Every finding on record at Life Care Center of Elizabethton

Based on facility policy review, observation, and interview, the facility failed to discard expired food items in 1 of 3 coolers, label and date opened food items and maintain kitchen equipment in a sanitary condition in 1 of 1 kitchen, which had the potential to affect 127 of 127 residents residing in the facility. The findings include: Review of the facility's policy titled, Cleaning Schedule, dated 5/12/2026, revealed .the Food and Nutrition Services department is maintained in a clean and sanitary manner in accordance with regulatory requirements .The Director of Food and Nutrition Services monitors the cleaning schedule .and appropriate completion tasks to maintain the department in a clean and sanitary manner . Review of the facility's policy titled, Food Safety, dated 5/26/2026, revealed .Food is stored and maintained in a clean, safe and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth .Store food on accordance with professional standards for food service safety .the 'use by date' guide is easily accessible to all associates involved with resident food storage .Food .labeled with the date received if not already indicated on the item .Opened packages of food are resealed tightly to prevent contamination of the food item and 'use by date' will be used when applicable . During an observation and interview on 7/27/2026 at 10:18 AM, with the Certified Dietary Manager (CDM) of the juice cooler revealed, 1 gallon of Whole Milk with an expiration date of 7/22/2026 and available for use. The CDM confirmed the milk was expired and was available for use. During an observation and interview on 7/27/2026 at 10:23 AM, with the CDM revealed 1 drop cooler with 1 opened and unlabeled bag of 11 chicken breasts with freezer burn, 1 opened and unlabeled half bag of French fries with freezer burn, 1 opened and unlabeled half bag of 50 chicken nuggets with freezer burn. The CDM confirmed the items were open, unlabeled, freezer burned, and available for use. During an observation and interview on 7/27/2026 at 10:28 AM, with the CDM revealed 1 milk cooler with a thick black substance in the folds and on the rubber seals on the freezer door. Further observation revealed a one-inch piece of brown food item on the rubber seal. The CDM confirmed the rubber seal had a thick black substance in the folds and on the rubber seals and had a one-inch brown piece of bacon on the rubber seal of the freezer door. During an observation on 7/27/2026 at 10:35 AM, revealed 1 large container of sugar with 1 scoop inside the container, and 1 large container of flour with 1 scoop inside the container. The CDM confirmed the scoops were touching the sugar and flour and were not stored properly. During an observation and interview on 7/27/2026 at 10:36 AM, with the CDM revealed 1 industrial mixer with orange dried food particles on the underside of the machine motor head. The CDM confirmed the machine was not sanitary and had not been cleaned. During an observation and interview on 7/27/2026 at 10:52 AM, with the CDM in the walk-in freezer revealed 1 opened and unlabeled bag of fish nuggets with freezer burn available for use. The CDM confirmed the item was open, unlabeled, freezer burned, and available for use.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage was properly contained in the kitchen. The findings include: Review of the facility's policy titled, Disposal of Garbage and Refuse, dated 5/12/2026, revealed .The facility will have a process to properly discard of garbage and refuse to prevent the soiling of food areas . During an observation and interview on 7/27/2026 at 10:41 AM, with the Certified Dietary Manager (CDM) in the food preparation area revealed two large gray trash containers overflowing and uncontained. A dietary food aide was preparing food items in close proximity to the open uncontained garbage. The CDM confirmed the trash was not contained, was overflowing, was not maintained within the trash receptacle, and was not kept in a sanitary condition.

Based on facility policy review, medical record review, and interview, the facility failed to revise the comprehensive care plan for 3 residents (Resident #3, # 84 and #121) of 31 residents reviewed for care plans. The findings include: Review of the facility's policy titled, Comprehensive Care Plans and Revisions, revised 8/29/2025, revealed .facility will ensure the timeliness of each resident's .care plan .when .changes occur .review and update the plan of care . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Pressure Ulcer of Left Hip, Epilepsy, and Paraplegia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the comprehensive care plan dated 6/3/2026, revealed Resident #3 had .Midline [long soft IV [Intravenous] tube place in upper arm to deliver IV fluids] .Assess site as ordered . Review of the Nurse's Notes dated 7/15/2026, revealed Resident #3 had . Midline pulled [discontinued] 7/14 [7/14/2026] . During an interview on 7/27/2027 at 11:59 AM, Resident #3 stated he did not have a midline anymore and that staff had removed it. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes Mellitus, Morbid Obesity, and Chronic Diastolic Congestive Heart Failure. Review of a Nutrition/ Dietary progress note for Resident #84 dated 3/19/2026, revealed .Refused wt [weight] . Review of a quarterly MDS assessment dated [DATE], revealed Resident #84 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed no weight was coded on the assessment. Review of a quarterly Nutrition Data Collection assessment for Resident #84 dated 6/23/2026, revealed .Resident refused wt [weight] at this time . Review of a comprehensive care plan for Resident #84 dated 6/23/2026, revealed the resident's refusal of being weighed was not outlined on the comprehensive care plan. Review of the Medical Record revealed Resident #121 was admitted to the facility on [DATE] readmitted [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus, Schizoaffective Disorder, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed Resident #121 scored a 3 on the BIMS assessment indicating the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #121 dated 6/23/2026, revealed .At risk for weight fluctuation r/t [related to] .Regular diet, puree texture, thin liquid .nutritional problem r/t MNA [mini nutritional assessment] .currently Regular Diet, Mechanically Altered Texture, Thin consistency date initiated 10/24/2025 revision on 12/10/2025 .supplements as ordered: 2 Cal Med Pass Supplement, Frozen Nutritional Supplement . Review of the physician orders for Resident #121 dated 7/29/2026, revealed .Regular diet Puree texture, Thin consistency start date 6/1/2026 .Nutritional Juice Drink two times a day . start date 6/15/2026 . During an interview on 7/29/2026 at 10:30 AM, the Registered Nurse (RN) MDS Coordinator confirmed Resident #3s care plan had not been revised to reflect discontinuation of the midline, Resident #84's revised to reflect refusal of weights, and Resident #121's revised to reflect current dietary interventions. During an interview on 7/29/2026 at 10:45 AM, the Director of Nursing (DON) confirmed Resident #3's care plan had not been revised to reflect discontinuation of midline, Resident #84's revised to reflect refusal of weights, and Resident #121's revised to reflect current dietary interventions.

Based on facility policy review, Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual review, medical record review, and interviews, the facility failed to ensure MDS assessments were accurate for 3 residents (Resident #135, Resident #98, and Resident #103) of 31 residents reviewed for MDS assessment accuracy. The findings include:Review of the facility's policy titled, Resident Assessment Instrument & [and] Care Plan Development, dated 8/29/2025, revealed .The facility will follow the procedures set forth in the Resident Assessment Instrument (RAI) User's Manual 3.0 when completing the MDS .Review of the MDS 3.0 RAI Manual Version 20.1, dated 10/2025, revealed .Health-related Quality of Life .residents covered by Level II PASRR [Pre-admission Screening and Resident Review] process may require certain care and services provided by the nursing home .Steps for Assessment .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness .Review of a PASRR dated 8/12/2024, revealed Resident #136 had a PASRR Level II Outcome related to a serious mental illness (Schizophrenia). Review of the medical record revealed Resident #136 admitted to the facility on [DATE] with diagnoses including Schizophrenia, Hyperlipidemia, and Hypertension. Review of an annual MDS assessment dated [DATE], revealed Resident #136 was not coded for a PASRR Level II outcome. Further review revealed the resident scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and had an active diagnosis of Schizophrenia. Review of the medical record revealed Resident #98 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Schizophrenia and Dementia.Review of a PASRR dated 9/18/2023, revealed Resident #98 had a PASRR Level II Outcome related to a serious mental illness (Schizophrenia). Review of an annual MDS assessment dated [DATE], revealed Resident #98 was not coded for a PASRR Level II outcome. Further review revealed the resident scored a 0 on the BIMS assessment which indicated the resident had severe cognitive impairment and had an active diagnosis of Schizophrenia.Review of the medical record revealed Resident #103 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Schizophrenia and Major Depressive Disorder.Review of a PASRR dated 11/18/2024, revealed Resident #103 had a PASRR Level II Outcome related to a serious mental illness (Schizophrenia, Psychotic Disorder, Major Depressive Disorder, and Anxiety). Review of an annual MDS assessment dated [DATE], revealed Resident #103 was not coded for a PASRR Level II outcome. Further review revealed the resident scored an 8 on the BIMS assessment which indicated the resident was moderately cognitively impaired and had active diagnoses including Anxiety, Depression, and Schizophrenia.During an interview on 7/29/2026 at 10:01 AM, Registered Nurse (RN) MDS Coordinator confirmed the annual MDS assessment for Resident #135 dated 5/11/2026, the annual MDS assessment for Resident #98 dated 6/26/2026, and the annual MDS assessment for Resident #103 dated 7/13/2026 was inaccurate and the PASRR level II status was not documented for Resident #136, Resident #98, and Resident #103 on the MDS assessment.During an interview on 7/29/2026 at 10:52 AM, the Director of Nursing (DON) stated it was the facility's expectation for MDS assessments to be coded accurately. The DON confirmed the facility failed to ensure the annual MDS assessment for Resident #135 dated 5/11/2026, the annual MDS assessment for Resident #98 dated 6/26/2026, and the annual MDS assessment for Resident #103 dated 7/13/2026 was inaccurate.

Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain a safe, clean, homelike environment for 4 resident rooms (room [ROOM NUMBER], # 216, #220, and #219) on 1 of 3 hallways observed. The findings include: Review of the facility's policy titled, Resident Belongings and Home like Environment, revised 4/1/2026, revealed .facility will provide .homelike environment .Refers to any environment in the facility that is frequented by residents .including .the residents' rooms . 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Anxiety, and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation on 7/27/2026 at 11:58 AM, in room [ROOM NUMBER] (Resident #11 resided in the room) revealed multiple areas of missing paint and multiple areas of penetration which exposed the dry wall plaster on the wall behind Resident #11's recliner. 2. Review of the medical record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including Depression, Anxiety, and Insomnia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #63 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. During an observation on 7/27/2026 at 12:01 PM, in room [ROOM NUMBER] (Resident #63 resided in this room) revealed multiple areas of missing paint and multiple areas of penetration which exposed the dry wall plaster to the wall behind Resident #63's bed. 3.Review of the medical record revealed Resident #131 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Hypertension, and Anxiety. Review of a significant change in status MDS assessment dated [DATE], revealed Resident #131 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. During an observation on 7/27/2026 at 3:30 PM, in room [ROOM NUMBER] (Resident #131 resided in the room) revealed multiple areas of missing paint and multiple areas of penetration which exposed the dry wall plaster to wall on right side of Resident #131's bed. 4.Review of the medical record revealed Resident #119 was admitted to the facility on [DATE] with diagnoses including Diabetes, Atrial Fibrillation, and Muscle Weakness. Review of a quarterly MDS assessment dated [DATE], revealed Resident #119 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. During an observation and interview on 7/27/2026 at 3:45 PM, in room [ROOM NUMBER] (Resident #119 resided in the room) revealed multiple areas of missing paint and multiple areas of penetration which exposed the dry wall plaster to the wall behind Resident #119's bed. During an interview and observation on 7/28/2026 at 10:10 AM, the Administrator observed the above observations, and confirmed the facility failed to ensure rooms were in good repair and failed to provide a home-like environment in room [ROOM NUMBER], #216, #220, and #219.

Based on facility policy review, Centers for Disease Control and Prevention (CDC) guideline review, medical record review, observation, and interview the facility failed to follow Contact Isolation Precautions for 1 resident (Resident #90) of 1 resident reviewed for contact isolation, the facility failed to follow Enhanced Barrier Precautions for 1 resident (Resident #2), the facility failed to ensure a direct patient care associate's fingernails were maintained for 1 associate (Registered Nurse A) of 5 direct patient care associates reviewed, and the facility failed to follow appropriate hand hygiene during wound care for 1 resident (Resident #130) of 2 residents observed for wound care. The findings include: Review of the facility's policy titled Hand Hygiene, dated 10/28/2025, revealed .Associates perform hand hygiene .after removing personal protective equipment .gloves .artificial nails and extenders not to be worn by health care workers who have direct contact with patients . Review of the facility policy titled, Contact Precautions, dated 6/3/2026, revealed .Contact precautions should be used when a resident develops signs and symptoms of a transmissible infection or has a laboratory confirmed infection that requires the use of contact precautions to prevent transmission of pathogens that are spread by direct .or indirect contact with the resident or environment .and requires the use of appropriate PPE [Personal Protective Equipment], including gowns and gloves .Don [apply] appropriate PPE before or upon entry into the resident room . Review of the facility policy titled, Enhanced Barrier Precautions, dated 6/5/2026, revealed .The facility should use Enhanced Barrier Precautions (EBP) .for residents that meet the following criteria, during high-contact resident care activities .wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized .High contact care activities include dressing .providing hygiene, changing linens, changing briefs .assisting with toileting, medical device care or use .Personal protective equipment (PPE) .protective items or garments worn to protect the body from hazards . Review of the CDC guidelines titled, Nail Length in LTC Facilities, undated revealed, .Nail length: Keep natural nails short, not extending past the fingertip .guidance specify less than one quarter of an inch [ approximately 6 millimeters] or less as the maximum length .Artificial nails: Prohibited in direct patient care areas, including long-term care settings . Review of the medical record revealed Resident #90 was admitted to the facility on [DATE] with diagnoses including Epilepsy, Anxiety, and Muscle Weakness. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #90 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the Physician's Order for Resident #90 dated 7/24/2026, revealed .Contact Isolation for ESBL [Extended Spectrum Beta-Lactamase] . During an observation on 7/27/2026 at 11:33 AM, revealed Resident #90's entrance way door had a contact isolation precaution sign posted which stated .PROVIDERS AND STAFF MUST .Put on gloves before room entry .Put on gown before room entry . Further observation revealed a plastic cart outside of Resident #90's door which contained Personal Protective Equipment (PPE) such as gowns and gloves. Continued observation revealed the Activity's Director entered Resident #90's room, did not apply gloves, did not apply a gown, provided assistance to the resident with placing a sweater on the resident, exited the room, and sanitized the hands. During an interview on 7/27/2026 at 11:38 AM, the Activity Director confirmed Resident #90 was on Contact Isolation Precautions. The Activity Director further confirmed she did not apply a gown or gloves prior to entering Resident #90's room. During an interview on 7/29/2026 at 10:52 AM, the Director of Nursing (DON) stated when a resident was on Contact Isolation Precautions staff were expected to wear a gown and gloves prior to entering the resident's room. The DON confirmed the Activity's Director failed to follow the facilities infection control policy when she failed to wear a gown and gloves prior to entering Resident #90's room. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including surgical aftercare following surgery on the Genitourinary System and Muscle Weakness. Review of the comprehensive care plan for Resident #2 dated 5/21/2026, revealed .Enhanced Barrier Precautions d/t [due to] Colostomy .reduce transmission of Multidrug resistant organism .staff to wear gown and gloves during high contact activities and dispose of in room . Review of a comprehensive MDS assessment dated [DATE], revealed Resident #2 scored a 9 on the BIMS assessment which indicated the resident had mild cognitive impairment. Further review revealed the resident had a colostomy. Review of a Physician Recapitulation Summary for Resident #2 dated 7/1/2026, revealed, .Enhanced Barrier Precautions Diagnosis: Colostomy . During an observation on 7/27/2026 at 3:15 PM and on 7/28/2026 at 2:40 PM, outside Resident #2's room, revealed an Enhanced Barrier Sign posted to the right upper door frame. During an observation on 7/29/2026 at 12:18 PM, outside Resident 2's room, revealed an Enhanced Barrier Sign posted to the right upper door frame. There was PPE located in the hallway available for use. Upon knocking on door and entering, revealed a Certified Nursing Assistant (CNA) A leaning against the bed providing person hygiene to Resident #2 and was not wearing any PPE. During an interview on 7/29/2026 at 12:25 PM, outside of Resident #2's Room with the DON present, the CNA stated he did not see the EBP signage prior to entering the room and confirmed he had not donned PPE prior to providing the resident personal hygiene. The DON stated she had recently provided education on appropriate use of PPE to the CNA and confirmed the expectation was for staff to follow infection control practices when providing high contact care activities. During an observation on 7/28/2026 at 7:45AM, Registered Nurse (RN) A was standing at the North Hall medication cart, RN A had thick purple fingernails with black spider webs painted on 2-4 of the nails, approximately one half inch to three quarters of an inch from fingertip. During an observation on 7/28/2026 at 3:39 PM, RN A was standing at North Hall medication cart, RN A had thick purple fingernails with black spider webs painted on 2-4 of the nails, approximately one half inch to three quarters of an inch from fingertip. During an interview on 7/28/2026 at 3:49 PM, the DON confirmed .her [RN A] nails are not appropriate, they [fingernails] are approximately one half inch to three quarters of an inch from her fingertip. Review of the medical record revealed Resident #130 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Diabetes, and Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #130 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. During an observation on 7/29/2026 at 3:14 PM, revealed Licensed Practical Nurse (LPN) B prepared wound care supplies for Resident #130. Further observation revealed LPN B sanitized the hands, applied gloves, and removed the resident's soiled dressing. LPN B removed the gloves, donned another pair of clean gloves, without cleaning or sanitizing the hands, and cleaned Resident #130's wound according to the Physician's orders. LPN B removed the soiled gloves and without cleaning or sanitizing the hands, donned another pair of clean gloves and applied a new dressing to Resident #130's left hip. Continued observation revealed no signs or symptoms of infection to Resident #130's left hip wound. During an interview on 7/29/2026 at 3:30 PM, LPN B confirmed she had not washed or sanitized her hands between the changing of the gloves during Resident #130's wound care. During an interview on 7/29/2026 at 4:00 PM, the DON confirmed LPN B did not follow appropriate infection control hand hygiene practices during wound care for Resident #130.

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure fingernail care and toenail care was provided to maintain comfort and hygiene for 1 resident (Resident #88) of 3 residents reviewed for nail care. The findings include: Review of the facility policy titled, Nail Care, dated 8/5/2021, revealed .The resident will receive assistance as needed to complete activities of daily living (ADL's) .the facility must ensure that residents receive treatment and care in accordance with professional standards of practice .including fingernail care .toenail care .ensure fingernails .ensure toenails .are clean and trimmed to avoid injury and infection . Review of the medical record revealed Resident #88 was admitted to the facility on [DATE], with diagnoses including Peripheral Vascular Disease, Diabetes Mellitus, and Hemiplegia to the left side. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #88 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact and had Peripheral Vascular Disease. Review of an Occupational evaluation note dated 4/10/2026, revealed .poor history of tolerance of splint wearing therefore not appropriate for therapy at this time . Review of the comprehensive care plan for Resident #88 dated 6/23/2026, revealed .resident has Peripheral Vascular Disease .keep toenails cut, inspect feet daily .assess pain level, circulation and skin integrity . Review of a Podiatry service list for March 2026 revealed Resident #88 had not received Podiatry services. Review of a Podiatry needs list for July 2026 received on 7/28/2026 revealed, Resident #88 had not been scheduled for Podiatry services. During an observation and interview on 7/27/2026 at 3:07 PM, revealed Resident #88 sitting in her electric wheelchair in front of her room. The resident had a left-hand contracture with fingers curled inward towards the palm. The resident's nails were long and untrimmed. Further observation revealed no injury to the inside of the left palm. Continued observation revealed Resident #88's bilateral feet had long untrimmed toenails and swelling of the left foot. During an interview, Resident #88 stated she had not had her nails or toenails trimmed .in some time . Resident #88 further stated she had peripheral vascular disease in her left foot and stated how important it was to keep her toenails trimmed because of the swelling. During an observation on 7/28/2026 at 3:41 PM, outside in the smoking area revealed Resident #88 sitting in her electric wheelchair. The resident had a left-hand contracture with the fingers curled inward towards the palm. Resident #88's fingernails were long and untrimmed. Further observation revealed bilateral feet with long untrimmed toenails and swelling of the left foot. During an observation on 7/29/2026 at 9:00 AM in Resident #88's room revealed the resident sitting in a recliner. The resident had a left-hand contracture with the fingers curled inward towards the palm. Resident #88's fingernails were long and untrimmed. Further observation revealed bilateral feet had long untrimmed toenails and swelling of the left foot. During an interview on 7/29/2026 at 9:50 AM in Resident #88's room, the Assistant Director of Nursing (ADON) confirmed the resident had long fingernails and toenails, and the nails had not been trimmed. The ADON stated Resident #88 should have been added to the podiatry list and was unaware of the resident's need for services. During an observation on 7/29/2026 at 9:55 AM in Resident #88's room, the Director of Nursing (DON) and the Licensed Practical Nurse (LPN) LPN C stated the length of Resident #88's fingernails and toenails were not acceptable and at minimum the resident should have been placed on the podiatry list. The DON and LPN confirmed the resident's fingernails and toenails had not been inspected, trimmed, or maintained.

Based on facility policy review, medical record review, and interviews the facility failed to assess and obtain a physician's order for medication self-administration for 1 resident (Resident #3 ) of 1 resident reviewed for self-administration of medication. The findings include: Review of the facility's policy titled, Self-Administration of Medication, dated 9/15/2025, revealed, .contact the resident's .physician to make them aware .facility will ensure that each resident who requests .self-administer medications .assessed by the interdisciplinary team .to determine if .resident is safe to self-administer medications .assessment will contain .resident's capability to follow directions .a reassessment .is conducted quarterly .to assure that safe self-administration .is still feasible . Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Pressure Ulcer of Left Hip, Epilepsy, and Paraplegia. Review of the Physician's Order for Resident #3 dated 12/24/2025, revealed . Indwelling catheter to straight drainage .Change every 30 days and prn [as needed] for infection, obstruction or when the closed system is compromised .related to NEUROMUSCULAR DYSFUNCTION OF BLADDER . Review of the Physician's Order for Resident #3 dated 12/25/2025, revealed . Clean Peristomal Skin .Apply skin prep to peristomal skin then apply wafer. (Fit cut to stoma size). Self care/ change .for colostomy every 3 days and as needed . Review of a comprehensive care plan for Resident #3 dated 5/21/2026, revealed . [Resident #3] desires to self administer his own colostomy/foley catheter care and catheter changes .Complete self administration assessment . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #3 had a foley catheter and colostomy. Review of the medical record revealed Resident #3 did not have documentation an assessment had been completed for the resident's ability to self-administer catheter/ostomy care. During an interview on 7/27/2026 at 10:59 AM, Resident #3 stated he cared for his foley catheter and colostomy care himself, using supplies provided by the facility. Resident #3 was knowledgeable on the process of caring for his foley catheter and colostomy in a safe and appropriate manner. During an interview on 7/29/2026 at 3:15 PM, the Director of Nursing (DON) confirmed an assessment on the ability to self-administer foley catheter care and colostomy care and a Physician's Order to self-administer care had not been obtained by the facility.

Based on the facility policy review, Lippincott Nursing Center website review, medical record review, and interviews, the facility failed to ensure basic nursing standards for the rights of medication administration were followed for 1 resident (Resident #6) of 7 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Administration of Medications, dated 9/9/2025, revealed .the facility must ensure .its residents are free of any significant medication errors .Medication Error .the observed or identified preparation or administration of medication .which is not in accordance with the prescriber's order .Accepted professional standards and principles which apply to professional services. Accepted professional standards and principles include .current commonly accepted health standards established by national organizations, boards, and councils .Staff who are responsible for medication administration will adhere to the 10 Rights of Medication Administration .Right Drug .Compare the order with the medication administration record (eMAR) for accuracy .Compare the label on the drug to the information on the eMAR three times before removing the container from the drawer .as the drugs is removed from the container .at the bedside before administering it to the patient . Right Resident .Be sure to verify the drugs .with the eMAR and two patient identifiers .ask resident his or hers full name and compare to the name on the medication or MAR [medication administration record] and compare the resident's photo .if resident is unable to tell you his or hers full name .validate the resident's identity with a second associate who is familiar with the resident . Review of the Lippincott Nursing Center Website resource of the Nursing Drug Handbook dated 2025- 2026, revealed .Medication Errors in Nursing .As a final step in the administration process .and the .defense against medication errors .nurses must follow the rights of medication administration .Right Patient .Right medication .Right dose . Review of the medical record revealed Resident #6 was re-admitted to the facility on [DATE] with diagnoses including Paranoid Schizophrenia, Dementia, and Neuropathy. Review of a comprehensive care plan for Resident #6 dated 6/9/2026, revealed .impaired cognitive ability/impaired thought process r/t [related to] Dementia .Communication Deficit .pain/discomfort r/t Neuropathy . Review of the eMAR for Resident #6 dated 6/7/2026 revealed no Physicians orders for Methadone (a synthetic Opioid used to treat chronic pain) Oral tablet 10 milligram (MG), Methadone Oral tablet 5 MG, or Oxycodone (a semi-synthetic Opioid used to treat moderate pain) Oral tablet 15 MG. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Depression, Anxiety Disorder, and Diabetic Neuropathy. Review of the eMAR for Resident #77 dated 6/22/2026, revealed the resident was ordered Methadone Oral tablet 10 MG, Methadone Oral tablet 5 MG, and Oxycodone Oral tablet 15 MG. Review of a nursing note for Resident #6 dated 6/7/2026, revealed .Nurse was giving HS [hour of sleep] medications and gave resident her roommates [Resident #77] medication. No injury noted. Team Health on call notified . Review of a nursing note for Resident #6 dated 6/7/2026, revealed .call placed to Team Health .in reference to med [medication] error, orders received to send resident to ER [emergency room] for evaluation and treatment. Call placed to 911 for transport . Review of a Team Health History and Physical note for Resident #6 dated 6/7/2026, revealed .Accidental overdose .called poison control for recommendations .patient has normal reaction advised observation for 8-12 hours .patient is pleasant and able to tell me where she is and her name and hold a conversation . Review of a Team Health Hospitalist Progress Note for Resident #6 dated 6/8/2026, revealed .Accidental overdose .Patient states she is feeling sleepy but denies other complaints. No shortness of breath, nausea, vomiting, or fevers .ROS [review of systems] and otherwise negative . no acute distress . Review of a Physician Progress Note dated 6/9/2026, revealed .patient discharged from the hospital .accidental overdose .patient doing well . During an interview on 7/29/2026 at 11:06 AM, Licensed Practical Nurse (LPN) E stated she was training a new staff member who had been a nurse for over 30 years. The trainer stated she was standing beside the nurse observing her pull the medications and go through the process for each resident. LPN E stated she heard a feeding tube alarm and asked LPN D (trainee) if she would be alright for a minute so she (LPN E) could check on the alarm. LPN D said she was fine.When I returned to the trainee, she was crying and stated she had given bed A's narcotic medications (Methadone 15 mg and Oxycodone 15 mg) to bed B by accident. I assessed the resident, called the Physician, 911, the Emergency room, the family, and the Executive Director . LPN E stated the resident was transported via Emergency Medical Services to the ER for evaluation and treatment. During Interview on 7/29/2026 at 1:05 PM, LPN D Stated It was her first weekend at the facility and she was training with another LPN (LPN E). LPN D stated she was preparing the medications with LPN E at her side observing and it was very busy. LPN D stated, .an alarm was sounding and the trainer asked if I would be okay for a minute while she went to check on it . LPN D stated she prepared medications for bed B's medications (Resident #6) and proceeded to pull the narcotics listed on the eMAR and narcotic book. The trainee stated she did not realize if she had turned to the wrong page in the book. The trainee stated, .I recall thinking, this little lady needs Methadone? It was a stupid error, me not checking the names . LPN D stated she was educated to check names on the doors and photos on the eMAR but had failed to double check. During an interview on 7/29/2026 at 4:25 PM, the Director of Nursing (DON) confirmed Resident #6 received the wrong medications, and the rights of medication administration were not followed.

Based on review of facility contract, facility policy, medical record review, facility documentation and interviews, the facility failed to complete a thorough medication regimen review to ensure 1 of 6 residents (Resident #5) reviewed for anticoagulation therapy received anticoagulation therapy for the diagnosis of Atrial Fibrillation and prevention of blood clot formation. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide anticoagulation therapy resulting in Resident #5 not receiving anticoagulation therapy from 10/31/2023 - 12/5/2023. The Executive Director (ED) was notified of the Immediate Jeopardy (IJ) on 2/28/2024 at 4:20 PM, in the conference room. The facility was cited Immediate Jeopardy at F-711. The IJ was effective on 11/15/2023 and was removed on 12/5/2023. The facility's corrective actions were taken on 12/5/2023. The Immediate Jeopardy was cited as past non-compliance for F-711 and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility contract titled, PHARMACY CONSULTANT AGREEMENT, showed .as of July 1, 2017 .RESPONSIBILITIES OF PHARMACY .Consultant shall identify any irregularities as defined in the State Operations Manual .Consultant will provide a summary report .which (a) documents that no irregularity as identified, or (b) reports any irregularities . Review of the facility policy titled, Pharmacy Services and Medication Regimen Review, reviewed 8/28/2023, showed .The facility maintains the resident's highest practicable level of physical .well-being and .minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist .The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing . Review of the medical record showed Resident #5 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Long Term (Current) Use of Anticoagulants and Myocardial Infarction. Review of hospital DISCHARGE SUMMARY documentation (sent with the resident) for Resident #5 showed .discharge date : 10/31/2023 .Discharge Medications .START taking these medications .apixaban [anticoagulant] 5 MG [milligram] .Commonly Known as Eliquis .1 tablet .2 .times a day .STOP taking these medications rivaroxaban [anticoagulant] 15 MG .Commonly known as Xarelto . Review of hospital Discharge to Outside Facility Form documentation (sent to the nursing home prior to the hospital discharge) for Resident #5 showed .10/31/23 Discharge Patient .[to named facility] .Meds [medications] .rivaroxaban 15 MG .2 .times a day with breakfast and dinner . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #5's Brief Interview of Mental Status (BIMS) score was 3, indicating the resident had severe cognitive impairment. The resident required assistance of one person with activities of daily living (ADL's). Review of the MDS discharge assessment showed Resident #5 was discharged to the hospital on 12/17/2023 and did not return. Review of a pharmacy consultation report for Resident #5 dated 11/20/2023, showed .To: Medical Director [MD]; [Director of Nursing (DON)] From: [Pharmacy Consultant] .Recommendation: Please discontinue Glipizide [antidiabetic] . No documentation of irregularities or mention of conflicting orders for anticoagulation were noted and the report was signed by the MD on 12/1/2023 and DON on 12/7/2023. Review of physician orders for Resident #5 showed Eliquis was ordered on 12/5/2023, 5 milligrams 2 times a day at 8:00 AM and 2:00 PM, for clot prevention. Documentation showed no orders for Xarelto, Eliquis, or any anticoagulant prior to 12/5/2023. Review of Facility's progress notes for Resident #5 showed .12/5/2023 .PT/INR at this time, PT 14.9 INR 1.2 . Review of the facility's MOBILE IMAGES report for Resident #5 showed .12/05/2023 .Ultrasound exam of head and neck .There is no evidence of mass or hematoma [pool of mostly clotted blood] involving the left occipital [back of the head] area .12/05/2023 .SKULL SERIES, 3 VIEWS .No intrinsic bony abnormality is identified .12/05/2023 . SPINE, CERVICAL 2-3 VIEWS .No fracture or other acute findings identified . Review of Resident #5's Nurse Practitioner (NP) #1 note dated 12/5/2023, showed .History of Present Illness: Resident seen for acute reports of head pain .he was lying in bed, alert, no acute distress .Noted a small circular spongy area that seemed to be slightly discolored .No decrease in range of motion noted to neck .had concern for bleeding as resident is supposed to be on Eliquis twice daily. I performed a medication review to assess milligram and noted that resident's Eliquis was not on his MAR [medication administration record]. Given that resident had not had Eliquis since admission and given his symptoms with medical history it was best to send resident to ER [emergency room ] . Review of the hospital ER records for Resident #5 showed .Date of Service 12/5/2023 4:15 PM .Chief Complaint .Neck Pain .No known injury .Patient cannot recall any trauma .Patient states that whenever he twists his neck to the left hurts the worst. No neurologic deficits noted .Neurological: Negative for weakness .He is not in acute distress .Will discharge home with supportive treatment .CT [computed tomography] head .No CT evidence for acute intracranial abnormality .CT Cervical Spine .There is no acute fracture or dislocation . During an interview on 2/20/2024 at 11:00 AM, the DON stated .when he [Resident #5] came in on admission there was two different medicines which were 2 separate anticoagulants .the one that was in the admission packet was Xarelto and the one .brought [with the resident by EMS (emergency medical services)] which was the discharge summary orders [for] .Eliquis. So when the admitting nurse [License Practical Nurse [( LPN) #1] saw this she called the nurse practitioner [NP #1] .asked her about having 2 of them [anticoagulants ordered] and the nurse practitioner told her to discontinue the Xarelto but never told her to go ahead and initiate the Eliquis .the nurse practitioner assumed he [Resident #5] would still be getting the Eliquis .and the pharmacy consultant did a medication review [for Resident #5] .and he didn't catch the discrepancy . During an interview on 2/21/2024 at 10:30 AM, NP #1 stated .he was supposed to be on Eliquis when he was admitted .I came over .looked at the papers with her [LPN #1] .I told her .start the Eliquis .[Resident #5] was complaining of neck pain at the back of his neck .when I discovered that it [Eliquis] had not been ordered .he was started back on his Eliquis the same day that he went out to the ER and came back on the 5th [12/5/2023] .I did a PT/INR on him before he went to the ER .his INR was 1.7 and with someone with his medical history you would want it [INR] to be between 2 and 4 . During a telephone interview on 2/21/2024 at 11:40 AM, LPN #1 stated .there is always that one set of admission orders that they fax over to admissions [nurse] and I had them before EMS arrived .the faxed orders are the ones that we put in the system [Point Click Care (PCC) ] .all those orders were put in before he [Resident #5] got to the facility .the one [anticoagulant] that was on there was the Xarelto .when he arrived .the papers .brought with him said Xarelto and Eliquis .pharmacy called to see which one was .[to] be the one given. I told them I would call [NP #1] .she verbally told me over the phone to dc [discontinue] the Xarelto and she would reevaluate the next day .she did not go over the papers with me .she just said to dc [discontinue] the Xarelto and that was the last thing she said about it .I dc'd the Xarelto that she said to .the Eliquis wasn't on the faxed orders so it wasn't put in the system so when she said to dc the Xarelto he had no blood thinners [anticoagulant] at all ordered .I figured she would do what she said and reevaluate and she would put him on one [anticoagulant] the next day . During a telephone interview on 2/23/2024 at 1:15 PM, the Pharmacy Consultant stated .as the Consultant I just do monthly reviews .with the orders that come across if an order doesn't get entered in PCC the pharmacist at the pharmacy would have no way of knowing that and I would not see it until the regular monthly review .main thing I'm looking at is if it's a new admission I will look at the admission orders .I would have looked at the orders what they are on currently what changes were made and why .I did not notice the discrepancy I did look at both documents .I look at the diagnoses too .yes, I look at the H&P [history and physical], new orders, and a discharge summary .I honestly don't know how it got missed . During an interview on 2/26/2024 at 2:40 PM, the ED stated .the providers [physician (MD) and nurse practitioners] and the pharmacy consultant didn't catch that he [Resident #5] was not on an anticoagulant . The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the Executive Director and Director of Nursing on 12/5/2023. Review of the RCA form dated 12/5/2023, showed .Problem: [Resident #5] admitted with orders for Xarelto [anticoagulant ], however, Eliquis [anticoagulant] mentioned in dc [discharge] summary. Admitting nurse contacted NP [#1] for clarification and order given to d/c [discontinue] Xarelto. Resident [#5] seen by multiple providers on multiple occasions with medication reviews being done. On 12/5/2023 resident was seen for neck pain and noted to not be on an ACO [anticoagulant]. At this point, concern noted about possible clot in head/neck area related to neck pain and resident not actively being on [Eliquis]. Provider [NP #1] assumed that nurse [LPN #1] would understand that Eliquis needed to be added to orders. Providers nor pharmacist caught this during medication review . Review of the RCA continued and showed 3 Why's were documented as follows: Why 1 Per providers, they do not review all medications. However, it is documented that all meds have been reviewed on several occasions. Per pharmacist, he conducted a thorough medication review and did not feel that this resident needed to be on an ACO per his review. Why 2 Providers and pharmacist failed to follow medication management, pharmacy services and medication regimen review, and physician services guideline policies. These policies were failed by failing to conduct a thorough medication review as outlined by these policies. Why 3 Root Cause Analysis Conclusion: Providers and pharmacist failed to follow facility policies which resulted in a failure to complete a thorough medication review. This resulted in this resident not being on an ACO. Review of Mobile Images patient report dated 12/5/2023, for Resident #5 confirmed x-ray was performed at facility with no negative findings. Review of Mobile Images patient report dated 12/5/2023, for Resident #5 confirmed Ultrasound was performed at facility with no negative findings. Review of facility Witness Interview/Statement Form dated 12/5/2023, confirmed the resident (#5)'s family was notified by the facility and the ER. Review of a Health Status Note dated 12/5/2023, for Resident #5 confirmed .PT/INR at this time PT 14.9 INR 1.2 . Review of NP #1's progress note dated 12/5/2023, for Resident #5 confirmed the resident was seen by provider. Review of hospital emergency department documentation dated 12/5/2023 confirmed a CT was completed with No CT evidence for acute intracranial abnormality resident was diagnosed with Torticollis and sent back to the facility. Review of the RCA continued and showed, 2.) How will the facility identify other residents who have the potential to be affected by the same deficient practice? 2a.) Review of 100% of all residents on ACO-no issues identified. Person responsible Licensed Nurse Evaluation method Audit. Goal or Measure of Success and Date 12/5/2023 Evaluation Date/Results Bring findings to QAPI [Quality Assurance and Performance Improvement] Meeting. Review of ACO Audit 2A showed a list of 22 residents on ACO with ACO orders and resident care plans. The audit was completed on 12/5/2023 by the DON with no issues identified. Interview on 2/28/2023 at 3:00 PM with the DON confirmed 100% of residents on anticoagulation medication were reviewed on 12/5/2023 with no negative findings. 2b.) Review of ACO Meeting-no issues identified. Person responsible Licensed Nurse Evaluation method Audit Goal or Measure of Success and Date 12/5/202 Evaluation Date/Results Bring findings to QAPI Meeting. Review of the ACO Audit 2B showed ACO Meeting to ensure proper order for 100% of residents on ACO with 22 residents listed. Interview with the ED on 2/28/2023 at 3:15 PM, confirmed 100% of residents on ACO were brought to the impromptu QAPI meeting on 12/5/2023. 3.) What systemic change will be made to ensure the deficient process does not reoccur? On 12/5/2023 Provided education to Medical Director (MD)/Nurse Practitioners (providers) on Medication Reconciliation across the Continuum of Care policy. Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes, entering orders expectation, medication review expectation, and Anticoagulation Management/Coumadin Therapy policy. Review of the facility's Education Acknowledgment Form for the MD, NP #1, NP #2, and facility in-service sign in sheets showed the above education was completed on 12/5/2023. Review of the facility's corrective actions showed on 12/5/2023, education was provided to the Pharmacist on Pharmacy Services and Medication Regimen Review policy, Medication Reconciliation Across the Continuum of Care policy, ACO PIP plan and processes, and medication review expectations. Review of facility's Education Acknowledgment Form for the Pharmacy Consultant showed the above education was completed on 12/5/2023. Telephone interview on 2/23/2024 at 2:30 PM, with the Pharmacy Consultant confirmed he was educated as the facility documentation review showed and was aware of the processes. Review of the facility's corrective actions showed any licensed nurse, provider, or pharmacist not trained on the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication by 12/5/2023 would not be permitted to work until education was provided. Review of the facility's corrective actions showed all newly hired nurses, medical providers, or pharmacists will be trained on the policy and procedure prior to going on duty. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction.

Based on review of facility contracts, facility policy, medical record review, facility documentation and interviews, the facility failed to ensure 1 of 6 residents (Resident #5) reviewed for anticoagulation therapy, received anticoagulation therapy for the diagnoses of Atrial Fibrillation (A-Fib) and prevention of blood clot formation. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to ensure the physician reviewed the total program of care, including medications, which resulted in Resident #5 not receiving anticoagulation therapy from 10/31/2023-12/5/2023. The Executive Director (ED) was notified of the Immediate Jeopardy (IJ) on 2/28/2024 at 4:20 PM, in the conference room. The facility was cited Immediate Jeopardy at F-684. The facility was cited Immediate Jeopardy at F-684 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective on 11/15/2023 and was removed on 12/5/2023. The facility's corrective actions were taken on 12/5/2023. The Immediate Jeopardy was cited as past non-compliance for F-684 and the facility is not required to submit a Plan of Correction. The IJ was effective on 11/15/2023. The IJ was removed on 12/5/2023. The facility's corrective action plan, which removed the immediacy of the jeopardy, was reviewed and corrective actions were validated onsite by the surveyor on 2/29/2024. The findings include: Review of a facility contract titled, PHARMACY CONSULTANT AGREEMENT, showed .as of July 1, 2017 .RESPONSIBILITIES OF PHARMACY .Consultant shall identify any irregularities as defined in the State Operations Manual .Consultant will provide a summary report .which (a) documents that no irregularity as identified, or (b) reports any irregularities . Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 1/3/2019, showed .NP [Nurse Practitioner #2] .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #2 on 9/25/2019. Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 9/1/2022, showed .NP #1 .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #1 on 12/13/2022. Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 9/1/2022, showed .MD [Medical Director] .The physician must visit and complete an initial comprehensive assessment .after admission .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by the MD on 1/18/2023. Review of a facility policy titled, Physician Services Guidelines, revised 3/10/2023, showed Documentation in the medical record must reflect supervision of the medical care of each patient in the facility .At the time of each visit, the physician must review the patient's total program of care, medications, treatments, and care plan . Review of a facility policy titled, Pharmacy Services and Medication Regimen Review, reviewed 8/28/2023, showed .The facility maintains the resident's highest practicable level of physical .well-being and .minimizes adverse consequences related to medication therapy to the extent possible, by providing oversight by a licensed pharmacist .The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing . Review of the medical record showed Resident #5 was admitted to the facility on [DATE], post hospitalization with diagnoses including Atrial Fibrillation, Long Term (Current) Use of Anticoagulants and Myocardial Infarction. Review of the hospital DISCHARGE SUMMARY for Resident #5 showed .discharge date : 10/31/2023 .[on] 10/28/23 .INR [international normalized ratio] 1.6 .Discharge Medications .START taking these medications .apixaban [anticoagulant] 5 MG [milligram] .Commonly Known as Eliquis .1 tablet .2 .times a day .STOP taking these medications rivaroxaban [anticoagulant] 15 MG .Commonly known as Xarelto . Review of the hospital Discharge to Outside Facility Form for Resident #5 showed .10/31/23 Discharge Patient .Meds [medications] to Resume Upon Discharge .rivaroxaban 15 MG .2 .times a day with breakfast and dinner . Review of the admission Minimum Data Set (MDS) assessment, dated 11/2/2023, showed Resident #5's Brief Interview of Mental Status (BIMS) score was 3, indicating the resident had severe cognitive impairment and required assistance of one person with activities of daily living (ADL's). Review of the discharge MDS showed Resident #5 was discharged on [DATE], to the hospital and did not return. Review of the facility progress notes for Resident #5 from 10/31/2023 through 12/5/2023, showed NP #1 saw the resident 12 times between 10/31/2023 and 11/30/2023, and documented .Reviewed meds . with each visit. Review of Resident #5's assessment by the MD on 11/9/2023, included a history and physical which showed .Patient also had A-fib sick sinus syndrome [group of heart rhythm problems] .Eliquis was continued for stroke prophylaxis [preventative] .Available hospital records reviewed today. Medications and plan of care reviewed .Reviewed and appropriate . Review of a pharmacy consultation report for Resident #5 dated 11/20/2023, showed .To: [MD]; [Director of Nursing (DON)] From: [Pharmacy Consultant] .Recommendation: Please discontinue Glipizide [antidiabetic] . Review showed no documentation of irregularities or mention of conflicting orders for anticoagulation were noted and the report was signed by the MD on 12/1/2023 and DON on 12/7/2023. Review of physician orders for Resident #5 showed Eliquis was ordered on 12/5/2023, 5 milligrams 2 times a day at 8:00 AM and 2:00 PM, for clot prevention. Documentation showed no orders for Xarelto, Eliquis, or any anticoagulant prior to 12/5/2023 . Review of the facility's MOBILE IMAGES report for Resident #5 showed .12/05/2023 .Ultrasound exam of head and neck .There is no evidence of mass or hematoma [pool of mostly clotted blood] involving the left occipital [back of the head] area .12/05/2023 .SKULL SERIES, 3 VIEWS .No intrinsic bony abnormality is identified .12/05/2023 .SPINE, CERVICAL 2-3 VIEWS .No fracture or other acute findings identified . Resident #5's NP #1's progress note, dated 12/5/2023, showed .History of Present Illness: Resident seen for acute reports of head pain .he was lying in bed, alert, no acute distress .Noted a small circular spongy area that seemed to be slightly discolored .No decrease in range of motion noted to neck .had concern for bleeding as resident is supposed to be on Eliquis twice daily. I performed a medication review to assess milligram [dose] and noted that resident's Eliquis was not on his MAR [medication administration record]. Given that resident had not had Eliquis since admission and given his symptoms with medical history it was best to send resident to ER [emergency room ] for eval [evaluation] and treat . Review of the hospital ER records for Resident #5 showed .Date of Service 12/5/2023 4:15 PM .Chief Complaint .Neck Pain .No known injury .Patient cannot recall any trauma .Patient states that whenever he twists his neck to the left hurts the worst. No neurologic deficits noted .Neurological: Negative for weakness .He is not in acute distress .Patient likely with torticollis [condition in which the neck muscles contract]. Will discharge home with supportive treatment .CT [computed tomography] head .No CT evidence for acute intracranial abnormality .CT Cervical Spine .There is no acute fracture or dislocation . Review of a facility email document, dated 12/27/2023, concerning Resident #5 from the Medical Director to the Executive Director (Administrator) showed .On 10/31/2023 Patient [Resident #5] was discharged from the hospital and admitted to the nursing home .Upon arrival to the nursing home, all medications per discharge summary was continued. There was a question about anticoagulation, and the nurse discussed with the nurse practitioner caring for the patient about anticoagulation issues, per the nurse practitioner she gave directions to stop Xarelto and start Eliquis 5 mg [milligrams] bid [twice a day] However there was some confusion and the nurse felt that she received directions to stop Xarelto but was unsure if she had to resume Eliquis. Accordingly anticoagulation was not resumed from 10/31/2023 through 12/5/2023 when he went into the emergency room .CT scan on 12/5/23 showed no evidence of stroke or Bleeding/hemorrhagic changes in the brain at this point patient was discharged back to the nursing home and at this point anticoagulation with Eliquis was appropriately resumed on 12/5/2023 .It is certainly unfortunate that there was some miscommunication leading to anticoagulation not being resumed on 10/31/2023 . During an interview on 2/20/2024 at 11:00 AM, the DON stated .when he [Resident #5] came in on admission there was two different medicines which were 2 separate anticoagulants .the one that was in the admission packet was Xarelto and the one .brought [by EMS transporting Resident #5] which was the discharge summary orders .[for] Eliquis. So when the admitting nurse [License Practical Nurse (LPN ) #1] saw this she called the nurse practitioner [NP #1] .asked her about having 2 of them [anticoagulants ordered] and the nurse practitioner told her to discontinue the Xarelto but never told her to go ahead and initiate the Eliquis .the nurse practitioner assumed he would still be getting the Eliquis .the provider [NP #1] had done several medication reviews on him [Resident #5] and the pharmacy consultant did a medication review also and he didn't catch the discrepancy .On 12/5 [12/5/2023] he was complaining of neck pain and she [NP #1] realized he was not on Eliquis . During an interview on 2/21/2024 at 10:30 AM, NP #1 stated .he was supposed to be on Eliquis when he was admitted .I came over .looked at the papers with her [LPN #1] .I told her .start the Eliquis .[Resident #5] was complaining of neck pain at the back of his neck .when I discovered that it [Eliquis] had not been ordered .I sent him to the ER to do diagnostics .thorough work up .they [hospital] did a CT of his head and neck and there wasn't any findings of fractures, clots anything like that .sent back to the facility and he was started back on his Eliquis the same day that he went out to the ER and came back on the 5th [12/5/2023] .I did a PT/INR on him before he went to the ER .his INR was 1.7 and with someone with his medical history you would want it [the INR] to be between 2 and 4 . During a telephone interview on 2/21/2024 at 11:40 AM, LPN #1 stated .there is always that one set of admission orders that they fax over to admissions [nurse] and I had them before EMS arrived .the faxed orders are the ones that we put in the system [Point Click Care (PCC)] .all those orders were put in before he [Resident #5] got to the facility .the one [anticoagulant] that was on there was the Xarelto .when he arrived .the papers .brought with him said Xarelto and Eliquis .pharmacy called to see which one was .[to] be the one given. I told them I would call [NP #1] .she verbally told me over the phone to dc [discontinue] the Xarelto and she would reevaluate the next day .she did not go over the papers with me .she just said to dc the Xarelto and that was the last thing she said about it .I dc'd the Xarelto that she said to .the Eliquis wasn't on the faxed [admission] orders so it wasn't put in the system so when she said to dc the Xarelto he had no blood thinners [anticoagulant] at all ordered .I figured she would do what she said and reevaluate and she would put him on one [anticoagulant] the next day .once he started getting sick and he was sent out that's when they realized that he wasn't on any .he hadn't gotten any blood thinners from when he got there [10/31/2023] until he went out to the hospital [12/5/2023] . During a telephone interview on 2/23/2024 at 1:15 PM, the Pharmacy Consultant stated .as the Consultant I just do monthly reviews .with the orders that come across if an order doesn't get entered in PCC the pharmacist at the pharmacy would have no way of knowing that and I would not see it until the regular monthly review .main thing I'm looking at is if it's a new admission I will look at the admission orders .I would have looked at the orders what they are on currently what changes were made and why .I did not notice the discrepancy I did look at both documents .I look at the diagnoses too .yes, I look at the H&P [history and physical], new orders, and a discharge summary .I honestly don't know how it [anticoagulant] got missed . During a telephone interview on 2/23/2023 at 1:45 PM, the MD stated .that H and P [history and physical] review I dictated [on 11/9/2023] from the discharge summary from the hospital .I thought he was supposed to be stopped from the Xarelto and started on Eliquis and that was missed .I don't think I caught it .no I did not pick up on that .there could have been a thrombotic stroke that could have happened but it did not happen .it could be possible it could have happened from not being on the blood thinners for 4 to 5 weeks [Resident #5 did not receive anticoagulation therapy for the first 34 days of his stay] . During an interview on 2/26/2024 at 2:40 PM, the ED stated .the providers [physician (MD) and nurse practitioners] and the pharmacy consultant didn't catch that he [Resident #5] was not on an anticoagulant . The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the ED and DON on 12/5/2023. Review of the RCA form, dated 12/5/2023, showed .Problem: [Resident #5] admitted with orders for Xarelto, however Eliquis mentioned in dc [discharge] summary. Admitting nurse contacted NP [#1] for clarification and order given to d/c Xarelto. Resident [#5] seen by multiple providers on multiple occasions with medication reviews being done. On 12/5/23 resident was seen for neck pain and noted to not be on an ACO [anticoagulant]. At this point, concern noted about possible clot in head/neck area related to neck pain and resident not actively being on [Eliquis]. Provider [NP #1] assumed that nurse [LPN #1] would understand that Eliquis needed to be added to orders. Providers [NP's or MD] nor pharmacist caught this during medication review . Review of the RCA continued and showed 3 Why's were documented as follows: Why 1 Per providers, they do not review all medications. However, it is documented that all meds have been reviewed on several occasions. Per pharmacist, he conducted a thorough medication review and did not feel that this resident needed to be on an ACO per his review. Why 2 Providers and pharmacist failed to follow medication management, pharmacy services and medication regimen review, and physician services guideline policies. These policies were failed by failing to conduct a thorough medication review as outlined by these policies. Why 3 Root Cause Analysis Conclusion: Providers and pharmacist failed to follow facility policies which resulted in a failure to complete a thorough medication review. This resulted in this resident not being on an ACO. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed x-ray was performed at facility with no negative findings. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed Ultrasound was performed at facility with no negative findings. Review of facility Witness Interview/Statement Form dated 12/5/2023, confirmed the resident (#5)'s family was notified by the facility and the ER. Review of a Health Status Note dated 12/5/2023, for Resident #5 confirmed .PT/INR at this time PT 14.9 INR 1.2 . Review of NP #1's progress note, dated 12/5/2023, for Resident #5 confirmed the resident was seen by provider. Review of the ER records for Resident #5, dated 12/5/2023, showed No CT evidence for acute intracranial abnormality and the resident was diagnosed with Torticollis. Resident #5 was sent back to facility the same day. Review of the RCA continued and showed, 2.) How will the facility identify other residents who have the potential to be affected by the same deficient practice? 2a.) Review of 100% of all residents on ACO-no issues identified. Person responsible Licensed Nurse Evaluation method Audit. Goal or Measure of Success and Date 12/5/2023 Evaluation Date/Results Bring findings to QAPI [Quality Assurance and Performance Improvement] Meeting. Review of ACO Audit 2A showed a list of 22 residents on ACO with ACO orders and resident care plans. The audit was completed on 12/5/2023 by the DON with no issues identified. Interview on 2/28/2023 at 3:00 PM, with the DON, confirmed 100% of residents on anticoagulation medication were reviewed on 12/5/2023 with no negative findings. 2b.) Review of ACO Meeting-no issues identified. Person responsible Licensed Nurse Evaluation method Audit Goal or Measure of Success and Date 12/5/202 Evaluation Date/Results Bring findings to QAPI Meeting. Review of the ACO Audit 2B showed ACO Meeting to ensure proper order for 100% of residents on ACO with 22 residents listed. Interview with the ED on 2/28/2023 at 3:15 PM, confirmed 100% of residents on ACO were brought to the impromptu QAPI meeting on 12/5/2023. 3.) What systemic change will be made to ensure the deficient process does not reoccur? On 12/5/2023 Provided education to Medical Director (MD)/Nurse Practitioners (providers) on Medication Reconciliation across the Continuum of Care policy. Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes, entering orders expectation, medication review expectation, and Anticoagulation Management/Coumadin Therapy policy. Review of the facility's Education Acknowledgment form for the MD, NP #1, NP #2, and facility in-service sign in sheets showed the above education was completed on 12/5/2023. Telephone interview with NP #1 on 2/23/2023 12:30 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP and was aware of the processes. Telephone interview with the MD on 2/23/2023 at 1:45 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes. Telephone interview with NP #2 on 2/23/2023 3:40 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP and processes. Review of the facility's corrective actions showed on 12/5/2023, education was provided to the Pharmacist on Pharmacy Services and Medication Regimen Review policy, Medication Reconciliation Across the Continuum of Care policy, ACO PIP plan and processes, and medication review expectations. Review of facility's Education Acknowledgment Form for the Pharmacy Consultant showed the above education was completed on 12/5/2023. Telephone interview on 2/23/2024 at 2:30 PM, with the Pharmacy Consultant confirmed he was educated as the facility documentation review showed and was aware of the processes. Review of facility documents showed on 12/5/2023, education was provided to all licensed nurses on Medication Reconciliation Across the Continuum of Care policy, Administration of Medications policy, Anticoagulant Management/Coumadin Therapy policy, ACO PIP plan and processes, and assistance available for any questions or concerns of discrepancy regarding medication. Review of the facility's in-service sign in sheets and employee list of licensed nursing staff showed the above training was completed on 12/5/2023. Interviews of licensed nursing staff were conducted on 2/23/2024 - 2/29/2023, with 5 LPN's working day shift (6 AM-6 PM), 3 LPN's working night shift (6 PM-6 AM ), 1 Registered Nurse (RN) working day shift and 2 RN's working night shift. All confirmed they were educated and were aware of the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication. Review of the facility's corrective actions showed any licensed nurse, provider, or pharmacist not trained on the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication by 12/5/2023 would not be permitted to work until education was provided. Review of the facility's corrective actions showed all newly hired nurses, medical providers, or pharmacist will be trained on the policy and procedure prior to going on duty. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction.

Based on review of the facility contract, facility policy, medical record review, facility documentation and interviews, the facility failed to provide physician services to ensure 1 of 6 residents (Resident #5) reviewed for anticoagulation therapy received anticoagulation therapy for the diagnosis of Atrial Fibrillation and prevention of blood clot formation. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to ensure the physician reviewed the total program of care, including medications, which resulted in Resident #5 not receiving anticoagulation therapy from 10/31/2023-12/5/2023. On 11/9/2023, Resident #5's medications were reviewed by the Medical Director (MD) and the MD failed to recognize the resident had not received the anticoagulant therapy for the treatment of Atrial Fibrillation and prevention of blood clot formation from admission on 10/31/2023. On 12/5/2023, Nurse Practitioner (NP) #1 discovered Resident #5 was not on any anticoagulation therapy. Resident #5 was evaluated and assessed by the NP 12 times between 10/31/2023 and 11/30/2023 and the NP failed to recognize the resident had not received the anticoagulant therapy for the treatment of Atrial Fibrillation and prevention of blood clot formation. The Executive Director (ED) was notified of the Immediate Jeopardy (IJ) on 2/28/2024 at 4:20 PM, in the conference room. The facility was cited Immediate Jeopardy at F-711. The IJ was effective on 11/15/2023 and was removed on 12/5/2023. The facility's corrective actions were taken on 12/5/2023. The Immediate Jeopardy was cited as past non-compliance for F-711 and the facility is not required to submit a Plan of Correction. The findings include: Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 1/3/2019, showed .NP [Nurse Practitioner #2] .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #2 on 9/25/2019. Review of a facility contract titled, Performance Requirement & Practice Agreement, revised 9/1/2022, showed .NP #1 .Visits may alternate with a .NP .The physician may delegate to alternate the routine monthly visit or acute care visit to his/her nurse practitioner .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by NP #1 on 12/13/2022. Review of a facility contract titled,+ Performance Requirement & Practice Agreement, revised 9/1/2022, showed .MD [Medical Director] .The physician must visit and complete an initial comprehensive assessment .after admission .Documentation in the patient's medical record will be comprehensive and will indicate a thorough examination and evaluation of the patient each visit . Review showed this contract was signed by the MD on 1/18/2023. Review of a facility policy titled, Physician Services Guidelines, revised 3/10/2023, showed Documentation in the medical record must reflect supervision of the medical care of each patient in the facility .At the time of each visit, the physician must review the patient's total program of care, medications, treatments, and care plan . Resident #5 was admitted to the facility on [DATE], post hospitalization with diagnoses including Atrial Fibrillation, Long Term (Current) Use of Anticoagulants and Myocardial Infarction. Review of the hospital DISCHARGE SUMMARY for Resident #5 showed .discharge date : 10/31/2023 .[on] 10/28/23 .INR [international normalized ratio] 1.6 .Discharge Medications .START taking these medications .apixaban [anticoagulant] 5 MG [milligram] .Commonly Known as Eliquis .1 tablet .2 .times a day .STOP taking these medications rivaroxaban [anticoagulant] 15 MG .Commonly known as Xarelto . Review of the hospital Discharge to Outside Facility Form for Resident #5 showed .10/31/23 Discharge Patient .Meds [medications] to Resume Upon Discharge .rivaroxaban 15 MG .2 .times a day with breakfast and dinner . Review of the admission Minimum Data Set (MDS) assessment, dated 11/2/2023, showed Resident #5's Brief Interview of Mental Status (BIMS) score was 3, indicating the resident had severe cognitive impairment and required assistance of one person with activities of daily living (ADL's). Review of the discharge MDS showed Resident #5 was discharged on [DATE], to the hospital and did not return. Review of Resident #5's the facility progress notes from 10/31/2023-12/5/2023 showed the resident was seen by NP #1 12 times between 10/31/2023 - 11/30/2023. The NP documented .Reviewed meds . with each visit. Medical record review showed Resident #5 was seen by the MD on 11/9/2023 and the completed history and physical documented showed .Patient also had A-fib sick sinus syndrome [group of heart rhythm problems] .Eliquis was continued for stroke prophylaxis [preventative] .Available hospital records reviewed today. Medications and plan of care reviewed .Reviewed and appropriate . Review of the physician orders for Resident #5 showed Eliquis was ordered on 12/5/2023, 5 milligrams 2 times a day at 8:00 AM and 2:00 PM, for clot prevention. Documentation showed no orders for Xarelto, Eliquis, or any anticoagulant prior to 12/5/2023. Resident #5's NP #1 progress note, dated 12/5/2023, showed .History of Present Illness: Resident seen for acute reports of head pain .he was lying in bed, alert, no acute distress .Noted a small circular spongy area that seemed to be slightly discolored .No decrease in range of motion noted to neck .had concern for bleeding as resident is supposed to be on Eliquis twice daily. I performed a medication review to assess milligram [dose] and noted that resident's Eliquis was not on his MAR [medication administration record]. Given that resident had not had Eliquis since admission and given his symptoms with medical history it was best to send resident to ER [emergency room ] for eval [evaluation] and treat . Review of the hospital ER records for Resident #5 showed .Date of Service 12/5/2023 4:15 PM .Chief Complaint .Neck Pain .No known injury .Patient cannot recall any trauma .Patient states that whenever he twists his neck to the left hurts the worst. No neurologic deficits noted .Neurological: Negative for weakness .He is not in acute distress .Patient likely with torticollis [condition in which the neck muscles contract]. Will discharge home with supportive treatment .CT [computed tomography] head .No CT evidence for acute intracranial abnormality .CT Cervical Spine .There is no acute fracture or dislocation . Review of a facility email from the Medical Director to the Executive Director (Administrator) dated 12/27/2023, concerning Resident #5 showed .On 10/31/2023 Patient [Resident #5] was discharged from the hospital and admitted to the nursing home .Upon arrival to the nursing home, all medications per discharge summary was continued. There was a question about anticoagulation, and the nurse discussed with the nurse practitioner, caring for the patient about anticoagulation issues per the nurse practitioner she gave directions to stop Xarelto and start Eliquis 5 mg [milligrams] bid [twice a day] However there was some confusion and the nurse felt that she received directions to stop Xarelto but was unsure if she had to resume Eliquis. Accordingly anticoagulation was not resumed from 10/31/2023 through 12/5/2023 when he went into the emergency room .CT scan on 12/5/23 showed no evidence of stroke or Bleeding/hemorrhagic changes in the brain at this point patient was discharged back to the nursing home and at this point anticoagulation with Eliquis was appropriately resumed on 12/5/2023 .It is certainly unfortunate that there was some miscommunication leading to anticoagulation not being resumed on 10/31/2023 . During an interview on 2/20/2024 at 11:00 AM, the DON stated .when he [Resident #5] came in on admission there was two different medicines which were 2 separate anticoagulants .the one that was in the admission packet was Xarelto and the one .brought [by EMS transporting Resident #5] which was the discharge summary orders .[for] Eliquis. So when the admitting nurse [License Practical Nurse (LPN) #1] saw this she called the nurse practitioner [NP #1] .asked her about having 2 of them [anticoagulants ordered] and the nurse practitioner told her to discontinue the Xarelto but never told her to go ahead and initiate the Eliquis .the nurse practitioner assumed he would still be getting the Eliquis .the provider [NP #1] had done several medication reviews on him and the pharmacy consultant did a medication review also and he didn't catch the discrepancy .On 12/5 [12/5/2023] he was complaining of neck pain and she [NP #1] realized he was not on Eliquis .the decision was made to send him to the hospital for further testing .the hospital .diagnosed him with torticollis . During an interview on 2/21/2024 at 10:30 AM, NP #1 stated .he [Resident #5] was supposed to be on Eliquis when he was admitted .I came over .looked at the papers with her [LPN #1] .I told her .start the Eliquis .[Resident #5] was complaining of neck pain at the back of his neck .when I discovered that it [Eliquis] had not been ordered .I sent him to the ER to do diagnostics .thorough work up .they [hospital] did a CT of his head and neck and there wasn't any findings of fractures, clots anything like that .sent back to the facility and he was started back on his Eliquis the same day that he went out to the ER and came back on the 5th [12/5/2023] .I did a PT/INR on him before he went to the ER .his INR was 1.7 and with someone with his medical history you would want it [INR] to be between 2 and 4 . During a telephone interview on 2/21/2024 at 11:40 AM, LPN #1 stated .there is always that one set of admission orders that they fax over to admissions [nurse] and I had them before EMS arrived .the faxed orders are the ones that we put in the system [Point Click Care (PCC) ] .all those orders were put in before he [Resident #5] got to the facility .the one [anticoagulant] that was on there was the Xarelto .when he arrived .the papers .brought with him said Xarelto and Eliquis .pharmacy called to see which one was .[to] be the one given. I told them I would call [NP #1] .she verbally told me over the phone to dc [discontinue] the Xarelto and she would reevaluate the next day .she did not go over the papers with me .she just said to dc the Xarelto and that was the last thing she said about it .I dc'd the Xarelto that she said to .the Eliquis wasn't on the faxed orders so it wasn't put in the system so when she said to dc the Xarelto he had no blood thinners [anticoagulant] at all ordered .I figured she would do what she said and reevaluate and she would put him on one [anticoagulant] the next day .once he started getting sick and he was sent out that's when they realized that he wasn't on any .he hadn't gotten any blood thinners from when he got there [10/31/2023] until he went out to the hospital [12/5/2023] . During a telephone interview on 2/23/2023 at 1:45 PM, the MD stated .that H and P [history and physical] review [on 11/9/2023] I dictated from the discharge summary from the hospital .I thought he was supposed to be stopped from the Xarelto and started on Eliquis and that was missed .I don't think I caught it .no I did not pick up on that .there could have been a thrombotic stroke that could have happened but it did not happen .it could be possible it could have happened from not being on the blood thinners for 4 to 5 weeks [Resident #5 did not receive anticoagulation therapy for the first 34 days of his stay] . During an interview on 2/26/2024 at 2:40 PM, the ED stated .the providers [physician (MD) and nurse practitioners] and the pharmacy consultant didn't catch that he [Resident #5] was not on an anticoagulant . The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA), dated 12/5/2023, and was completed by the Executive Director and Director of Nursing on 12/5/2023. The facility's corrective actions were validated onsite by the surveyor on 2/29/2024. The corrective action plan included a Root Cause Analysis (RCA) and was completed by the Executive Director and Director of Nursing on 12/5/2023. Review of the RCA form, dated 12/5/2023, showed .Problem: [Resident #5] admitted with orders for Xarelto , however Eliquis mentioned in dc [discharge] summary. Admitting nurse [LPN #1] contacted NP [#1] for clarification and order given to d/c [discontinue] Xarelto. Resident [#5] seen by multiple providers on multiple occasions with medication reviews being done. On 12/5/23 resident was seen for neck pain and noted to not be on an ACO [anticoagulant]. At this point, concern noted about possible clot in head/neck area related to neck pain and resident not actively being on [Eliquis]. Provider [NP #1] assumed that nurse [LPN #1] would understand that Eliquis needed to be added to orders. Providers [NP's or MD] nor pharmacist caught this during medication review . Review of the RCA continued and showed 3 Why's were documented as follows: Why 1 Per providers, they do not review all medications. However, it is documented that all meds have been reviewed on several occasions. Per pharmacist, he conducted a thorough medication review and did not feel that this resident needed to be on an ACO per his review. Why 2 Providers and pharmacist failed to follow medication management, pharmacy services and medication regimen review, and physician services guideline policies. These policies were failed by failing to conduct a thorough medication review as outlined by these policies. Why 3 Root Cause Analysis Conclusion: Providers and pharmacist failed to follow facility policies which resulted in a failure to complete a thorough medication review. This resulted in this resident not being on an ACO. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed x-ray was performed at facility with no negative findings. Review of Mobile Images report, dated 12/5/2023, for Resident #5 confirmed Ultrasound was performed at facility with no negative findings. Review of facility Witness Interview/Statement Form dated 12/5/2023, confirmed the resident (#5)'s family was notified by the facility and the ER. Review of a Health Status Note dated 12/5/2023, for Resident #5 confirmed .PT/INR at this time PT 14.9 INR 1.2 . Review of NP #1's progress note dated 12/5/2023, for Resident #5 confirmed the resident was seen by provider. Review of the hospital ER report showed on 12/5/2023, Resident #5 was sent to ER for CT . Scan completed with .No CT evidence for acute intracranial abnormality . and the resident was diagnosed with Torticollis. Resident #5 was sent back to facility same day. Review of the RCA continued and showed, 2.) How will the facility identify other residents who have the potential to be affected by the same deficient practice? 2a.) Review of 100% of all residents on ACO-no issues identified. Person responsible Licensed Nurse Evaluation method Audit. Goal or Measure of Success and Date 12/5/2023 Evaluation Date/Results Bring findings to QAPI [Quality Assurance and Performance Improvement] Meeting. Review of ACO Audit 2A showed a list of 22 residents on ACO with ACO orders and resident care plans. The audit was completed on 12/5/2023 by the DON with no issues identified. Interview on 2/28/2023 at 3:00 PM with the DON confirmed 100% of residents on anticoagulation medication were reviewed on 12/5/2023 with no negative findings. 2b.) Review of ACO Meeting-no issues identified. Person responsible Licensed Nurse Evaluation method Audit Goal or Measure of Success and Date 12/5/202 Evaluation Date/Results Bring findings to QAPI Meeting. Review of the ACO Audit 2B showed ACO Meeting to ensure proper order for 100% of residents on ACO with 22 residents listed. Interview with the ED on 2/28/2023 at 3:15 PM, confirmed 100% of residents on ACO were brought to the impromptu QAPI meeting on 12/5/2023. 3.) What systemic change will be made to ensure the deficient process does not reoccur? On 12/5/2023 Provided education to Medical Director (MD)/Nurse Practitioners (providers) on Medication Reconciliation across the Continuum of Care policy. Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes, entering orders expectation, medication review expectation, and Anticoagulation Management/Coumadin Therapy policy. Review of the facility's Education Acknowledgment form for the MD, NP#1, NP#2, and facility in-service sign in sheets showed the above education was completed on 12/5/2023. Telephone interview with NP #1 on 2/23/2023 12:30 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and was aware of the processes. Telephone interview with the MD on 2/23/2023 at 1:45 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP [Performance Improvement Plan] and processes. Telephone interview with NP #2 on 2/23/2023 3:40 PM, confirmed she was educated on the Medication Reconciliation across the Continuum of Care policy, Physician Services Guidelines policy, Medication Management policy, ACO PIP and processes. Review of the facility's corrective actions showed any licensed nurse, provider, or pharmacist not trained on the processes for reconciliation across the continuum of care, administration of medications, anticoagulant management, the ACO PIP plan, and assistance available for any questions or concerns of discrepancy regarding medication by 12/5/2023 would not be permitted to work until education was provided. Review of the facility's corrective actions showed all newly hired nurses, medical providers, or pharmacist will be trained on the policy and procedure prior to going on duty. The IJ was cited as past noncompliance and the facility is not required to submit a plan of correction.

Based on facility policy review, medical record review, observation and interview, the facility failed to ensure the comprehensive care plan was accurate for 1 resident (Resident #64) and failed to implement the comprehensive care plan related to fall interventions for 1 resident (Resident #12) of 24 residents reviewed for comprehensive care plans. The findings include: Review of the facility's policy titled, Comprehensive Care Plan and Revisions, dated 8/22/2023, showed .ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/ her needs . Resident #64 was admitted to the facility on [DATE] with diagnoses including Dementia and Schizophrenia. Review of Resident #64's comprehensive care plan revised 9/22/2023, showed .1/4 side bed rails per manufacturer guidelines . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #64 had not used bed rails. Review of the Physician Recapitulation Orders dated 10/18/2023 showed .Safety Interventions: 1/4 side [bed] rails . During an observation on 11/12/2023 at 12:25 PM, Resident #64's room did not have bed rails present on bed. During an observation on 11/13/2023 at 9:45 AM, Resident #64's room did not have bed rails present on bed. During an interview on 11/14/2023 at 8:45 AM, the Director of Nursing (DON) stated multiple facility assessments showed the bed rails were not indicated for Resident #64. The DON confirmed the intervention for bed rails had been added to the comprehensive care plan in error. 49568 Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Type 2 Diabetes, History of Falling, Anxiety Disorder and Insomnia. Review of a quarterly MDS assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Further review showed the resident had a history of falls. Review of Resident #12's comprehensive care plan dated 11/2/2023, showed .Resident is at risk for falls at risk for falls. Gait/balance problems .Unaware of safety needs .Interventions .Bed bolsters .concave mattress to bed . and toilet riser . Continued review showed the resident had not had a fall after the interventions were put in place. During an observation on 11/14/2023 at 3:00 PM, Resident #12 was seated in the wheelchair in the resident's room. Further observation showed the resident did not have the following fall interventions in place: bed bolsters, concave mattress, and a toilet riser. During an interview on 11/14/2023 at 3:48 PM, Licensed Practical Nurse (LPN) #3 stated Resident #12 was a high falls risk and had multiple fall interventions in place to include bed bolsters, concave mattress, and toilet riser. During an observation and interview in Resident #12's room on 11/14/2023 at 4:05 PM, LPN #3 confirmed the resident did not have the concave mattress, bed bolsters, or toilet riser in place. During an observation and interview in Resident #12's room on 11/14/2023 at 4:20 PM, the Director of Nursing confirmed the resident did not have a concave mattress, bed bolsters, or toilet riser in place and the facility failed to follow the resident's comprehensive care plan related to falls.

Based on facility policy review, medical record review, observation and interview, the facility failed to maintain a safe, clean, homelike environment in 2 resident (Resident #20 and Resident #24) rooms of 69 resident rooms observed. The findings include: Review of the facility's policy titled, Keeping a Resident's Room in Order, reviewed 7/17/2023, showed .It is the responsibility of all staff to create a homelike environment and promptly address any cleaning needs in an effort to keep residents' rooms orderly .Housekeeping .services .necessary to maintain a sanitary, orderly, and comfortable interior .Ensure the bedside/overbed table is clean . Review of the facility's policy titled, Housekeeping Services, reviewed 6/4/2023, showed .The facility will provide a safe, clean, comfortable and homelike environment .Routine Cleaning .Keep .surfaces visibly clean on a regular basis, and clean spills promptly .Clean and disinfect all high-touch surfaces at least once daily .Examples .bedside tables .Dust daily to remove particles from .surfaces in the resident area .Resident rooms .Clean .at least daily .floors . Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea and Chronic Respiratory Failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. During an observation in Resident #20's room on 11/13/2023 at 9:50 AM, the bedside table had a brown colored crusty debris on the bottom legs of the table, and the oxygen concentrator was dirty with dust and loose particles. Further observation showed brown debris around the base boards of the room and the floor underneath the bed had a brown color dried sticky liquid. During an observation and interview in Resident #20's room on 11/13/2023 at 10:00 AM, Licensed Practical Nurse (LPN) #1 confirmed the bedside table, oxygen concentrator, baseboards and the area underneath the resident's bed was a mess and needed to be cleaned. During an observation and interview in Resident #20's room on 11/13/2023 at 10:05 AM, the Housekeeping Supervisor stated resident rooms are cleaned daily and confirmed the resident's bedside table, oxygen concentrator, area around the baseboards, and underneath the bed was dirty and needed to be cleaned. Resident #24 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Overactive Bladder, Parkinson's Disease, and Major Depressive Disorder. Review of a quarterly MDS assessment dated [DATE], showed Resident #24 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. During an observation on 11/12/2023 at 11:10 AM, a dark black color on the floor under the sink was noted, the floors had dark scuffed marks, and the bathroom had a strong urine odor. During an observation on 11/13/2023 at 8:36 AM, showed Resident #24's room had a strong urine odor, the floors had dark scuffed marks, and a dark black color on the floor under the sink. During an interview on 11/13/2023 at 8:45 AM, the Housekeeping Supervisor stated the facility did not wax the floors in the resident rooms and the floors were hard to keep clean. The Housekeeping Supervisor confirmed Resident #24's room had a strong urine odor, the floor was dirty, and the room needed to be cleaned. She stated the room would be cleaned immediately. During an observation and interview in Resident #24's room on 11/14/2023 at 9:40 AM, with the Administrator and Regional [NAME] President (RVP) showed Resident #24's room floor was clean, there was no strong odor of urine (the room was cleaned on 11/13/2023), and a dark black color was observed on the floor under the sink. The RVP stated, I wonder if the sink leaked, I will get Maintenance to look at it. During an interview on 11/14/2023 at 12:30 PM, the Maintenance Supervisor stated the facility's roof leaked in August 2021 and Resident #24's room was affected by the leak. He stated he thought the black discoloration under the resident's sink was from the tar off the shingles.

Based on facility policy review, medical record review, observation and interview, the facility failed to honor the right to self-determination related to resident's choices for bathing for 1 resident (Resident #31) of 24 residents reviewed for choices. The findings include: Review of the facility's policy titled, Resident Rights, revised 9/25/2023, showed .The resident has a right to be treated with respect and dignity .The resident has a right to choose activities, schedules .health care and providers of health care services consistent with his or her interests, assessments, plan of care . Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Venous Ulcer of the Left Lower Extremity, Chronic Obstructive Pulmonary Disease, Chronic Pain, Depressive Disorder, Anxiety and Vascular Dementia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #31 had no rejection of care behaviors and required extensive assistance of 1 person for bed mobility, dressing, toilet use and personal hygiene. Review of the Resident Tasks sheet undated, showed .ADL [Activities of Daily Living]-Bathing Tuesday, Friday and PRN [As needed] (NIGHTS) . Review of the Health Status Note dated 10/3/2023 at 11:31 PM, showed .Resident refused to take shower/bath at this time. She states, I want to take showers in the day time. This nurse tried to encourage her to at least take a bed bath and res [resident] still refused . Review of the Health Status Note dated 10/18/2023 at 3:10 AM, showed . Resident was offer [offered] bed bath this evening and resident refused. Resident stated she did not like having baths at night and that she would prefer to have showers in the day time . Review of the Health Status Note dated 11/7/2023 at 9:15 PM, showed .Resident refused a shower this shift. Stated she was too tired . Review of the facility's bathing documentation from 9/13/2023 - 11/13/2023, showed the resident received a bed bath on 9/15/2023, 9/27/2023, 10/17/2023, 10/28/2023 and 11/8/2023. The resident refused bathing on 9/23/2023, 9/27/2023,10/3/2023, 10/7/2023, 10/14/2023, 10/21/2023, 10/24/2023, 11/3/2023, 11/8/2023 and 11/11/2023. During an observation and interview on 11/12/2023 at 11:52 AM, in Resident #31's room, showed the resident lying in bed. Resident #31's hair was disheveled and otherwise appeared clean with no odors noted. Resident #31 stated the facility had her scheduled for bathing on night shift and it was usually offered between 11:00 PM and 12:00 AM. Resident #31 preferred bathing during the day and had notified facility staff of her preferences for bathing times. Resident #31 was unable to name the facility staff she had notified regarding her bathing preferences. During an interview on 11/13/2023 at 4:15 PM, Licensed Practical Nurse (LPN) #4 stated she had recently switched from night shift to day shift and was familiar with Resident #31. Resident #31 was scheduled for bathing on Tuesday and Friday on night shift. LPN #4 stated the resident refused bathing often because she preferred bathing on day shift. LPN #4 stated she had reported Resident #31's preferences for bathing to an unknown staff member on an unknown date. During an interview on 11/13/2023 at 4:33 PM, the Director of Nursing (DON) stated the medical record showed Resident #31 was scheduled for bathing twice weekly on Tuesday and Friday nights. The DON stated she was unaware the resident preferred bathing during the day. The DON confirmed the nursing progress notes on 10/3/2023, 10/17/2023, and 11/7/2023 confirmed the resident preferred bathing on dayshift and the DON was unaware why Resident #31's bathing schedule had not been changed to day shift. The DON confirmed it was her expectation residents were bathed according to their preferences. During a telephone interview on 11/13/2023 at 9:05 PM, Certified Nursing Assistant (CNA) #3 confirmed the resident was scheduled for bathing on night shift and the resident refused at times because she would prefer to receive baths on dayshift. CNA #3 stated she had reported the resident's bathing preference to staff and was unable to recall who or when she had reported the resident's preferences.

Based on facility policy review, medical record review, facility documentation review and interview, the facility failed to report an allegation of abuse to the state agency timely for 1 resident (Resident #25) of 24 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse - Identification of Types, reviewed 7/18/2023, showed .It is the policy of this facility to identify abuse .of residents .This includes but is not limited to identifying and understanding the different types of abuse and possible indicators .Injuries of unknown source - An injury should be classified as an 'injury of unknown source' when all of the following criteria are met .The source of the injury was not observed by any person; and .The source of the injury could not be explained by the resident; and .The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) .The risk for abuse may increase when a resident exhibits a behavior(s) that may provoke a reaction by staff, residents, or others, such as .Verbally aggressive behavior, such as screaming .Physically aggressive behavior .Resistive to care and services .Possible indicators of physical abuse include an injury that is suspicious because the source of the injury is not observed . Review of the facility's policy titled, Abuse - Protection of Residents, reviewed /18/2023, showed .In response to allegations of abuse .the facility must .Report the results of all investigations .to other officials in accordance with State law, including the State Survey Agency . Review of the facility's policy titled, Abuse- Reporting and Response - Suspicion of a Crime, revised 10/13/2023, showed .The facility will ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the prescribed timeframes to the appropriate entities .it must be reported to local Law Enforcement and State Survey Agency as follows .If the resident or person receiving care at the facility does not incur a serious bodily injury .shall be reported not later than 24 hours after forming the suspicion . Resident #25 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Anxiety, Psychosis, Recurrent Depressive Disorders, and Dementia with Behavioral Disturbance. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident scored a 4 on the Brief Interview for Mental Status (BIMS) interview, which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan dated 9/26/2023, showed .The resident has behavior problems of being restless, anxious .and can become aggressive with care . Review of the Weekly Skin Integrity Data Collection form dated 11/4/2023, showed the resident's skin was intact with no new findings. Review of Registered Nurse (RN) Supervisor #1's Nursing Alert Note dated 11/11/2023 at 12:22 PM, showed LATE ENTRY .Patient noted to have scattered discoloration to bilateral forearms and hands/fingers; x [times] 2 skin discolorations to right upper arm, x1 small skin discoloration right upper arm (posterior), skin discoloration noted to left upper arm. discolorations consistent with transfers, long term anticoagulant therapy and increased patient restlessness/agitation . Review of the Weekly Skin Integrity Data Collection form dated 11/11/2023 at 12:22 PM, with a lock date of 11/12/2023 at 6:37 PM, showed new findings of .discolorations to bilat [bilateral] extrem [extremities] .scattered discoloration to bilat forearms, hands, fingers .discolorations to right upper arm .discolorations to left upper arm . It was noted that the provider, ED [Executive Director/Administrator], DON [Director of Nursing], and POA [Power of Attorney] were notified of the new findings. Review of the Assistant Director of Nursing (ADON)'s Health Status Note dated 11/11/2023 at 8:15 PM, showed .IDT [Interdisciplinary Team] .met this evening to discuss incident that occurred earlier today with a new intervention added of skin repair cream to bilateral upper extremities as tolerated. Will follow up in 3-5 days . Review of a signed witness statement dated 11/12/2023, from the Administrator, showed .Spoke with [Resident #25's Responsible Party] with [RN Supervisor #1] present. [Resident #25's Responsible Party] expressed concern about bruising to bilateral upper arms. She also stated that [Resident #25] had been crying out and begging for her to take her home. [RN Supervisor #1] and I looked at bruising which appeared consistent with transferring. [Resident #25] had just been transferred from the bed to her chair Thursday evening. I told [Resident #25's Responsible Party] that I would talk to the staff that had cared overnight. After speaking to multiple staff members, I called [Resident #25's Responsible Party] back .to speak with her about the bruising and to discuss that it appeared to be consistent with transferring. I asked [Resident #25's Responsible Party] if she was concerned that the bruising was malicious. She stated that no, she did not and felt that it had likely occurred during a transfer. I continued my investigation which included 100% interview with residents of a BIMS of 10 or above, 100% skin assessment with residents of a BIMS of 9 or below, 100% interview with staff members along with education. Based on the facility investigation, the bruising was determined to be consistent with transferring due to her use of blood thinners, behaviors, and interviews conducted . During an observation and interview on 11/12/2023 at 3:30 PM, in the resident's room, Resident #25's responsible party stated that the resident started stating that someone was hurting her on .Friday night [11/10/2023] . and bruises were observed on the resident's upper arms on Saturday 11/11/2023. The resident's responsible party stated she had no previous concerns about Resident #25 being mistreated in the facility. Resident #25's responsible party discussed the concerns of the resident's bruising with the Administrator and Registered Nurse (RN) Supervisor #1 on Saturday 11/11/2023. Observation continued and showed Resident #25 was calm while the responsible party was in the room and when the responsible party left the room, Resident #25 became upset and started yelling for her to come back. During an interview on 11/12/2023 at 4:00 PM, the Administrator stated Resident #25's Responsible Party notified RN Supervisor #1 that Resident #25 had bruises to her bilateral upper extremities on 11/11/2023. RN Supervisor #1 did a skin assessment of the resident and noted bruising to Resident #25's upper arms. RN supervisor #1 notified the Administrator of the findings. The Administrator spoke with Resident #25's Responsible Party on 11/11/2023 and the responsible party stated she did not feel like the bruising was malicious. The Administrator stated she did not report the bilateral bruising as an injury of unknown origin or abuse allegation because .we felt the bruises were consistent with transfers . During an observation on 11/12/2023 at 4:31 PM, in the resident's room, with 2 surveyors, the Social Services Director, Administrator, RN Supervisor #1, and Resident #25's Responsible Party, Resident #25 had 1 bruise to the inner right upper arm, 2 bruises to the top of the right upper arm, and a bruise to the right hand. RN Supervisor #1 stated the resident had a blood draw in the right hand last week on .Wednesday or Thursday . that explained the bruise to the right hand. Continued observation showed Resident #25 had a quarter size bruise to the left upper arm and bruising to the left index finger. The bruises on the upper arms and left index finger were consistent with the size and shape of fingerprints. Immediately after the observation at 4:38 PM, both surveyors, Resident #25's Responsible Party, and the Administrator went outside Resident #25's room to talk. Resident #25's Responsible Party stated Resident #25 began stating that someone hurt her on .Friday night [11/10/2023] . and bruising was noticed on the resident's arms on Saturday (11/11/2023). Resident #25's Responsible Party stated that she didn't think anyone would maliciously hurt the resident but was concerned about the bruising. Resident #25's Responsible Party stated she verbalized her concerns to RN Supervisor #1 and the Administrator on Saturday. During an interview on 11/13/2023 at 9:26 AM, in the conference room, with 3 surveyors present, the Administrator stated she became aware of the bruising on Resident #25's bilateral upper arms on Saturday 11/11/2023 at approximately 3:00 PM. The Administrator stated she began an investigation. The Administrator confirmed the injury had not been reported to the state agency because .we did not feel like the incident was abuse or the injury was suspicious . During an interview on 11/14/2023 at 8:29 AM, the ADON stated the facility had an IDT meeting on 11/11/2023 because of Resident #25's Responsible Party's statements about bruising to the resident's upper arms. IDT Meetings are conducted whenever there are allegations and .All IDT members have to meet when there are incidents like that . During a telephone interview on 11/14/2023 at 9:52 AM, RN Supervisor #1 stated she was the weekend RN supervisor on 11/11/2023. RN Supervisor #1 stated she became aware of the bruises from the dayshift CNAs on Saturday morning [11/11/2023] .it was before lunch and after breakfast . The CNAs worked weekends only and stated the bruising was not present when they worked with the resident last weekend. RN Supervisor #1 notified the Administrator and the DON within just a few minutes of being notified. RN Supervisor #1 performed a skin assessment and noted scattered bruising on the resident's bilateral upper arms. The CNAs were unaware of any event that caused the bruising. The Administrator and RN Supervisor #1 spoke with Resident #25's Responsible Party on 11/11/2023. Resident #25's Responsible Party .was 50/50 on how the bruising occurred . Review of facility's investigation documentation provided to the surveyor on 11/14/2023, titled [Resident #25] Timeline showed .11/11/23 .Approximately 3 pm: ED notified of concern voiced by [Resident #25's Responsible Party] of bruising to bilateral upper arms. ED and [RN Supervisor #1] entered room and looked at bruising. [Resident #25's Responsible Party] stated that resident had new behavior of yelling out as of Friday and begging for her to take her home. ED asked [Resident #25's Responsible Party] if resident had mentioned any concerns with any staff member in particular to which she said no. ED asked [Resident #25's Responsible Party] if she herself had any concerns with any staff member in particular which she said no. ED assured [Resident #25's Responsible Party] that facility would conduct an investigation into the new skin findings .11/12/23 .Approximately 2 pm: Surveyor reported concern to ED that [Resident #25's Responsible Party] had concerns related to resident's bruising .ED, DON, and SW [Social Worker] went to speak with [Resident #25's Responsible Party]. ED asked [Resident #25's Responsible Party] if she now felt that bruising may be malicious or abusive and explained that they would need to report the incident through the proper chains such as state, police, aps [Adult Protective Services], and ombudsman if so. [Resident #25's Responsible Party] responded 'No .' .Surveyors, ED, SW, and [RN Supervisor #1] went back to resident's room and observed skin and spoke with [Resident #25's Responsible Party] again .11/13/23 .Decision made by IDT to report the incident at 9:56 am: Call placed to 911 .9:57 am .Call placed to .Ombudsman .10:07 am: [named police officer] arrived to facility .10:30 am: Report submitted to URIS [state agency reporting system] .10:47 am: APS report made .[2 days after the bruising was observed] .

Based on facility policy review, medical record review and interviews, the facility failed to maintain an accurate medical record for 1 resident (Resident #64) of 24 residents reviewed for medical records. The findings include: Review of the facility's policy titled, Auditing and Monitoring of Medical Records, dated 4/10/2023, .monitoring of medical record documentation is conducted to ensure medical records are completed and accurate . Resident #64 was admitted to the facility on [DATE] with diagnoses including Dementia and Schizophrenia. Review of the Admission Record dated 4/11/2023, showed the Schizophrenia diagnosis had been resolved and removed from the record. Review of a Pre-Admission Screening and Resident Review (PASARR) dated 9/18/2023, showed .Diagnosis .Schizophrenia .Level I Positive .onsite Level II evaluation will be initiated . Review of a Psychiatric Evaluation dated 10/9/2023, showed .Diagnosis, Assessment and Plan .Dementia .Disorganized Schizophrenia .behaviors are being monitored . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #64 scored 4 on the Brief Interview of Mental Status (BIMS) assessment, which indicated the resident was severely cognitively impaired, had verbal behavioral symptoms directed towards others, and bed rails had not been used. Review of Resident #64's comprehensive care plan revised 10/19/2023, showed .1/4 side bed rails per manufacturer guidelines .behavior problems of being restless, anxious, refusing care . During an observation on 11/12/2023 at 12:25 PM, Resident #64's room did not have bed rails present on the bed. During an interview on 11/13/2023 at 3:51 PM, the Psychiatric Nurse Practitioner stated Resident #64 had an active diagnosis for Schizophrenia, had been monitored for behaviors and treated at the facility for Schizophrenia. During an interview on 11/13/2023 at 4:05 PM, the Health Information Manager (HIM) stated Resident #64's diagnosis for Schizophrenia was considered active and should be present on the active diagnosis listing. The HIM confirmed the diagnosis for Schizophrenia had been resolved off the medical record in error. Review of the Physician Recapitulation Orders dated 11/14/2023, showed .Safety Interventions: 1/4 side [bed] rails .Monitor for behaviors r/t [related to] anxiety such as refusing care, has the potential to be aggressive with others, being restless and anxious, and talks to self and television really loud (yells) and document if any behaviors are present every shift for Schizophrenia . During an interview on 11/14/2023 at 8:45 AM, the Director of Nursing (DON) stated multiple facility assessments concluded the bed rails were not indicated for Resident #64. The DON confirmed Resident #64's physician order for bed rails had been added to the medical record in error.

Based on facility policy review, observation and interview, the facility failed to post daily staffing timely for 1 of 3 days observed. The findings include: Review of the facility's policy titled, Staffing, revised 8/7/2023, showed .The facility maintains adequate staff on each shift to meet residents' needs, posts daily staffing data .The facility must post the nurse staffing data .on a daily basis at the beginning of each shift . During an observation on 11/12/2023 at 10:55 AM, showed the daily staff posting was dated 11/11/2023. During an interview on 11/12/2023 at 10:57 AM, the Social Services Director (SSD) stated she was the weekend supervisor and confirmed the daily staff posting was for 11/11/2023. During an interview on 11/12/2023 at 11:34 AM, the Administrator stated it was her expectation that daily staffing was posted by 8:00 AM.

Based on facility policy review, manufacturer guidelines, medical record review, observation and interview, the facility failed to follow manufacturer guidelines to clean nebulizer equipment for 1 residents (Resident #20) of 25 residents reviewed with nebulizer equipment. The findings include: Review of the facility policy titled, Nebulizer therapy, small volume, revised 5/22/2023, showed .Rinse the nebulizer with sterile water and allow it to air-dry .Disinfect the nebulizer following the manufacturer's instructions . Review of manufacturer guidelines, titled Compressor Nebulizer, dated 11/7/2023, showed .After each use, disassemble .Wash in warm soapy water and rinse well. Allow to air dry . Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea and Chronic Respiratory Failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. Review of Resident #20's active Physician Order Summary Report showed .Ipratropium-Albuterol Solution [medication used to treat COPD] 0.5-2.5 (3] .MG [Milligram]/3ML [Milliliter] .3 ml inhale orally via [by] nebulizer every 12 hours for COPD .Order Status .Active .Order Date 10/17/2023 . Review of Resident #20's Medication Administration Record (MAR) for 11/2023, showed . Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML .3 ml inhale orally via nebulizer every 12 hours for COPD . Further review showed the medication was administered on 11/12/2023 and 11/13/2023 at 8:00 AM. During an observation on 11/12/2023 at 12:40 PM, Resident #20 lying in bed with the eyes closed and a nebulizer mask was observed on the bedside table with the tubing, mask, mouthpiece attached, and open to air. Further observation showed the mask had white debris attached to the inside of the mask. During an observation on 11/13/23 at 9:50 AM, Resident #20 lying awake in bed. Further observation showed a nebulizer mask was on the bedside table with the tubing, mask, mouthpiece attached, open to air, and no barrier in place. Further observation showed the mask had white debris attached to the inside the mask. Resident #20 stated he received breathing treatments twice daily and received a treatment on the morning of 11/13/2023 (unsure of the exact time). During an interview on 11/13/2023 at 10:00 AM, Licensed Practical Nurse (LPN) #1 stated Resident #20 received nebulizer treatments twice a day and had received a treatment on the morning of 11/13/2023. The LPN confirmed the nebulizer mask and mouthpiece was not washed or rinsed after use.

Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 Resident (Resident #3) of 6 residents reviewed for abuse. The findings include: Review of facility abuse policy titled Protection of Residents: Reducing the Threat of Abuse & Neglect last revised 8/10/2021 showed .Residents must not be subjected to abuse by anyone. This includes .other residents .It is the policy and practice of this facility that all residents will be protected from all types of abuse .Abuse .It includes .physical abuse .Physical Abuse-Includes but is not limited to, hitting, slapping . Review of the medical record showed Resident #2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had severe cognitive impairment. The resident required assistance of one person with activities of daily living (ADLs) and showed the resident exhibited no behaviors during the review period. Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] showed Resident #3 was cognitively intact. The resident required assistance of one person with ADLs. Review of a facility investigation showed on 9/6/2022 at 6:50 PM Resident #2 was wheeling down the hallway in his wheelchair and attempting to pass the corner next to the smoke door on the South Hall. Resident #2 started ramming Resident #3's wheelchair with his wheelchair and Resident #2's wheelchair became caught in Resident #3's back wheel of his wheelchair. Resident #2 became agitated and hit Resident #3 on the back of the head with an open hand and pulled his hair. Review of the investigation showed witness statements corroborated the incident and was substantiated by the facility. During an interview with Resident #3 on 9/27/2022 at 10:00 AM, outside of the conference room the resident stated .another resident [Resident #2] pulled my hair and slapped me on the back . During an interview on 9/27/2022 at 11:00 AM, the Administrator stated .on 9/6/2022 I was notified by the Certified Nurse Assistant [CNA] staff that [Resident #2] had hit [Resident #3] .I asked [Resident #3] what had happened and he stated that [Resident #2] was behind him and had pulled his hair and had hit him in the back of the head with an open hand .I asked the residents sitting there if anyone else had witnessed the event and [Resident #6] stated that she had seen [Resident #2] hit [Resident #3] .we did substantiate it there were witnesses and [Resident #3] is alert and oriented . During an interview on 9/28/2022 at 8:30 AM, in the resident's room Resident #6 stated .we [residents] were down waiting to go outside and a resident [Resident #2] came up to another resident [Resident #3] and was trying to get around him. He [Resident #2] was in a wheelchair, they both were, he couldn't get around him [Resident #3]. He [Resident #2] reached up and hit him [Resident #3] on the back of the head with his open hand .

Based on review of facility policy, review of a hospice contract, medical record review, review of a facility investigation, and interview, the facility failed to ensure a process was in place to honor a resident's end of life wishes for 1 resident (Resident #1) of 6 residents reviewed for advance directive status. The facility failed to make readily available a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to ensure a system was in place to honor end-of-life wishes placed Resident #1 in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was notified of the IJ on [DATE] at 4:15 PM, in the conference room. The facility was cited Immediate Jeopardy (IJ) for F-678 at a scope and severity of J which constitutes Substandard Quality of Care. The IJ was effective on [DATE] and was removed on [DATE] when the facility implemented a corrective action plan. Corrective actions were validated onsite by the surveyor on [DATE]. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled Advance Directives and Advance Care Planning last revised [DATE] showed .Do Not Resuscitate (DNR) order - A medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer cardiopulmonary resuscitation (CPR) in the event of cardiac respiratory arrest .The DNR order is incorporated into the residents care plan and is periodically reviewed, at least quarterly .The Director of Nursing or designee establishes a system to inform all direct care staff of the residents DNR status .Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning .This review should focus on the existing advance directives .match the current goals of care for the resident. The social services director or designee should document this conversation in the medical record and assist as needed with updating the documents that need revision in accordance with state and federal requirements .DNR order is flagged appropriately on the resident's chart to alert staff as to status . Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR) Guidelines revised [DATE] showed .To ensure that each facility is able to and does provide basic life support .in accordance with related physicians orders, such as DNR's and the resident's advance directives .initiate CPR unless: A valid Do Not Resuscitate (DNR) order is in place .Facilities must also have procedures in place to document a resident's choices regarding issues like CPR .Physicians orders to support these choices should be obtained as soon as possible after admission, or a change in resident preference or condition, to facilitate staff in honoring resident choices .Facilities must address how resident preferences and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Hospice Coordination of Care last reviewed [DATE] showed .The care of the resident receiving hospice services must reflect ongoing communication and collaboration between the nursing home and the hospice staff .ensure that each resident's written plan of care includes .the most recent hospice plan of care . Review of the facility's HOSPICE SERVICE AGREEMENT showed .between [hospice] and [Facility], dated as of the 1st day of [DATE] (Effective Date) .COMMUNICATION .Communication protocol. Hospice and Facility shall work together to develop a written communication protocol governing how they will communicate all information needed for the Hospice Patients' care .including how such communication will be documented to ensure that the needs of Hospice Patients are addressed and met twenty-four (24) hours a day .protocol shall include .changes to the Hospice Plan of Care . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired on [DATE] at the facility. Medical record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .FULL CODE [initiate CPR] limited interventions .[DATE] .Hospice to consult for evaluation and treatment if indicated .[DATE] . Medical record review of an ADMISSION CONSENT/ELECTION OF HOSPICE BENEFITS form dated [DATE] for Resident #1 showed .HOSPICE ELECTION EFFECTIVE DATE: [DATE] . Medical record review of a HOSPICE PLAN OF CARE dated [DATE] for Resident #1 showed .certification period: From [DATE] To [DATE] .Advance Directives Information .POST [physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a POST form for Resident #1 dated [DATE] showed .Do Not .Resuscitate .DNR .Comfort Measures Only .Physician .[hospice medical director] .Date Prepared [DATE] . Medical record review of the facility's CARE PLAN CONFERENCE RECORD for Resident #1 dated [DATE] showed .Full code .CPR . The care plan conference did not include hospice agency staff. Medical record review of HOSPICE COORDINATED PLAN OF CARE note for Resident #1 dated [DATE], [DATE], [DATE], [DATE], and [DATE] showed .Caregiver Support issues .DNR status . Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 00, indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADLs). Medical record review of a current care plan for Resident #1 last reviewed [DATE], showed .Resident has Advance Directives CPR - Full Code Date Initiated: [DATE] .Code status will be reviewed on a quarterly bases [basis] and PRN [as needed] . Review of the facility's investigation dated [DATE] showed on [DATE] at 2:40 PM, Resident #1 was observed in her wheelchair in the dayroom by Certified Nursing Assistant (CNA) #1 who thought the resident's (skin) color did not look right. CNA #1 yelled for Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator #1 to check on Resident #1. The resident was found to be without a pulse and had no respirations. LPN/MDS Coordinator #1 went to the nurses' station and checked the resident's chart for her POST form. The POST form located in the front of the chart stated the resident was a full code. CNA #1 paged a code blue (term used to summon additional help for someone in cardiac arrest). Resident #1 was pushed back to her room by wheelchair and laid on the floor. CNA #2 and Registered Nurse (RN) #3 started CPR on Resident #1. CPR continued until a more current POST form indicating the resident was a DNR was found under the hospice tab in the resident's medical record by RN #2, at which time CPR was stopped. Review showed .Summary of Investigative Facts: Most current up to date POST not filed in chart appropriately and communicated to facility appropriately by hospice .MD [Medical Director] notified, and family member notified .Current Interventions QAPI [Quality Assurance Performance Improvement] initiated . During an interview on [DATE] at 9:20 AM, the Administrator stated .What had happened with her [Resident #1] was she had been found expired [on [DATE]] and the first POST [form] in the front of the chart said CPR was to be performed so CPR was started .so when the hospice one [POST form] was found and it was noticed to have a more recent date that said DNR .it was in the back of the chart under the hospice tab .CPR was stopped .the facility was not notified of the update .the nurse [hospice nurse] did not tell anyone that the DNR status had been updated .CPR was performed for a very short period of time, I would say less than a couple of minutes at the most .what they [hospice] should have done was say there has been an updated POST form .the hospice nurse brought the updated code status to the facility on [DATE]th [[DATE]] . During a telephone interview on [DATE] at 11:00 AM, Hospice RN #1 stated .there is a medical records box behind the nurse's desk and that is where I put the POST form [for Resident #1] .I don't recall what day it was .whoever the charge nurse .would have been at the time is who I would have spoken with . During an telephone interview on [DATE] at 11:40 AM, LPN #3 (charge nurse on [DATE]) stated .I don't recall hospice giving me any paperwork .if an order is changed or a DNR is updated, it's usually handed to the nurse by hospice; but I was never handed any DNR order for her [Resident #1] .I was aware that hospice was coming in to see her, but I never got any paperwork from hospice on a DNR .we are supposed to look at the post forms before we start CPR, and we know where it is in the chart, and if hospice put it in their tab, then I would have never looked in the hospice tab . During an interview on [DATE] at 12:00 PM, CNA #1 stated .I'm the one that found her [Resident #1]. She was sitting in the dayroom. She was sitting in her wheelchair and her color wasn't right .that was about 2:30 or 2:40 PM [on [DATE]] .[LPN/MDS coordinator #1] was walking down the hall. I hollered at her and she came and helped .when [LPN/MDS Coordinator #1] pulled the chart, she said she [Resident #1] was a full code, so I got on the phone and called a code blue over the speaker .they put her on the floor in her room and they started doing compressions on her .someone went and got the chart .and found that she [Resident #1] had been changed to a DNR .they stopped [CPR] right then and there as soon as they found that out .they didn't do it for very long at all . During a telephone interview on [DATE] at 1:00 PM, RN #2 (former ADON) stated .somebody shouted down the hall that they needed help .they checked the chart and the POST form said that she [Resident #1] was a full code .I was coming up the hallway and I thought that they [the family] changed her [Resident #1's code status] because I talked to the family and her sister said that she was going to change her to a DNR .so I checked the hospice tab and there was a updated POST form that they [hospice] had put in there .they [hospice] did not inform the facility .it [POST form] was all just stuffed in the paperwork they bring .it was mixed with other paperwork .as soon as I found it I shouted out that she was a DNR and they stopped the code .the nursing staff and the Director of Nursing was in there with her [Resident #1] .they performed CPR maybe a minute or two . During a telephone interview on [DATE] at 11:30 AM, RN #3 (former DON) stated .a code blue was called .she [Resident #1] was in the day room and she was up in her chair. She was visibly purple .no respirations .no heart beat .she was taken to her room and laid in the floor .I'm running down the hallway and I said grab the chart .[POST form] in the front of the chart .[Resident #1] was a full code .I tried to get an airway with an Ambu bag [device used to provide ventilation to patients who are not breathing]. I couldn't get an airway, so I suctioned her .I found out she was a DNR while I was trying to get an airway . [CNA #2] started compressions .she [RN #2] yelled down the hallway 'stop [Resident #1] is a DNR' and everybody pulled back immediately .she [Resident #1] was a hospice patient .that's why she [RN #2] looked in the hospice tab . During a telephone interview on [DATE] at 11:45 AM, CNA #2 stated .I was the one that actually started compressions. It was about 2 or 2:30 PM [on [DATE]] .I was in another resident's room and the next thing that I heard was somebody called a code blue .we got her [Resident #1] out of her chair and myself and [LPN #4] switched off as far as compressions go .I did compressions a couple of minutes or so. The whole thing didn't last 5 minutes or so, if that .my shoulders were starting to give out, so I just swapped off with her [LPN #4] .[LPN #4] started compressions. She didn't do them very long .I took back over and did it for maybe a minute tops, if that .I'm not sure who came in, but somebody came in and said that she was a DNR, so we just stopped doing compressions . During a telephone interview on [DATE] at 9:30 AM, Physician #1 stated .they [the facility] called me about that as soon as they realized that she [Resident #1] was a DNR .my expectations is that if they [residents] are a DNR they should not do CPR . During an interview on [DATE] at 10:10 AM, LPN #4 stated .a code blue was announced around 2:30 PM .when we went in her [Resident #1's] room they were saying she is a full code and when I went in they had [Resident #1] in the floor and [CNA #1] had already started compressions and [RN #3] was at her [Resident #1's] head with the Ambu bag and I went to the right side .I switched out with [CNA #2] with doing CPR and after 2 minutes we switched back and he [CNA #2] took over CPR .and then [RN #2] came running around the corner and said 'stop she is a DNR' .we stopped and [RN #2] said the DNR POST form was misplaced in the chart and she [Resident #1] had 2 POST forms in the chart .one that was signed here at the facility and the one from hospice .the one from hospice was the most recent .it was in the back of the chart with the hospice papers . During a telephone interview on [DATE] at 10:15 AM, Resident #1's sister stated .yes they [the facility] called us when she [Resident #1] passed away .they told me they called a code blue on her .I think they tried to bring her back .I don't remember who it was that I talked to about making her a DNR .I didn't want them to try to bring her back . The facility's corrective actions were validated onsite by the surveyors on [DATE]. The corrective action plan included the following: A. On [DATE], the Executive Director (ED) and the Director of Nursing (DON) initiated an investigation and completed a root cause analysis identifying a lack of communication regarding changes to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Incidents Follow - up & Recommendation Form confirmed the investigation was completed on [DATE]. B. On [DATE], the DON, Social Services Director (SSD), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), Minimum Data Set Coordinator (MDSC), and a Licensed Nurse completed a 100% audit of all active residents for: 1. Current code status orders 2. Completed POST form with all appropriate signatures 3. Care plan for code status Review of the facility's TIMELINE OF EVENTS documentation and the facility's midnight resident census worksheet dated [DATE], showed the audits were completed on [DATE] with no errors identified. The facility completed an additional audit on [DATE] with no errors identified. C. On [DATE], the DON, Executive Director (ED), ADON, a Licensed Nurse, and all contracted hospice agencies initiated a hospice process change that included: 1. Hospice communication (verbal or written) will be directed to the Charge Nurse and DON. If the DON is unavailable communication should be given to the Charge Nurse immediately and follow up communication should be given to the DON as soon as practical. The Charge Nurse will notify the physician and responsible party and/or resident for any orders, code status change, or change in condition. 2. The ED (or designee) will complete daily visitor log checks Monday - Friday and identify any hospice visits. The hospice visits will then be reviewed with the hospice agency to ensure all proper documentation and/or changes from the visit have been received. On [DATE], review of a Hospice Communication Process (document used for daily visitor log checks) dated [DATE] through [DATE] showed the process had been implemented and hospice staff was signing into the facility at the time of their visits. 3. Any communication issues or topics between the hospice agency and the facility will be discussed and addressed in the clinical grand round meetings (held each morning Monday through Friday). During clinical grand rounds, new admissions, readmissions, new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Monthly meetings will be held between the administrative team (ED, DON, ADON, and SSD) and each hospice group. The hospice plan of care will be reviewed to ensure it matches the facility plan of care for the resident. The POST form and orders will also be reviewed for each resident to ensure the hospice information matches facility information. Any change in condition of the resident or other concern will also be discussed during the meeting. Upcoming facility care planning meetings will be discussed so hospice can make note to attend these meetings if possible. 5. During scheduled care plan meetings, the hospice plan of care, the POST form, any changes in condition, and overall status of residents will be reviewed. Notation of hospice attendance will be noted in the care plan conference note. 6. The attending physician and the responsible party will be notified of any changes to the code status, and the order, care plan, and the Point of Care (POC) resident profile (facility electronic medical record system) will be updated to reflect any changes made to code status on the POST form. 7. Hospice charts will be reviewed Monday-Friday by the Social Worker (SW) and the ED (or designee in their absence) to ensure that code status, order, and care plan all match. Any discrepancy will be clarified with the facility Medical Director and hospice Physician immediately. D. On [DATE]-[DATE], the DON and the ED provided education to 100% of facility staff on: 1. Advance directives and advanced care planning 2. CPR guidelines 3. POST form 4. Hospice communication 5. Appropriate updating of the POST form, POC resident profile care plan, and orders with each new admission, readmission, and change of condition. All new hires will receive the education in orientation. Review of facility sign in sheets, facility employee list, and interview on [DATE] at 2:50 PM, with the Administrator, confirmed education was provided to all facility staff. Staff interviews conducted on [DATE] - [DATE] with 5 Certified Nurse Assistants (CNAs) working day shift (6:00 AM - 6:00 PM), 3 CNAs working night shift (6:00 PM - 6:00 AM), 5 Licensed Practical Nurses (LPNs) working day shift (6:00 AM - 6:00 PM), 2 LPNs working night shift (6:00 PM - 6:00 AM), 2 Registered Nurses (RNs) working day shift 6:00 AM - 6:00 PM), Social Services Director (SSD), and the Activities Assistant confirmed they had received the education and were aware of advance directives, advanced care planning, CPR guidelines, POST form, Hospice communication, and Appropriate updating of POST, POC resident profile care plan, and orders with each new admission, readmission, and change of condition. E. A staff quiz on the hospice communication process changes and advance directive education was conducted by the SDC and the DON and 100% of the staff completed the quiz by [DATE]. Review of facility employee list audit for the hospice communication process change and advance directive quiz education, and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the quiz was completed with all facility staff. Staff interviews conducted on [DATE] - [DATE] with 5 CNAs working day shift (6:00 AM - 6:00 PM), 3 CNAs working night shift (6:00 PM - 6:00 AM), 5 LPNs working day shift (6:00 AM - 6:00 PM), 2 LPNs working night shift (6:00 PM - 6:00 AM), 2 RNs working day shift 6:00 AM - 6:00 PM), the Social Services Director (SSD), and the Activities Assistant confirmed they had completed the quiz and understood the process change. F. A mock code blue drill was conducted with 100% of staff by SDC and the DON and completed by [DATE]. Review of staff in-service sheets and interview on [DATE] at 2:50 PM, with the Administrator, confirmed a mock code blue drill was conducted with 100% of staff. Staff interviews confirmed participation and understanding of the drill. G. On [DATE], the DON and the ED provided education to facility contracted hospice agencies on: 1. Communication 2. Documentation 3. POST forms 4. Advance Directives During review of the hospice contracts, hospice sign in sheets, and interview on [DATE] at 12:50 PM, the Administrator, confirmed the facility provided education to facility contracted hospice providers. Interviews conducted with 2 hospice RNs and 1 hospice RN Patient Care Manager confirmed they had received the education and were aware of the process for communication, documentation, POST forms, and advance directives. H. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse initiated an audit on all new/re-admissions for: 1. Current code status orders 2. POST Form 3. Care Plan for code status 4. Resident POC Profile The audit will be completed 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for 4 weeks. Review of the facility's audit forms dated [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed all new/re-admissions had been audited and the audits were ongoing. I. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse initiated an audit on all active hospice residents for: 1. Current code status orders 2. POST Form 3. Care Plan for code status 4. Resident POC Profile The audit will be completed 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for 4 weeks. Review of the facility's audit form dated [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. J. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse, during care plan meetings, will audit: 1. Current code status orders 2. POST form 3. Care Plan for code status 4. Resident POC Profile 5. Hospice Plan of Care (when applicable) The audits will be completed 1 time a week for 12 weeks. Review of the facility's audit form dated [DATE] - [DATE], and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. K. On [DATE], the DON, ADON, and the SDC initiated an audit on all nursing staff for verification of: 1. Current CPR certification 2. Certification on file in record 3. Upcoming expiration dates within the next month The audits will be completed 1 time a month for 3 months. Review of the facility's audit form dated [DATE] and [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. L. On [DATE], the DON, ADON, ED, Social Worker (SW), and MDSC initiated monthly hospice communication meetings to be held with all hospice agencies to review: 1. POST form 2. Order 3. Care plan 4. Resident POC Profile 5. Hospice Plan of Care 6. Communication expectation and evaluation The meetings will be held 1 time a month for 3 months. Review of the facility's audit form dated [DATE] and [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the facility had hospice communication meetings on [DATE] and [DATE] and the meetings were ongoing. M. On [DATE], the ED, DON, ADON, and SW initiated visitor log audits to review hospice visits and to ensure all appropriate hospice communication and documentation was obtained. The audits will be conducted 5 times a week for 12 weeks. Review of the facility's audit form dated [DATE] through [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed communication with hospice staff and facility staff was being done and the audits were ongoing. N. On [DATE], the DON, ADON, SDC, MDSC, and a Licensed Nurse completed an audit on all Cardiopulmonary Resuscitation (CPR) certified staff to ensure all staff was current with their certifications, with no issues identified. Review of the facility's audit form dated [DATE] and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the audits were completed on [DATE] with no issues identified. O. On [DATE], the Performance Improvement plan for Advance Directives was validated by the Quality Assurance and Performance Improvement (QAPI) Committee. Review of the QAPI sign in sheet dated [DATE] and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the performance improvement plan was validated by QAPI committee on [DATE].

Based on review of facility policy, medical record review, review of a facility investigation, and interviews, the facility failed to revise a comprehensive care plan to include current code status for 1 resident (Resident #1) of 6 residents reviewed for care plans. The facility's failure to revise the care plan resulted in Resident #1 receiving Cardiopulmonary Resuscitation (CPR) against the resident's and the resident's representative wishes and placed the resident in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was notified of the IJ on [DATE] at 4:15 PM, in the conference room. The IJ was effective on [DATE] and was removed on [DATE] when the facility implemented a corrective action plan. Corrective actions were validated onsite by the surveyor on [DATE]. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled Resident Assessment Instrument & Care Plan reviewed [DATE] showed .A comprehensive care plan must be .Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments . Review of the facility's policy titled Advance Directives and Advance Care Planning last revised [DATE] showed .Do Not Resuscitate (DNR) order - A medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer cardiopulmonary resuscitation (CPR) in the event of cardiac respiratory arrest .The DNR order is incorporated into the residents care plan and is periodically reviewed, at least quarterly .Each time the resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning .This review should focus on the existing advance directives .match the current goals of care for the resident. The social services director or designee should document this conversation in the medical record and assist as needed with updating the documents that need revision in accordance with state and federal requirements . Review of the facility's policy titled Hospice Coordination of Care last reviewed [DATE] showed .The care of the resident receiving hospice services must reflect ongoing communication and collaboration between the nursing home and the hospice staff .ensure that each resident's written plan of care includes both the most recent hospice plan of care . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired on [DATE] at the facility. Medical record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .FULL CODE [initiate CPR] limited interventions .[DATE] .Hospice to consult for evaluation and treatment if indicated .[DATE] . Medical record review of an ADMISSION CONSENT/ELECTION OF HOSPICE BENEFITS form dated [DATE] for Resident #1 showed .HOSPICE ELECTION EFFECTIVE DATE: [DATE] . Medical record review of a HOSPICE PLAN OF CARE dated [DATE] for Resident #1 showed .certification period: From [DATE] To [DATE] .Advance Directives Information .POST - [DATE] - Pending signature for DNR with comfort measures only . Medical record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Do Not Resuscitate .DNR .Comfort Measures Only .Physician .[hospice medical director] .Date Prepared [DATE] . Medical record review of the facility's CARE PLAN CONFERENCE RECORD for Resident #1 dated [DATE] showed .Full code .CPR . The care plan conference did not include hospice agency staff. Medical record review of HOSPICE COORDINATED PLAN OF CARE notes for Resident #1 dated [DATE], [DATE], [DATE], [DATE], and [DATE] showed .Caregiver Support issues .DNR status . Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview for Mental Status (BIMS) score was 00, indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADLs). Medical record review of a current care plan for Resident #1, last reviewed on [DATE], showed .Resident has Advance Directives CPR - Full Code Date Initiated: [DATE] .Code status will be reviewed on a quarterly bases [basis] and PRN [as needed] . Review of the facility's investigation dated [DATE] showed Resident #1 was observed in the dayroom at 2:40 PM with poor color, no pulse, and no respirations. Facility staff checked the medical record and found in the record Resident #1 was a Full Code. Facility staff began CPR. CPR continued until a more current POST form indicating the resident was a DNR was found in the resident's medical record, at which time CPR was stopped. During an interview on [DATE] at 12:20 PM, the Social Services Director (SSD) stated .we reviewed it [Resident #1's POST form] from the chart and computer. It showed [Resident #1 was a] full code .her [Resident #1's] code status wasn't correct on her care plan. It should have been updated to a DNR . During an interview on [DATE] at 12:50 PM, the Administrator stated .we felt it was a communication error and also secondary to that it [Resident #1's POST form] wasn't filed in the appropriate place [in the medical record] . During an interview on [DATE] at 1:25 PM, Licensed Practical Nurse (LPN)/MDS Coordinator #1 stated .I pull up the care plan on the computer and I read down each of the problems and what their goals are .we read over what the care plan says .the code status should have been reviewed .no the hospice care plan didn't match with the facility care plan .hospice is supposed to communicate it to the nurse and they would have put it in the computer and I would have updated her [Resident #1's] care plan from there .her care plan was incorrect at the time that she coded .she should not have had CPR . During a telephone interview on [DATE] at 10:15 AM, Resident #1's sister stated .yes they [the facility] called us when she [Resident #1] passed away .they told me they called a code blue [initiated CPR and resuscitative measures] on her .I think they tried to bring her back .I didn't want them to try to bring her back . The facility's corrective actions were validated onsite by the surveyors on [DATE]. The corrective action plan included the following: A. On [DATE], the Executive Director (ED) and the Director of Nursing (DON) initiated an investigation and completed a root cause analysis identifying a lack of communication regarding changes to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Incidents Follow - up & Recommendation Form confirmed the investigation was completed on [DATE]. B. On [DATE], the DON, Social Services Director (SSD), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), Minimum Data Set Coordinator (MDSC), and a Licensed Nurse completed a 100% audit of all active residents for: 1. Current code status orders 2. Completed POST form with all appropriate signatures 3. Care plan for code status Review of the facility's TIMELINE OF EVENTS documentation and the facility's midnight resident census worksheet dated [DATE], showed the audits were completed on [DATE] with no errors identified. The facility completed an additional audit on [DATE] with no errors identified. C. On [DATE], the DON, Executive Director (ED), ADON, a Licensed Nurse, and all contracted hospice agencies initiated a hospice process change that included: 1. Hospice communication (verbal or written) will be directed to the Charge Nurse and DON. If the DON is unavailable communication should be given to the Charge Nurse immediately and follow up communication should be given to the DON as soon as practical. The Charge Nurse will notify the physician and responsible party and/or resident for any orders, code status change, or change in condition. 2. The ED (or designee) will complete daily visitor log checks Monday - Friday and identify any hospice visits. The hospice visits will then be reviewed with the hospice agency to ensure all proper documentation and/or changes from the visit have been received. On [DATE], review of a Hospice Communication Process (document used for daily visitor log checks) dated [DATE] through [DATE] showed the process had been implemented and hospice staff was signing into the facility at the time of their visits. 3. Any communication issues or topics between the hospice agency and the facility will be discussed and addressed in the clinical grand round meetings (held each morning Monday through Friday). During clinical grand rounds, new admissions, readmissions, new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Monthly meetings will be held between the administrative team (ED, DON, ADON, and SSD) and each hospice group. The hospice plan of care will be reviewed to ensure it matches the facility plan of care for the resident. The POST form and orders will also be reviewed for each resident to ensure the hospice information matches facility information. Any change in condition of the resident or other concern will also be discussed during the meeting. Upcoming facility care planning meetings will be discussed so hospice can make note to attend these meetings if possible. 5. During scheduled care plan meetings, the hospice plan of care, the POST form, any changes in condition, and overall status of residents will be reviewed. Notation of hospice attendance will be noted in the care plan conference note. 6. The attending physician and the responsible party will be notified of any changes to the code status, and the order, care plan, and the Point of Care (POC) resident profile (facility electronic medical record system) will be updated to reflect any changes made to code status on the POST form. 7. Hospice charts will be reviewed Monday-Friday by the Social Worker (SW) and the ED (or designee in their absence) to ensure that code status, order, and care plan all match. Any discrepancy will be clarified with the facility Medical Director and hospice Physician immediately. D. On [DATE]-[DATE], the DON and the ED provided education to 100% of facility staff on: 1. Advance directives and advanced care planning 2. CPR guidelines 3. POST form 4. Hospice communication 5. Appropriate updating of the POST form, POC resident profile care plan, and orders with each new admission, readmission, and change of condition. All new hires will receive the education in orientation. Review of facility sign in sheets, facility employee list, and interview on [DATE] at 2:50 PM, with the Administrator, confirmed education was provided to all facility staff. Staff interviews conducted on [DATE] - [DATE] with 5 Certified Nurse Assistants (CNAs) working day shift (6:00 AM - 6:00 PM), 3 CNAs working night shift (6:00 PM - 6:00 AM), 5 Licensed Practical Nurses (LPNs) working day shift (6:00 AM - 6:00 PM), 2 LPNs working night shift (6:00 PM - 6:00 AM), 2 Registered Nurses (RNs) working day shift 6:00 AM - 6:00 PM), Social Services Director (SSD), and the Activities Assistant confirmed they had received the education and were aware of advance directives, advanced care planning, CPR guidelines, POST form, Hospice communication, and Appropriate updating of POST, POC resident profile care plan, and orders with each new admission, readmission, and change of condition. E. A staff quiz on the hospice communication process changes and advance directive education was conducted by the SDC and the DON and 100% of the staff completed the quiz by [DATE]. Review of facility employee list audit for the hospice communication process change and advance directive quiz education, and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the quiz was completed with all facility staff. Staff interviews conducted on [DATE] - [DATE] with 5 CNAs working day shift (6:00 AM - 6:00 PM), 3 CNAs working night shift (6:00 PM - 6:00 AM), 5 LPNs working day shift (6:00 AM - 6:00 PM), 2 LPNs working night shift (6:00 PM - 6:00 AM), 2 RNs working day shift 6:00 AM - 6:00 PM), the Social Services Director (SSD), and the Activities Assistant confirmed they had completed the quiz and understood the process change. F. A mock code blue drill was conducted with 100% of staff by SDC and the DON and completed by [DATE]. Review of staff in-service sheets and interview on [DATE] at 2:50 PM, with the Administrator, confirmed a mock code blue drill was conducted with 100% of staff. Staff interviews confirmed participation and understanding of the drill. G. On [DATE], the DON and the ED provided education to facility contracted hospice agencies on: 1. Communication 2. Documentation 3. POST forms 4. Advance Directives During review of the hospice contracts, hospice sign in sheets, and interview on [DATE] at 12:50 PM, the Administrator, confirmed the facility provided education to facility contracted hospice providers. Interviews conducted with 2 hospice RNs and 1 hospice RN Patient Care Manager confirmed they had received the education and were aware of the process for communication, documentation, POST forms, and advance directives. H. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse initiated an audit on all new/re-admissions for: 1. Current code status orders 2. POST Form 3. Care Plan for code status 4. Resident POC Profile The audit will be completed 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for 4 weeks. Review of the facility's audit forms dated [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed all new/re-admissions had been audited and the audits were ongoing. I. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse initiated an audit on all active hospice residents for: 1. Current code status orders 2. POST Form 3. Care Plan for code status 4. Resident POC Profile The audit will be completed 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for 4 weeks. Review of the facility's audit form dated [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. J. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse, during care plan meetings, will audit: 1. Current code status orders 2. POST form 3. Care Plan for code status 4. Resident POC Profile 5. Hospice Plan of Care (when applicable) The audits will be completed 1 time a week for 12 weeks. Review of the facility's audit form dated [DATE] - [DATE], and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. K. On [DATE], the DON, ADON, and the SDC initiated an audit on all nursing staff for verification of: 1. Current CPR certification 2. Certification on file in record 3. Upcoming expiration dates within the next month The audits will be completed 1 time a month for 3 months. Review of the facility's audit form dated [DATE] and [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. L. On [DATE], the DON, ADON, ED, Social Worker (SW), and MDSC initiated monthly hospice communication meetings to be held with all hospice agencies to review: 1. POST form 2. Order 3. Care plan 4. Resident POC Profile 5. Hospice Plan of Care 6. Communication expectation and evaluation The meetings will be held 1 time a month for 3 months. Review of the facility's audit form dated [DATE] and [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the facility had hospice communication meetings on [DATE] and [DATE] and the meetings were ongoing. M. On [DATE], the ED, DON, ADON, and SW initiated visitor log audits to review hospice visits and to ensure all appropriate hospice communication and documentation was obtained. The audits will be conducted 5 times a week for 12 weeks. Review of the facility's audit form dated [DATE] through [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed communication with hospice staff and facility staff was being done and the audits were ongoing. N. On [DATE], the DON, ADON, SDC, MDSC, and a Licensed Nurse completed an audit on all Cardiopulmonary Resuscitation (CPR) certified staff to ensure all staff was current with their certifications, with no issues identified. Review of the facility's audit form dated [DATE] and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the audits were completed on [DATE] with no issues identified. O. On [DATE], the Performance Improvement plan for Advance Directives was validated by the Quality Assurance and Performance Improvement (QAPI) Committee. Review of the QAPI sign in sheet dated [DATE] and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the performance improvement plan was validated by QAPI committee on [DATE]. Refer to F-678.

Based on review of facility policy, review of a hospice service agreement, medical record review, review of a facility investigation, and interviews, the facility failed to ensure an effective communication process and procedure was in place with a hospice provider to ensure a Do Not Resuscitate (DNR) status was honored for 1 resident (Resident #1) of 6 residents reviewed for hospice services. The facility's failure to ensure effective communication was in place resulted in Resident #1 receiving Cardiopulmonary Resuscitation (CPR) against the resident's and the resident's representative wishes and placed the resident in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator was notified of the IJ on [DATE] at 4:15 PM, in the conference room. The IJ was effective on [DATE] and was removed on [DATE] when the facility implemented a corrective action plan. Corrective actions were validated onsite by the surveyor on [DATE]. The IJ was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of the facility's policy titled Advance Directives and Advance Care Planning last revised [DATE] showed .Do Not Resuscitate (DNR) order - A medical order issued by a physician or other authorized non-physician practitioner that directs healthcare providers not to administer cardiopulmonary resuscitation (CPR) in the event of cardiac respiratory arrest .The Director of Nursing or designee establishes a system to inform all direct care staff of the residents DNR status .DNR order is flagged appropriately on the resident's chart to alert staff as to status . Review of the facility's policy titled Cardiopulmonary Resuscitation (CPR) Guidelines revised [DATE] showed .To ensure that each facility is able to and does provide basic life support .in accordance with related physicians orders, such as DNR's and the resident's advance directives .Facilities must also have procedures in place to document a resident's choices regarding issues like CPR .Physicians orders to support these choices should be obtained as soon as possible after admission, or a change in resident preference or condition, to facilitate staff in honoring resident choices .Facilities must address how resident preferences and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled Hospice Coordination of Care last reviewed [DATE] showed .The care of the resident receiving hospice services must reflect ongoing communication and collaboration between the nursing home and the hospice staff . Review of the facility's policy titled HOSPICE SERVICE AGREEMENT showed .between [hospice] and [Facility], dated as of the 1st day of [DATE] (Effective Date) .COMMUNICATION .Communication protocol. Hospice and Facility shall work together to develop a written communication protocol governing how they will communicate all information needed for the Hospice Patients' care .including how such communication will be documented to ensure that the needs of Hospice Patients are addressed and met twenty-four (24) hours a day . Medical record review showed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident expired on [DATE] at the facility. Medical record review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .FULL CODE [initiate CPR] limited interventions .[DATE] .Hospice to consult for evaluation and treatment if indicated .[DATE] . Medical record review of an ADMISSION CONSENT/ELECTION OF HOSPICE BENEFITS form dated [DATE] for Resident #1 showed .HOSPICE ELECTION EFFECTIVE DATE: [DATE] . Medical record review of a HOSPICE PLAN OF CARE dated [DATE] for Resident #1 showed .certification period: From [DATE] To [DATE] .Advance Directives Information .POST [physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a POST form for Resident #1 dated [DATE] showed .Do Not .Resuscitate .DNR .Comfort Measures Only .Physician .[hospice medical director] .Date Prepared [DATE] . Medical record review of HOSPICE COORDINATED PLAN OF CARE note for Resident #1 dated [DATE], [DATE], [DATE], [DATE], and [DATE] showed .Caregiver Support issues .DNR status . Medical record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 00, indicating the resident had severe cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADLs). Review of the facility's investigation dated [DATE] showed on [DATE] at 2:40 PM, Resident #1 was observed in her wheelchair in the dayroom by Certified Nursing Assistant (CNA) #1 who thought the resident's (skin) color did not look right. CNA #1 yelled for Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator #1 to check on Resident #1. The resident was found to be without a pulse and had no respirations. LPN/MDS Coordinator #1 went to the nurses' station and checked the resident's chart for her POST form. The POST form located in the front of the chart stated the resident was a full code. CNA #1 paged a code blue (term used to summon additional help for someone in cardiac arrest). Resident #1 was pushed back to her room by wheelchair and laid on the floor. CNA #2 and Registered Nurse (RN) #3 started CPR on Resident #1. CPR continued until a more current POST form indicating the resident was a DNR was found under the hospice tab in the resident's medical record by RN #2, at which time CPR was stopped. Review revealed .Summary of Investigative Facts: Most current up to date POST not filed in chart appropriately and communicated to facility appropriately by hospice .MD [Medical Director] notified, and family member notified .Current Interventions QAPI [Quality Assurance Performance Improvement] initiated . During an interview on [DATE] at 9:20 AM, the Administrator stated .What had happened with her [Resident #1] was she had been found expired [on [DATE]] and the first POST [form] in the front of the chart said CPR was to be performed so CPR was started .so when the hospice one [POST form] was found and it was noticed to have a more recent date that said DNR .it was in the back of the chart under the hospice tab .CPR was stopped .the facility was not notified of the update .the nurse [hospice nurse] did not tell anyone that the DNR status had been updated .what they [hospice] should have done was say there has been an updated POST form . During a telephone interview on [DATE] at 11:00 AM, Hospice RN #1 stated .there is a medical records box behind the nurse's desk and that is where I put the POST form [for Resident #1] .I don't recall what day it was .whoever the charge nurse .would have been at the time is who I would have spoken with . During an telephone interview on [DATE] at 11:40 AM, LPN #3 (charge nurse on [DATE]) stated .I don't recall hospice giving me any paperwork .if an order is changed or a DNR is updated, it's usually handed to the nurse by hospice; but I was never handed any DNR order for her [Resident #1] .I never got any paperwork from hospice on a DNR .we are supposed to look at the post forms before we start CPR, and we know where it is in the chart, and if hospice put it in their tab, then I would have never looked in the hospice tab . During a telephone interview on [DATE] at 1:00 PM, RN #2 (former ADON) stated .they checked the chart and the POST form said that she [Resident #1] was a full code .I was coming up the hallway and I thought that they [the family] changed her [Resident #1's code status] because I talked to the family and her sister said that she was going to change her to a DNR .so I checked the hospice tab and there was a updated POST form that they [hospice] had put in there .they [hospice] did not inform the facility .it [POST form] was all just stuffed in the paperwork they bring and it wasn't even in the front. It was mixed with other paperwork .we contacted the hospice agency and told them anytime there is an updated POST form it has to come through administration. It can't just be stuffed in the back of a chart . During an telephone interview on [DATE] at 11:30 AM, RN #3 (former DON) stated .a code blue was called .I'm running down the hallway and I said grab the chart .[POST form] in the front of the chart .[Resident #1] was a full code .I found out she was a DNR .[CNA #2] started compressions .she [RN #2] yelled down the hallway 'stop [Resident #1] is a DNR' and everybody pulled back immediately .she [Resident #1] was a hospice patient .that's why she [RN #2] looked in the hospice tab . During an interview on [DATE] at 12:50 PM, the Administrator stated .[Resident #1's POST form] wasn't filed in the appropriate place [in the medical record] .we felt it was a communication error .we did education with our hospice group and our nurses .on the hospice end we shared the same concern about communication on how we needed any changes to be updated to us . During an interview on [DATE] at 10:10 AM, LPN #4 stated .a code blue was announced around 2:30 PM .when we went in her [Resident #1's] room they were saying she is a full code .and then [RN #2] came running around the corner and said 'stop she is a DNR' .we stopped and [RN #2] said the DNR POST form was misplaced in the chart and she [Resident #1] had 2 POST forms in the chart .one that was signed here at the facility and the one from hospice .the one from hospice was the most recent .it was in the back of the chart with the hospice papers . The facility's corrective actions were validated onsite by the surveyors on [DATE]. The corrective action plan included the following: A. On [DATE], the Executive Director (ED) and the Director of Nursing (DON) initiated an investigation and completed a root cause analysis identifying a lack of communication regarding changes to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Incidents Follow - up & Recommendation Form confirmed the investigation was completed on [DATE]. B. On [DATE], the DON, Social Services Director (SSD), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), Minimum Data Set Coordinator (MDSC), and a Licensed Nurse completed a 100% audit of all active residents for: 1. Current code status orders 2. Completed POST form with all appropriate signatures 3. Care plan for code status Review of the facility's TIMELINE OF EVENTS documentation and the facility's midnight resident census worksheet dated [DATE], showed the audits were completed on [DATE] with no errors identified. The facility completed an additional audit on [DATE] with no errors identified. C. On [DATE], the DON, Executive Director (ED), ADON, a Licensed Nurse, and all contracted hospice agencies initiated a hospice process change that included: 1. Hospice communication (verbal or written) will be directed to the Charge Nurse and DON. If the DON is unavailable communication should be given to the Charge Nurse immediately and follow up communication should be given to the DON as soon as practical. The Charge Nurse will notify the physician and responsible party and/or resident for any orders, code status change, or change in condition. 2. The ED (or designee) will complete daily visitor log checks Monday - Friday and identify any hospice visits. The hospice visits will then be reviewed with the hospice agency to ensure all proper documentation and/or changes from the visit have been received. On [DATE], review of a Hospice Communication Process (document used for daily visitor log checks) dated [DATE] through [DATE] showed the process had been implemented and hospice staff was signing into the facility at the time of their visits. 3. Any communication issues or topics between the hospice agency and the facility will be discussed and addressed in the clinical grand round meetings (held each morning Monday through Friday). During clinical grand rounds, new admissions, readmissions, new physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Monthly meetings will be held between the administrative team (ED, DON, ADON, and SSD) and each hospice group. The hospice plan of care will be reviewed to ensure it matches the facility plan of care for the resident. The POST form and orders will also be reviewed for each resident to ensure the hospice information matches facility information. Any change in condition of the resident or other concern will also be discussed during the meeting. Upcoming facility care planning meetings will be discussed so hospice can make note to attend these meetings if possible. 5. During scheduled care plan meetings, the hospice plan of care, the POST form, any changes in condition, and overall status of residents will be reviewed. Notation of hospice attendance will be noted in the care plan conference note. 6. The attending physician and the responsible party will be notified of any changes to the code status, and the order, care plan, and the Point of Care (POC) resident profile (facility electronic medical record system) will be updated to reflect any changes made to code status on the POST form. 7. Hospice charts will be reviewed Monday-Friday by the Social Worker (SW) and the ED (or designee in their absence) to ensure that code status, order, and care plan all match. Any discrepancy will be clarified with the facility Medical Director and hospice Physician immediately. D. On [DATE]-[DATE], the DON and the ED provided education to 100% of facility staff on: 1. Advance directives and advanced care planning 2. CPR guidelines 3. POST form 4. Hospice communication 5. Appropriate updating of the POST form, POC resident profile care plan, and orders with each new admission, readmission, and change of condition. All new hires will receive the education in orientation. Review of facility sign in sheets, facility employee list, and interview on [DATE] at 2:50 PM, with the Administrator, confirmed education was provided to all facility staff. Staff interviews conducted on [DATE] - [DATE] with 5 Certified Nurse Assistants (CNAs) working day shift (6:00 AM - 6:00 PM), 3 CNAs working night shift (6:00 PM - 6:00 AM), 5 Licensed Practical Nurses (LPNs) working day shift (6:00 AM - 6:00 PM), 2 LPNs working night shift (6:00 PM - 6:00 AM), 2 Registered Nurses (RNs) working day shift 6:00 AM - 6:00 PM), Social Services Director (SSD), and the Activities Assistant confirmed they had received the education and were aware of advance directives, advanced care planning, CPR guidelines, POST form, Hospice communication, and Appropriate updating of POST, POC resident profile care plan, and orders with each new admission, readmission, and change of condition. E. A staff quiz on the hospice communication process changes and advance directive education was conducted by the SDC and the DON and 100% of the staff completed the quiz by [DATE]. Review of facility employee list audit for the hospice communication process change and advance directive quiz education, and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the quiz was completed with all facility staff. Staff interviews conducted on [DATE] - [DATE] with 5 CNAs working day shift (6:00 AM - 6:00 PM), 3 CNAs working night shift (6:00 PM - 6:00 AM), 5 LPNs working day shift (6:00 AM - 6:00 PM), 2 LPNs working night shift (6:00 PM - 6:00 AM), 2 RNs working day shift 6:00 AM - 6:00 PM), the Social Services Director (SSD), and the Activities Assistant confirmed they had completed the quiz and understood the process change. F. A mock code blue drill was conducted with 100% of staff by SDC and the DON and completed by [DATE]. Review of staff in-service sheets and interview on [DATE] at 2:50 PM, with the Administrator, confirmed a mock code blue drill was conducted with 100% of staff. Staff interviews confirmed participation and understanding of the drill. G. On [DATE], the DON and the ED provided education to facility contracted hospice agencies on: 1. Communication 2. Documentation 3. POST forms 4. Advance Directives During review of the hospice contracts, hospice sign in sheets, and interview on [DATE] at 12:50 PM, the Administrator, confirmed the facility provided education to facility contracted hospice providers. Interviews conducted with 2 hospice RNs and 1 hospice RN Patient Care Manager confirmed they had received the education and were aware of the process for communication, documentation, POST forms, and advance directives. H. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse initiated an audit on all new/re-admissions for: 1. Current code status orders 2. POST Form 3. Care Plan for code status 4. Resident POC Profile The audit will be completed 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for 4 weeks. Review of the facility's audit forms dated [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed all new/re-admissions had been audited and the audits were ongoing. I. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse initiated an audit on all active hospice residents for: 1. Current code status orders 2. POST Form 3. Care Plan for code status 4. Resident POC Profile The audit will be completed 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for 4 weeks. Review of the facility's audit form dated [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. J. On [DATE], the DON, SSD, ADON, SDC, MDSC, and a Licensed Nurse, during care plan meetings, will audit: 1. Current code status orders 2. POST form 3. Care Plan for code status 4. Resident POC Profile 5. Hospice Plan of Care (when applicable) The audits will be completed 1 time a week for 12 weeks. Review of the facility's audit form dated [DATE] - [DATE], and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. K. On [DATE], the DON, ADON, and the SDC initiated an audit on all nursing staff for verification of: 1. Current CPR certification 2. Certification on file in record 3. Upcoming expiration dates within the next month The audits will be completed 1 time a month for 3 months. Review of the facility's audit form dated [DATE] and [DATE] - [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the audits had been completed and were ongoing. L. On [DATE], the DON, ADON, ED, Social Worker (SW), and MDSC initiated monthly hospice communication meetings to be held with all hospice agencies to review: 1. POST form 2. Order 3. Care plan 4. Resident POC Profile 5. Hospice Plan of Care 6. Communication expectation and evaluation The meetings will be held 1 time a month for 3 months. Review of the facility's audit form dated [DATE] and [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed the facility had hospice communication meetings on [DATE] and [DATE] and the meetings were ongoing. M. On [DATE], the ED, DON, ADON, and SW initiated visitor log audits to review hospice visits and to ensure all appropriate hospice communication and documentation was obtained. The audits will be conducted 5 times a week for 12 weeks. Review of the facility's audit form dated [DATE] through [DATE], and interview on [DATE] at 2:50 PM, with the Administrator, confirmed communication with hospice staff and facility staff was being done and the audits were ongoing. N. On [DATE], the DON, ADON, SDC, MDSC, and a Licensed Nurse completed an audit on all Cardiopulmonary Resuscitation (CPR) certified staff to ensure all staff was current with their certifications, with no issues identified. Review of the facility's audit form dated [DATE] and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the audits were completed on [DATE] with no issues identified. O. On [DATE], the Performance Improvement plan for Advance Directives was validated by the Quality Assurance and Performance Improvement (QAPI) Committee. Review of the QAPI sign in sheet dated [DATE] and interview on [DATE] at 12:50 PM, with the Administrator, confirmed the performance improvement plan was validated by QAPI committee on [DATE]. Refer to F-678.