 5/17/18 at 11:00 a.m. charge nurse LVN X said all licensed nurses were responsible to check the lab results and call the doctor for any abnormal lab. She said she was not aware about Resident #54's labs from the [MEDICAL TREATMENT] center were not done. In an interview on 5/18/18 at 10:30 AM the DON said she checked Resident #54's lab from [MEDICAL TREATMENT] center and they were not in the chart. The DON said, This was not being done. The DON said that the in-house [MEDICAL TREATMENT] company does the labs. Resident #124: Record review of Resident #124's Face Sheet revealed a [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #124's physician's orders [REDACTED]. Record review of the Resident #124's record revealed no record that the lab was done on 5-7-18. In an interview on 5/18/18 at 10:30 AM the DON stated she was going to check Resident #124's lab results and call the lab company. The DON came back and said the lab was not done and that the facility was having problems with the current lab company. Resident #50: Record review of the Admission Record for Resident #50, dated 04/03/18, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #50's NP progress note dated 04/16/18 revealed .CURRENT LABS: CBC, BMP, magnesium if not already done .hemoglobin A1c 10.6 . Record review of a physician order [REDACTED]. Record review of the NP progress note dated 04/23/18 revealed CBC, BMP magnesium, and BNP (B-Type Natriuretic Peptide) on 4/26/18. CBC, BMP, every Thursdays. Record review of the lab results revealed the labs were drawn on 04/24/18 and not on 04/23/18. The lab results page reflected a Magnesium level was drawn and was within normal limits. There was no Ammonia level on the lab result. Record review of the lab results for Resident #50 revealed no labs were drawn on 05/03/18 (Thursday) as ordered. Interview on 05/15/18 at 11:30 a.m. ADON B said the lab reports were placed either in the paper chart medical record or downloaded onto the computer. Observation and interview at that time revealed ADON B printed the labs for 04/26/18, and then searched the paper chart medical record and confirmed the lab results for 05/03/18 were not located in the computer or the paper chart. Interview on 05/15/18 at 11:36 a.m. with the Medical Records Director revealed she searched her documentation and did not locate a lab result for 05/03/18. She said, Whatever they sent me has been uploaded. I double checked. Resident #11: Record review of the Admission Record for Resident #11 revealed a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Care Plan (no date) for Resident #11 revealed _____ (Resident #11) needs [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) r/t (related to) [MEDICAL CONDITION]. An Intervention/Task was reflected as Monitor labs and report to doctor as needed. Record review of the computerized orders for Resident #11 revealed CBC and BMP with [MEDICAL TREATMENT], ask the [MEDICAL TREATMENT] nurse to fax results. The 'start date' was 04/14/18, a Saturday. Record review of the lab results page for Resident #11 revealed the labs were not conducted on the next [MEDICAL TREATMENT] session on 04/16/18 (Monday). The page reflected there was a CBC and BMP lab processed on 04/18/18. There were no other lab results, except for a Sputum Culture, located in the paper chart or the computer chart. Record review of a physician's orders [REDACTED]. Record review of the lab results page for Resident #46 revealed no lab results for the order dated 4/24/18. Observation on 05/14/18 at 9:15 a.m. revealed Resident #11 to be in her room. She was receiving a [MEDICAL TREATMENT] treatment. A nurse was in the room, and she stated she was with the [MEDICAL TREATMENT] contract service. She said the resident received [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Resident #11 did not respond to a verbal greeting. Interview on 05/16/18 at 9:01 a.m. with the same [MEDICAL TREATMENT] nurse revealed she said she did everything regarding the [MEDICAL TREATMENT] process. She said she was filling in for the week and was not sure what the lab schedule was. Resident #16 Record review of the face sheet for Resident #16 revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]. Record review of the NP Progress Note dated 4/24/18 revealed the following documentation: AFIB- ON [MEDICATION NAME] PLAN TO CONTINUE 4-6 WEEKS. discharged ,[DATE] FROM THE HOSPITAL. Will continue [MEDICATION NAME] per neurosurgeon until follow up with cardiologist. Transition oral anticoagulation- will repeat labs works for cardiology appointment on Thursday 4/26. Record review of the lab results revealed the sample was collected on 4/29/18 and did not include results or an indication that Resident #16 had test collected for PT/INR. In an interview on 05/17/18 12:16 PM the DON, said she did not have the lab results for Resident #16 because the resident does not require PT/INR. After explaining that the resident had an order for [REDACTED]. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 1:01 PM they agreed the lab for Resident #16 should have been done but they were unable to provide any results or evidence that it was drawn. Resident #25: Record Review of Resident #25's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's [DIAGNOSES REDACTED]. Record review of Resident #25's Admission MDS dated [DATE] revealed Resident #25 had a BIMS of 12/15, indicating moderately impaired decision skills and required extensive assistance with one person for bed mobility, transfer, locomotion, dressing, toileting and personal hygiene ADLs. Further record review of Resident#25's admission MDS dated [DATE] revealed she required supervision setup assistance with eating ADL. Record review of Resident #25's file revealed a physician's orders [REDACTED]. Further record review of Resident #25 physician's orders [REDACTED]. Record review of Resident #25's record revealed documentation dated 04/22/2018 at 5:49p.m. indicating a Family member stated that psychiatrist previously ordered a B12, B level lab to be done but the lab had not been done. The family member stated the psychiatrist needed those results to determine next step in medication therapy, order was resubmitted stat. Record review of the labs provided by ADON A revealed: 4-23-18 Vitamin B12 Results 1971.0 with an expected range [PHONE NUMBER]. Continued review of lab results dated 04/23/2018 indicated TSH, B9 and Vitamin D were not completed. In an interview on 05/14/18 10:08 am Resident #25's Family member complained that Resident #25 was assessed by a Psychologist to determine cognitive loss. The family member said the facility does not do labs as ordered, and facility was not paying attention when Resident #25 was showing signs of confusion. The Family member stated a lab for B12 was order on 04/12/2018 and when she followed up on the order the facility had not done the labs. The facility then reordered the lab stat on 04/22/2018. Family member further stated the Psychiatrist needed the B12 lab results before being able to treat Resident #25. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they all agreed that they have an issue with the labs and the current lab company. They said the lab company was new and sometimes they responded late or do not send results timely. They also said they identified results errors and had to get labs retested . They said that they were aware of issues since April. When asked if they have called the lab company to discuss the issues, they said no. They said they were trying to get lab service with another lab and an application was sent last week to acquire new lab services. They said they were trying to get their own lab services here at the facility. When asked who was responsible for ensuring labs were done, they said all charge nurses and ADON's were responsible for ensuring labs were done. They said nurses were also responsible for ensuring lab results were communicated to NP A, who makes recommendations based on test results. During an interview with the Lab Supervisor on 5/18/18 at 2:33 PM, she stated ADON B left a message last week and Reported every once in a while the facility says they do not get lab results, that they were using the wrong fax number and requested results be sent to an alternative fax number. She said she had not discussed the message left with the facility because she had not been able to get in contact with them. The Supervisor said that the facility had not requested a meeting with them to report concerns about accuracy or timeliness of lab results.Record review of the lab service policy dated 5/19/18 provided by the facility revealed in part: .all requests for diagnostic services will be ordered by the physician .lab requisition log will be filled out by the Nurse receiving the orders .physician or extender will be notified upon facility receiving lab results . Record review of the service agreement between the facility and the laboratory service company revealed in part: .provider responsibilities .provider will perform only those tests order by the facility's and residents' attending physician .provider will notify facility of all critical/STAT results on residents in the best possible mode of correspondence and as required as quickly as the test results are completed and verified .results of all routine tests shall be provided to the facility by fax within 24 hours from the time the specimen is drawn .facility responsibilities .facility assures provider that all tests ordered are supported by a physician's orders [REDACTED].should any question arise over results, the provider should be notified immediately and given all pertinent information regarding specifics so that quality control procedures and polices be instituted immediately in order to maintain integrity of specimen and also provide proper quality or care to the resident . The Administrator and DON were notified on 5/18/18 at 11:52 am of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 5/21/18 at 9:22 am. POR included in part: .A complete audit of all the residents' orders was completed on 5/18/2018 to ensure that all ordered labs were completed. . residents were assessed for any changes in condition and the physicians were notified of the missing labs. The facility is changing to Quest Labs with a projected start date of 5/22/2018. The nursing staff will be in-serviced on the new lab protocol on 5/21/2018 . The Administrator and DON were immediately reeducated by the VP of Clinical Services regarding Resident Rights on 5/18/2018. The residents have the right to all care necessary for them to have the highest possible level of health. This includes the right to be free from abuse and neglect. It also includes the right to have labs completed timely and accurately and to have the system monitored. An in-service was immediately started with staff regarding Resident Rights. The in-service was completed by the Administrator and designees on 5/18/2018. This will be monitored by the Administrator. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. o The nurse will input all lab orders received by the physician in the electronic medical record. Stat orders should be entered as soon as they are received by the nurse, and regular orders need to be entered by the end of the shift. o The lab needs to be recorded on a requisitions

Based on observation, interview and record review, the facility failed to administer in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 8 of 24 residents reviewed for Administration (Resident #44, #48, #54, #124, #50, #11, #16 and #25) in that The Administrator failed to: - Intervene and implement corrective measures when the contracted laboratory services were not completing labs as ordered by the physician. -To supervise the DON and the ADON to ensure nursing staff were receiving timely and accurate labs. The DON failed to: -To supervise and monitor the nursing staff to ensure they were receiving timely and accurate labs and that labs were done as ordered. These failures resulted in an IJ on 5/18/18. While the IJ was lowered on 5/22/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 8 residents and placed an additional 63 residents who require laboratory services at risk of not being provided with appropriate and timely medical intervention resulting in decline in their quality of care, quality of life, hospitalization and cause possible death. Findings include: In an interview with the Administrator on 5/21/18 at 9:30 am, he said he thought the Immediate Jeopardy came about because the facility failed to monitor labs as closely as they should. He said clearly there were several labs that were missed. The Administrator said he was aware of the issue but not the pervasiveness of the issues with labs. The Administrator said they started in-services and planned to put new policies in place as a corrective action. He said the facility has policies and procedures, corporate consultants, the Medical Director and other facilities as resources available to himself and staff. In an interview with the DON on 5/21/18 at 9:45 am, she said she thought the Immediate Jeopardy came about because the facility failed to monitor labs. She said she started to train nurses on laboratory procedures to ensure all labs were drawn and results were communicated to the physician. She said she was training nurses on laboratory procedures. The DON said the facility has policies and procedures, corporate consultants, the Medical Director and other facilities as resources available to herself and nursing staff. She also said that laboratory services had a consultant who was available for in-services. The DON provided an in service conducted on 5/4/18 with nurses with the topic to include how to completely fill out the lab requisition form and the daily lab order log. No other in-service on laboratory issues were done until monitoring of the POR. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they all agreed that they have an issue with the labs and the current lab company. They said the lab company was new and sometimes they responded late or do not send results timely. They also said they identified results errors and had to get labs retested . They said that they were aware of issues since April. When asked if they have called the lab company to discuss the issues, they said no. They said they were trying to get lab service with another lab and an application was sent last week to acquire new lab services. They said they were trying to get their own lab services here at the facility. When asked who was responsible for ensuring labs were done, they said all charge nurses and ADON's were responsible for ensuring labs were done. They said nurses were also responsible for ensuring lab results were communicated to NP A, who makes recommendations based on test results. During an interview with the Lab Supervisor on 5/18/18 at 2:33 PM, she stated ADON B left a message last week and Reported every once in a while the facility says they do not get lab results, that they were using the wrong fax number and requested results be sent to an alternative fax number. She said she had not discussed the message left with the facility because she had not been able to get in contact with them. The Supervisor said that the facility had not requested a meeting with them to report concerns about accuracy or timeliness of lab results. Resident #44: Record Review of Resident #44's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting right dominant side, [MEDICAL CONDITION], type 2 diabetes mellitus with unspecified complications, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION] of unspecified iliac vein, [MEDICAL CONDITIONS], disease of esophagus, constipation, and systemic lupus [DIAGNOSES REDACTED]tosus. Record review of Resident #44's Admission MDS assessment dated [DATE] revealed Resident #44 had a BIMS score of 11/15, indicating moderately impaired decision-making skills and required extensive assistance with one person for bed mobility, transfer, walking in room or corridor and toileting ADLs. Further record review of Resident#44's admission MDS dated [DATE] revealed she required limited assistance with 1 person for locomotion, dressing, eating and personal hygiene ADLs. The MDS was marked that she received anticoagulants every day. Record review of Resident #44's care plan dated initiated unknown with a target date of 6-22-18 revealed Resident #44 had complications with anticoagulant therapy. Resident #44's Care plan read: Focus: At risk for complication of anticoagulant therapy Goal: Medication will remain within therapeutic range as determined by physician during review period. Intervention/Tasks: Anticoagulant medication as ordered. Do not give vitamin K. Lab as ordered. Observe for signs/symptoms of abnormal bleeding such as bruising or black, tarry stools. Report findings to physician. Report any critical values to physician. Patient noted with bruising to rt arm due to blood drawn on 04/16/2018. Monitor site closely and any additional bruising. Report any critical values to physician. Record review of Resident #44's care plan dated initiated unknown with a target date of 6-22-18 revealed Resident #44 is on anticoagulant therapy. Resident #44's Care plan read: Focus: Resident is on Anticoagulant therapy [MEDICATION NAME] sodium r/t: [MEDICAL CONDITION]. Goal: Resident will be free from discomfort or adverse reactions related to anticoagulant use through the review date. Intervention/Tasks: Labs as ordered. Report abnormal lab results to the MD. Weekly skin inspection. Medication as ordered, Dose changes based on labs. Record review of admission orders [REDACTED]. Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the PT/INR lab results between the dates of 3-26-18 to 4-19-18 for Resident #44 provided by ADON-A revealed that labs were not done on 04/05/18, 04/12/18, and 04/16/18. Record review of Resident #44's PT/INR lab results dated (MONTH) 19, (YEAR) revealed PT of 170.9 (PT expected range was 9.1 - 10.9) and an INR of 8.66 (INR expected range was 0.93-1.11) Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-19-18 revealed in part: . Resident was admitted for [MEDICAL CONDITIONS] and GERD. She is on [MEDICATION NAME] sodium therapy which is currently on hold due to critical labs value of INR greater than 18.66 and PT greater than 170.0 NP notified of the result and directed to send her to (hospital) for [MEDICATION NAME] sodium toxicity .Resident was transferred to hospital emergency room for [MEDICATION NAME] sodium toxicity. In an interview 05/14/18 at 10:34 a.m. with Resident #44's Family member she said the resident went out to the hospital due to too much [MEDICATION NAME] sodium in her system on 4-19-18. She said the new doctor increased the resident's [MEDICATION NAME] sodium from 2.5mg to 7.5mg causing her to PT/INR to go up. The Family member stated she just came back to facility two weeks ago. The Family member was concerned saying that the facility did labs to check the PT/INR but not as many labs as they should have done. The family member said that the resident had never been on a [MEDICATION NAME] sodium dosage higher than 3mg because it was too much for Resident #44. In an interview with NP A on 05/17/18 11:54 AM, she said she worked M-F in the facility and coordinates with all physicians that serve the facility. She said Resident #44 has a [MEDICATION NAME] sodium sensitivity and the medication is adjusted often. She said she was usually on 2-3 mg. She said the dose was adjusted by NP B. She said she adjusted the dose based on lab results from 4/9/18, where the value was 1.6. and it was the last lab available. She said Resident #44 was also on antibiotics which can have an effect on the [MEDICATION NAME] sodium levels. She said she was made aware of the bruising to the arm but felt it was a result of the blood draw. She said they did compression to stop the bleeding. She said they gave a dose of Vit K and sent her to the hospital where she was given 8 units of frozen plasma. She said she was not aware that there were labs missing. She said labs were important to understand how to adjust the dose of [MEDICATION NAME]. In an interview with NP B on 05/17/18 03:15 PM, he said he was responsible for changing the dose of the [MEDICATION NAME] sodium. He said Resident #44 had a [MEDICATION NAME] sodium sensitivity and had a history of [REDACTED].#44 usually had a level of 2-3 often but would present with lab values between 1-1.6. He said she received bolus doses of 7.5 due to low lab values. He said Resident #44 was usually on a low dose (2.5mg). He said the attending physician spoke with the family regarding long term goals due to instability of [MEDICATION NAME] sodium levels. He said they considered palliative care or hospice because the levels were difficult to control. He said Resident Miller was also on Bactrim for 2 days and [MEDICATION NAME], which can have an effect on [MEDICATION NAME] sodium levels. He said he wrote the standing order for PT/INR drawn on Mondays and Thursdays. He said he was aware that there were labs missing. He said he wrote a note on 5/2/18 in regard to missing labs. He said he was not aware that labs were missing between 4/9- 4/19. He said nurses report results to him or to NP A who was at the facility M-F. He said she coordinates care with physicians that come to the facility. He said it was important to draw labs because the results help the physician determine how to adjust the dose. He said the facility has an issue with labs and have failed to make sure the standing orders are completed. He said he has talked to the facility regarding failure to complete lab orders. Resident #48: Record review of Resident # 48's face sheet revealed an admission date of [DATE] with the following diagnoses; acute hematogenous osteo[DIAGNOSES REDACTED], non-pressure chronic ulcer of leg, acute embolism and [MEDICAL CONDITION] of lower extremity, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], gastrostomy, [MEDICAL CONDITION] and [MEDICAL CONDITIONS] disease, chronic pain, [MEDICAL CONDITION], and long- term use of anticoagulants. Record review of Resident #48 Physician order [REDACTED]. Record review of Resident #48 Medication Administration Record [REDACTED]. Further review revealed that Resident #48 was administered [MEDICATION NAME] sodium 3.5mg via Gastrostomy Tube starting 04/30/18 and held on 5/9 and 5/14. Record review of Resident #48 lab results revealed that Resident #48 lab for PT/INR was not done for 5/7 (Monday) and 5/11 (Friday), and 5/16 (Monday). Resident #54: Record review of Resident #54's Face Sheet revealed an [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #54's physician's orders [REDACTED].#54 on [MEDICAL TREATMENT] days Monday, Wednesday and Friday revealed in part: .please obtain lab results from [MEDICAL TREATMENT] and in house: On 4/27/18 had CBC, BMP from [MEDICAL TREATMENT] On 4/29/18 Had CBC with differential and BMP On 4/30/18 had CBC, and BMP every week from [MEDICAL TREATMENT] center stat. Record review of Resident # 54's record revealed no documentation indicating above lab from [MEDICAL TREATMENT] recommendation were obtained. The last lab on the computer was dated 3/8/18. Resident #124: Record review of Resident #124's Face Sheet revealed a [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #124's physician's orders [REDACTED]. Record review of the resident's record revealed no record that the lab was done. Resident #50: Record review of the Admission Record for Resident #50, dated 04/03/18, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of an NP progress note dated 04/16/18 revealed CURRENT LABS: CBC, BMP, magnesium if not already done .hemoglobin A1c 10.6 . Record review of a physician order [REDACTED]. Record review of the NP progress note dated 04/23/18 revealed CBC, BMP magnesium, and BNP (B-Type Natriuretic Peptide) on 4/26/18. CBC, BMP, every Thursdays. Record review of the lab results revealed the labs were drawn on 04/24/18 and not on 04/23/18. The lab results page reflected a Magnesium level was drawn and was within normal limits. There was no Ammonia level on the lab result. Resident #11: Record review of the Admission Record for Resident #11 revealed a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the computerized orders for Resident #11 revealed CBC and BMP with [MEDICAL TREATMENT], ask the [MEDICAL TREATMENT] nurse to fax results. The 'start date' was 04/14/18, a Saturday. Record review of the lab results page for Resident #11 revealed the labs were not conducted on the next [MEDICAL TREATMENT] session on 04/16/18 (Monday). The page reflected there was a CBC and BMP lab processed on 04/18/18. There were no other lab results, with the exception of a Sputum Culture, located in the paper chart or the computer chart Resident #16: Record review of the face sheet for Resident #16 revealed a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]. Record review of the lab results revealed the sample was collected on 4/29/18 and did not include results or an indication that Resident #16 had test collected for PT/INR. In an interview on 05/17/18 12:16 PM the DON, said she did not have the results for Resident #16 because the resident does not require PT/INR. After explaining that the resident had an order for [REDACTED]. Resident #25: Record Review of Resident #25's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's [DIAGNOSES REDACTED]. Record review of Resident #25's file revealed a physician's orders [REDACTED]. Further record review of Resident #25 physician's orders [REDACTED]. Record review of Resident #25's record revealed documentation dated 04/22/2018 at 5:49p.m. indicating a Family member stated that psychiatrist previously ordered a B12, B level lab to be done but the lab had not been done. The family member stated the psychiatrist needed those results to determine next step in medication therapy, order was resubmitted stat. Record review of the labs provided by ADON A revealed: 4-23-18 Vitamin B12 Results 1971.0 with an expected range [PHONE NUMBER]. Continued review of lab results dated 04/23/2018 indicated TSH, B9 and Vitamin D were not completed. The Administrator and DON were notified on 5/18/18 at 11:52 am of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 5/21/18 at 9:22 am. POR included in part: .A complete audit of all the residents' orders was completed on 5/18/2018 to ensure that all ordered labs were completed. . residents were assessed for any changes in condition and the physicians were notified of the missing labs. The facility is changing to Quest Labs with a projected start date of 5/22/2018. The nursing staff will be in-serviced on the new lab protocol on 5/21/2018 . The Administrator and DON were immediately reeducated by the VP of Clinical Services regarding Resident Rights on 5/18/2018. The residents have the right to all care necessary for them to have the highest possible level of health. This includes the right to be free from abuse and neglect. It also includes the right to have labs completed timely and accurately and to have the system monitored. An in-service was immediately started with staff regarding Resident Rights. The in-service was completed by the Administrator and designees on 5/18/2018. This will be monitored by the Administrator. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. o The nurse will input all lab orders received by the physician in the electronic medical record. Stat orders should be entered as soon as they are received by the nurse, and regular orders need to be entered by the end of the shift. o The lab needs to be recorded on a requisitions form and the form needs to be placed in the lab binder under the date it needs to be collected. o The lab needs documented on the daily lab orders form in the lab binder. o Each morning the ADONs will review the labs order from the previous day and record them on the lab tracking log. o The ADONs will review the requisition binder to ensure that a requisition form has been completed for all ordered labs. o The DON/ADONs will bring the lab tracking log to the morning meeting. They will review the charts to ensure that the lab results have been received, the physician has been notified of abnormal labs, and new orders have been received if applicable. o Any unfinished labs or missing components identified in the morning meeting will be reviewed during stand down. o All medications that require monitoring will be care planned within 48 hours of the order being received. This system will be monitored and maintained by the DON starting 5/18/2018 . The Administrator and DON were immediately reeducated on 5/18/2018 by the VP of Clinical Services regarding abuse, neglect, and exploitation and reporting according to TX DADS Provider Letter 17-18. An in-service was immediately started with staff on 5/18/2018 regarding abuse, neglect, and exploitation and reporting according to TX DADS Provider Letter 17-18. The in-service will be completed by the Administrator and designees. This will be monitored by the Administrator . The Administrator, DON, and ADONs were immediately in-serviced by the VP of Clinical Services regarding the laboratory system and monitoring. The DON and ADONs immediately in-serviced the nurses regarding the lab process. The process will be monitored by the DON and ADONs during the daily clinical meeting. This monitoring started on 5/18/2018. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. No nurse will work a shift after 5/19/2018 without first being in-serviced . The facility was monitored between 5-18-18 and 05-22-18 with the following results: Record review of the forms revealed that in-services were conducted on all three shifts with the nursing staff attending. As of 5/22/18 most of the staff had been in-serviced. During the monitoring phase, interviews were conducted by the surveyors on different shifts with the nursing staff, nurse management, and CNA's. All interviewed staff verbalized up to date knowledge on new laboratory procedures, abuse and neglect, and resident rights. Observations were conducted during the monitoring phase of the eight residents that were identified with concerns related to laboratory services and no concerns were noted. According to the CMS 672 the census was 71 residents.

- Resident #44 was not provided the physician ordered lab tests used to regulate her anticoagulant medication. Resident #44 was transferred to the hospital and diagnosed with [REDACTED]. - Resident #48's lab for PT/INR was not done as ordered by the physician. - Resident #54's lab order for BMP and CBC from [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #124's lab order for Hemoglobin A1C was not done as ordered by the physician. - Resident #50's lab order for CBC, BMP, and Ammonia level was not done as ordered by the physician. - Resident #11's lab order for CBC and BMP for [MEDICAL TREATMENT] were not done as ordered by the physician. - Resident #16's lab order for PT/INR was not done as ordered by the physician. - Resident #25's lab order for TSH, B12, B9 and Vitamin D level were not done as ordered by the physician. Labs were reordered and TSH, B9 and Vitamin D were still not done. These failures resulted in an IJ on 5/18/18. While the IJ was lowered on 5/22/18 the facility remained out of compliance at a scope of isolated and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures affected 8 residents and placed an additional 63 residents who require laboratory services at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, quality of life, hospitalization and possible death. Findings included: Resident #44: Record Review of Resident #44's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44's [DIAGNOSES REDACTED]. [MEDICAL CONDITION] following unspecified [MEDICAL CONDITION] disease affecting right dominant side, [MEDICAL CONDITION], type 2 diabetes mellitus with unspecified complications, [MEDICAL CONDITION], acute embolism and [MEDICAL CONDITION] of unspecified iliac vein, [MEDICAL CONDITIONS], disease of esophagus, constipation, and systemic lupus [DIAGNOSES REDACTED]tosus. Record review of Resident #44's Admission MDS assessment dated [DATE] revealed Resident #44 had a BIMS score of 11/15, indicating moderately impaired decision-making skills and required extensive assistance with one person for bed mobility, transfer, walking in room or corridor and toileting ADLs. Further record review of Resident#44's admission MDS dated [DATE] revealed she required limited assistance with 1 person for locomotion, dressing, eating and personal hygiene ADLs. The MDS was marked that she received anticoagulant medication every day. Record review of Resident #44's undated care plan revealed Resident #44 had complications with anticoagulant therapy. Resident #44's Care plan read: Focus: At risk for complication of anticoagulant therapy Goal: Medication will remain within therapeutic range as determined by physician during review period. Intervention/Tasks: Anticoagulant medication as ordered, do not give vitamin K, lab as ordered. Observe for signs/symptoms of abnormal bleeding such as bruising or black, tarry stools. Report findings to physician. Report any critical values to physician. Patient noted with bruising to rt arm due to blood drawn on 04/16/2018. Monitor site closely and any additional bruising. Report any critical values to physician. Intervention/Tasks: Labs as ordered. Report abnormal lab results to the MD. Weekly skin inspection. Medication as ordered, Dose changes based on labs. Record review of admission orders [REDACTED]. Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of the PT/INR lab results between the dates of 3-26-18 to 4-19-18 for Resident #44 provided by ADON-A revealed that labs were not done on 04/05/18, 04/12/18, and 04/16/18. Record review of physician order [REDACTED]. Record review of an additional order dated 03/24/18 revealed to administer [MEDICATION NAME] sodium 7.5 mg one time per day until 3/25/18. Record review of Resident #44's PT/INR lab results dated 3/29/18 revealed PT of 20.1 (PT expected range was 9.1 - 10.9) and an INR of 2.10 (INR expected range was 0.93-1.11) Record review of Resident #44's PT/INR lab results dated 4/2/18 revealed PT of 26.3 (PT expected range was 9.1 - 10.9) and an INR of 2.76 (INR expected range was 0.93-1.11) Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 continued to receive [MEDICATION NAME] sodium 3mg every evening from 4/1/18 to 4/10/18. Record review of Resident #44's PT/INR lab results dated 4-9-18 revealed PT of 10.5 (PT expected range was 9.1 - 10.9) and an INR of 1.08 (INR expected range was 0.93-1.11) Further record review of Resident #44's MARs for (MONTH) (YEAR) revealed an order for [REDACTED]. The order was discontinued on 4/12/2018 with new orders to start [MEDICATION NAME] sodium 3mg every evening on 4/13/18. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a new physician order [REDACTED]. Record review of Resident #44's nursing notes dated 4-14-18 revealed Resident #44's family had concerns that patient had blood tinge mucus when she blew her nose. The NP for Resident#44's MD was called and received new order for [MEDICATION NAME] sodium to be given 7.5mg 2 days, then 5mg [MEDICATION NAME] sodium thereafter. PT/INR to be drawn on Monday. Nursing noted entered by LVN-LL. In an interview on 05/17/2018 at 04:17p.m. with LVN-LL revealed she did call Resident #44's MD to notify him of the blood in mucus noted in nursing notes on 4-14-18. Continued interview with LVN-LL revealed she did receive new physician's orders [REDACTED].#44's physician and it should be in the nurses' notes. Record review of Resident #44's nursing notes dated 4-15-18 revealed Family member of Resident #44 reported slight tinge of blood in mucus doctor was notified. New order of [MEDICATION NAME] sodium received, Resident #44 was alert and oriented with episodes of confusion. Record review of Resident #44's MARs for (MONTH) (YEAR) revealed Resident #44 received a physician's orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-17-18 revealed ADON-A was called to Resident #44's room due to large bruise to right inner arm. Upon assessment Resident noted with 23 cm x 17cm purple/black bruise, dressing removed, no bleeding noted. The notes revealed that a pressure dressing was applied on 4-16-18 after blood was drawn due to increased bleeding. The resident was currently taking 7.5mg [MEDICATION NAME] sodium for the past two days. No redness, warmth, hematoma/knot felt, pt denied pain or discomfort. NP A notified. Record review of Resident #44's nursing notes dated 4-18-18 revealed large bruise of unknow origin noted to right hand covering the brachium and the antecubital area. Further review of nursing notes dated 4-18-18 revealed Resident #44 had confusion and weakness noted. Resident #44 stated, I'm crying happy tears because I'm going to the Lord today. Resident #44 noted to be alert and oriented verbally responsive with periods of forgetfulness/confusion. Record review of Resident #44's PT/INR lab results dated (MONTH) 19, (YEAR) revealed PT of 170.9 (PT expected range was 9.1 - 10.9) and an INR of 8.66 (INR expected range was 0.93-1.11) Record review of Resident #44's physician orders [REDACTED]. Record review of Resident #44's nursing notes dated 4-19-18 revealed in part: . Resident was admitted for [MEDICAL CONDITIONS] and GERD. She is on [MEDICATION NAME] sodium therapy which is currently on hold due to critical labs value of INR greater than 18.66 and PT greater than 170.0 NP notified of the result and directed to send her to (hospital) for [MEDICATION NAME] sodium toxicity .Resident was transferred to hospital emergency room for [MEDICATION NAME] sodium toxicity. Record review of Resident #44's nursing notes dated 4/25/18 revealed Resident #44 arrived via stretcher in no distress, no sob, denies any pain or discomfort, skin warm, dry, and intact, soft and non-tender, bruising noted to BUE, no [MEDICAL CONDITION] noted, no active bleeding . continue to monitor. Record review of Resident #44's physician's orders [REDACTED]. Record review of the labs produced by the facility revealed that the labs for 5-10-18 and 05-14-18 were not done as ordered. Labs were done instead on 5/08/18 and 05/16/18. Recorded review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of Resident #44's (MONTH) (YEAR) MAR indicated [REDACTED]. Record review of nurses' note for Resident #44 dated 5/1/18 revealed that a PT/INR critical lab with values of 78.4 for PT and 8.43 of INR was received and NP was informed. The NP gave orders for vitamin K 10 mg one time, hold the [MEDICATION NAME] sodium, repeat PT/INR in the morning, and to monitor for bleeding .lab requisition made. Record review of lab result dated 05/02/18 revealed the PT was 29.2 and the INR was 3.08. lab result dated 05/03/18 had results of 12.6 for PT and 1.31 for INR. In an interview 05/14/18 at 10:34 a.m. with Resident #44's Family member she said the resident went out to the hospital due to too much [MEDICATION NAME] sodium in her system on 4-19-18. She said the new doctor increased the resident's [MEDICATION NAME] sodium from 2.5mg to 7.5mg causing her to PT/INR to go up. The Family member stated the resident just came back to facility two weeks ago. The Family member said she was concerned that the facility did labs to check the PT/INR but not as many labs as they should have done. The family member said that the resident had never been on a [MEDICATION NAME] sodium dosage higher than 3mg because it was too much for Resident #44. In an interview on 05/17/2018 at 10:35a.m. with ADON-A she said that orders for labs were written in the lab book by nurses at least two weeks in advance because things changed so quickly. She said that she was not aware that some labs were missing. In an interview with NP A on 05/17/18 11:54 AM, she said she worked M-F in the facility and coordinates with all physicians that serve the facility. She said Resident #44 has a [MEDICATION NAME] sodium sensitivity and the medication is adjusted often. She said she was usually on 2-3 mg. She said the dose was adjusted by NP B. She said she adjusted the dose based on lab results from 4/9/18, where the value was 1.6. and it was the last lab available. She said Resident #44 was also on antibiotics which can have an effect on the [MEDICATION NAME] sodium levels. She said she was made aware of the bruising to the arm but felt it was a result of the blood draw. She said they did compression to stop the bleeding. She said they gave a dose of Vitamin K and sent her to the hospital where she was given 8 units of frozen plasma. She said she was not aware that there were labs missing. She said labs were important to understand how to adjust the dose of [MEDICATION NAME]. Observation on 05/17/2018 at 12:15p.m. of Resident #44 revealed Resident in bed with some bruising midway to left arm. Resident appeared confused, unable to find call light that was next to her in bed. In an interview with NP B on 05/17/18 03:15 PM, he said he was responsible for changing the dose of the [MEDICATION NAME] sodium. He said Resident #44 had a [MEDICATION NAME] sodium sensitivity and had a history of [REDACTED].#44 usually had a PT/INR levels between 2-3 often but would present with PT/INR lab values between 1-1.6. He said she received bolus doses of 7.5mg of [MEDICATION NAME] sodium due to low lab values. He said Resident #44 was usually on a low dose of [MEDICATION NAME] sodium (2.5mg). He said the attending physician spoke with the family regarding long term goals due to instability of [MEDICATION NAME] sodium levels. He said they considered palliative care or hospice because the levels were difficult to control. He said Resident #44 was also on Bactrim for 2 days and [MEDICATION NAME], which can have an effect on [MEDICATION NAME] sodium levels. He said he wrote the standing order for PT/INR drawn on Mondays and Thursdays. He said he was aware that there were labs missing. He said he wrote a note on 5/2/18 regarding missing labs. He said he was not aware that labs were missing between 4/9- 4/19. He said nurses report results to him or to NP A who was at the facility M-F. He said she coordinates care with physicians that come to the facility. He said it was important to draw labs because the results help the physician determine how to adjust the dose. He said the facility has an issue with labs and have failed to make sure the standing orders are completed. He said he has talked to the facility regarding failure to complete lab orders. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they agreed there were labs that were not done. Resident #48: Record review of Resident # 48's face sheet revealed an admission date of [DATE] with the following diagnoses; acute hematogenous osteo[DIAGNOSES REDACTED], non-pressure chronic ulcer of leg, acute embolism and [MEDICAL CONDITION] of lower extremity, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], gastrostomy, [MEDICAL CONDITION] and [MEDICAL CONDITIONS] disease, chronic pain, [MEDICAL CONDITION], and long- term use of anticoagulants. Record review of Resident #48 Care Plan dated 04/26/18 revealed that resident was being care planned for anticoagulant therapy with one of the interventions to draw labs as ordered. Record review of Resident #48 Physician order [REDACTED]. Record review of Resident #48 MAR indicated [REDACTED]. Further review revealed that Resident #48 was administered [MEDICATION NAME] sodium 3.5mg via Gastrostomy Tube starting 04/30/18 and held on 5/9 and 5/14. Record review of Resident #48 lab results revealed that Resident #48 lab for PT/INR was not done for 5/7 (Monday) and 5/11 (Friday), and 5/16 (Monday). In an interview with DON on 05/21/18 at 10:00 a.m. copies of labs for Resident #48 were requested. The DON submitted the following dates of labs: 4/27, 4/30,5/2, 5/3, 5/4, 5/9, 5/14, and last lab drawn 5/18. The DON confirmed these were all labs drawn with results on Resident #48. Record review of the last lab drawn for Resident #48 revealed the results were PT-12.0 and INR- 1.25. indicating high levels (expected range was PT- 9.1-10.9 and INR- 0.93-1.11) Resident #54: Record review of Resident #54's Face Sheet revealed an [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #54's physician's orders [REDACTED].#54 on [MEDICAL TREATMENT] days Monday, Wednesday and Friday revealed in part: .please obtain lab results from [MEDICAL TREATMENT] and in house: On 4/27/18- CBC, BMP from [MEDICAL TREATMENT] On 4/29/18- CBC with differential and BMP On 4/30/18- CBC, and BMP every week from [MEDICAL TREATMENT] center stat. Record review of Resident # 54's record revealed no documentation indicating above lab from [MEDICAL TREATMENT] were done. The last lab on the computer was dated 3/8/18. In an interview on 5/17/18 at 11:00 a.m. charge nurse LVN X said all licensed nurses were responsible to check the lab results and call the doctor for any abnormal lab. She said she was not aware about Resident #54's labs from the [MEDICAL TREATMENT] center were not done. In an interview on 5/18/18 at 10:30 AM the DON said she checked Resident #54's lab from [MEDICAL TREATMENT] center and they were not in the chart. The DON said, This was not being done. The DON said that the in-house [MEDICAL TREATMENT] company does the labs. Resident #124: Record review of Resident #124's Face Sheet revealed a [AGE] years old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #124's physician's orders [REDACTED]. Record review of the Resident #124's record revealed no record that the lab was done on 5-7-18. In an interview on 5/18/18 at 10:30 AM the DON stated she was going to check Resident #124's lab results and call the lab company. The DON came back and said the lab was not done and that the facility was having problems with the current lab company. Resident #50: Record review of the Admission Record for Resident #50, dated 04/03/18, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of Resident #50's NP progress note dated 04/16/18 revealed .CURRENT LABS: CBC, BMP, magnesium if not already done .hemoglobin A1c 10.6 . Record review of a physician order [REDACTED]. Record review of the NP progress note dated 04/23/18 revealed CBC, BMP magnesium, and BNP (B-Type Natriuretic Peptide) on 4/26/18. CBC, BMP, every Thursdays. Record review of the lab results revealed the labs were drawn on 04/24/18 and not on 04/23/18. The lab results page reflected a Magnesium level was drawn and was within normal limits. There was no Ammonia level on the lab result. Record review of the lab results for Resident #50 revealed no labs were drawn on 05/03/18 (Thursday) as ordered. Interview on 05/15/18 at 11:30 a.m. ADON B said the lab reports were placed either in the paper chart medical record or downloaded onto the computer. Observation and interview at that time revealed ADON B printed the labs for 04/26/18, and then searched the paper chart medical record and confirmed the lab results for 05/03/18 were not located in the computer or the paper chart. Interview on 05/15/18 at 11:36 a.m. with the Medical Records Director revealed she searched her documentation and did not locate a lab result for 05/03/18. She said, Whatever they sent me has been uploaded. I double checked. Resident #11: Record review of the Admission Record for Resident #11 revealed a [AGE] year-old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Care Plan (no date) for Resident #11 revealed _____ (Resident #11) needs [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) r/t (related to) [MEDICAL CONDITION]. An Intervention/Task was reflected as Monitor labs and report to doctor as needed. Record review of the computerized orders for Resident #11 revealed CBC and BMP with [MEDICAL TREATMENT], ask the [MEDICAL TREATMENT] nurse to fax results. The 'start date' was 04/14/18, a Saturday. Record review of the lab results page for Resident #11 revealed the labs were not conducted on the next [MEDICAL TREATMENT] session on 04/16/18 (Monday). The page reflected there was a CBC and BMP lab processed on 04/18/18. There were no other lab results, except for a Sputum Culture, located in the paper chart or the computer chart. Record review of a physician's orders [REDACTED]. Record review of the lab results page for Resident #46 revealed no lab results for the order dated 4/24/18. Observation on 05/14/18 at 9:15 a.m. revealed Resident #11 to be in her room. She was receiving a [MEDICAL TREATMENT] treatment. A nurse was in the room, and she stated she was with the [MEDICAL TREATMENT] contract service. She said the resident received [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. Resident #11 did not respond to a verbal greeting. Interview on 05/16/18 at 9:01 a.m. with the same [MEDICAL TREATMENT] nurse revealed she said she did everything regarding the [MEDICAL TREATMENT] process. She said she was filling in for the week and was not sure what the lab schedule was. Resident #16 Record review of the face sheet for Resident #16 revealed a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review of physician's orders [REDACTED]. Record review of the NP Progress Note dated 4/24/18 revealed the following documentation: AFIB- ON [MEDICATION NAME] PLAN TO CONTINUE 4-6 WEEKS. discharged ,[DATE] FROM THE HOSPITAL. Will continue [MEDICATION NAME] per neurosurgeon until follow up with cardiologist. Transition oral anticoagulation- will repeat labs works for cardiology appointment on Thursday 4/26. Record review of the lab results revealed the sample was collected on 4/29/18 and did not include results or an indication that Resident #16 had test collected for PT/INR. In an interview on 05/17/18 12:16 PM the DON, said she did not have the lab results for Resident #16 because the resident does not require PT/INR. After explaining that the resident had an order for [REDACTED]. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 1:01 PM they agreed the lab for Resident #16 should have been done but they were unable to provide any results or evidence that it was drawn. Resident #25: Record Review of Resident #25's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's [DIAGNOSES REDACTED]. Record review of Resident #25's Admission MDS dated [DATE] revealed Resident #25 had a BIMS of 12/15, indicating moderately impaired decision skills and required extensive assistance with one person for bed mobility, transfer, locomotion, dressing, toileting and personal hygiene ADLs. Further record review of Resident#25's admission MDS dated [DATE] revealed she required supervision setup assistance with eating ADL. Record review of Resident #25's file revealed a physician's orders [REDACTED]. Further record review of Resident #25 physician's orders [REDACTED]. Record review of Resident #25's record revealed documentation dated 04/22/2018 at 5:49p.m. indicating a Family member stated that psychiatrist previously ordered a B12, B level lab to be done but the lab had not been done. The family member stated the psychiatrist needed those results to determine next step in medication therapy, order was resubmitted stat. Record review of the labs provided by ADON A revealed: 4-23-18 Vitamin B12 Results 1971.0 with an expected range [PHONE NUMBER]. Continued review of lab results dated 04/23/2018 indicated TSH, B9 and Vitamin D were not completed. In an interview on 05/14/18 10:08 am Resident #25's Family member complained that Resident #25 was assessed by a Psychologist to determine cognitive loss. The family member said the facility does not do labs as ordered, and facility was not paying attention when Resident #25 was showing signs of confusion. The Family member stated a lab for B12 was order on 04/12/2018 and when she followed up on the order the facility had not done the labs. The facility then reordered the lab stat on 04/22/2018. Family member further stated the Psychiatrist needed the B12 lab results before being able to treat Resident #25. In an interview with the Administrator, with DON, VP of Clinical Services, and VP of Operations present on 05/17/18 01:01 PM, they all agreed that they have an issue with the labs and the current lab company. They said the lab company was new and sometimes they responded late or do not send results timely. They also said they identified results errors and had to get labs retested . They said that they were aware of issues since April. When asked if they have called the lab company to discuss the issues, they said no. They said they were trying to get lab service with another lab and an application was sent last week to acquire new lab services. They said they were trying to get their own lab services here at the facility. When asked who was responsible for ensuring labs were done, they said all charge nurses and ADON's were responsible for ensuring labs were done. They said nurses were also responsible for ensuring lab results were communicated to NP A, who makes recommendations based on test results. During an interview with the Lab Supervisor on 5/18/18 at 2:33 PM, she stated ADON B left a message last week and Reported every once in a while the facility says they do not get lab results, that they were using the wrong fax number and requested results be sent to an alternative fax number. She said she had not discussed the message left with the facility because she had not been able to get in contact with them. The Supervisor said that the facility had not requested a meeting with them to report concerns about accuracy or timeliness of lab results. Record review of the lab service policy dated 5/19/18 provided by the facility revealed in part: .all requests for diagnostic services will be ordered by the physician .lab requisition log will be filled out by the Nurse receiving the orders .physician or extender will be notified upon facility receiving lab results . Record review of the service agreement between the facility and the laboratory service company revealed in part: .provider responsibilities .provider will perform only those tests order by the facility's and residents' attending physician .provider will notify facility of all critical/STAT results on residents in the best possible mode of correspondence and as required as quickly as the test results are completed and verified .results of all routine tests shall be provided to the facility by fax within 24 hours from the time the specimen is drawn .facility responsibilities .facility assures provider that all tests ordered are supported by a physician's orders [REDACTED].should any question arise over results, the provider should be notified immediately and given all pertinent information regarding specifics so that quality control procedures and polices be instituted immediately in order to maintain integrity of specimen and also provide proper quality or care to the resident . The Administrator and DON were notified on 5/18/18 at 11:52 am of the IJ situation due to the above failures and a POR was requested. The POR was received and after two revisions, it was accepted on 5/21/18 at 9:22 am. POR included in part: .A complete audit of all the residents' orders was completed on 5/18/2018 to ensure that all ordered labs were completed. . residents were assessed for any changes in condition and the physicians were notified of the missing labs. The facility is changing to Quest Labs with a projected start date of 5/22/2018. The nursing staff will be in-serviced on the new lab protocol on 5/21/2018 . The Administrator and DON were immediately reeducated by the VP of Clinical Services regarding Resident Rights on 5/18/2018. The residents have the right to all care necessary for them to have the highest possible level of health. This includes the right to be free from abuse and neglect. It also includes the right to have labs completed timely and accurately and to have the system monitored. An in-service was immediately started with staff regarding Resident Rights. The in-service was completed by the Administrator and designees on 5/18/2018. This will be monitored by the Administrator. The VP of Clinical Services immediately in-serviced the Administrator, DON, and ADONs on the lab system and monitoring on 5/18/2018. The DON and ADONs immediately in-serviced the nurses on the lab system protocol on 5/18/2018. This in-service will be completed on 5/19/2018 by 10:00 a.m. No nurse will work a shift after 5/19/2018 without first being in-serviced. o The nurse will input all lab orders received by the physician in the electronic medical record. Stat orders should be entered as soon as they are received by the nurse, and regular orders need to be entered by the end of the shift. o The lab needs to be recorded on a requisitions form and the form needs to be placed in the lab binder under the date it needs to be collected. o The lab needs documented on the daily lab orders form in the lab binder. o Each morning the ADONs will review the labs order from the previous day and record them on the lab tracking log. o The ADONs will review the requisition binder to ensure that a requisition form has been completed for all ord (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure 1 of 5 (RN T) licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of seven residents reviewed for respiratory care. (CR #1) in that -The facility failed to ensure RN-T had the competency and skills necessary to provide care to include vent care to CR#1 when she started experiencing a change in condition. -The facility failed to ensure RN- T was trained on emergency response. Staff did not contact 911 in a timely manner when CR #1 continued to experience respiratory distress. -The facility failed to ensure nurses that were assigned to care for residents in the vent unit were trained on vent care, vent equipment, and emergency management of vent dependant patients. -EMS arrived at the facility and transported the resident to the hospital where she passed away. These failures resulted in an IJ on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of isolated and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one discharged resident and placed 7 residents that were vent dependent at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, and quality of life, respiratory distress, and possible death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; Acute Respiratory Distress, Pneumonia,[MEDICAL CONDITIONS] Status, Dependence on Ventilator, [MEDICAL CONDITION], Type 2 Diabetes Mellitus, [MEDICAL CONDITION], Hypertension, Primary [MEDICAL CONDITION] Hypertension, Diastolic Heart Failure, and End Stage [MEDICAL CONDITION]. Record review of CR # 1 MDS assessment dated [DATE] revealed that CR #1 had a BIMS score of 15, indicating no cognitive issues. Further record review revealed that CR # 1 was totally dependent on staff for activities of daily living and required special treatments for the following: oxygen therapy, suctioning, [MEDICAL CONDITION] care, and ventilator or respirator. Record review of CR #1 48 hour baseline care plan dated [DATE] revealed that resident was being care planned for communication, activities of daily living (transfers, bed mobility, dressing, incontinence both bowel and bladder, and bathing), [MEDICAL TREATMENT], and specialized services needed (Respiratory Care and Enteral Feeding). Record review of CR # 1 Admission Summary Note dated [DATE] at 11:06p.m. revealed in part: .Guest arrived via stretcher from hospital in no distress, alert able to communicate by writing and gestures. No SOB,[MEDICAL CONDITION] line no excess secretions noted, skin warm and dry to touch. Abdomen Soft and non- tender, [DEVICE] patent, eats during day and feeding tube on from 6p to 6a, no s/s of hypo/[MEDICAL CONDITION] noted,[MEDICAL CONDITION] at 28% during the day and vent assist at evening . Record review of CR #1 Physician order [REDACTED].# 1's ventilator setting where: AC-12, tidal volume-500, Oxygen 40%, and a PEEP of 5 every night shift for airway. Record review of Daily Respiratory Note completed by RT-U dated [DATE] at 6:09 am for CR #1 revealed in part: . right and left lung sounds pre and post treatment with crackles and coarse productive sputum. CR # 1 on the vent, respiratory treatments [MEDICAL CONDITION]/suctioning. CR # 1 in no acute resp. distress . Record review of CR #1 Progress Notes completed by RN-T dated [DATE] at 9:48am (late entry) read in part .around 2300 (11:00 pm), patient was restless and nurse checked v/s BP ,[DATE], Pulse 78, RR 20, O2 Sat 98% on vent, blood sugar 114, performed pain assessment and PRN Tylenol 650 mg administered and patient was able to calm down and slept. Around 01:00 am, patient woke up with restless and agitated. At 01:20 am, nurse called patients doctor, but went straight to the voicemail. At 01:05 am, called IPC and spoke to staff who promise to send message to the Doctor and call back. At 02:05 am, called IPC again and asked for at least one time order for medication for restless and agitation. IPC staff member said the Doctor did not call her back .administered PRN Tylenol 650mg. Patient was able to sleep for a while till 04:30 am. At 0500 am went to check on patient and assessed the labored breathing. O2 Sat was 88% on vent and pulse was 128, nurse called for the respiratory therapist and v/s performed. BP ,[DATE], RR 22, HR 115, O2 sat 99% on vent, blood sugar 153. 911 called and patient sent out of the facility at 06:00 am . Record review of the EMS patient care report dated [DATE] revealed in part: .called out for a breathing problem .arrived at the facility at 5:47 am .the nurse stated that the patient had been in respiratory distress since 11:30 pm last night. Pt found in the facility bed in respiratory distress. The pt. was unresponsive .also EMTs noticed the suction canister full of mucus next to the bed .patient was transferred from the facility bed to the stretcher. Patient needed to be suctioned, so the respiratory therapist tried to suction the patient but the suction catheter would not go through the [MEDICAL CONDITION]. The respiratory therapist lifted the [MEDICAL CONDITION] tamer (tube securing device) to see why the catheter would not go through and the EMT noted that the [MEDICAL CONDITION] was twisted. EMTs asked the respiratory therapist why was the tube twisted, the therapist did not answer. The respiratory therapist then completely pulled out the connection device of the [MEDICAL CONDITION] and was unable to place the tube connection back in the [MEDICAL CONDITION]. The respiratory therapist then ran out of the room to go get a new connection .the therapist was unable to install the new [MEDICAL CONDITION] connection .EMT loaded the patient to the ambulance and on the way to the hospital the patient went in to [MEDICAL CONDITION] . Record review of CR # 1 hospital noted dated [DATE] at 6:34am read in part: .arrived at [DATE] at 6:12 am . CPR in progress .(facility) called 911 because patient was in respiratory distress. EMS said when they arrived on the scene, patient had spontaneous breathing. EMS said they wanted to suction pts.[MEDICAL CONDITION] could not get the suction through patient trach. EMS said the Respiratory Therapist at facility pulled [MEDICAL CONDITION], patient was having respiratory distress and EMS was unable to bag patient via BVM (bag valve mask). EMS said patient went into [MEDICAL CONDITION] en route . Record review of the hospital history of present illness dated [DATE] revealed in part: .arrived in [MEDICAL CONDITION] via EMS .per EMS, patient had difficulty breathing, and they report that someone had remove the trach. There was a problem associated with the [MEDICAL CONDITION], but the exact problem is unclear. Healthcare Provider attempted to adjust trach, but reportedly pulled it out or it somehow became dislodged . Record review of CR # 1 Physician Note in the ER dated [DATE] at 6:53am Revealed in part .History provided by the EMS is somewhat vague, and the fine details are unclear, however what is clear is that the patient was having some difficulty with her [MEDICAL CONDITION] at the nursing facility, and at some point this [MEDICAL CONDITION] became dislodged. Provider prior to the emergency department attempted to replace the [MEDICAL CONDITION]. EMS reported that they were having a very difficult time bagging the patient, meeting a lot of resistance .On presentation, the patient was attempted to be bagged through the [MEDICAL CONDITION], which was in the [MEDICAL CONDITION] site. The patient was again extremely difficult to bag .we attempted bag mask ventilation through the oropharynx, which was not successful .it became immediately clear that the patient did not have an intact airway .was in [MEDICAL CONDITION] and remained asystolic . Attempt was made at incising through the [MEDICAL CONDITION] membrane, but was unsuccessful .At this point, the patient had been asystolic for a prolonged period of time with prolonged CPR and she had been without ventilation or oxygenation for extremely prolonged time . It was determined that the patient was very unlikely to have any type of a reasonable outcome .Resuscitative efforts were discontinued .Time of death was 0630 . Record review of CR #1's late entry Respiratory Notes completed by RT-U dated [DATE] at 4:46 pm read in part: . about 11:00p.m. I made my rounds, I found patient crossed legged across the bed trying to crawl out of bed, struggling, agitated, and restless. Upon communicating and reading through her lips, she indicated to me that she was hot, and was fanning herself try to stay cool. She also indicated that she wanted to go to the bathroom. I then indicated to the nurses and CNA about her condition and wanting to go to the bathroom. I then asked them to look for a fan for her and to offer her a bed pan. According to the CNA, she refused the bed pan. I then checked her O2 saturation 99%. I also checked her ventilator to make sure that her prescribed parameters were ok .About 1:00am upon checking on the patient, she was still restless and agitated, complaint still being hot, restless, agitated, her legs crossed hanging out of the bed and her beddings/bed covers on the floor. At this time, I observed that the patient was in labored respiration. Checked her Oxygenation saturation 98% and on close observation I noticed that her abdomen was heavily distended and sounds tympanic upon percussion. I then indicated to the nurses especially RN-T that patient was not doing well and that they needed to address the issue because she was restless, agitated and now labored .I then advised them to try and call the Doctor and the patient needs to get to ER. I then started monitoring the patient condition closely up until 4:00am and 5:00am. Up until now, pt. was still agitated, restless and her laboring has increased .I made clear to the nurse that she need to get to the ER as soon as possible as her condition was getting worse .about 5:00am, I had to force them to call 911. So 911 was called and the patient was then picked up to the ER . Interview on [DATE] at 10:40 am RT-S said she worked the 2p-10p PRN. RT-S said she provided care for CR #1 on [DATE]. RT-S said CR #1 complained of shortness of breath towards the end of her shift between ,[DATE]pm therefore she administered a breathing treatment to resident and placed her back on the ventilator. RT-S said later on resident complaint of pain on her leg and she reported it to the nurse. RT-S said she followed back up with CR #1 who was then watching T.V. and communicated that she was feeling better and the resident wrote on piece a paper to her that she was doing a good job. RT-S said she then gave report to the oncoming RT. In a phone interview on [DATE] at 4:30 p.m. CNA A said that near the start of her shift (10:00 p.m. on [DATE]) CNA B was trying to get help for CR #1. She said the resident was sweating profusely and was hot. CNA A said the resident was complaining about being short of breath to RN T. CNA A said, The biggest problem was she couldn't breathe, and she was telling (the RN- T and RT-U) she couldn't breathe. She was having a hard time breathing. CNA A said the resident was in distress since around 11:00 p.m. CNA A said that when the Paramedics arrived in the morning, CR #1 seemed unresponsive. In a phone interview on [DATE] at 8:30 p.m. CNA B said when she started her shift on Saturday ([DATE] at 10:00 p.m.) CR #1 was different CNA B said I told the nurses something was wrong. CR #1 said she couldn't breathe. I told the nurse and the RT-U. She was sweating, snot running out of her nose. The nurse suctioned her nose and said Oh, she's just restless. Her eyes were bloodshot. CNA B said of RT-U, He came in there, didn't pay attention to what I was saying. I told him she needed suctioning, and he didn't suction. CNA B said the resident was in distress from the start of her shift until the morning. She said Towards the end of the shift she was crying. Bloodshot, red. Breathing hard like she couldn't breathe. In a phone interview on [DATE] at 8:45 p.m. with CNA A she said when the Paramedics arrived, they tried to suction CR #1, and tried to intubate her, but could not. She said, They had to use the ambu-bag on the trach. She couldn't breathe at night, asking for help. Interview on [DATE] at 11:05am ADON said CR # 1 left the facility via 911. ADON said she found out after the resident was sent to a local hospital. The ADON said CR #1 was at the Nursing facility for 3 days. The ADON said RN-T was the nurse taking care of CR #1 on the night shift on [DATE]. The ADON said RN-T reported that CR #1 was anxious. The ADON said the facility was going to terminate RN-T because she did not inform herself or Administration about the change in condition on CR #1, but RN-T resigned on her own. Interview on [DATE] at 11:10am with the Administrator said CR #1 went to a local hospital and believed resident had expired. In a phone interview on [DATE] at 11:25am RN-T said she worked the 10p-6a shift on [DATE]. RN-T said she started working at the facility in (MONTH) of (YEAR) full time. RN-T said she became a nurse in (YEAR). RN-T said when she came on her shift for the 10p-6a, CR #1 was a little restless and the resident O2 sat was 99% and resident vitals were okay. RN-T said CR #1 was unable to communicate due to resident being on the vent. RN-T said she checked resident medications and found that some of the resident's medications were on hold so she called the Doctor at around 11pm and it went to voicemail. RN-T said she then placed a call to the NP and the call went to voice-mail as well then she called the IPC and spoke to staff that informed her they would call the Doctor. RN-T said the happenings around CR #1 were in her Nursing Notes. Interview on [DATE] at 1:05pm RN-T said whenever there was a change in a resident condition in the facility the protocol was to notify the PCP and if they did not answer, then contact the Physician/NP then call the IPC group. RN-T said she had never heard of a Medical Director. RN-T said she never received training in suctioning residents with a [MEDICAL CONDITION] or for taking care of residents who were ventilator dependent. RN-T said the only training she received on ventilator patients was when she did clinical rotation in Nursing School. RN-T said she took on the assignment of caring for CR #1 who was ventilator dependent unit because the facility had a Respiratory Therapist. An attempted interview via phone on [DATE] at 12:45pm with RT-U was unsuccessful. There was no answer and was unable to leave a voice-mail. Record review of letter of resignation from RT-U dated [DATE] read in part: .On behalf of my manager of respiratory department . I hereby transfer my letter of Resignation effective from today. It has been my pleasure working with all of you. Thanks for all you do for the care of your residents and to every one of us working with you, saving life. Sincerely . Further record review of facility Separation Report signed by the facility Respiratory Director dated [DATE] revealed that the termination of RT-U was marked as personal and not eligible for rehire. Interview on [DATE] at 12:35pm the NP said CR #1 came to the facility over the weekend. The NP said she had received a call from the Nursing facility staff that CR # 1 had been admitted to the facility and a Medication Reconciliation was done with the nurse over the phone. The NP said she gave orders to continue all previous medications except for [MEDICATION NAME]. The NP said the reason she did not give orders to resume the medication [MEDICATION NAME] was because she wanted to first assess CR #1 due to resident history of Respiratory Distress and [MEDICAL CONDITION]. The NP said the facility staff reported to her that CR #1 was not in any distress and resident was stable upon admission. Interview on [DATE] at 1:27pm with Director of Respiratory Therapy (DRT) she said she received a call from RT-U at 6:30am on [DATE] informing her that CR #1 had to be sent out to the hospital because she was experiencing some respiratory distress. The DRT said RT-U reported to her that when CR #1 was sent out to the hospital the resident's oxygen saturation was good. The DRT said CR #1 was to be on [MEDICAL CONDITION] during the day and would go back on the ventilator at night around 10 or 11pm. The DRT said she noticed RT-U had not done any documentation on CR #1 on the 10p-6a shift for [DATE] and told RT-U that he needed to come in and document a late entry. In an interview with the DRT on [DATE] at 2:50 pm she said that because CR #1 was on [MEDICAL CONDITION] the day and then on a vent during the night, RT U should have documented that 2 ventilator checks were performed during the night and there was no documentation that it was done. The DRT also said she did not understand why RT-U was assessing CR #1 abdomen instead of the lung sounds because the abdomen was not an RT's area of study but the respiratory system was. Interview on [DATE] at 2:08pm the ADON said the only people that RN-T was calling to notify of change in CR #1 condition was the IPC who notifies the Physician. The ADON said the NP and Physician did not see CR #1 because she came to the facility late on a Friday night. The ADON said when she spoke with RN-T and asked why she didn't call the Medical Director, the NP, or herself, RN-T could not give an answer. Interview on [DATE] at 12:20 pm the facility Administrator and the ADON both said that they believed that based on the documentation in change in condition for CR #1 that facility staff was monitoring CR #1 and following the facility protocol. Both agreed that they wished that RN-T would have reached out to Administration to tell them what was going on. The ADON said she did do in-service just could not remember what day. The Administrator and the ADON said RT-U was employed on a PRN base and was no longer employed at the facility. Interview on [DATE] at 2:00 pm the interim DON said he was in agreement with the Administrator and ADON that the facility staff was following protocol in monitoring CR #1. The interim DON said after reviewing the documentation of RN-T and RT-U regarding CR #1, there was room for improvement but did not see a deficiency. The interim DON said when he reviewed RT-U documentation that he had to force RN-T to call the Physician he did not know what he meant by that and would have to talk to RT-U to clarify. The interim DON said RT-U no longer worked at the facility. Interview on [DATE] at 3:25pm the interim DON said after reading RN-T and RT-U documentation again, the Physician/NP should have been called. The interim DON said that if there were no results from calling the Physician/NP, CR # 1 should have been sent out to the hospital. Interview on [DATE] at 3:17pm with LVN-C, who was working on hall 500 (ventilator dependent unit) said she had been working at the facility for 2 years. She said 2 years ago was the last time she received training on ventilator dependent residents. Interview on [DATE] at 8:55am with ADON said whenever a resident experience a change in condition, the nurse was to notify the family and the Doctor and carry out any orders received. Interview on [DATE] at 11:45am with the ADON regarding the nurses in the facility being in-serviced on how to care for residents on Ventilators. The ADON said the facility have Respiratory Therapist in the facility 24 hours a day and seven days a week to care for the seven residents on vents they have. The ADON said the nurses were in-serviced on caring for residents with ventilators at the time of hire, before taking an assignment with residents who were ventilator dependent. ADON said the nurses receive at least two days or more if needed in training with the ventilators before taking care of a ventilator resident. The ADON said this training was done at the time of hire and yearly. The ADON said she did not believe the facility had a check off for ventilator training with return demonstration. Interview on [DATE] at 12:25pm the interim DON said it was the Respiratory Therapist Director that trained the nurses in the facility on ventilators and the facility did have a check off list of the training. The DON said training was done with the staff every year. Record review of five nurses personnel files revealed no training or check off list with return demonstration of understanding on how to care for ventilator dependent residents. Record review of a list provided by the ADON revealed that 21 nurses (LVNs and RNs) had worked on the 500 Hall in the month of (MONTH) (YEAR). Record review of the personnel files of some of the nurses that worked on the Hall-500 (Vent dependent residents) for the month of (MONTH) (YEAR) revealed no ventilator use training. Record review of Nursing facility last In-service Training Report with the Nursing department on SBARs, change in condition and worsening, notifying MD,NP, family, or charge nurse was dated [DATE]. Interview on [DATE] at 1:25pm LVN-B said he work the 10p-6a shift on a full time basis on halls ,[DATE]. LVN-B said he did not received orientation on ventilators at the time of hire. LVN-B said the ventilator residents were staffed with Registered Nurses. LVN-B said if a resident started to experience a change in condition, he would first do an assessment, call the Doctor immediately and if the Doctor did not respond, he would call the facility Medical Director. Interview on [DATE] at 1:30 p.m. the DRT said she provided training to nurses, but did not conduct classes. She added, There may be people, PRNs or weekend I may never see to train. She said the RT could have done ABG's (arterial blood gases) and called the Physician or her if there was complications. She added that if a resident was in respiratory distress, the Respiratory Therapist was responsible. Interview on [DATE] at 10:45am the DRT said she goes over with the CNA's and nurses on how to report signs of distress with a resident on a ventilator. The DRT said she tries to do annual training on everyone because the facility have staff that come and go. The DRT said she ensured that the RT's working at the facility were competent in their skills, they have to complete a check off list demonstrating their skills and she hired people with at least [AGE] years of experience. Interview and observation on [DATE] at 11:55am LVN-D said she had been a nurse for 7 years and had been working at the facility for about 6 months. She said she normally worked the 500-hall were the vent patients were. LVN-D said she was still learning how to work with ventilators. The surveyor took LVN-D to a resident room that was ventilator dependent and asked her what the settings meant on the machine such as PEEP, Tidal Volume, Pressure Control, Pressure Support, and breath rate. LVN-D said she was not for sure and would have to find out. LVN-D said she was trained but felt the training did not stick with her. LVN-D said she had never worked with vent-dependent residents before until she became a nurse in this Nursing facility. Interview on [DATE] at 12:08 pm the Administrator said he started working at the facility in (MONTH) of (YEAR) and the interim DON that the facility have now was interim at that time. The Administrator said he confirmed with the Director of Respiratory that the facility started accepting vent dependent residents about 2-,[DATE] years ago. After multiple requests from the Interim DON, the Administrator and the ADON, the facility was did not provide documentation of nurse training or return demonstration for the facility nurses on ventilator dependent residents. Record review of facility Policy on Mechanical Ventilation revised (MONTH) 2010: .While the resident is on mechanical ventilation, assess for the following: 1)Signs and symptoms of [MEDICAL CONDITION], including: Diminished lung sounds, cyanosis, fatigue, and pallor . .2)Airway obstruction(such as indicated) .3)Arterial blood gases or oxygen saturation .4)Vital signs .5) Cardiac rhythm The Administrator and interim DON were notified on [DATE] at 2:00 pm of the IJ situation due to the above failures and a POR was requested. The POR was received and after 2 revisions it was accepted on [DATE] at 1:50pm. POR included in part: . All residents were immediately assessed on [DATE] by the DON, ADON, and Licensed Nurses for any changes in condition. These assessments were completed on [DATE]. All the following in-services will be completed with staff prior to them working their next schedule shift . Prompt Assessment Licensed Nurses were reeducated on [DATE] on promptly assessing residents each shift and documenting in a daily skilled nursing note, and completing an SBAR for any changes in condition. This education was conducted by the Director of Nurses, and Assistant Director of Nursing. Documentation will be monitored for completion prior to the end of each shift by the DON, ADONs, and designees using the 24 Summary. The Administrator will monitor the timely completion of the inservice. Completion Date: [DATE] All ventilator patients were immediately assessed by the Director of Respiratory Therapy (DRT) and Licensed Respiratory Therapists for potential changes in condition on [DATE] and was completed on [DATE]. No new changes in condition were noted. Licensed Respiratory Therapists were reeducated on [DATE] on promptly assessing residents each shift and documenting in a daily respiratory therapy note. This education was conducted by the DRT and designee. Documentation will be monitored for completion prior to the end each of each shift by the DON, ADONs, DRT, and designee. The Administrator will monitor the timely completion of the inservice. Completion Date: [DATE] All departments were reeducated on the Stop and Watch tool on [DATE] by the DON, ADON, and designee. This will be monitored by the Administrator. Completion Date: [DATE] A new policy was implemented on [DATE] that report needs to be given between nursing and respiratory therapy at the change of each shift. Physician Notification Licensed Nurses and Respiratory Therapist were immediately inserviced on [DATE] on notifying physicians in a timely manner. This was conducted by the DON, ADON, DRT, and designee. All changes in conditions will be reviewed during the daily clinical meeting. Completion Date: [DATE] Calling 911 in a Timely Manner Licensed Nurses and Respiratory Therapists were reeducated on [DATE] on the existing protocols regarding emergency situations and when to calling 911. This was conducted by the DON, ADONs, DRT, and designee. This will be monitored by the Administrator, DON, and ADONs. Completion Date: [DATE] Training to Identify Emergency Issues for Vent Dependent Patients and General Vent Training DON and the DRT immediately started an inservice on [DATE] on identification of emergency issues related to vent dependent patients and reporting any changes in a condition to the physician in a timely manner in accordance with facility policy and procedures. This will be monitored by the Administrator. Completion Date: [DATE] An in-service was immediately started on [DATE] for all Licensed Nurses and Respiratory Therapist on the type of vent used at the facility and settings. This will be monitored by the Administrator. Completion Date: [DATE] Any Significant Change to Supervisor and Physician An in-service was immediately started on [DATE] for Licensed Nurses and Respiratory Therapist on reporting significant changes in condition to supervisor and physician. This in-service will be completed by the DON, ADON, DRT, and designee. This will be monitored by the Administrator . The facility was monitored from [DATE] until [DATE] by the surveyors with the following results: Record review revealed new training and in-services were done with facility staff in the following areas: -when and who to report in timely manner of a change in resident condition utilizing the stop and watch and SBAR documentation as a guiding tool. -Abuse/Neglect and who to report to. -When it is appropriate to alert 911 EMS in transferring a resident to a higher level of care after experiencing a change in condition and notifying all parties. -Ventilator training with the nursing staff and respiratory staff in caring for resident vent dependent (recognizing the vent settings and what they mean as well as recognizing a change in condition (resp. distress) and notifying the Physician, Medical Director, RP, and Administration. -Performing prompt assessments on resident (s) experiencing a change in condition and reporting to Physician/NP, Medical Director, and RP (responsible party) in a timely manner Record review of the forms revealed that In-services were conducted on all three shifts with the nursing staff attending. During the monitoring phase, interviews were conducted by the surveyor(s) on different shifts with the nursing staff, nurse management, and CNAs. All interviewed staff verbalized up to date knowledge on new communication procedures, notification of changes and ventilator use training. Observations were conducted during the monitoring of the seven residents that were ventilator dependent and they were stable. Nurses were observed [MEDICAL CONDITION] appropriately. Interview on [DATE] at 10:30am with the interim DON he said that he believed the IJ happened because of the lapse in time and urgency in providing CR #1 a higher level of care. He said the type of training he provided to ensure the nurses were competent to care for residents who were ventilator dependent was a general skill competency ventilator training which covered the ventilator settings and why resident was on a ventilator. The interim DON said the type of plan that was in place for ventilator dependent resident(s) was training the nurses. The DON said the resources that are available to him and the facility staff is the Nurse Practitioner, [MEDICAL CONDITION] Specialist which is the Medical Director. The DON said the facility also have the Primary Care Physician, and a vendor that comes to the facility to give training to the staff on ventilator dependent residents. No documentation was provided by the Interim DON that a general skill competency was done or that an outside vendor or the PCP had provided training to the staff on ventilator dependent residents before the exit on [DATE]. The Administrator and the interim DON were informed on [DATE] at 10:35 am that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the Administrator, 7 residents were ventilator dependent in the facility.

Based on observation, interview, and record review the facility failed to ensure resident who needs respiratory care, including [MEDICAL CONDITION] care and ventilators, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care for one (1) of eleven (11) residents reviewed for [MEDICAL CONDITION] and ventilator use care. (CR # 1) -RN-T and the RT-U failed to provide prompt care to CR#1, who was a ventilator dependent resident, when she experienced respiratory distress. -The facility failed to consult with the Medical Director in a timely manner when CR # 1 continued to experience respiratory distress for over six hours and there was no response from the PCP. -Staff did not contact 911 in a timely manner when CR #1 continued to experience respiratory distress. -RN-T was not trained on ventilator care, vent equipment, and emergency management or vent dependent patients. -The facility nurses that were assigned to care for residents in the vent unit were not trained on vent care, vent equipment, and emergency management of vent dependent patients. -EMS arrived at the facility and transported the resident to the hospital where she passed away. These failures resulted in an IJ on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of isolated and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one discharged resident and placed 7 residents that were vent dependent at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, quality of life, result in respiratory distress, and possible death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; Acute Respiratory Distress, Pneumonia,[MEDICAL CONDITIONS] Status, Dependence on Ventilator, [MEDICAL CONDITION], Type 2 Diabetes Mellitus, [MEDICAL CONDITION], Hypertension, Primary [MEDICAL CONDITION] Hypertension, Diastolic Heart Failure, and End Stage [MEDICAL CONDITION]. Record review of CR # 1 MDS assessment dated [DATE] revealed that CR #1 had a BIMS score of 15, indicating no cognitive issues. Further record review revealed that CR # 1 was totally dependent on staff for activities of daily living and required special treatments for the following: oxygen therapy, suctioning, [MEDICAL CONDITION] care, and ventilator or respirator. Record review of CR #1 48 hour baseline care plan dated [DATE] revealed that resident was being care planned for communication, activities of daily living (transfers, bed mobility, dressing, incontinence both bowel and bladder, and bathing), [MEDICAL TREATMENT], and specialized services needed (Respiratory Care and Enteral Feeding). Record review of CR # 1 Admission Summary Note dated [DATE] at 11:06p.m. revealed in part: .Guest arrived via stretcher from hospital in no distress, alert able to communicate by writing and gestures. No SOB,[MEDICAL CONDITION] line no excess secretions noted, skin warm and dry to touch. Abdomen Soft and non- tender, [DEVICE] patent, eats during day and feeding tube on from 6p to 6a, no s/s of hypo/[MEDICAL CONDITION] noted,[MEDICAL CONDITION] at 28% during the day and vent assist at evening . Record review of CR #1 Physician order [REDACTED].# 1's ventilator setting where: AC-12, tidal volume-500, Oxygen 40%, and a PEEP of 5 every night shift for airway. Record review of Daily Respiratory Note completed by RT-U dated [DATE] at 6:09 am for CR #1 revealed in part: . right and left lung sounds pre and post treatment with crackles and coarse productive sputum. CR # 1 on the vent, respiratory treatments [MEDICAL CONDITION]/suctioning. CR # 1 in no acute resp. distress . Record review of CR #1 Progress Notes completed by RN-T dated [DATE] at 9:48am (late entry) read in part .around 2300 (11:00 pm), patient was restless and nurse checked v/s BP ,[DATE], Pulse 78, RR 20, O2 Sat 98% on vent, blood sugar 114, performed pain assessment and PRN Tylenol 650 mg administered and patient was able to calm down and slept. Around 01:00 am, patient woke up with restless and agitated. At 01:20 am, nurse called patients doctor, but went straight to the voicemail. At 01:05 am, called IPC and spoke to staff who promise to send message to the Doctor and call back. At 02:05 am, called IPC again and asked for at least one time order for medication for restless and agitation. IPC staff member said the Doctor did not call her back .administered PRN Tylenol 650mg. Patient was able to sleep for a while till 04:30 am. At 0500 am went to check on patient and assessed the labored breathing. O2 Sat was 88% on vent and pulse was 128, nurse called for the respiratory therapist and v/s performed. BP ,[DATE], RR 22, HR 115, O2 sat 99% on vent, blood sugar 153. 911 called and patient sent out of the facility at 06:00 am . Record review of the EMS patient care report dated [DATE] revealed in part: .called out for a breathing problem .arrived at the facility at 5:47 am .the nurse stated that the patient had been in respiratory distress since 11:30 pm last night. Pt found in the facility bed in respiratory distress. The pt. was unresponsive .also EMTs noticed the suction canister full of mucus next to the bed .patient was transferred from the facility bed to the stretcher. Patient needed to be suctioned, so the respiratory therapist tried to suction the patient but the suction catheter would not go through the [MEDICAL CONDITION]. The respiratory therapist lifted the [MEDICAL CONDITION] tamer (tube securing device) to see why the catheter would not go through and the EMT noted that the [MEDICAL CONDITION] was twisted. EMTs asked the respiratory therapist why was the tube twisted, the therapist did not answer. The respiratory therapist then completely pulled out the connection device of the [MEDICAL CONDITION] and was unable to place the tube connection back in the [MEDICAL CONDITION]. The respiratory therapist then ran out of the room to go get a new connection .the therapist was unable to install the new [MEDICAL CONDITION] connection .EMT loaded the patient to the ambulance and on the way to the hospital the patient went in to [MEDICAL CONDITION] . Record review of CR # 1 hospital noted dated [DATE] at 6:34am read in part: .arrived at [DATE] at 6:12 am . CPR in progress .(facility) called 911 because patient was in respiratory distress. EMS said when they arrived on the scene, patient had spontaneous breathing. EMS said they wanted to suction pts.[MEDICAL CONDITION] could not get the suction through patient trach. EMS said the Respiratory Therapist at facility pulled [MEDICAL CONDITION], patient was having respiratory distress and EMS was unable to bag patient via BVM (bag valve mask). EMS said patient went into [MEDICAL CONDITION] en route . Record review of the hospital history of present illness dated [DATE] revealed in part: .arrived in [MEDICAL CONDITION] via EMS .per EMS, patient had difficulty breathing, and they report that someone had remove the trach. There was a problem associated with the [MEDICAL CONDITION], but the exact problem is unclear. Healthcare Provider attempted to adjust trach, but reportedly pulled it out or it somehow became dislodged . Record review of CR # 1 Physician Note in the ER dated [DATE] at 6:53am revealed in part .History provided by the EMS is somewhat vague, and the fine details are unclear, however what is clear is that the patient was having some difficulty with her [MEDICAL CONDITION] at the nursing facility, and at some point this [MEDICAL CONDITION] became dislodged. Provider prior to the emergency department attempted to replace the [MEDICAL CONDITION]. EMS reported that they were having a very difficult time bagging the patient, meeting a lot of resistance .On presentation, the patient was attempted to be bagged through the [MEDICAL CONDITION], which was in the [MEDICAL CONDITION] site. The patient was again extremely difficult to bag .we attempted bag mask ventilation through the oropharynx, which was not successful .it became immediately clear that the patient did not have an intact airway .was in [MEDICAL CONDITION] and remained asystolic . Attempt was made at incising through the [MEDICAL CONDITION] membrane, but was unsuccessful .At this point, the patient had been asystolic for a prolonged period of time with prolonged CPR and she had been without ventilation or oxygenation for extremely prolonged time . It was determined that the patient was very unlikely to have any type of a reasonable outcome .Resuscitative efforts were discontinued .Time of death was 0630 . Record review of CR #1's late entry Respiratory Notes completed by RT-U dated [DATE] at 4:46 pm read in part: . about 11:00p.m. I made my rounds, I found patient crossed legged across the bed trying to crawl out of bed, struggling, agitated, and restless. Upon communicating and reading through her lips, she indicated to me that she was hot, and was fanning herself try to stay cool. She also indicated that she wanted to go to the bathroom. I then indicated to the nurses and CNA about her condition and wanting to go to the bathroom. I then asked them to look for a fan for her and to offer her a bed pan. According to the CNA, she refused the bed pan. I then checked her O2 saturation 99%. I also checked her ventilator to make sure that her prescribed parameters were ok .About 1:00am upon checking on the patient, she was still restless and agitated, complaint still being hot, restless, agitated, her legs crossed hanging out of the bed and her beddings/bed covers on the floor. At this time, I observed that the patient was in labored respiration. Checked her Oxygenation saturation 98% and on close observation I noticed that her abdomen was heavily distended and sounds tympanic upon percussion. I then indicated to the nurses especially RN-T that patient was not doing well and that they needed to address the issue because she was restless, agitated and now labored .I then advised them to try and call the Doctor and the patient needs to get to ER. I then started monitoring the patient condition closely up until 4:00am and 5:00am. Up until now, pt. was still agitated, restless and her laboring has increased .I made clear to the nurse that she need to get to the ER as soon as possible as her condition was getting worse .about 5:00am, I had to force them to call 911. So 911 was called and the patient was then picked up to the ER . Interview on [DATE] at 10:40 am RT-S said she worked the 2p-10p PRN. RT-S said she provided care for CR #1 on [DATE]. RT-S said CR #1 complained of shortness of breath towards the end of her shift between ,[DATE]pm therefore she administered a breathing treatment to resident and placed her back on the ventilator. RT-S said later on resident complaint of pain on her leg and she reported it to the nurse. RT-S said she followed back up with CR #1 who was then watching T.V. and communicated that she was feeling better and the resident wrote on piece a paper to her that she was doing a good job. RT-S said she then gave report to the oncoming RT. In a phone interview on [DATE] at 4:30 p.m. CNA A said that near the start of her shift (10:00 p.m. on [DATE]) CNA B was trying to get help for CR #1. She said the resident was sweating profusely and was hot. CNA A said the resident was complaining about being short of breath to RN T. CNA A said, The biggest problem was she couldn't breathe, and she was telling (the RN- T and RT-U) she couldn't breathe. She was having a hard time breathing. CNA A said the resident was in distress since around 11:00 p.m. CNA A said that when the Paramedics arrived in the morning, CR #1 seemed unresponsive. In a phone interview on [DATE] at 8:30 p.m. CNA B said when she started her shift on Saturday ([DATE] at 10:00 p.m.) CR #1 was different CNA B said I told the nurses something was wrong. CR #1 said she couldn't breathe. I told the nurse and the RT-U. She was sweating, snot running out of her nose. The nurse suctioned her nose and said Oh, she's just restless. Her eyes were bloodshot. CNA B said of RT-U, He came in there, didn't pay attention to what I was saying. I told him she needed suctioning, and he didn't suction. CNA B said the resident was in distress from the start of her shift until the morning. She said Towards the end of the shift she was crying. Bloodshot, red. Breathing hard like she couldn't breathe. In a phone interview on [DATE] at 8:45 p.m. with CNA A she said when the Paramedics arrived, they tried to suction CR #1, and tried to intubate her, but could not. She said, They had to use the ambu-bag on the trach. She couldn't breathe at night, asking for help. Interview on [DATE] at 11:05am ADON said CR # 1 left the facility via 911. ADON said she found out after the resident was sent to a local hospital. The ADON said CR #1 was at the Nursing facility for 3 days. The ADON said RN-T was the nurse taking care of CR #1 on the night shift on [DATE]. The ADON said RN-T reported that CR #1 was anxious. The ADON said the facility was going to terminate RN-T because she did not inform herself or Administration about the change in condition on CR #1, but RN-T resigned on her own. Interview on [DATE] at 11:10am with the Administrator said CR #1 went to a local hospital and believed resident had expired. In a phone interview on [DATE] at 11:25am RN-T said she worked the 10p-6a shift on [DATE]. RN-T said she started working at the facility in (MONTH) of (YEAR) full time. RN-T said she became a nurse in (YEAR). RN-T said when she came on her shift for the 10p-6a, CR #1 was a little restless and the resident O2 sat was 99% and resident vitals were okay. RN-T said CR #1 was unable to communicate due to resident being on the vent. RN-T said she checked resident medications and found that some of the resident's medications were on hold so she called the Doctor at around 11pm and it went to voicemail. RN-T said she then placed a call to the NP and the call went to voice-mail as well then she called the IPC and spoke to staff that informed her they would call the Doctor. RN-T said the happenings around CR #1 were in her Nursing Notes. Interview on [DATE] at 1:05pm RN-T said whenever there was a change in a resident condition in the facility the protocol was to notify the PCP and if they did not answer, then contact the Physician/NP then call the IPC group. RN-T said she had never heard of a Medical Director. RN-T said she never received training in suctioning residents with a [MEDICAL CONDITION] or for taking care of residents who were ventilator dependent. RN-T said the only training she received on ventilator patients was when she did clinical rotation in Nursing School. RN-T said she took on the assignment of caring for CR #1 who was ventilator dependent unit because the facility had a Respiratory Therapist. An attempted interview via phone on [DATE] at 12:45pm with RT-U was unsuccessful. There was no answer and was unable to leave a voice-mail. Record review of letter of resignation from RT-U dated [DATE] read in part: .On behalf of my manager of respiratory department . I hereby transfer my letter of Resignation effective from today. It has been my pleasure working with all of you. Thanks for all you do for the care of your residents and to every one of us working with you, saving life. Sincerely . Further record review of facility Separation Report signed by the facility Respiratory Director dated [DATE] revealed that the termination of RT-U was marked as personal and not eligible for rehire. Interview on [DATE] at 12:35pm the NP said CR #1 came to the facility over the weekend. The NP said she had received a call from the Nursing facility staff that CR # 1 had been admitted to the facility and a Medication Reconciliation was done with the nurse over the phone. The NP said she gave orders to continue all previous medications except for [MEDICATION NAME]. The NP said the reason she did not give orders to resume the medication [MEDICATION NAME] was because she wanted to first assess CR #1 due to resident history of Respiratory Distress and [MEDICAL CONDITION]. The NP said the facility staff reported to her that CR #1 was not in any distress and resident was stable upon admission. Interview on [DATE] at 1:27pm with Director of Respiratory Therapy (DRT) she said she received a call from RT-U at 6:30am on [DATE] informing her that CR #1 had to be sent out to the hospital because she was experiencing some respiratory distress. The DRT said RT-U reported to her that when CR #1 was sent out to the hospital the resident's oxygen saturation was good. The DRT said CR #1 was to be on [MEDICAL CONDITION] during the day and would go back on the ventilator at night around 10 or 11pm. The DRT said she noticed RT-U had not done any documentation on CR #1 on the 10p-6a shift for [DATE] and told RT-U that he needed to come in and document a late entry. In an interview with the DRT on [DATE] at 2:50 pm she said that because CR #1 was on [MEDICAL CONDITION] the day and then on a vent during the night, RT U should have documented that 2 ventilator checks were performed during the night and there was no documentation that it was done. The DRT also said she did not understand why RT-U was assessing CR #1 abdomen instead of the lung sounds because the abdomen was not an RT's area of study but the respiratory system was. Interview on [DATE] at 2:08pm the ADON said the only people that RN-T was calling to notify of change in CR #1 condition was the IPC who notifies the Physician. The ADON said the NP and Physician did not see CR #1 because she came to the facility late on a Friday night. The ADON said when she spoke with RN-T and asked why she didn't call the Medical Director, the NP, or herself, RN-T could not give an answer. Interview on [DATE] at 12:20 pm the facility Administrator and the ADON both said that they believed that based on the documentation in change in condition for CR #1 that facility staff was monitoring CR #1 and following the facility protocol. Both agreed that they wished that RN-T would have reached out to Administration to tell them what was going on. The ADON said she did do in-service just could not remember what day. The Administrator and the ADON said RT-U was employed on a PRN base and was no longer employed at the facility. Interview on [DATE] at 2:00 pm the interim DON said he was in agreement with the Administrator and ADON that the facility staff was following protocol in monitoring CR #1. The interim DON said after reviewing the documentation of RN-T and RT-U regarding CR #1, there was room for improvement but did not see a deficiency. The interim DON said when he reviewed RT-U documentation that he had to force RN-T to call the Physician he did not know what he meant by that and would have to talk to RT-U to clarify. The interim DON said RT-U no longer worked at the facility. Interview on [DATE] at 3:25pm the interim DON said after reading RN-T and RT-U documentation again, the Physician/NP should have been called. The interim DON said that if there were no results from calling the Physician/NP, CR # 1 should have been sent out to the hospital. Interview on [DATE] at 3:17pm with LVN-C, who was working on hall 500 (ventilator dependent unit) said she had been working at the facility for 2 years. She said 2 years ago was the last time she received training on ventilator dependent residents. Interview on [DATE] at 8:55am with ADON said whenever a resident experience a change in condition, the nurse was to notify the family and the Doctor and carry out any orders received. Interview on [DATE] at 11:45am with the ADON regarding the nurses in the facility being in-serviced on how to care for residents on Ventilators. The ADON said the facility have Respiratory Therapist in the facility 24 hours a day and seven days a week to care for the seven residents on vents they have. The ADON said the nurses were in-serviced on caring for residents with ventilators at the time of hire, before taking an assignment with residents who were ventilator dependent. ADON said the nurses receive at least two days or more if needed in training with the ventilators before taking care of a ventilator resident. The ADON said this training was done at the time of hire and yearly. The ADON said she did not believe the facility had a check off for ventilator training with return demonstration. Interview on [DATE] at 12:25pm the interim DON said it was the Respiratory Therapist Director that trained the nurses in the facility on ventilators and the facility did have a check off list of the training. The DON said training was done with the staff every year. Record review of five nurses personnel files revealed no training or check off list with return demonstration of understanding on how to care for ventilator dependent residents. Record review of a list provided by the ADON revealed that 21 nurses (LVNs and RNs) had worked on the 500 Hall in the month of (MONTH) (YEAR). Record review of the personnel files of some of the nurses that worked on the Hall-500 (Vent dependent residents) for the month of (MONTH) (YEAR) revealed no ventilator use training. Record review of Nursing facility last In-service Training Report with the Nursing department on SBARs, change in condition and worsening, notifying MD,NP, family, or charge nurse was dated [DATE]. Interview on [DATE] at 1:25pm LVN-B said he work the 10p-6a shift on a full time basis on halls ,[DATE]. LVN-B said he did not received orientation on ventilators at the time of hire. LVN-B said the ventilator residents were staffed with Registered Nurses. LVN-B said if a resident started to experience a change in condition, he would first do an assessment, call the Doctor immediately and if the Doctor did not respond, he would call the facility Medical Director. Interview on [DATE] at 1:30 p.m. the DRT said she provided training to nurses, but did not conduct classes. She added, There may be people, PRNs or weekend I may never see to train. She said the RT could have done ABG's (arterial blood gases) and called the Physician or her if there was complications. She added that if a resident was in respiratory distress, the Respiratory Therapist was responsible. Interview on [DATE] at 10:45am the DRT said she goes over with the CNA's and nurses on how to report signs of distress with a resident on a ventilator. The DRT said she tries to do annual training on everyone because the facility have staff that come and go. The DRT said she ensured that the RT's working at the facility were competent in their skills, they have to complete a check off list demonstrating their skills and she hired people with at least [AGE] years of experience. Interview and observation on [DATE] at 11:55am LVN-D said she had been a nurse for 7 years and had been working at the facility for about 6 months. She said she normally worked the 500-hall were the vent patients were. LVN-D said she was still learning how to work with ventilators. The surveyor took LVN-D to a resident room that was ventilator dependent and asked her what the settings meant on the machine such as PEEP, Tidal Volume, Pressure Control, Pressure Support, and breath rate. LVN-D said she was not for sure and would have to find out. LVN-D said she was trained but felt the training did not stick with her. LVN-D said she had never worked with vent-dependent residents before until she became a nurse in this Nursing facility. Interview on [DATE] at 12:08 pm the Administrator said he started working at the facility in (MONTH) of (YEAR) and the interim DON that the facility have now was interim at that time. The Administrator said he confirmed with the Director of Respiratory that the facility started accepting vent dependent residents about 2-,[DATE] years ago. After multiple requests from the Interim DON, the Administrator and the ADON, the facility was did not provide documentation of nurse training or return demonstration for the facility nurses on ventilator dependent residents. Record review of facility Policy on Mechanical Ventilation revised (MONTH) 2010: .While the resident is on mechanical ventilation, assess for the following: 1)Signs and symptoms of [MEDICAL CONDITION], including: Diminished lung sounds, cyanosis, fatigue, and pallor . .2)Airway obstruction(such as indicated) .3)Arterial blood gases or oxygen saturation .4)Vital signs .5) Cardiac rhythm The Administrator and interim DON were notified on [DATE] at 2:00 pm of the IJ situation due to the above failures and a POR was requested. The POR was received and after 2 revisions it was accepted on [DATE] at 1:50pm. POR included in part: . All residents were immediately assessed on [DATE] by the DON, ADON, and Licensed Nurses for any changes in condition. These assessments were completed on [DATE]. All the following in-services will be completed with staff prior to them working their next schedule shift . Prompt Assessment Licensed Nurses were reeducated on [DATE] on promptly assessing residents each shift and documenting in a daily skilled nursing note, and completing an SBAR for any changes in condition. This education was conducted by the Director of Nurses, and Assistant Director of Nursing. Documentation will be monitored for completion prior to the end of each shift by the DON, ADONs, and designees using the 24 Summary. The Administrator will monitor the timely completion of the inservice. Completion Date: [DATE] All ventilator patients were immediately assessed by the Director of Respiratory Therapy (DRT) and Licensed Respiratory Therapists for potential changes in condition on [DATE] and was completed on [DATE]. No new changes in condition were noted. Licensed Respiratory Therapists were reeducated on [DATE] on promptly assessing residents each shift and documenting in a daily respiratory therapy note. This education was conducted by the DRT and designee. Documentation will be monitored for completion prior to the end each of each shift by the DON, ADONs, DRT, and designee. The Administrator will monitor the timely completion of the inservice. Completion Date: [DATE] All departments were reeducated on the Stop and Watch tool on [DATE] by the DON, ADON, and designee. This will be monitored by the Administrator. Completion Date: [DATE] A new policy was implemented on [DATE] that report needs to be given between nursing and respiratory therapy at the change of each shift. Physician Notification Licensed Nurses and Respiratory Therapist were immediately inserviced on [DATE] on notifying physicians in a timely manner. This was conducted by the DON, ADON, DRT, and designee. All changes in conditions will be reviewed during the daily clinical meeting. Completion Date: [DATE] Calling 911 in a Timely Manner Licensed Nurses and Respiratory Therapists were reeducated on [DATE] on the existing protocols regarding emergency situations and when to calling 911. This was conducted by the DON, ADONs, DRT, and designee. This will be monitored by the Administrator, DON, and ADONs. Completion Date: [DATE] Training to Identify Emergency Issues for Vent Dependent Patients and General Vent Training DON and the DRT immediately started an inservice on [DATE] on identification of emergency issues related to vent dependent patients and reporting any changes in a condition to the physician in a timely manner in accordance with facility policy and procedures. This will be monitored by the Administrator. Completion Date: [DATE] An in-service was immediately started on [DATE] for all Licensed Nurses and Respiratory Therapist on the type of vent used at the facility and settings. This will be monitored by the Administrator. Completion Date: [DATE] Any Significant Change to Supervisor and Physician An in-service was immediately started on [DATE] for Licensed Nurses and Respiratory Therapist on reporting significant changes in condition to supervisor and physician. This in-service will be completed by the DON, ADON, DRT, and designee. This will be monitored by the Administrator . The facility was monitored from [DATE] until [DATE] by the surveyors with the following results: Record review revealed new training and in-services were done with facility staff in the following areas: -when and who to report in timely manner of a change in resident condition utilizing the stop and watch and SBAR documentation as a guiding tool. -Abuse/Neglect and who to report to. -When it is appropriate to alert 911 EMS in transferring a resident to a higher level of care after experiencing a change in condition and notifying all parties. -Ventilator training with the nursing staff and respiratory staff in caring for resident vent dependent (recognizing the vent settings and what they mean as well as recognizing a change in condition (resp. distress) and notifying the Physician, Medical Director, RP, and Administration. -Performing prompt assessments on resident (s) experiencing a change in condition and reporting to Physician/NP, Medical Director, and RP (responsible party) in a timely manner Record review of the forms revealed that In-services were conducted on all three shifts with the nursing staff attending. During the monitoring phase, interviews were conducted by the surveyor(s) on different shifts with the nursing staff, nurse management, and CNAs. All interviewed staff verbalized up to date knowledge on new communication procedures, notification of changes and ventilator use training. Observations were conducted during the monitoring of the seven residents that were ventilator dependent and they were stable. Nurses were observed [MEDICAL CONDITION] appropriately. Interview on [DATE] at 9:35 am the Administrator said he thought the Immediate Jeopardy came about because resident went out to hospital due to a change in condition. Administrator said he became aware of the situation in the next clinical meeting. Administrator said the facility did investigate and implement corrective measures. The Administrator said the resources that are available to himself and the staff are facility policies/procedures, Medical Director, Physician Involvement, and Corporate Support. Interview on [DATE] at 10:30am with the interim DON he said that he believed the IJ happened because of the lapse in time and urgency in providing CR #1 a higher level of care. He said the type of training he provided to ensure the nurses were competent to care for residents who were ventilator dependent was a general skill competency ventilator training which covered the ventilator settings and why resident was on a ventilator. The interim DON said the type of plan that was in place for ventilator dependent resident(s) was training the nurses. The DON said the resources that are available to him and the facility staff is the Nurse Practitioner, [MEDICAL CONDITION] Specialist which is the Medical Director. The DON said the facility also have the Primary Care Physician, and a vendor that comes to the facility to give training to the staff on ventilator dependent residents. No documentation was provided by the Interim DON that a general skill competency was done or that an outside vendor or the PCP had provided training to the staff on ventilator dependent residents before the exit on [DATE]. The Administrator and the interim DON were informed on [DATE] at 10:35 am that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provid (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure residents rights to be free from neglect for one of 6 residents (CR #1) reviewed for neglect in that, -RN-T and the RT-U failed to provide prompt care to CR#1, who was a ventilator dependent resident, when she started experiencing a change in condition to include SOB, agitation, respiratory distress. -The facility failed to consult with the Medical Director in a timely manner when CR # 1 continued to experience respiratory distress for over six hours and there was no response from the PCP. -Staff did not contact 911 in a timely manner when CR #1 continued to experience respiratory distress. -RN-T was not trained on vent care, vent equipment, and emergency management or vent dependant patients. -The facility nurses that were assigned to care for residents in the vent unit were not trained on vent care, vent equipment, and emergency management of vent dependant patients. -EMS arrived at the facility and transported the resident to the hospital where she passed away. These failures resulted in an IJ on on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of isolated and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one discharged resident and placed 7 residents that were vent dependent at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, quality of life, cause respiratory distress, and possible death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; Acute Respiratory Distress, Pneumonia,[MEDICAL CONDITIONS] Status, Dependence on Ventilator, [MEDICAL CONDITION], Type 2 Diabetes Mellitus, [MEDICAL CONDITION], Hypertension, Primary [MEDICAL CONDITION] Hypertension, Diastolic Heart Failure, and End Stage [MEDICAL CONDITION]. Record review of CR # 1 MDS assessment dated [DATE] revealed that CR #1 had a BIMS score of 15, indicating no cognitive issues. Further record review revealed that CR # 1 was totally dependent on staff for activities of daily living and required special treatments for the following: oxygen therapy, suctioning, [MEDICAL CONDITION] care, and ventilator or respirator. Record review of CR #1 48 hour baseline care plan dated [DATE] revealed that resident was being care planned for communication, activities of daily living (transfers, bed mobility, dressing, incontinence both bowel and bladder, and bathing), [MEDICAL TREATMENT], and specialized services needed (Respiratory Care and Enteral Feeding). Record review of CR # 1 Admission Summary Note dated [DATE] at 11:06p.m. revealed in part: .Guest arrived via stretcher from hospital in no distress, alert able to communicate by writing and gestures. No SOB,[MEDICAL CONDITION] line no excess secretions noted, skin warm and dry to touch. Abdomen Soft and non- tender, [DEVICE] patent, eats during day and feeding tube on from 6p to 6a, no s/s of hypo/[MEDICAL CONDITION] noted,[MEDICAL CONDITION] at 28% during the day and vent assist at evening . Record review of CR #1 Physician Orders dated [DATE] revealed CR # 1's ventilator setting where: AC-12, tidal volume-500, Oxygen 40%, and a PEEP of 5 every night shift for airway. Record review of Daily Respiratory Note completed by RT-U dated [DATE] at 6:09 am for CR #1 revealed in part: . right and left lung sounds pre and post treatment with crackles and coarse productive sputum. CR # 1 on the vent, respiratory treatments [MEDICAL CONDITION]/suctioning. CR # 1 in no acute resp. distress . Record review of CR #1 Progress Notes completed by RN-T dated [DATE] at 9:48am (late entry) read in part .around 2300 (11:00 pm), patient was restless and nurse checked v/s BP ,[DATE], Pulse 78, RR 20, O2 Sat 98% on vent, blood sugar 114, performed pain assessment and PRN Tylenol 650 mg administered and patient was able to calm down and slept. Around 01:00 am, patient woke up with restless and agitated. At 01:20 am, nurse called patients doctor, but went straight to the voicemail. At 01:05 am, called IPC and spoke to staff who promise to send message to the Doctor and call back. At 02:05 am, called IPC again and asked for at least one time order for medication for restless and agitation. IPC staff member said the Doctor did not call her back .administered PRN Tylenol 650mg. Patient was able to sleep for a while till 04:30 am. At 0500 am went to check on patient and assessed the labored breathing. O2 Sat was 88% on vent and pulse was 128, nurse called for the respiratory therapist and v/s performed. BP ,[DATE], RR 22, HR 115, O2 sat 99% on vent, blood sugar 153. 911 called and patient sent out of the facility at 06:00 am . Record review of the EMS patient care report dated [DATE] revealed in part: .called out for a breathing problem .arrived at the facility at 5:47 am .the nurse stated that the patient had been in respiratory distress since 11:30 pm last night. Pt found in the facility bed in respiratory distress. The pt. was unresponsive .also EMTs noticed the suction canister full of mucus next to the bed .patient was transferred from the facility bed to the stretcher. Patient needed to be suctioned, so the respiratory therapist tried to suction the patient but the suction catheter would not go through the [MEDICAL CONDITION]. The respiratory therapist lifted the [MEDICAL CONDITION] tamer (tube securing device) to see why the catheter would not go through and the EMT noted that the [MEDICAL CONDITION] was twisted. EMTs asked the respiratory therapist why was the tube twisted, the therapist did not answer. The respiratory therapist then completely pulled out the connection device of the [MEDICAL CONDITION] and was unable to place the tube connection back in the [MEDICAL CONDITION]. The respiratory therapist then ran out of the room to go get a new connection .the therapist was unable to install the new [MEDICAL CONDITION] connection .EMT loaded the patient to the ambulance and on the way to the hospital the patient went in to [MEDICAL CONDITION] . Record review of CR # 1 hospital noted dated [DATE] at 6:34am read in part: .arrived at [DATE] at 6:12 am . CPR in progress .(facility) called 911 because patient was in respiratory distress. EMS said when they arrived on the scene, patient had spontaneous breathing. EMS said they wanted to suction pts.[MEDICAL CONDITION] could not get the suction through patient trach. EMS said the Respiratory Therapist at facility pulled [MEDICAL CONDITION], patient was having respiratory distress and EMS was unable to bag patient via BVM (bag valve mask). EMS said patient went into [MEDICAL CONDITION] en route . Record review of the hospital history of present illness dated [DATE] revealed in part: .arrived in [MEDICAL CONDITION] via EMS .per EMS, patient had difficulty breathing, and they report that someone had remove the trach. There was a problem associated with the [MEDICAL CONDITION], but the exact problem is unclear. Healthcare Provider attempted to adjust trach, but reportedly pulled it out or it somehow became dislodged . Record review of CR # 1 Physician Note in the ER dated [DATE] at 6:53am Revealed in part .History provided by the EMS is somewhat vague, and the fine details are unclear, however what is clear is that the patient was having some difficulty with her [MEDICAL CONDITION] at the nursing facility, and at some point this [MEDICAL CONDITION] became dislodged. Provider prior to the emergency department attempted to replace the [MEDICAL CONDITION]. EMS reported that they were having a very difficult time bagging the patient, meeting a lot of resistance .On presentation, the patient was attempted to be bagged through the [MEDICAL CONDITION], which was in the [MEDICAL CONDITION] site. The patient was again extremely difficult to bag .we attempted bag mask ventilation through the oropharynx, which was not successful .it became immediately clear that the patient did not have an intact airway .was in [MEDICAL CONDITION] and remained asystolic . Attempt was made at incising through the [MEDICAL CONDITION] membrane, but was unsuccessful .At this point, the patient had been asystolic for a prolonged period of time with prolonged CPR and she had been without ventilation or oxygenation for extremely prolonged time . It was determined that the patient was very unlikely to have any type of a reasonable outcome .Resuscitative efforts were discontinued .Time of death was 0630 . Record review of CR #1's late entry Respiratory Notes completed by RT-U dated [DATE] at 4:46 pm read in part: . about 11:00p.m. I made my rounds, I found patient crossed legged across the bed trying to crawl out of bed, struggling, agitated, and restless. Upon communicating and reading through her lips, she indicated to me that she was hot, and was fanning herself try to stay cool. She also indicated that she wanted to go to the bathroom. I then indicated to the nurses and CNA about her condition and wanting to go to the bathroom. I then asked them to look for a fan for her and to offer her a bed pan. According to the CNA, she refused the bed pan. I then checked her O2 saturation 99%. I also checked her ventilator to make sure that her prescribed parameters were ok .About 1:00am upon checking on the patient, she was still restless and agitated, complaint still being hot, restless, agitated, her legs crossed hanging out of the bed and her beddings/bed covers on the floor. At this time, I observed that the patient was in labored respiration. Checked her Oxygenation saturation 98% and on close observation I noticed that her abdomen was heavily distended and sounds tympanic upon percussion. I then indicated to the nurses especially RN-T that patient was not doing well and that they needed to address the issue because she was restless, agitated and now labored .I then advised them to try and call the Doctor and the patient needs to get to ER. I then started monitoring the patient condition closely up until 4:00am and 5:00am. Up until now, pt. was still agitated, restless and her laboring has increased .I made clear to the nurse that she need to get to the ER as soon as possible as her condition was getting worse .about 5:00am, I had to force them to call 911. So 911 was called and the patient was then picked up to the ER . Interview on [DATE] at 10:40 am RT-S said she worked the 2p-10p PRN. RT-S said she provided care for CR #1 on [DATE]. RT-S said CR #1 complained of shortness of breath towards the end of her shift between ,[DATE]pm therefore she administered a breathing treatment to resident and placed her back on the ventilator. RT-S said later on resident complaint of pain on her leg and she reported it to the nurse. RT-S said she followed back up with CR #1 who was then watching T.V. and communicated that she was feeling better and the resident wrote on piece a paper to her that she was doing a good job. RT-S said she then gave report to the oncoming RT. In a phone interview on [DATE] at 4:30 p.m. CNA A said that near the start of her shift (10:00 p.m. on [DATE]) CNA B was trying to get help for CR #1. She said the resident was sweating profusely and was hot. CNA A said the resident was complaining about being short of breath to RN T. CNA A said, The biggest problem was she couldn't breathe, and she was telling (the RN- T and RT-U) she couldn't breathe. She was having a hard time breathing. CNA A said the resident was in distress since around 11:00 p.m. CNA A said that when the Paramedics arrived in the morning, CR #1 seemed unresponsive. In a phone interview on [DATE] at 8:30 p.m. CNA B said when she started her shift on Saturday ([DATE] at 10:00 p.m.) CR #1 was different CNA B said I told the nurses something was wrong. CR #1 said she couldn't breathe. I told the nurse and the RT-U. She was sweating, snot running out of her nose. The nurse suctioned her nose and said Oh, she's just restless. Her eyes were bloodshot. CNA B said of RT-U, He came in there, didn't pay attention to what I was saying. I told him she needed suctioning, and he didn't suction. CNA B said the resident was in distress from the start of her shift until the morning. She said Towards the end of the shift she was crying. Bloodshot, red. Breathing hard like she couldn't breathe. In a phone interview on [DATE] at 8:45 p.m. with CNA A she said when the Paramedics arrived, they tried to suction CR #1, and tried to intubate her, but could not. She said, They had to use the ambu-bag on the trach. She couldn't breathe at night, asking for help. Interview on [DATE] at 11:05am ADON said CR # 1 left the facility via 911. ADON said she found out after the resident was sent to a local hospital. The ADON said CR #1 was at the Nursing facility for 3 days. The ADON said RN-T was the nurse taking care of CR #1 on the night shift on [DATE]. The ADON said RN-T reported that CR #1 was anxious. The ADON said the facility was going to terminate RN-T because she did not inform herself or Administration about the change in condition on CR #1, but RN-T resigned on her own. Interview on [DATE] at 11:10am with the Administrator said CR #1 went to a local hospital and believed resident had expired. In a phone interview on [DATE] at 11:25am RN-T said she worked the 10p-6a shift on [DATE]. RN-T said she started working at the facility in (MONTH) of (YEAR) full time. RN-T said she became a nurse in (YEAR). RN-T said when she came on her shift for the 10p-6a, CR #1 was a little restless and the resident O2 sat was 99% and resident vitals were okay. RN-T said CR #1 was unable to communicate due to resident being on the vent. RN-T said she checked resident medications and found that some of the resident's medications were on hold so she called the Doctor at around 11pm and it went to voicemail. RN-T said she then placed a call to the NP and the call went to voice-mail as well then she called the IPC and spoke to staff that informed her they would call the Doctor. RN-T said the happenings around CR #1 were in her Nursing Notes. Interview on [DATE] at 1:05pm RN-T said whenever there was a change in a resident condition in the facility the protocol was to notify the PCP and if they did not answer, then contact the Physician/NP then call the IPC group. RN-T said she had never heard of a Medical Director. RN-T said she never received training in suctioning residents with a [MEDICAL CONDITION] or for taking care of residents who were ventilator dependent. RN-T said the only training she received on ventilator patients was when she did clinical rotation in Nursing School. RN-T said she took on the assignment of caring for CR #1 who was ventilator dependent unit because the facility had a Respiratory Therapist. An attempted interview via phone on [DATE] at 12:45pm with RT-U was unsuccessful. There was no answer and was unable to leave a voice-mail. Record review of letter of resignation from RT-U dated [DATE] read in part: .On behalf of my manager of respiratory department . I hereby transfer my letter of Resignation effective from today. It has been my pleasure working with all of you. Thanks for all you do for the care of your residents and to every one of us working with you, saving life. Sincerely . Further record review of facility Separation Report signed by the facility Respiratory Director dated [DATE] revealed that the termination of RT-U was marked as personal and not eligible for rehire. Interview on [DATE] at 12:35pm the NP said CR #1 came to the facility over the weekend. The NP said she had received a call from the Nursing facility staff that CR # 1 had been admitted to the facility and a Medication Reconciliation was done with the nurse over the phone. The NP said she gave orders to continue all previous medications except for [MEDICATION NAME]. The NP said the reason she did not give orders to resume the medication [MEDICATION NAME] was because she wanted to first assess CR #1 due to resident history of Respiratory Distress and [MEDICAL CONDITION]. The NP said the facility staff reported to her that CR #1 was not in any distress and resident was stable upon admission. Interview on [DATE] at 1:27pm with Director of Respiratory Therapy (DRT) she said she received a call from RT-U at 6:30am on [DATE] informing her that CR #1 had to be sent out to the hospital because she was experiencing some respiratory distress. The DRT said RT-U reported to her that when CR #1 was sent out to the hospital the resident's oxygen saturation was good. The DRT said CR #1 was to be on [MEDICAL CONDITION] during the day and would go back on the ventilator at night around 10 or 11pm. The DRT said she noticed RT-U had not done any documentation on CR #1 on the 10p-6a shift for [DATE] and told RT-U that he needed to come in and document a late entry. In an interview with the DRT on [DATE] at 2:50 pm she said that because CR #1 was on [MEDICAL CONDITION] the day and then on a vent during the night, RT U should have documented that 2 ventilator checks were performed during the night and there was no documentation that it was done. The DRT also said she did not understand why RT-U was assessing CR #1 abdomen instead of the lung sounds because the abdomen was not an RT's area of study but the respiratory system was. Interview on [DATE] at 2:08pm the ADON said the only people that RN-T was calling to notify of change in CR #1 condition was the IPC who notifies the Physician. The ADON said the NP and Physician did not see CR #1 because she came to the facility late on a Friday night. The ADON said when she spoke with RN-T and asked why she didn't call the Medical Director, the NP, or herself, RN-T could not give an answer. Interview on [DATE] at 12:20 pm the facility Administrator and the ADON both said that they believed that based on the documentation in change in condition for CR #1 that facility staff was monitoring CR #1 and following the facility protocol. Both agreed that they wished that RN-T would have reached out to Administration to tell them what was going on. The ADON said she did do in-service just could not remember what day. The Administrator and the ADON said RT-U was employed on a PRN base and was no longer employed at the facility. Interview on [DATE] at 2:00 pm the interim DON said he was in agreement with the Administrator and ADON that the facility staff was following protocol in monitoring CR #1. The interim DON said after reviewing the documentation of RN-T and RT-U regarding CR #1, there was room for improvement but did not see a deficiency. The interim DON said when he reviewed RT-U documentation that he had to force RN-T to call the Physician he did not know what he meant by that and would have to talk to RT-U to clarify. The interim DON said RT-U no longer worked at the facility. Interview on [DATE] at 3:25pm the interim DON said after reading RN-T and RT-U documentation again, the Physician/NP should have been called. The interim DON said that if there were no results from calling the Physician/NP, CR # 1 should have been sent out to the hospital. Interview on [DATE] at 3:17pm with LVN-C, who was working on hall 500 (ventilator dependent unit) said she had been working at the facility for 2 years. She said 2 years ago was the last time she received training on ventilator dependent residents. Interview on [DATE] at 8:55am with ADON said whenever a resident experience a change in condition, the nurse was to notify the family and the Doctor and carry out any orders received. Interview on [DATE] at 11:45am with the ADON regarding the nurses in the facility being in-serviced on how to care for residents on Ventilators. The ADON said the facility have Respiratory Therapist in the facility 24 hours a day and seven days a week to care for the seven residents on vents they have. The ADON said the nurses were in-serviced on caring for residents with ventilators at the time of hire, before taking an assignment with residents who were ventilator dependent. ADON said the nurses receive at least two days or more if needed in training with the ventilators before taking care of a ventilator resident. The ADON said this training was done at the time of hire and yearly. The ADON said she did not believe the facility had a check off for ventilator training with return demonstration. Interview on [DATE] at 12:25pm the interim DON said it was the Respiratory Therapist Director that trained the nurses in the facility on ventilators and the facility did have a check off list of the training. The DON said training was done with the staff every year. Record review of five nurses personnel files revealed no training or check off list with return demonstration of understanding on how to care for ventilator dependent residents. Record review of a list provided by the ADON revealed that 21 nurses (LVNs and RNs) had worked on the 500 Hall in the month of (MONTH) (YEAR). Record review of the personnel files of some of the nurses that worked on the Hall-500 (Vent dependent residents) for the month of (MONTH) (YEAR) revealed no ventilator use training. Record review of Nursing facility last In-service Training Report with the Nursing department on SBARs, change in condition and worsening, notifying MD,NP, family, or charge nurse was dated [DATE]. Interview on [DATE] at 1:25pm LVN-B said he work the 10p-6a shift on a full time basis on halls ,[DATE]. LVN-B said he did not received orientation on ventilators at the time of hire. LVN-B said the ventilator residents were staffed with Registered Nurses. LVN-B said if a resident started to experience a change in condition, he would first do an assessment, call the Doctor immediately and if the Doctor did not respond, he would call the facility Medical Director. Interview on [DATE] at 1:30 p.m. the DRT said she provided training to nurses, but did not conduct classes. She added, There may be people, PRNs or weekend I may never see to train. She said the RT could have done ABG's (arterial blood gases) and called the Physician or her if there was complications. She added that if a resident was in respiratory distress, the Respiratory Therapist was responsible. Interview on [DATE] at 10:45am the DRT said she goes over with the CNA's and nurses on how to report signs of distress with a resident on a ventilator. The DRT said she tries to do annual training on everyone because the facility have staff that come and go. The DRT said she ensured that the RT's working at the facility were competent in their skills, they have to complete a check off list demonstrating their skills and she hired people with at least [AGE] years of experience. Interview and observation on [DATE] at 11:55am LVN-D said she had been a nurse for 7 years and had been working at the facility for about 6 months. She said she normally worked the 500-hall were the vent patients were. LVN-D said she was still learning how to work with ventilators. The surveyor took LVN-D to a resident room that was ventilator dependent and asked her what the settings meant on the machine such as PEEP, Tidal Volume, Pressure Control, Pressure Support, and breath rate. LVN-D said she was not for sure and would have to find out. LVN-D said she was trained but felt the training did not stick with her. LVN-D said she had never worked with vent-dependent residents before until she became a nurse in this Nursing facility. Interview on [DATE] at 12:08 pm the Administrator said he started working at the facility in (MONTH) of (YEAR) and the interim DON that the facility have now was interim at that time. The Administrator said he confirmed with the Director of Respiratory that the facility started accepting vent dependent residents about 2-,[DATE] years ago. After multiple requests from the Interim DON, the Administrator and the ADON, the facility was did not provide documentation of nurse training or return demonstration for the facility nurses on ventilator dependent residents. Record review of the facility policy titled Abuse and Neglect Protocols dated ,[DATE] reveale in part: .Our facility will not tolerate guest abuse, neglect or mistreatment .neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, and mental illness . The Administrator and interim DON were notified on [DATE] at 2:00 pm of the IJ situation due to the above failures and a POR was requested. The POR was received and after 2 revisions it was accepted on [DATE] at 1:50pm. POR included in part: . All residents were immediately assessed on [DATE] by the DON, ADON, and Licensed Nurses for any changes in condition. These assessments were completed on [DATE]. All the following in-services will be completed with staff prior to them working their next schedule shift. Freedom From Abuse and Neglect The Administrator and DON were immediately reeducated on [DATE] by the Senior Executive Director on abuse, neglect, and exploitation and reporting according to TX DADS Provider Letter,[DATE]. An inservice was immediately started on [DATE] with staff regarding abuse, neglect, and exploitation and reporting according to TX DADS Provider Letter ,[DATE]. The inserivce will be completed by the Administrator and designees. This will be monitored by the Administrator. Completion Date: [DATE] Prompt Assessment Licensed Nurses were reeducated on [DATE] on promptly assessing residents each shift and documenting in a daily skilled nursing note, and completing an SBAR for any changes in condition. This education was conducted by the Director of Nurses, and Assistant Director of Nursing. Documentation will be monitored for completion prior to the end of each shift by the DON, ADONs, and designees using the 24 Summary. The Administrator will monitor the timely completion of the inservice .All ventilator patients were immediately assessed by the Director of Respiratory Therapy (DRT) and Licensed Respiratory Therapists for potential changes in condition on [DATE] and was completed on [DATE]. No new changes in condition were noted . Calling 911 in a Timely Manner Licensed Nurses and Respiratory Therapists were reeducated on [DATE] on the existing protocols regarding emergency situations and when to calling 911. This was conducted by the DON, ADONs, DRT, and designee. This will be monitored by the Administrator, DON, and ADONs . Completion Date: [DATE] Any Significant Change to Supervisor and Physician An in-service was immediately started on [DATE] for Licensed Nurses and Respiratory Therapist on reporting significant changes in condition to supervisor and physician. This in-service will be completed by the DON, ADON, DRT, and designee. This will be monitored by the Administrator . The facility was monitored from [DATE] until [DATE] by the surveyors with the following results: Record review revealed new training and in-services were done with facility staff in the following areas: -when and who to report in timely manner of a change in resident condition utilizing the stop and watch and SBAR documentation as a guiding tool. -Abuse/Neglect and who to report to. -When it is appropriate to alert 911 EMS in transferring a resident to a higher level of care after experiencing a change in condition and notifying all parties. -Ventilator training with the nursing staff and respiratory staff in caring for resident vent dependent (recognizing the vent settings and what they mean as well as recognizing a change in condition (resp. distress) and notifying the Physician, Medical Director, RP, and Administration. -Performing prompt assessments on resident (s) experiencing a change in condition and reporting to Physician/NP, Medical Director, and RP (responsible party) in a timely manner Record review of the forms revealed that In-services were conducted on all three shifts with the nursing staff attending. During the monitoring phase, interviews were conducted by the surveyor(s) on different shifts with the nursing staff, nurse management, and CNAs. All interviewed staff verbalized up to date knowledge on new communication procedures, notification of changes and ventilator use training. Observations were conducted during the monitoring of the seven residents that were ventilator dependent and they were stable. Nurses were observed [MEDICAL CONDITION] appropriately. Interview on [DATE] at 9:35 am the Administrator said he thought the Immediate Jeopardy came about because resident went out to hospital due to a change in condition. Administrator said he became aware of the situation in the next clinical meeting. Administrator said the facility did investigate and implement corrective measures. The Administrator said the resources that are available to himself and the staff are facility policies/procedures, Medical Director, Physician Involvement, and Corporate Support. Interview on [DATE] at 10:30am with the interim DON he said that he believed the IJ happened because of the lapse in time and urgency in providing CR #1 a higher level of care. He said the type of training he provided to ensure the nurses were competent to care for residents who were ventilator dependent was a general skill competency ventilator training which covered the ventilator settings and why resident was on a ventilator. The interim DON said the type of plan that was in place for ventilator dependent resident(s) was training the nurses. The DON said the resources that are available to him and the facility staff is the Nurse Practitioner, [MEDICAL CONDITION] Specialist which is the Medical Director. The DON said the facility also have the Primary Care Physician, and a vendor that comes to the facility to give training to the staff on ventilator dependent residents. No documentation was provided by the Interim DON that a general skill competency was done or that an outside vendor or the PCP had provided training to the staff on ventilator dependent residents before the exit on [DATE]. The Administrator and the interim DON were informed on [DATE] at 10:35 am that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the Administrator, 7 residents were ventilator dependent in the facility.

Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications), a need to alter treatment significantly and a decision to transfer the resident had to be made for 1 of 7 residents reviewed for notification of changes (CR # 1) in that, - RN-T and RT-U did not consult with the physician when CR#1 was experiencing respiratory distress for over six hours. - CR # 1 continued to experience respiratory distress and there was no response from the PCP. -Staff did not contact 911 in a timely manner when CR #1 continued to experience respiratory distress for over 6 hours. -EMS arrived at the facility and transported the resident to the hospital where she passed away. These failures resulted in an IJ on [DATE]. While the IJ was lowered on [DATE] the facility remained out of compliance at a scope of isolated and a severity of actual harm due to facility requiring more time to monitor the plan of removal for effectiveness. These failures affected one discharged resident and placed 7 residents that were vent dependent at risk of not being provided with appropriate and timely medical intervention resulting in a decline in their quality of care, and quality of life, respiratory distress, and possible death. Findings Included: Record review of CR #1 face sheet revealed a [AGE] year old admitted to the facility on [DATE] with the following diagnoses; Acute Respiratory Distress, Pneumonia,[MEDICAL CONDITIONS] Status, Dependence on Ventilator, [MEDICAL CONDITION], Type 2 Diabetes Mellitus, [MEDICAL CONDITION], Hypertension, Primary [MEDICAL CONDITION] Hypertension, Diastolic Heart Failure, and End Stage [MEDICAL CONDITION]. Record review of CR # 1 MDS assessment dated [DATE] revealed that CR #1 had a BIMS score of 15, indicating no cognitive issues. Further record review revealed that CR # 1 was totally dependent on staff for activities of daily living and required special treatments for the following: oxygen therapy, suctioning, [MEDICAL CONDITION] care, and ventilator or respirator. Record review of CR #1 48 hour baseline care plan dated [DATE] revealed that resident was being care planned for communication, activities of daily living (transfers, bed mobility, dressing, incontinence both bowel and bladder, and bathing), [MEDICAL TREATMENT], and specialized services needed (Respiratory Care and Enteral Feeding). Record review of CR # 1 Admission Summary Note dated [DATE] at 11:06p.m. revealed in part: .Guest arrived via stretcher from hospital in no distress, alert able to communicate by writing and gestures. No SOB,[MEDICAL CONDITION] line no excess secretions noted, skin warm and dry to touch. Abdomen Soft and non- tender, [DEVICE] patent, eats during day and feeding tube on from 6p to 6a, no s/s of hypo/[MEDICAL CONDITION] noted,[MEDICAL CONDITION] at 28% during the day and vent assist at evening . Record review of CR #1 Physician order [REDACTED].# 1's ventilator setting where: AC-12, tidal volume-500, Oxygen 40%, and a PEEP of 5 every night shift for airway. Record review of Daily Respiratory Note completed by RT-U dated [DATE] at 6:09 am for CR #1 revealed in part: . right and left lung sounds pre and post treatment with crackles and coarse productive sputum. CR # 1 on the vent, respiratory treatments [MEDICAL CONDITION]/suctioning. CR # 1 in no acute resp. distress . Record review of CR #1 Progress Notes completed by RN-T dated [DATE] at 9:48am (late entry) read in part .around 2300 (11:00 pm), patient was restless and nurse checked v/s BP ,[DATE], Pulse 78, RR 20, O2 Sat 98% on vent, blood sugar 114, performed pain assessment and PRN Tylenol 650 mg administered and patient was able to calm down and slept. Around 01:00 am, patient woke up with restless and agitated. At 01:20 am, nurse called patients doctor, but went straight to the voicemail. At 01:05 am, called IPC and spoke to staff who promise to send message to the Doctor and call back. At 02:05 am, called IPC again and asked for at least one time order for medication for restless and agitation. IPC staff member said the Doctor did not call her back .administered PRN Tylenol 650mg. Patient was able to sleep for a while till 04:30 am. At 0500 am went to check on patient and assessed the labored breathing. O2 Sat was 88% on vent and pulse was 128, nurse called for the respiratory therapist and v/s performed. BP ,[DATE], RR 22, HR 115, O2 sat 99% on vent, blood sugar 153. 911 called and patient sent out of the facility at 06:00 am . Record review of the EMS patient care report dated [DATE] revealed in part: .called out for a breathing problem .arrived at the facility at 5:47 am .the nurse stated that the patient had been in respiratory distress since 11:30 pm last night. Pt found in the facility bed in respiratory distress. The pt. was unresponsive .also EMTs noticed the suction canister full of mucus next to the bed .patient was transferred from the facility bed to the stretcher. Patient needed to be suctioned, so the respiratory therapist tried to suction the patient but the suction catheter would not go through the [MEDICAL CONDITION]. The respiratory therapist lifted the [MEDICAL CONDITION] tamer (tube securing device) to see why the catheter would not go through and the EMT noted that the [MEDICAL CONDITION] was twisted. EMTs asked the respiratory therapist why was the tube twisted, the therapist did not answer. The respiratory therapist then completely pulled out the connection device of the [MEDICAL CONDITION] and was unable to place the tube connection back in the [MEDICAL CONDITION]. The respiratory therapist then ran out of the room to go get a new connection .the therapist was unable to install the new [MEDICAL CONDITION] connection .EMT loaded the patient to the ambulance and on the way to the hospital the patient went in to [MEDICAL CONDITION] . Record review of CR # 1 hospital noted dated [DATE] at 6:34am read in part: .arrived at [DATE] at 6:12 am . CPR in progress .(facility) called 911 because patient was in respiratory distress. EMS said when they arrived on the scene, patient had spontaneous breathing. EMS said they wanted to suction pts.[MEDICAL CONDITION] could not get the suction through patient trach. EMS said the Respiratory Therapist at facility pulled [MEDICAL CONDITION], patient was having respiratory distress and EMS was unable to bag patient via BVM (bag valve mask). EMS said patient went into [MEDICAL CONDITION] en route . Record review of the hospital history of present illness dated [DATE] revealed in part: .arrived in [MEDICAL CONDITION] via EMS .per EMS, patient had difficulty breathing, and they report that someone had remove the trach. There was a problem associated with the [MEDICAL CONDITION], but the exact problem is unclear. Healthcare Provider attempted to adjust trach, but reportedly pulled it out or it somehow became dislodged . Record review of CR # 1 Physician Note in the ER dated [DATE] at 6:53am Revealed in part .History provided by the EMS is somewhat vague, and the fine details are unclear, however what is clear is that the patient was having some difficulty with her [MEDICAL CONDITION] at the nursing facility, and at some point this [MEDICAL CONDITION] became dislodged. Provider prior to the emergency department attempted to replace the [MEDICAL CONDITION]. EMS reported that they were having a very difficult time bagging the patient, meeting a lot of resistance .On presentation, the patient was attempted to be bagged through the [MEDICAL CONDITION], which was in the [MEDICAL CONDITION] site. The patient was again extremely difficult to bag .we attempted bag mask ventilation through the oropharynx, which was not successful .it became immediately clear that the patient did not have an intact airway .was in [MEDICAL CONDITION] and remained asystolic . Attempt was made at incising through the [MEDICAL CONDITION] membrane, but was unsuccessful .At this point, the patient had been asystolic for a prolonged period of time with prolonged CPR and she had been without ventilation or oxygenation for extremely prolonged time . It was determined that the patient was very unlikely to have any type of a reasonable outcome .Resuscitative efforts were discontinued .Time of death was 0630 . Record review of CR #1's late entry Respiratory Notes completed by RT-U dated [DATE] at 4:46 pm read in part: . about 11:00p.m. I made my rounds, I found patient crossed legged across the bed trying to crawl out of bed, struggling, agitated, and restless. Upon communicating and reading through her lips, she indicated to me that she was hot, and was fanning herself try to stay cool. She also indicated that she wanted to go to the bathroom. I then indicated to the nurses and CNA about her condition and wanting to go to the bathroom. I then asked them to look for a fan for her and to offer her a bed pan. According to the CNA, she refused the bed pan. I then checked her O2 saturation 99%. I also checked her ventilator to make sure that her prescribed parameters were ok .About 1:00am upon checking on the patient, she was still restless and agitated, complaint still being hot, restless, agitated, her legs crossed hanging out of the bed and her beddings/bed covers on the floor. At this time, I observed that the patient was in labored respiration. Checked her Oxygenation saturation 98% and on close observation I noticed that her abdomen was heavily distended and sounds tympanic upon percussion. I then indicated to the nurses especially RN-T that patient was not doing well and that they needed to address the issue because she was restless, agitated and now labored .I then advised them to try and call the Doctor and the patient needs to get to ER. I then started monitoring the patient condition closely up until 4:00am and 5:00am. Up until now, pt. was still agitated, restless and her laboring has increased .I made clear to the nurse that she need to get to the ER as soon as possible as her condition was getting worse .about 5:00am, I had to force them to call 911. So 911 was called and the patient was then picked up to the ER . Interview on [DATE] at 10:40 am RT-S said she worked the 2p-10p PRN. RT-S said she provided care for CR #1 on [DATE]. RT-S said CR #1 complained of shortness of breath towards the end of her shift between ,[DATE]pm therefore she administered a breathing treatment to resident and placed her back on the ventilator. RT-S said later on resident complaint of pain on her leg and she reported it to the nurse. RT-S said she followed back up with CR #1 who was then watching T.V. and communicated that she was feeling better and the resident wrote on piece a paper to her that she was doing a good job. RT-S said she then gave report to the oncoming RT. In a phone interview on [DATE] at 4:30 p.m. CNA A said that near the start of her shift (10:00 p.m. on [DATE]) CNA B was trying to get help for CR #1. She said the resident was sweating profusely and was hot. CNA A said the resident was complaining about being short of breath to RN T. CNA A said, The biggest problem was she couldn't breathe, and she was telling (the RN- T and RT-U) she couldn't breathe. She was having a hard time breathing. CNA A said the resident was in distress since around 11:00 p.m. CNA A said that when the Paramedics arrived in the morning, CR #1 seemed unresponsive. In a phone interview on [DATE] at 8:30 p.m. CNA B said when she started her shift on Saturday ([DATE] at 10:00 p.m.) CR #1 was different CNA B said I told the nurses something was wrong. CR #1 said she couldn't breathe. I told the nurse and the RT-U. She was sweating, snot running out of her nose. The nurse suctioned her nose and said Oh, she's just restless. Her eyes were bloodshot. CNA B said of RT-U, He came in there, didn't pay attention to what I was saying. I told him she needed suctioning, and he didn't suction. CNA B said the resident was in distress from the start of her shift until the morning. She said Towards the end of the shift she was crying. Bloodshot, red. Breathing hard like she couldn't breathe. In a phone interview on [DATE] at 8:45 p.m. with CNA A she said when the Paramedics arrived, they tried to suction CR #1, and tried to intubate her, but could not. She said, They had to use the ambu-bag on the trach. She couldn't breathe at night, asking for help. Interview on [DATE] at 11:05am ADON said CR # 1 left the facility via 911. ADON said she found out after the resident was sent to a local hospital. The ADON said CR #1 was at the Nursing facility for 3 days. The ADON said RN-T was the nurse taking care of CR #1 on the night shift on [DATE]. The ADON said RN-T reported that CR #1 was anxious. The ADON said the facility was going to terminate RN-T because she did not inform herself or Administration about the change in condition on CR #1, but RN-T resigned on her own. Interview on [DATE] at 11:10am with the Administrator said CR #1 went to a local hospital and believed resident had expired. In a phone interview on [DATE] at 11:25am RN-T said she worked the 10p-6a shift on [DATE]. RN-T said she started working at the facility in (MONTH) of (YEAR) full time. RN-T said she became a nurse in (YEAR). RN-T said when she came on her shift for the 10p-6a, CR #1 was a little restless and the resident O2 sat was 99% and resident vitals were okay. RN-T said CR #1 was unable to communicate due to resident being on the vent. RN-T said she checked resident medications and found that some of the resident's medications were on hold so she called the Doctor at around 11pm and it went to voicemail. RN-T said she then placed a call to the NP and the call went to voice-mail as well then she called the IPC and spoke to staff that informed her they would call the Doctor. RN-T said the happenings around CR #1 were in her Nursing Notes. Interview on [DATE] at 1:05pm RN-T said whenever there was a change in a resident condition in the facility the protocol was to notify the PCP and if they did not answer, then contact the Physician/NP then call the IPC group. RN-T said she had never heard of a Medical Director. RN-T said she never received training in suctioning residents with a [MEDICAL CONDITION] or for taking care of residents who were ventilator dependent. RN-T said the only training she received on ventilator patients was when she did clinical rotation in Nursing School. RN-T said she took on the assignment of caring for CR #1 who was ventilator dependent unit because the facility had a Respiratory Therapist. An attempted interview via phone on [DATE] at 12:45pm with RT-U was unsuccessful. There was no answer and was unable to leave a voice-mail. Interview on [DATE] at 12:35pm the NP said CR #1 came to the facility over the weekend. The NP said she had received a call from the Nursing facility staff that CR # 1 had been admitted to the facility and a Medication Reconciliation was done with the nurse over the phone. The NP said she gave orders to continue all previous medications except for [MEDICATION NAME]. The NP said the reason she did not give orders to resume the medication [MEDICATION NAME] was because she wanted to first assess CR #1 due to resident history of Respiratory Distress and [MEDICAL CONDITION]. The NP said the facility staff reported to her that CR #1 was not in any distress and resident was stable upon admission. Interview on [DATE] at 1:27pm with Director of Respiratory Therapy (DRT) she said she received a call from RT-U at 6:30am on [DATE] informing her that CR #1 had to be sent out to the hospital because she was experiencing some respiratory distress. The DRT said RT-U reported to her that when CR #1 was sent out to the hospital the resident's oxygen saturation was good. The DRT said CR #1 was to be on [MEDICAL CONDITION] during the day and would go back on the ventilator at night around 10 or 11pm. The DRT said she noticed RT-U had not done any documentation on CR #1 on the 10p-6a shift for [DATE] and told RT-U that he needed to come in and document a late entry. In an interview with the DRT on [DATE] at 2:50 pm she said that because CR #1 was on [MEDICAL CONDITION] the day and then on a vent during the night, RT U should have documented that 2 ventilator checks were performed during the night and there was no documentation that it was done. The DRT also said she did not understand why RT-U was assessing CR #1 abdomen instead of the lung sounds because the abdomen was not an RT's area of study but the respiratory system was. Interview on [DATE] at 2:08pm the ADON said the only people that RN-T was calling to notify of change in CR #1 condition was the IPC who notifies the Physician. The ADON said the NP and Physician did not see CR #1 because she came to the facility late on a Friday night. The ADON said when she spoke with RN-T and asked why she didn't call the Medical Director, the NP, or herself, RN-T could not give an answer. Interview on [DATE] at 12:20 pm the facility Administrator and the ADON both said that they believed that based on the documentation in change in condition for CR #1 that facility staff was monitoring CR #1 and following the facility protocol. Both agreed that they wished that RN-T would have reached out to Administration to tell them what was going on. The ADON said she did do in-service just could not remember what day. The Administrator and the ADON said RT-U was employed on a PRN base and was no longer employed at the facility. Interview on [DATE] at 2:00 pm the interim DON said he was in agreement with the Administrator and ADON that the facility staff was following protocol in monitoring CR #1. The interim DON said after reviewing the documentation of RN-T and RT-U regarding CR #1, there was room for improvement but did not see a deficiency. The interim DON said when he reviewed RT-U documentation that he had to force RN-T to call the Physician he did not know what he meant by that and would have to talk to RT-U to clarify. The interim DON said RT-U no longer worked at the facility. Interview on [DATE] at 3:25pm the interim DON said after reading RN-T and RT-U documentation again, the Physician/NP should have been called. The interim DON said that if there were no results from calling the Physician/NP, CR # 1 should have been sent out to the hospital. Interview on [DATE] at 8:55am with ADON said whenever a resident experience a change in condition, the nurse was to notify the family and the Doctor and carry out any orders received. Record review of Nursing facility last In-service Training Report with the Nursing department on SBARs, change in condition and worsening, notifying MD,NP, family, or charge nurse was dated [DATE]. Interview on [DATE] at 1:25pm LVN-B said he work the 10p-6a shift on a full time basis on halls ,[DATE]. LVN-B said if a resident started to experience a change in condition, he would first do an assessment, call the Doctor immediately and if the Doctor did not respond, he would call the facility Medical Director. A policy for notification of changes was requested but was not provided before exit on [DATE]. The Administrator and interim DON were notified on [DATE] at 2:00 pm of the IJ situation due to the above failures and a POR was requested. The POR was received and after 2 revisions it was accepted on [DATE] at 1:50pm. POR included in part: . All residents were immediately assessed on [DATE] by the DON, ADON, and Licensed Nurses for any changes in condition. These assessments were completed on [DATE]. All the following in-services will be completed with staff prior to them working their next schedule shift. Prompt Assessment Licensed Nurses were reeducated on [DATE] on promptly assessing residents each shift and documenting in a daily skilled nursing note, and completing an SBAR for any changes in condition. This education was conducted by the Director of Nurses, and Assistant Director of Nursing. Documentation will be monitored for completion prior to the end of each shift by the DON, ADONs, and designees using the 24 Summary. The Administrator will monitor the timely completion of the inservice. Completion Date: [DATE] All ventilator patients were immediately assessed by the Director of Respiratory Therapy (DRT) and Licensed Respiratory Therapists for potential changes in condition on [DATE] and was completed on [DATE]. No new changes in condition were noted All departments were reeducated on the Stop and Watch tool on [DATE] by the DON, ADON, and designee. This will be monitored by the Administrator. Completion Date: [DATE] A new policy was implemented on [DATE] that report needs to be given between nursing and respiratory therapy at the change of each shift. Physician Notification Licensed Nurses and Respiratory Therapist were immediately inserviced on [DATE] on notifying physicians in a timely manner. This was conducted by the DON, ADON, DRT, and designee. All changes in conditions will be reviewed during the daily clinical meeting. Completion Date: [DATE] Calling 911 in a Timely Manner Licensed Nurses and Respiratory Therapists were reeducated on [DATE] on the existing protocols regarding emergency situations and when to calling 911. This was conducted by the DON, ADONs, DRT, and designee. This will be monitored by the Administrator, DON, and ADONs . Any Significant Change to Supervisor and Physician An in-service was immediately started on [DATE] for Licensed Nurses and Respiratory Therapist on reporting significant changes in condition to supervisor and physician. This in-service will be completed by the DON, ADON, DRT, and designee. This will be monitored by the Administrator . The facility was monitored from [DATE] until [DATE] by the surveyors with the following results: Record review revealed new training and in-services were done with facility staff in the following areas: -when and who to report in timely manner of a change in resident condition utilizing the stop and watch and SBAR documentation as a guiding tool. -When it is appropriate to alert 911 EMS in transferring a resident to a higher level of care after experiencing a change in condition and notifying all parties. -Ventilator training with the nursing staff and respiratory staff in caring for resident vent dependent (recognizing the vent settings and what they mean as well as recognizing a change in condition (resp. distress) and notifying the Physician, Medical Director, RP, and Administration. -Performing prompt assessments on resident (s) experiencing a change in condition and reporting to Physician/NP, Medical Director, and RP (responsible party) in a timely manner Record review of the forms revealed that In-services were conducted on all three shifts with the nursing staff attending. During the monitoring phase, interviews were conducted by the surveyor(s) on different shifts with the nursing staff, nurse management, and CNAs. All interviewed staff verbalized up to date knowledge on new communication procedures, notification of changes and ventilator use training. Observations were conducted during the monitoring of the seven residents that were ventilator dependent and they were stable. Nurses were observed [MEDICAL CONDITION] appropriately The Administrator and the interim DON were informed on [DATE] at 10:35 am that the IJ was lowered; however the facility remained out of compliance at an isolated level and a severity of actual harm that is not an IJ to resident health or safety due to facility needing more time to train the staff. According to a list provided by the Administrator, 7 residents were ventilator dependent in the facility.