Every finding on record at Madisonville Health and Rehabilitation, LLC

Based on observation, interview and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.During observation of the laundry room on 05/22/2026, the two staff members present were asked to verbalize the process on handling soiled linen. They both stated they only wore gloves when handling soiled linen instead of the standard precaution of donning gloves and a gown. This failure had the potential to affect all residents in the facility.Additionally, the facility failed to ensure proper infection control procedures during wound care treatment for one of three sampled residents reviewed for wound care, Resident (R)67. During observation of wound care on 05/20/2026, Licensed Practical Nurse (LPN)2 set up a sterile field while wearing clean gloves and placed a plastic bag in the floor for soiled wound care materials. She then failed to perform hand hygiene and don new gloves before attempting to clean the resident's wound.The findings include:Review of the facility policy, titled Infection Prevention and Control Program, reviewed/revised 04/2026, revealed laundry and direct care staff would handle, store, process, and transport linens to prevent spread of infection.Review of the facility policy, titled Laundry, reviewed 04/2026, revealed that laundry staff would be in-serviced on handling linens and laundry on a regular basis.An interview was conducted on 05/22/2026 at 11:18 AM, with the Housekeeping Floor Technician who was working in the laundry room on that date. She stated laundry staff wore gloves when handling soiled laundry. She further stated she thought they were supposed to wear long gloves, but regular gloves were all they had available for use. In further interview, the Housekeeping Floor Technician stated she knew she was supposed to wear an apron when handling the dirty laundry but didn't know where they were kept as she did not normally work in the laundry. She stated she just helped out in the laundry when there was no one else.During an interview, on 05/22/2026 at 11:20 AM, with the Laundry Technician, she stated it was her second day in that position. She stated she was told the previous day to wear gloves when handling the dirty laundry but had not been told to wear an apron or gown, and did not know where the aprons were kept. When questioned if she had someone precepting her, she said someone from housekeeping worked with her yesterday.Observation of the laundry room on 05/22/2026 at 11:25 AM, with the Housekeeping Floor Technician and the Laundry Technician, revealed no aprons or gowns were located.During an interview, on 05/22/2026 at 12:15 PM, with the Infection Control Nurse, she stated the facility had already started working on things in the laundry room. When questioned what she meant by that, she stated an employee from laundry came to her and asked her about the concern of not wearing a gown or apron while handling laundry. She stated the laundry was handled by an outside company and not by the facility. The Infection Control Nurse further stated standard precautions should be followed and monitored by herself, including the laundry process. She acknowledged, even though staff handling the laundry were not facility employees, improper handling of the laundry could affect the facility residents and staff.During an interview, on 05/22/2026 at 1:35 PM, with the Administrator, she stated the laundry staff were actually employees of an outside company and not the facility. In further interview, the Administrator agreed laundry staff should be monitored for infection control even though they were contracted out by an outside company.2. Additional review of the facility policy, titled Infection Prevention and Control Program, reviewed/revised 04/2026, revealed all staff will perform proper hand hygiene to prevent the spread of infection to other personnel, residents, and visitors. Hand hygiene shall be performed in accordance with the facility established hand hygiene procedures.Review of the facility policy, titled Wound Treatment Management, reviewed/revised 04/2026, revealed to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Review of R67's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 04/16/2026, with diagnosis including history of atherosclerotic heart disease, hypertension, and non-Alzheimer's dementia.Review of R67's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 5 out of 15, which indicated severe cognitive impairment.Observation of R67's wound care treatment on 05/20/2026 at 11:25 AM, performed by LPN2, revealed the nurse donned clean gloves, set up a sterile field on the side table and placed a plastic bag on the floor for soiled materials. LPN2 then failed to remove her gloves, perform hand hygiene and don new gloves before picking up the normal saline/wound cleanser to begin wound treatment to the resident's left buttocks wound. LPN2 was then stopped by the State Survey Agency (SSA) Surveyor. During interview with LPN2 during this process, she stated, I should have changed my gloves and washed my hands after setting up the clean field and prior to attempting to clean the wound and put the soiled gloves in a proper container instead of throwing them in a bag on the floor.

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This failure had the potential to affect all residents who consumed meals from the kitchen.Observation of the kitchen, on 05/20/2026, revealed multiple food items uncovered in the freezer and dry storage pantry; and a box of uncovered oatmeal cookie dough in the freezer stored underneath an ice-covered condenser. Additionally, there were several large bins which contained salt, sugar, and breadcrumbs, which were soiled on the outside.Further, observation on 05/21/2026, revealed the [NAME] was not wearing a beard net properly, in order to cover all facial hair. Additionally, observation revealed the box of uncovered oatmeal cookie dough was again in the freezer stored underneath the ice-covered condenser, and had not been discarded.The findings include:Review of the facility policy titled, Food Storage-Dry Goods, dated 10/2019, revealed the facility's policy would ensure all dry goods were appropriately stored in accordance with guidelines of the Food & Drug Administration (FDA) Food Code. Further, the Dietary Manager would ensure that all packaged and canned food items should be kept clean, dry, and properly sealed.Review of the facility policy titled, Food Storage-Cold, dated 10/2019, revealed the facility's policy would ensure all frozen and refrigerated food items were appropriately stored in accordance with guidelines of the Food & Drug Administration (FDA) Food Code. Further, the Dietary Manager would ensure all food items were stored properly in covered containers and arranged in a manner to prevent cross contamination.Review of the facility policy titled, Staff Attire, dated 10/2019, revealed the Dietary Manager would ensure all staff members had facial hair properly restrained. Review of the facility policy titled, Job Description; Dietary Manager, dated 10/2019, revealed the Dietary Manager's duties and responsibilities would manage the operation of the dietary department including meeting company policies, and state and federal regulations regarding safe food handling techniques. Additionally, food storage areas would be monitored to ensure health and sanitation regulations were being met. 1. Observation of the kitchen's dry storage pantry, on 05/20/2026 at 10:00 AM, revealed one large bag of bow-tie pasta, two bags of spaghetti noodles, one bag of linguine noodles, and one large bag of rigatoni noodles which were opened and unsealed. 2. Observation of the walk-in freezer, on 05/20/2026 at 10:15 AM, revealed a large box of personal-sized pizza packages with one package opened and uncovered. Further observation revealed a box of sausage patties, a box of Salisbury steak patties, a box of pork patties, and a box of beef steak fritters, all in their original containers; however, all boxes were uncovered and the contents inside the boxes were exposed to air contaminants. Additionally, observation of the freezer on 05/20/2026 at 10:15 AM, revealed a box of uncovered oatmeal cookie dough stored underneath an ice-covered condenser which had an excessive amount of ice build-up. During this observation, the Dietary Manager moved the box of uncovered oatmeal cookie dough box to another shelf.During an interview with the Dietary Manager, on 05/20/2026 at 10:25 AM, she stated all dietary staff had been trained and educated on food storage and safety. She further stated staff should ensure food was covered securely to prevent cross-contamination when stored. 3. Continued observation of the kitchen, on 05/20/2026 at 10:35 AM, revealed several large bins which contained salt, sugar, and breadcrumbs. The bin covers and front of the bins were soiled with grime and what appeared to be dried drops of liquids. During the observation, the Dietary Manager stated she had just overlooked cleaning the outside of the bins.4. During a second observation of the kitchen, on 05/21/2026 at 11:30 AM, Cook1's beard net was positioned between his mouth and chin and did not fully cover his moustache and beard hair.During an interview with Cook1, on 05/21/2026 at 11:35 AM, and on 05/22/2026 at 11:10 AM, he stated he was aware the beard net should be covering all of his facial hair, but he did not realize it had slipped down. He further stated there was the potential for hair to fall into a resident's food causing contaminated food which may cause illness, if he wore his beard net improperly. 5. A second observation of the walk-in freezer, on 05/21/2026 at 11:45 AM, revealed the same box of oatmeal cookie dough was again stored underneath the freezer condenser and had not been discarded once discovered on 05/20/2026.During a follow up interview with the Dietary Manager, on 05/22/2026 at 11:20 AM, she stated it was her expectation for all dietary staff to ensure all food items were sealed or covered properly and dated before being stored in the dry pantry and/or the freezer. She further stated the box of oatmeal cookie dough that had been opened, uncovered and left underneath the condenser in the freezer should have been discarded when discovered. Additionally, the Dietary Manager stated hairnets and beard nets were to be worn properly covering all exposed hair, including facial hair, to prevent cross-contamination She further stated she would never want to serve residents unsafe food. During an interview with the Administrator, on 05/22/2026 at 2:00 PM, she stated it was her expectation for dietary staff to follow facility policy and procedures to ensure proper food storage. Further, she stated all food items were to be sealed properly to prevent concerns with contamination. Additionally, she stated all staff should wear hair and beard nets in a proper manner to ensure all hair was contained.

Based on observation, interview, record review, and review of facility policy, the facility failed to provide food that accommodated resident preferences for 1 of 26 residents in the dining room during meal service on 05/20/2026, Resident (R) 69. Observation of lunch meal service on 05/20/2026, revealed R69 was given ice cream as a substitute item for dessert, without asking if he wanted the scheduled strawberry shortcake dessert.The findings include: Review of the facility policy, titled Resident Rights, reviewed 04/2026, revealed the resident has the right to and the facility must have promoted and facilitated resident self-determination through the support of resident choice. The resident has the right to make choices about aspects of his life in the facility. Review of R69's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 01/25/2024 with diagnoses including history of a stroke, hypertension, and non-Alzheimer's dementia. Review of R69's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/2026, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 9 out of 15, which indicated moderate cognitive impairment. During observation of lunch meal service in the dining room on 05/20/2026 at 12:25 PM, R69 received a cup of chocolate ice cream for dessert instead of pureed strawberry shortcake as was indicated on his meal card. During an interview, on 05/20/2026 at 12:30 PM, R69 stated he wanted the strawberry shortcake, not the ice cream but he was not asked which dessert he wanted. The resident never received the serving of strawberry shortcake. During an interview, on 05/21/2026 at 12:10 PM, with the Dietary Manager, she stated the staff should have pureed the strawberry shortcake for the resident if that was the dessert listed on his meal card. She further stated staff should not have selected an alternative dessert for R69 without asking him what dessert he wanted. During an interview, on 05/22/2026 at 1:24 PM, with the Administrator, she stated ice cream was an acceptable substitution for cake, but residents should be asked what substitute desserts they would prefer.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure residents had a right to a safe, clean, sanitary, and comfortable environment. Observations in the facility's laundry room on 04/17/2026 revealed the floor around and behind the washing machines covered in dirt and the concrete floor in disrepair.The findings include:Review of the facility's policy titled Safe and Homelike Environment, revised 06/01/2025, revealed it was the facility's policy to ensure that the resident can receive care and services safely and that the physical layout of the facility does not pose a safety risk. Further review of the policy revealed it was the facility's policy to provide a sanitary environment by keeping resident care equipment clean and properly stored, including equipment used in the completion of the activities of daily living.Review of the facility's policy titled Resident Rights, revised 06/2025, revealed the resident has the right to a safe, clean, comfortable, and homelike environment.Review of the Facesheet revealed the facility admitted Resident (R)10 on 06/24/2025. Resident 10's diagnoses included chronic obstructive pulmonary disease (COPD), acute on chronic systolic heart failure, type two diabetes mellitus, and end stage renal disease.During an interview with the complainant on 04/17/2026 at 10:02 AM, she stated that the facility had lost most of R10's clothing during the four days that resident was at the facility. She stated that a worker allowed her in the laundry room to look for missing items and she found the items she was looking for. She stated that the laundry room was extremely hot and messy. She stated there were clothes everywhere, it was dirty, and trash was overflowing. She stated that she was concerned for the workers that are in there with the laundry room being so hot.During an interview with State Registered Nurse Aide (SRNA) 2 on 04/17/2026 at 10:15 AM, she stated that it's always been hot in the laundry room especially during the summer months. She also stated that the laundry room had always been a little messy with clothes, but it got worse within the past couple years.Observations in the laundry room on 04/17/2026 at approximately 2:10 PM, revealed the floor in between and behind the washing machine to be covered and caked with dirt, a dry and flaky substance, and loose concrete. Continued observation revealed the piping and chemical tubing behind washing machines to be covered in same dry, flaky substance. Further observation revealed multiple buckets of laundry chemicals and detergents with stickers with the word corrosive on them.During an interview with Housekeeper 1 on 04/17/2026 at 2:15 PM, she stated she had been reporting issues like piles of clothing in the clean laundry room from off shifts. She stated that they had reported this spill behind the washing machines to maintenance and maintenance told housekeeping to clean it up themselves.During an interview with the environmental services (EVS) manager on 04/17/2026 at 2:20 PM, she stated that she was from another facility owned by the company, she stated that Clean Slate was the company that provided chemicals and was supposed to clean behind the washers and dryers. She stated that it looked like a bucket of neutralizer was spilled and no one cleaned it up for a long time. She did point out that they had paper checklists to monitor, that lint traps were cleaned accordingly, but not for the washing machines.During an interview with the Regional Director of Aramark company on 04/22/2026 at 12:00 PM, she stated that the representative with Clean Slate was responsible for and provided all the chemicals. She stated that in February, she texted and sent pictures to Clean Slate inquiring about the dried flaky substance. He stated that most environmental service and maintenance issues were relayed by word of mouth, but they do have a computerized work order system to make facility maintenance aware.During an interview with a representative from Clean Slate on 04/22/2026 at 1:30 PM, he stated that the maintenance of the machines themselves was the responsibility of the facility, and the facilities hired maintenance man. He stated that he only installs the products and refilled the buckets of chemicals. He stated that well over a year ago, the ports at the back of the washing machines were clogged, causing chemicals to spill and leak all over the floor. He stated that he took the ports out and cleaned them and had to move around the tubing. He stated that he had not seen any more leaks since he had done that. He stated the environmental services staff member that was there when he came, told him that maintenance would clean up the mess, but never did.During an interview with the Maintenance Department Director, he stated that he entered this position March 31st, 2025. He stated that there had not been any leaks of the products in the time of his employment. He stated that he went in the laundry room to clean the dryers and the lint, however EVS is responsible for cleaning the washing machines. He stated that most times workers would verbally convey any maintenance needs that arose, but some personnel utilize the TELS computer system. He stated that the TELS system would rate the problem according to severity. He stated that the EVS supervisor quit about two weeks ago, so they had different people from different facilities coming in to help. He stated that he cleaned up the mess on Monday 04/20/2026. He stated that he believed it was detergent because it got sudsy when he sprayed it with water. He stated that the plumbing in the floor was okay because all the water went down the overflow trap, but that he would be putting in a new drain hole itself. He stated that he did inspections of the laundry room on a quarterly basis. He stated that he told the previous EVS supervisor to have housekeeping clean it up, but it was never done.During an interview with the Administrator on 04/23/2026 at 12:45 PM, she stated they had a lot of problems with the previous EVS manager, which is why she was no longer employed. She stated they had help from other facilities come in to assist with laundry and housekeeping. She stated that she had a meeting with the Director of Maintenance and the Regional Director of Aramark on 04/22/2026. She stated that during the meeting it was determined that from now on maintenance will conduct a weekly routine check on the area and new Aramark employees will be made aware to alert maintenance of any issues immediately. She stated that the EVS supervisor was to be in contact with the Clean Slate company if needed. She stated that maintenance fixed the concrete on this day 04/23/2026. She stated that residents are not allowed to, nor do they go into the laundry area at any time. She stated that family members are allowed to go in the clean side of the laundry room only if they are escorted by staff.

Based on observation, interview, and review of facility policy, the facility failed to ensure the corridors were equipped with hand rails on each side as required. The findings include: Review of the facility policy titled, Resident Rights, revised 03/22/2022, revealed the resident had the right to a safe, clean, comfortable, home-like environment, including but not limited to treatments and supports for daily living safety. Review of the facility policy titled, Accidents and Supervision, revised 02/21/2024, revealed the residents' environment was to remain as free of accident hazards as possible. The policy further stated each resident was to receive adequate assistive devices to prevent accidents. Observation on 04/29/2025 at 2:40 PM, revealed the corridor outside of the dayroom had a hand rail secured to only one side with a bookshelf located on the other side. In interview on 05/01/25 at 3:10 PM, the Facility Maintenance Director stated the bookshelf was already located on that wall before he became Maintenance Director in March of this year. He stated he was not aware of the federal regulations regarding side rails being secured on each side in corridors. He further stated the timeline to replace the missing side rail was first thing tomorrow or Monday. In interview with the Administrator on 05/01/25 at 4:13 PM, she stated the hand rails had been off for about three weeks now. The Administrator said she was not aware that federal regulations required hand rails on each side of the corridor. She reported the bookcases had been moved back into the day room and maintenance staff were currently placing the rails back up in the corridor at this time. The Administrator further stated someone could have potentially fallen trying to go down the hallway with only the one rail on one side of the corridor.

Based on observation, interview, record review and facility policy review, the facility failed to establish and maintain an infection prevention and control program to ensure a sanitary, safe environment or 2 of 18 sampled residents, (Resident (R)62 and R21. The findings included: Review of the facility policy, Hand Hygiene, revised 03/19/2024, revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Per review, that applied to all staff working in all locations within the facility. Continued review revealed staff were to perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Further review revealed the use of gloves would not replace hand hygiene. In addition, review revealed staff were to perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1. Review of the facesheet for R62 revealed the facility admitted the resident on 07/20/2022, with diagnoses which included: psychotic disorder and pressure ulcer of left upper back. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R62 to have a Brief Interview for Mental Status (BIMS) score of three out of 15 which indicated the resident had severe cognitive impairment. During observation on 05/01/2025 at 1:16 PM, of wound care for R62, with LPN 2, she failed to clean the overbed table and place a barrier down prior to placing the clean wound care supplies on it. Per observation, LPN 2 failed to wash her hands prior to applying gloves, and failed to sanitize her hands during the observation prior to reapplying new gloves. During the observation, LPN 2 was observed to lay soiled gloves and dressings beside her clean supplies on the overbed table. Continued observation revealed LPN 2 also redressed R62's wound, donned more gloves; however, failed to wash her hands. Observation revealed LPN 2 took the disposable measuring tapes she used to measure R62's right great toe and right shoulder wounds, wrote on them, then took the tapes out of the resident's room her desk. Further observation revealed LPN 2 stapled them together and placed them in her desk failing to place them in a sealed barrier. In addition, the LPN failed to wash her hands prior to leaving R62's room, and failed to clean the overbed table where her dressings had been placed. 2. Review of the facesheet for R21 revealed the facility admitted the resident on 10/18/2013, with diagnoses which included, anoxic brain damage, epilepsy, and hemiplegia and hemiparesis following cerebral infarction. Review of the Quarterly MDS assessment dated [DATE], revealed the facility had not completed a BIMS assessment, since the resident could not answer the questions. Further review of Section C of the MDS Assessment revealed, the facility assessed R21 to have severe cognitive impairment and was never/rarely understood. During observation on 05/01/2025 at 10:25 AM, of a skin assessment with LPN 2, for R21 the LPN failed to wash her hands prior to entering the resident's room where she donned gloves. Per observation, while assessing R21's buttocks and anus, LPN 2 observed excoriation. Continued observation revealed LPN 2, with her soiled gloves on, applied a barrier cream on her gloved hand and then applied the cream to R21's inner buttocks and around the anus. Observation revealed the LPN then turned R21 to a supine position, loosened the resident's brief and exposed the frontal perineal area with the same soiled gloves on. Further observation revealed LPN 2 then used the same soiled gloves and placed the barrier cream on her other glove, and applied the cream to R21's scrotum, and re-fastened the brief. In addition, observation further revealed LPN 2 removed the soiled gloves and left R21's room without washing or sanitizing her hands. In interview on 05/01/2025 at 1:16 PM, the Infection Preventionist (IP) stated she watched staff quarterly and annually yearly performing skills, especially hand hygiene. She said she added particular skills as needed, especially hand hygiene related activities. The IP reported she expected staff to use the hand sanitizer in the rooms for easy access instead storing hand sanitizer in their pockets. She stated that prevented them from having to put their dirty hands in their pockets to retrieve sanitizer. The IP said she expected staff to place soiled items in a trash bag at the end of the resident's bed or having a bag hanging off the overbed table. She further stated staff could also use the trash can in the resident's room. The IP additionally stated however, the soiled trash needed to be bagged and removed from the room after staff completed dressing changes, incontinence care, etc. In interview with the Wound Care Nurse on 05/01/2025 at 2:34 PM, she stated she expected staff to follow the resident's wound care orders and the facility's hand washing policy as written. She further stated we have an infection control risk if handwashing was not done properly. During interview with the Director of Nursing (DON) on 05/01/2025 at 2:48 PM, she stated she expected nursing staff to follow the facility's wound care and handwashing policies as written. She further stated she expected staff to place soiled supplies in the trash can or bag and remove it from the resident's room. The DON additionally stated she expected the nurses to be prudent with wound care and hand washing. During interview with the Administrator on 05/01/2025 at 4:18 PM, she stated she expected staff to follow the facility's policies as written for handwashing and wound care. She further stated she also expected staff to follow physician orders as written.

Based on observation, interview, record review, and review of facility policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice regarding wound care for 1 of 2 residents sampled for skin assessments out of the total 18 sampled residents, (Resident (R)21). The findings include: Review of the facility policy, Wound Treatment Management, revised on 03/24/2025, revealed the facility's policy was to promote wound healing of various types. Per review, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician's orders. Review of R21's facesheet revealed the facility admitted the resident on 10/18/2013, with diagnoses which included, anoxic brain damage, epilepsy, and hemiplegia and hemiparesis following cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had not completed the Brief Interview for Mental Status (BIMS) assessment of the resident. Further review of the MDS Assessment revealed under Part C the facility assessed R21 to have severe cognitive impairment and as never/rarely understood. During observation of a skin assessment for R21 on 05/01/2025 at 10:25 AM, Licensed Practical Nurse (LPN) 2 placed a barrier cream onto the excoriated areas on the resident's buttocks, anus, and scrotum. During interview on 05/01/2025 at 2:55 PM, LPN 2 stated she failed to get an order from the provider for the barrier cream prior to applying it on the resident. She stated however, she often independently applied barrier cream or other treatments on residents if a new skin problem was found during a skin assessment. She stated she would then call a provider for orders for the treatment. LPN 2 said the providers did not mind the staff doing that. She further stated she was sure the policy would note to call the provider first for an order; however, she was not sure what the policy said. During interview on 05/01/2025 at 2:01 PM, the Family Nurse Practitioner stated she expected nursing staff to ask her about an order prior to using a treatment for wound care. During interview on 05/01/2025 at 3:51 PM, the Director of Nursing (DON) stated she expected all her nurses to secure an order for any care or treatment requiring an order. She further stated staff were never to give any medication or treatment without a provider order. During interview on 05/01/2025 at 4:18 PM, the Administrator stated she expected all staff to follow physician orders as written and not to give any type of medication (including creams) without an order.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents was free of a significant medication error related to the use of an implanted [MEDICATION(S)] pain pump and oral opioids. Resident #1 was receiving [MEDICATION(S)] ,d+[DATE] milligrams (mg) by mouth every five (5) hours for pain and on [DATE], Resident #1's implanted pain pump was turned on and filled with [MEDICATION(S)]. There was no evidence the facility ensured the nurse contacted the physician to ensure the oral [MEDICATION(S)] should be continued due to the resident's history/sensitivities (possible overdose in past due to pain pump) per facility policy. The facility failed to ensure the dose of [MEDICATION(S)] from the pump was documented on the Medication and Treatment Administration Records (MAR/TAR), so staff were aware of how much [MEDICATION(S)] was being administered to the resident. In addition, the facility to ensure the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Resident #1 showed signs of lethargy; and licensed staff was made aware. However, there was no evidence licensed staff monitored the resident closely for adverse reactions to ensure adverse reactions were promptly identified from [DATE] at approximately 2:31 PM (returned from pump turned on) until [DATE] at approximately 1:20 PM (resident passed away), per the facility's policy. The facility's failure to ensure monitoring and assessments were done related to adverse or subsequent actions of [MEDICATION(S)] pain pump and oral opioids being given concurrently; has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified in the areas of 42 CFR 483.10, Resident Rights, at F551; 42 CFR 483.21, Comprehensive Resident Centered Care Plans at F656 and F658; 42 CFR 483.45 Pharmacy Services, at F760; at a Scope and Severity of a J. Substandard Quality of Care was identified at 42 CFR 483.45, Pharmacy Services. Immediate Jeopardy (IJ) was identified on [DATE] and was determined to exist on [DATE]. The facility was notified of the IJ on [DATE]. The findings include: Review of facility policy titled, Adverse Consequences and Medication Errors, last revised [DATE] revealed residents receiving any medication that has a potential for an adverse consequences will be monitored to ensure that any such consequences are promptly identified and reported. The staff and practitioner will strive to minimize adverse consequences by determining the resident is not taking other medications that would be incompatible with the prescribed medications and has no condition, history, or sensitivities that would preclude use of that medication. When a resident receives a medication order it is evaluated to determine the dose, route of administration, duration, and monitoring are in agreement with current clinical practice, clinical guidelines, and/or manufacturer's specifications for use. Facility must monitor the resident for possible medication-related adverse consequences, including mental status and level of consciousness. When a clinically significant change in condition/status, an unexplained decline in function or cognition, addition or discontinuation of medications and/or non-pharmacological interventions. change in dose. Check wording In the event of a significant medication-related error or adverse consequences, immediate action is taken as necessary, to protect resident safety and welfare. Significant was defined as requiring medication discontinuation or dose modification, requiring hospitalization , requiring treatment with a prescription medication, life threatening and/or resulting in death. The attending physician is notified promptly of any significant medication error or adverse consequences. Review of facility policy titled, Narcotic Infusion, and Administration of, dated [DATE] revealed all nurses responsible for the care and management of patients receiving narcotic infusions should be knowledgeable and competent in the administration procedures and potential consequences associated with this therapy.Monitor resident for s/s of an adverse reaction which must include but not be limited to cardiovascular (bradycardia, [CONDITION(S)], tachycardia, flushing), CNS (agitation, seizures, [CONDITION(S)], nervousness, sedation, visual disturbances, weakness), Respiratory (respiratory depression or respiratory variation), and Hypersensitivity (angioedema, urticarial, bronchospasm, anaphylaxis). Notify the physician if decrease in respiratory rate or pattern, [MEDICATION(S)] (opioid inhibitor) may be required for respiratory depression. The use of [MEDICATION(S)] may eliminate all pain relief and its antagonist action must be overcome by the reintroduction of the opioid [MEDICATION(S)]. Emergency Intervention of respiratory distress: Stop infusion, if level of consciousness and or respiratory depression indicates use of [MEDICATION(S)], adhere to specific written orders, observe and monitor vital signs as the reversal of respiratory depression may induce pain crisis, call for assistance, remain with patient, notify physician, do not start narcotic infusion without specific orders. Closed record review revealed the facility admitted Resident #1 on [DATE] with diagnoses, which included Type II Diabetes Mellitus with Diabetic [CONDITION(S)] Heart Failure, Low Back Pain, Other Chronic Pain, and Chronic Obstructive Pulmonary Disease. Further review revealed the resident expired on [DATE] at 1:20 PM. Review of Hospital Records dated [DATE]-[DATE] revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the hospital due to lethargy suspected to be due to overdose. Resident #1's implanted pain pump was turned off and the resident was discharged back to the facility on [DATE]. Review of Resident #1's facility Progress Note, dated [DATE] revealed a decision was made to not have implanted pain pump turned back on and the resident was to receive oral opioids. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 had an appointment to see Physician #2 on [DATE] at 1:00 PM for [MEDICATION(S)] pump refill. Review of Resident #1's February 2020 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Progress Note dated [DATE] at 2:31 PM revealed Resident #1 was seen by Physician #2 with [MEDICATION(S)] pump filled and turned on and staff that accompanied resident was told for staff to monitor the resident for sedation. However, further review of the Progress Notes and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed there was no evidence the physician was contacted to clarify if the resident should continue to receive the [MEDICATION(S)] along with the [MEDICATION(S)] or an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the licensed nurse failed to identify the amount of [MEDICATION(S)] the resident was receiving per pain pump was on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 2:24 PM, [DATE] at 4:51 PM and [DATE] at 10:17 AM revealed, she was working the day Resident #1 returned with pain pump turned on and refilled. LPN #1 stated she had not received any orders from Physician #2 upon return from pain pump appointment, and the staff that accompanied the resident said the instructions they received was to watch Resident #1 for sedation. LPN #1 stated she did not get any vital signs on Resident #1 upon return from the appointment. LPN #1 revealed she did not try to call attending physician to clarify the resident's order for oral [MEDICATION(S)] or to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1's appointment. Review of Resident #1's February 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the February 2020 TAR revealed Resident #1 had a [MEDICATION(S)] PCA and to observe for signs and symptoms (S/S) of adverse reactions to implanted [MEDICATION(S)] pump every shift. If complications noted send to ER. Notify Physician #2 at phone #, notify ER physician of implanted pump and send copy of pump manual, emergency medical information. The following to be documented on TAR each shift - 0 = asymptomatic, 2 = excitability/anxiety, 3 = very slow and shallow breathing (<,d+[DATE] respirations per minute), 4+ = unconsciousness or inability to awaken every shift. Further review revealed Registered Nurse (RN) #1 initialed and placed a check mark for the evening/night shift on [DATE], which was not included in the codes. Interview [DATE] at approximately 5:00 PM with Registered Nurse (RN) #1 revealed revealed she worked on [DATE] and received report from LPN #1. She stated she was made aware Resident #1's pain pump was turned on and refilled with [MEDICATION(S)] with no new orders. RN #1 stated the accompanying aides had notified the staff of instructions to watch for sedation and [MEDICATION(S)] could always be given if there was a problem. RN #1 stated Resident #1 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #1 during her shift. She stated she should have obtained vital signs. She revealed Resident #1 was awake when given [MEDICATION(S)] on [DATE] at approximately 1:00 AM. Interview with LPN #3 on [DATE] at 12:38 PM revealed she worked on [DATE] at 3:00 AM until approximately 7:00 AM. LPN #3 stated she was told in report from RN #1 that Resident #1's implanted pain pump was turned on and refilled. She stated she made rounds around 3:50 AM and Resident #1 was asleep, and administered another pain pill ([MEDICATION(S)] ,d+[DATE]) to Resident#1 at approximately 5:15 AM. Did she ask for this pain pill LPN #3 stated Resident #1 should have been assessed more frequently because the pain pump had been turned off last year and resident was now receiving pain pump and [MEDICATION(S)] ,d+[DATE] mg. Further review of the February 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with Certified Medication Technician (CMT) #1 on [DATE] at 1:38 PM revealed on the morning of [DATE] she woke up Resident #1 to give the resident his/her medication and the resident went back to sleep. Further review of Resident #1's Progress Notes dated [DATE] revealed at 10:32 AM, the resident was showered and was returned to bed; at 11:30 AM, the resident's blood sugar was 224 with sliding scale insulin given; and, blood sugar was checked again after lunch tray was provided with a reading of 155. However, further review of the Progress Notes revealed there was no documented evidence licensed staff assessed the resident for sedation to include vital signs/adverse reactions, per facility policy. Review of a Nursing Progress Note dated [DATE] at 1:12 PM, revealed the nurse was summoned to room with Resident #1 not responding to stimuli and the Supervisor paged to room at 1:15 PM. The resident was not responding to verbal or tactile stimuli and sternal rub; and, the resident's lips and fingers were cyanotic, and there was no respirations or pulse noted. Interview with CNA #1 on [DATE] at 11:45 AM revealed Resident #1 was hard to wake up, and at approximately 11:10 AM, she had to wake up the resident for his/her shower and obtain extra assistance to transfer resident to shower chair because resident was so sleepy. CNA #1 stated CNA #2 made LPN #1 aware of the resident's condition, LPN #1 spoke to the resident, and they decided to assist the resident back to bed due to being afraid the resident would fall out of wheelchair. CNA #1 stated Resident #1's lunch tray was served at approximately 12:15 PM and CNA #2 could not get resident to wake up when lunch tray served so she asked her to see if she could get the resident awake to eat meal. CNA #1 stated she was finally able to get the resident awake enough to eat a few bites and drink some fluids. She stated she went to get LPN #1, and the LPN checked the resident's blood sugar and it as 155. Interview with Certified Nursing Assistant (CNA) #2 on [DATE] at 12:08 PM revealed Resident #1 required assistance of two (2) staff with transfer to/from shower chair (normally required one staff) which was not routine for resident) and had stated he/she did not feel good but did not want to go back to bed. CNA #2 stated Resident #1 was assisted back to bed by two (2) staff due to fear the resident would fall from wheelchair. CNA #2 revealed Resident #1 would not wake up when lunch tray was served and CNA #1 tried to get resident awake to eat something. CNA #2 stated she did not remember the nurse obtaining the resident's vital signs. Further interview with LPN #1 on [DATE] at 2:24 PM, [DATE] at 4:51 PM and [DATE] at 10:17 AM LPN #1 revealed the morning of [DATE], Resident #1 was served breakfast and resident was carrying on a normal conversation. LPN #1 stated she checked the resident's blood sugar, went back and gave insulin. She stated the resident was responding but was sleepy, due to being up the night before. LPN #1 revealed she obtained the resident's blood sugar at time of shower and it was elevated and she told CNA #1 and CNA #2 to assist Resident #1 back to bed after shower. She revealed when lunch was served she administered the resident insulin and informed staff to make sure the resident ate lunch. She stated a little after 1:00 PM, the CNAs told her to come look at resident. The resident was pale and sweaty so she checked the resident's blood sugar and it was 155 at that time, and while she was talking to the resident, the resident acted as if he/she was going to vomit. She stated she told the CNA to grab trash can and she went to get supervisor. When she returned from paging supervisor the resident had passed. She revealed she did not try to call physician and did not take vital signs anytime that morning. Interview with the Director of Nursing (DON) on [DATE] at 11:20 AM and [DATE] at 3:10 PM revealed the CNAs stated the resident should go to bed because he/she looked tired and later the resident appeared clammy, and looked like possibly trying to throw up. The DON stated Resident #1 was tired to the CNAs and they were afraid that the resident might fall asleep and fall out of chair. The DON further revealed staff should always observe for sedation, and shallow respirations. She stated the opioids did not affect the resident, as she was completely awake and if staff would have administered [MEDICATION(S)] it would not have affected the resident. Interview on [DATE] at 3:38 PM with Administrator revealed the facility is at the mercy of outside physicians and they have to provide their dictation. The Administrator stated staff should follow the plan of care and the orders in place at the facility. The Administrator revealed the only thing he was told was that Resident #1 had said a needle was put in the pump and there was old medication was in the pump, and the resident had a follow up appointment in two (2) weeks. The Administrator stated it was the responsibility of the medical or the clinical managers, or admissions coordinators of the acute care facility to provide information related to the resident's visits. Interview with Physician #1 (Resident #1's attending physician and Medical Director) on [DATE] at approximately 1:41 PM revealed Resident#1 had pain pump. She stated she did not know how long the pain pump had been turned off, but there had been a hospital recommendation for removal because Resident#1 was overmedicated at that time. Physician #1 stated it was recommended to control pain with the pain pump off, at that time. Physician #1 revealed the resident has the right to ask for appointment and at some point staff at urging of Resident #1 made an appointment. Physician #1 stated she did not know Resident #1 had appointment the day went to pain clinic but the resident had chronic pain and had been informed that Physician #1 could not give any oral medication than what resident was already on. Physician #1 further revealed if outside physician makes changes then that physician would write orders to address changes in medication. Physician #1 also stated staff should monitor resident's vitals when changes to medications and she would expect orders for more monitoring if Physician #2 thought it was needed. Physician #1 stated she was familiar with history of resident and opioids were originally recommended because Resident #1 was overmedicated. Physician #1 revealed she would assume that guardianship would mean any procedures they have, then the guardian makes decision if the resident is not able to make the decisions for his/herself. She stated it was her understanding Resident#1 made decision to go to Physician #2, and she could not address if resident should or should not have went. She further revealed she was not aware the pain pump was turned back on until she was made aware the resident had passed. She stated she could not say what the resident's cause of death was without an autopsy. Further interview with Physician #1 on [DATE] at 3:53 PM revealed she did not expect nurses to second-guess physicians. Interview on [DATE] at approximately 1:42 PM with Regional Nurse Consultant/Administrator/Director of Nursing revealed the staff should follow facility policies related to assessment of resident with [MEDICATION(S)] pain pump turned on and use of routine opioids concurrently. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides in the facility since [DATE]. 2. On [DATE], all current residents were assessed for change in condition by facility employed RN's and LPN's. No change in condition was identified for these residents. 3. On [DATE], all current residents currently on opioid medications were assessed for signs or symptoms of adverse effects, or medication error. No concerns were identified. No additional residents were identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. 4. On ,d+[DATE]-[DATE] all current residents who had appointments within the next thirty (30) days were reviewed by Unit Manager (UM). The Responsible party, including Power of Attorney or court appointed guardians, were notified and recorded in the clinical record by Unit Manager 5. On [DATE], care plans on all current residents receiving prescribed opioids were reviewed for addressing and implementation of resident preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or Staffing Development Coordinator (SDC). 6. On [DATE], all current residents who had an active order for opioids were evaluated for a need of PRN [MEDICATION(S)] by the Medical Director. Forty (40) residents received orders for opioid reversal agent. 7. Education was drafted by Administrator, who is also a RN, and she provided education to the DON, ADON, SDC, and UM on [DATE] and [DATE]. Education consisted of change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and Resident Assessment Instrument (RAI) manual requirements. Education was also provided on pain management including oral, intravenous (IV), and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. Additionally, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). 8. Beginning [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM on side effects of pain medication including pain pump monitoring and change in condition. This education also included the purpose of the [MEDICATION(S)] pump, the functionality of the pump, and the risks associated with opioid medications delivered intrathecally in conjunction with or without opioid management. The education also included the need for available antidote for residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], education to licensed staff was started by the ADON and/or SDC on notifying residents responsible party, power of attorney or court appointed guardian of upcoming appointments and documenting notification in resident's medical record. On [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM, on updating care plans and implementation of interventions to meet resident goals, medical, physical mental, psychosocial needs. No licensed staff will work after [DATE], before receiving the required education. Education was completed with all licensed staff by [DATE]. 9. New hires will be educated during orientation by the DON, ADON, SDC and/or UM. 10. An order identifying that Resident #1 had an implanted pain pump with [MEDICATION(S)] medication was present on the TAR. The facility utilizes CMA's to assist in the delivery of routine medications and therefore they utilize the MAR. while the licensed nursing staff utilize the TAR. It would be inappropriate for the order to be placed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Moreover, the EHR software employed by the facility is unable to list an order on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility employees did not administer the [MEDICATION(S)] that was used in the implanted pain pump. 11. On [DATE], the QA Committee (Medical Director, Administrator, DON, and ADON) met to discuss the event set forth in the notice of immediate jeopardy. 12. Beginning [DATE], five (5) random residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff will also ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs are in place and followed. The residents will also be reviewed for side effects of pain medication, changes in condition, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then three (3) times a week times two (2) months, then two (2) times a week x one (1) month, then a minimum of quarterly. This will be completed by DON, ADON, SDC, and UM. Beginning on [DATE] weekend monitoring to be completed by Weekend RN Supervisor, Administrator, MDS Coordinator, DON, ADON, SDC or UM. Monitoring to include the audits mentioned above. The results of this audit will be reported to QA by the DON and/or ADON. 13. QA meeting will be held weekly times eight (8) weeks then monthly times one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, Regional Reimbursement Director and or Chief Operating Officer) will attend the weekly QA meeting times eight (8) weeks. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Discharge/Transfer Summary dated [DATE] revealed Resident #1 passed away. Review of State Death Certificated signed by Physician #1 and dated [DATE] revealed expiration of the resident. 2. Review of change in condition audit dated [DATE] revealed the DON had completed audit of all residents for change in status. No concerns identified. Interview with the DON on [DATE] at 3:55 PM revealed she conducted the audit related to change in condition. No concerns were identified. 3. Review of a list of residents currently on opioid medications revealed the residents were assessed on [DATE], for signs or symptoms of adverse effects, or medication error. No concerns were identified and there were no additional residents identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. Interview with the DON, on [DATE] at 3:55 PM revealed she conducted the audit related to resident being assessed for signs/symptoms of adverse effects, or medication error. No concerns were identified. 4. Review of a list of residents with appointments on [DATE] through [DATE] revealed UM #3 ensured the residents' responsible party, guardian, or Power of Attorney was made aware of the appointments and documented in the medical record. Interview on [DATE] at 3:35 PM with UM #3 revealed she had completed audit related to resident appointments and ensure responsible party, guardian, or POA were made aware and documented the notification in the medical record. 5. Review of a Daily Census Form dated [DATE] revealed all residents receiving prescribed opioids care plans were reviewed to ensure the care plans addressed and were implemented related to preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or SDC. Interviews on [DATE] with ADON at 3:40 PM, DON at 3:55 PM, and Administrator at 4:29 PM revealed they completed the audit of all residents' care plans who were received opioid medication on [DATE]. No concerns were identified. 6. Review of a list of residents who were on opioid medication revealed all current residents on opioids were evaluated by the Medical Director with orders written for as needed [MEDICATION(S)] for forty (40) residents on [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she was involved in writing the [MEDICATION(S)] orders and availability. 7. Review of education provided by the Administrator to the DON, ADON, SDC and UM on [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the EDK. Review of signature pages dated [DATE] and [DATE] revealed the DON, ADON, SDC, and UM were provided the above education. Further review revealed Post Tests were conducted and the staff scored 100%. Interviews on [DATE] with UM #3 at 3:35 PM, and on [DATE], UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM and SDC at 4:20 PM revealed they had been educated on the above information. 8. Review of education provided to Licensed Staff by the DON, ADON, SDC and UM on [DATE], [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). Review of signature pages dated [DATE], [DATE], and [DATE] revealed all licensed staff was provided the above education. Further review revealed Post Tests were conducted and each staff scored 100%. Interviews on [DATE] with LPN #2 at 10:44 AM, LPN #5 at 11:07 AM, LPN #3 at 12:14 PM, LPN #1 at 12:31 PM, RN #1, at 1:41 PM, RN #2 at 3:30 PM, and the MDS Coordinator, at 4:20 PM, revealed they received the above education. 9. Review of a list of new hires revealed there were no licensed staff hired after [DATE]. 10. Interview on [DATE] at 4:29 PM with Administrator revealed there were no other residents with pain pumps 11. Review of QA Signature page revealed an Ad-Hoc Quality Assurance (QA) meeting was conducted on [DATE]. Interviews on [DATE] with the ADON at 3:40 PM, DON at 3:55 PM, Acting Medical Director at 4:00 PM, and MDS Coordinator at 4:10 PM revealed they were present for Ad-Hoc meeting and discussed how to address removal of Immediate Jeopardy. 12. Review of daily audits conducted seven (7) days a week five (5) random residents starting on [DATE], revealed the residents' records were reviewed to ensure notification of responsible party, power of attorney, or court appointed guardian of upcoming appointments; and, documentation in resident's medical record. Records were also reviewed to ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs in place and followed. In addition, residents were reviewed for side effects of pain medication, changes in condition, signs and symptoms of adverse effects, concurrent opioid therapies, and to ensure opioid antidote available; seven days a week. Interviews on [DATE] with UM #3, on [DATE] with UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM, MDS Coordinator at 4:10 PM, revealed they were reviewing five (5) random resident a day to ensure the above information was in place. Interview on [DATE] at 4:29 PM with Administrator revealed he would review the the daily audits to include weekend audits. 13. Review of [DATE] QA meeting minutes revealed the Regional Clinical Services, Administrator, DON, MDS Coordinator, and SDC attended and discussed F551 (Guardian, Notification / Communication), F656 (Comprehensive Care Plan Implementation), F658 (Standards of Practice), and F760 (Significant Medication Error). Interviewed with Regional Clinical Services on [DATE] at 2:00 PM revealed she was involved in the QA meeting dated [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she attended the QA meeting on [DATE]. Interview with the Administrator on [DATE] at 1:03 PM revealed QA meetings will be held weekly for eight (8) weeks to ensure AoC implemented.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure professional standards of practice were provided for one (1) of three (3) sampled residents related to assessment of resident with implanted [MEDICATION(S)] pain pump and use of routine opioids (Resident #1). Resident #1's implanted pain pump was turned off in [DATE] due to possible overdose. On [DATE], Resident #1 returned to the facility from the pain clinic with his/her implanted pain pump turned back on and filled with [MEDICATION(S)]. Resident #1 was also ordered [MEDICATION(S)] ,d+[DATE] mg every five (5) hours prior to the pump being turned on. On the morning of [DATE], staff identified Resident #1 was hard to wake up, required extensive assistance of two (2) staff for transfer for shower, and was unable to sit in wheelchair safely due to lethargy. The resident passed away on [DATE] at approximately 1:20 PM. Record review and interviews revealed there was no evidence the licensed staff clarified the oral [MEDICATION(S)] should continue and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, there was no evidence staff followed facility policy related to monitoring the resident for side effects/adverse reactions to include sedation/vital signs due to the resident receiving [MEDICATION(S)] pain pump and oral [MEDICATION(S)] concurrently. In addition, the facility failed to ensure staff were properly trained on the use of pain pump, per the facility's policy. The facility's failure to provide care according to professional standards of practice has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC), was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy for Administration of Narcotic Infusion revealed all nurses responsible for the care and management of residents receiving narcotic infusions should be knowledgeable and competent in the administration procedures and potential complications associated with this therapy. This included monitoring of vital signs, signs/symptoms of adverse reactions, and notification to the Physician of a decrease in respiratory rate or pattern. The emergency intervention for respiratory distress was to stop the narcotic infusion, and if the level of consciousness and/or respiratory depression indicated use of [MEDICATION(S)] ([MEDICATION(S)]), adhere to written orders and follow the policy. Closed record review revealed the facility admitted Resident #1 on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident expired on [DATE]. Review of Resident #1's Comprehensive Care Plan dated [DATE] revealed the resident was care planned for at risk for alteration in comfort, related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed interventions to be on alert for effectiveness of pain interventions, impact on functional ability and cognition; side effects of pain medication (confusion, hallucinations, nausea/vomiting), shortness of breath, doing schedules, and intervene as indicated, . In addition, there were interventions to obtain vital signs as ordered and as needed, report occurrences to the physician, and pain assessment every shift. Review of Hospital Records dated [DATE]-[DATE] revealed Resident #1 was admitted to the hospital due to lethargy suspected to be due to overdose and the implanted pain pump was turned off. The resident was discharged back to the facility on [DATE]. Review of Resident #1's facility Progress Note, dated [DATE] revealed a decision was made to not have implanted pain pump turned back on and the resident was to receive oral opioids. Review of the February 2020 Medication Administration Record (MAR) revealed Resident #1 was receiving [MEDICATION(S)] ,d+[DATE] mg every five hours when awake. Review of Progress Notes dated [DATE] at 2:31 PM revealed Resident #1 was seen by Physician #2 and implanted pump was filled with [MEDICATION(S)] and turned on with instructions to monitor for sedation. However, further review of the MAR and Progress Notes revealed there was no documented evidence a clarification was made with the physician to ensure the oral [MEDICATION(S)] should continue to be administered; a pain assessment was conducted every shift, an order was obtained for [MEDICATION(S)] (opioid reversal agent) in case of overdose, or how much [MEDICATION(S)] the resident was receiving via implanted pain pump; per nursing professional standards of practice/facility policy. Further review of the February 2020 (MAR) revealed Resident #1 was administered [MEDICATION(S)] ,d+[DATE] on [DATE] at 8:28 PM and on [DATE] at 12:59 AM, 5:49 AM, and 9:46 AM, in conjunction with receiving [MEDICATION(S)] via implanted pain pump. In addition, further review of the Progress Notes, Weight/Vital Sign Record, and MAR/TAR revealed there was no documented evidence staff assessed the resident for sedation to include vital signs, or adverse reactions, per facility policy. Review of Progress Notes revealed at 10:32 AM, the resident was showered and was returned to bed; and at 11:30 AM, the resident's blood sugar was 224 with sliding scale insulin given. In addition, blood sugar was checked again after lunch tray was provided to resident with reading of 155. Further review of the Progress Notes revealed there was no documented evidence staff assessed the resident for sedation to include vital signs, per facility policy. Review of a Nursing Progress Note dated [DATE] at 1:12 PM, revealed the nurse was summoned to room with Resident #1 not responding to stimuli and the Supervisor paged to room at 1:15 PM. The resident was not responding to verbal or tactile stimuli and sternal rub; and, the resident's lips and fingers were cyanotic, and there was no respirations or pulse noted. Interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 2:24 PM, [DATE] at 4:51 PM and [DATE] at 10:17 AM revealed no new orders were provided by Physician #2 upon return from pain pump appointment, just an instruction to watch Resident #1 for sedation. LPN #1 stated she did not get any vital signs on Resident #1 upon return from the appointment. She revealed she also did not call the attending physician to clarify if oral pain medications should continue because Physician #1 was in house on [DATE] and was aware Resident #1 was going to appointment. LPN #1 stated the morning of [DATE] Resident #1 was responding but was sleepy, due to being up the night before. She further stated she obtained the resident's blood sugar at time of shower and it was elevated and she told CNA #1 and CNA #2 to assist Resident #1 back to bed after shower. She revealed when lunch was served she administered the resident insulin and informed staff to make sure the resident ate lunch. A little after 1:00 PM, the CNAs told her to come look at resident. The resident was pale and sweaty so she checked the resident's blood sugar and it was 155 at that time, and while she was talking to the resident, the resident acted like he/she was going to vomit, and she told the CNA to grab trash can and she went to get supervisor. She stated when she returned from paging supervisor the resident had passed. and did not try to call doctor and did not take vital signs anytime that morning. She also revealed she did not remember having any facility training on the use of implanted pain pumps. Interviews with Licensed Practical Nurse (LPN) #3 (worked [DATE], 3:00 AM - 7:00 AM) on [DATE] 12:38 PM and 5:00 PM and Registered Nurse (RN) #1 (worked [DATE], 3:00 PM-3:00 AM) on [DATE] at 12:38 PM, revealed they were aware Resident #1 had been to the physician to get his/her pain pump refilled, and came back with no new orders. LPN #3 and RN #1 stated they did not assess the resident's vital signs, or for any signs and symptoms of sedation, per facility policy. RN #1 stated that Resident #1 was awake at approximately 1:00 AM when given pain pill and LPN #3 stated she administered [MEDICATION(S)] at 5:15 AM. LPN #3 stated she had not received any training at the facility related to implanted pain pumps. Interview with the Weekend Supervisor on [DATE] at 11:47 AM revealed she had not received any training on the use of a [MEDICATION(S)] pain pump prior the Resident #1 passing away. Interview with Certified Medication Technician (CMT) #1 on [DATE] at 1:38 PM revealed she had received no training related to an implanted pain pump. Interview with Staff Development Coordinator (SDC) on [DATE] at 2:17 PM revealed there had been no education of staff on implanted pain pumps. Interview with the Director of Nursing (DON) and Administrator on [DATE] at 3:40 PM revealed the facility had not provided any training on the use of implanted pain pumps. Further interview with Regional Nurse Consultant, Administrator and DON on [DATE] at approximately 1:42 PM revealed the staff should follow the facility's policies related to assessment of resident with [MEDICATION(S)] pain pump and use of routine opioids concurrently. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides in the facility since [DATE]. 2. On [DATE], all current residents were assessed for change in condition by facility employed RN's and LPN's. No change in condition was identified for these residents. 3. On [DATE], all current residents currently on opioid medications were assessed for signs or symptoms of adverse effects, or medication error. No concerns were identified. No additional residents were identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. 4. On ,d+[DATE]-[DATE] all current residents who had appointments within the next thirty (30) days were reviewed by Unit Manager (UM). The Responsible party, including Power of Attorney or court appointed guardians, were notified and recorded in the clinical record by Unit Manager 5. On [DATE], care plans on all current residents receiving prescribed opioids were reviewed for addressing and implementation of resident preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or Staffing Development Coordinator (SDC). 6. On [DATE], all current residents who had an active order for opioids were evaluated for a need of PRN [MEDICATION(S)] by the Medical Director. Forty (40) residents received orders for opioid reversal agent. 7. Education was drafted by Administrator, who is also a RN, and she provided education to the DON, ADON, SDC, and UM on [DATE] and [DATE]. Education consisted of change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and Resident Assessment Instrument (RAI) manual requirements. Education was also provided on pain management including oral, intravenous (IV), and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. Additionally, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). 8. Beginning [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM on side effects of pain medication including pain pump monitoring and change in condition. This education also included the purpose of the [MEDICATION(S)] pump, the functionality of the pump, and the risks associated with opioid medications delivered intrathecally in conjunction with or without opioid management. The education also included the need for available antidote for residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], education to licensed staff was started by the ADON and/or SDC on notifying residents responsible party, power of attorney or court appointed guardian of upcoming appointments and documenting notification in resident's medical record. On [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM, on updating care plans and implementation of interventions to meet resident goals, medical, physical mental, psychosocial needs. No licensed staff will work after [DATE], before receiving the required education. Education was completed with all licensed staff by [DATE]. 9. New hires will be educated during orientation by the DON, ADON, SDC and/or UM. 10. An order identifying that Resident #1 had an implanted pain pump with [MEDICATION(S)] medication was present on the TAR. The facility utilizes CMA's to assist in the delivery of routine medications and therefore they utilize the MAR. while the licensed nursing staff utilize the TAR. It would be inappropriate for the order to be placed on the MAR as this would prompt non-licensed staff to monitor for adverse reactions. Moreover, the EHR software employed by the facility is unable to list an order on the MAR without an individual signing that they have administered the medication. Facility employees did not administer the [MEDICATION(S)] that was used in the implanted pain pump. 11. On [DATE], the QA Committee (Medical Director, Administrator, DON, and ADON) met to discuss the event set forth in the notice of immediate jeopardy. 12. Beginning [DATE], five (5) random residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff will also ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs are in place and followed. The residents will also be reviewed for side effects of pain medication, changes in condition, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then three (3) times a week times two (2) months, then two (2) times a week x one (1) month, then a minimum of quarterly. This will be completed by DON, ADON, SDC, and UM. Beginning on [DATE] weekend monitoring to be completed by Weekend RN Supervisor, Administrator, MDS Coordinator, DON, ADON, SDC or UM. Monitoring to include the audits mentioned above. The results of this audit will be reported to QA by the DON and/or ADON. 13. QA meeting will be held weekly times eight (8) weeks then monthly times one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, Regional Reimbursement Director and or Chief Operating Officer) will attend the weekly QA meeting times eight (8) weeks. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Discharge/Transfer Summary dated [DATE] revealed Resident #1 passed away. Review of State Death Certificated signed by Physician #1 and dated [DATE] revealed expiration of the resident. 2. Review of change in condition audit dated [DATE] revealed the DON had completed audit of all residents for change in status. No concerns identified. Interview with the DON on [DATE] at 3:55 PM revealed she conducted the audit related to change in condition. No concerns were identified. 3. Review of a list of residents currently on opioid medications revealed the residents were assessed on [DATE], for signs or symptoms of adverse effects, or medication error. No concerns were identified and there were no additional residents identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. Interview with the DON, on [DATE] at 3:55 PM revealed she conducted the audit related to resident being assessed for signs/symptoms of adverse effects, or medication error. No concerns were identified. 4. Review of a list of residents with appointments on [DATE] through [DATE] revealed UM #3 ensured the residents' responsible party, guardian, or Power of Attorney was made aware of the appointments and documented in the medical record. Interview on [DATE] at 3:35 PM with UM #3 revealed she had completed audit related to resident appointments and ensure responsible party, guardian, or POA were made aware and documented the notification in the medical record. 5. Review of a Daily Census Form dated [DATE] revealed all residents receiving prescribed opioids care plans were reviewed to ensure the care plans addressed and were implemented related to preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or SDC. Interviews on [DATE] with ADON at 3:40 PM, DON at 3:55 PM, and Administrator at 4:29 PM revealed they completed the audit of all residents' care plans who were received opioid medication on [DATE]. No concerns were identified. 6. Review of a list of residents who were on opioid medication revealed all current residents on opioids were evaluated by the Medical Director with orders written for as needed [MEDICATION(S)] for forty (40) residents on [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she was involved in writing the [MEDICATION(S)] orders and availability. 7. Review of education provided by the Administrator to the DON, ADON, SDC and UM on [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the EDK. Review of signature pages dated [DATE] and [DATE] revealed the DON, ADON, SDC, and UM were provided the above education. Further review revealed Post Tests were conducted and the staff scored 100%. Interviews on [DATE] with UM #3 at 3:35 PM, and on [DATE], UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM and SDC at 4:20 PM revealed they had been educated on the above information. 8. Review of education provided to Licensed Staff by the DON, ADON, SDC and UM on [DATE], [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). Review of signature pages dated [DATE], [DATE], and [DATE] revealed all licensed staff was provided the above education. Further review revealed Post Tests were conducted and each staff scored 100%. Interviews on [DATE] with LPN #2 at 10:44 AM, LPN #5 at 11:07 AM, LPN #3 at 12:14 PM, LPN #1 at 12:31 PM, RN #1, at 1:41 PM, RN #2 at 3:30 PM, and the MDS Coordinator, at 4:20 PM, revealed they received the above education. 9. Review of a list of new hires revealed there were no licensed staff hired after [DATE]. 10. Interview on [DATE] at 4:29 PM with Administrator revealed there were no other residents with pain pumps 11. Review of QA Signature page revealed an Ad-Hoc Quality Assurance (QA) meeting was conducted on [DATE]. Interviews on [DATE] with the ADON at 3:40 PM, DON at 3:55 PM, Acting Medical Director at 4:00 PM, and MDS Coordinator at 4:10 PM revealed they were present for Ad-Hoc meeting and discussed how to address removal of Immediate Jeopardy. 12. Review of daily audits conducted seven (7) days a week five (5) random residents starting on [DATE], revealed the residents' records were reviewed to ensure notification of responsible party, power of attorney, or court appointed guardian of upcoming appointments; and, documentation in resident's medical record. Records were also reviewed to ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs in place and followed. In addition, residents were reviewed for side effects of pain medication, changes in condition, signs and symptoms of adverse effects, concurrent opioid therapies, and to ensure opioid antidote available; seven days a week. Interviews on [DATE] with UM #3, on [DATE] with UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM, MDS Coordinator at 4:10 PM, revealed they were reviewing five (5) random resident a day to ensure the above information was in place. Interview on [DATE] at 4:29 PM with Administrator revealed he would review the the daily audits to include weekend audits. 13. Review of [DATE] QA meeting minutes revealed the Regional Clinical Services, Administrator, DON, MDS Coordinator, and SDC attended and discussed F551 (Guardian, Notification / Communication), F656 (Comprehensive Care Plan Implementation), F658 (Standards of Practice), and F760 (Significant Medication Error). Interviewed with Regional Clinical Services on [DATE] at 2:00 PM revealed she was involved in the QA meeting dated [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she attended the QA meeting on [DATE]. Interview with the Administrator on [DATE] at 1:03 PM revealed QA meetings will be held weekly for eight (8) weeks to ensure AoC implemented.

Based on interview, record review, and facility policy review, it was determined the facility failed to implement the care plan for one (1) of three (3) sampled residents (Resident #1) related to pain medication. Resident #1 was care planned for staff to monitor for side effects of pain medication, report occurrences to the physician, to obtain vital signs as ordered and as needed (PRN); to notify physician of significant abnormalities, and to conduct pain assessments every shift. On [DATE], Resident #1's implanted pain pump was turned on after being off for ten (10) months due to overdose; and refilled with [MEDICATION(S)]. In addition, the resident continued to receive [MEDICATION(S)] routinely by mouth (four {4} doses between [DATE] at 8:28 PM and [DATE] at 9:46 AM). Staff identified Resident #1 was lethargic, hard to wake up, and required more assistance with transfers on the morning of [DATE]. Licensed staff failed to conduct pain assessments every shift, monitor Resident #1's vital signs, and assess for adverse reactions, due to the concurrent use of routine opioids and implanted [MEDICATION(S)] pain pump; per care plan. Resident #1 passed away on [DATE] at approximately 1:20 PM. In addition, the resident's plan of care revealed the resident was no longer able to make medical decisions and staff should communicate with the guardian and caregivers regarding the resident's needs. However, the resident's guardian was not notified of the resident's appointment to turn on the [MEDICATION(S)] pain pump. The facility's failure to implement the care plan has caused or was likely to cause serious injury, harm, impairment, or death to a resident, Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC), was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of facility policy titled, Care Plans, Comprehensive Person-Centered last revised [DATE] revealed a comprehensive person-centered care plan which includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care plan process will include measurable objectives and timeframes, and describe services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Closed record review revealed the facility admitted Resident #1 on [DATE] with diagnoses, which included Type II Diabetes Mellitus with Diabetic [CONDITION(S)] Heart Failure, Low Back Pain, Other Chronic Pain, and Chronic Obstructive Pulmonary Disease. Review of Quarterly Minimum Data Set (MDS) assessment, dated [DATE] revealed the facility assessed Resident #1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the MDS assessment revealed the facility assessed the resident had pain frequently with a pain scale of six (6) on a scale of zero to ten (,d+[DATE]) with ten (10) being the most severe. Further review revealed the resident expired on [DATE] at 1:20 PM. Review of Resident #1's Comprehensive Care Plan for at risk for alteration in comfort, and, resident is at risk for Cardiac/Respiratory distress; dated [DATE], revealed interventions to be on alert for impact on functional ability and cognition; monitor for side effects of pain medication (confusion, hallucinations, nausea/vomiting), shortness of breath; and, and intervene as indicated. In addition, further review revealed interventions to obtain vital signs as ordered and as needed, report occurrences to the physician, and pain assessment every shift. Review of the Nursing Notes dated [DATE] at 2:31 PM revealed the resident's implanted [MEDICATION(S)] pain pump was filled and turned on at pain clinic; and, staff were instructed to watch for sedation. In addition, review of the February 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, review of the Nursing Notes, dated [DATE] through [DATE], Weight and Vitals Summary, and February 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of Resident #1's Pain Assessments revealed the last pain assessment was completed on [DATE], with no assessment completed after the resident's [MEDICATION(S)] pain pump was turned back on and refilled. Review of a Progress Note dated [DATE] at 1:12 PM, revealed nurse was summoned to room with resident not responding to stimuli and Supervisor paged to room at 1:15 PM. The resident was not responding to verbal or tactile stimuli, sternal rub, lips and finger cyanotic, no respiration or pulse noted. Resident #1 passed away. Interviews with Licensed Practical Nurse (LPN) #3 (worked [DATE], 3:00 AM - 7:00 AM) on [DATE] at 5:00 PM and Registered Nurse (RN) #1 (worked [DATE], 3:00 PM-3:00 AM) on [DATE] at 12:38 PM, revealed they were aware the resident's implanted pain pump was turned back on and filled with [MEDICATION(S)] on [DATE]. LPN #3 and RN #1 stated they failed to monitor for side effects of pain medication and obtain vital signs. LPN #3 and RN #1 further revealed they should have monitored the resident's vital signs and for adverse reactions due to the pain pump being turned back on and receiving oral [MEDICATION(S)] concurrently. Interviews with Certified Nursing Assistant (CNA) #2 on [DATE] at 12:08 PM, and CNA #2 on [DATE] at 11:45 AM, revealed Resident #1 was hard to wake up the morning of [DATE], and required extensive assistance of both of them to transfer to/from shower chair. In addition, the CNAs stated the resident was hard to wake for lunch tray and only ate a few bites. The CNAs revealed they put the resident back to bed after shower because they were afraid the resident would fall out of the chair. The CNAs stated they made Licensed Practical Nurse (LPN) #1 aware and LPN #1 obtained blood sugars. Interview with LPN #1 on [DATE] at 2:24 PM, on [DATE] at 4:51 PM, and on [DATE] at 10:17 AM, revealed there were no new orders for Resident #1 when he/she returned from pain pump appointment on [DATE] and the staff that was with the resident reported they were instructed to monitor for sedation. LPN #1 stated she did not obtain any vital signs when the resident returned from the appointment on [DATE]. She revealed on the morning of [DATE], Resident #1 was sleepy due to being up the night before and she asked the CNAs to lay the resident back down in bed, after shower. She stated she obtained the resident's blood sugar several times throughout the morning but did not obtain any vital signs on [DATE]. Further review of the resident's plan of care revealed he/she was a long term resident due to non-compliance with medication and serious safety issues; and was no longer able to manage personal affairs/finances or make medical decisions due to impaired cognitive function/impaired thought processes related to forgetfulness and impaired decision making ability. Communicate with resident, guardian and caregivers regarding capabilities and needs. Interview with Resident #1's Guardians, on [DATE] at 1:24 PM and 2:04 PM revealed they were not made aware an appointment was made for [DATE] to have Resident #1's [MEDICATION(S)] pain pump refilled and turned on until [DATE] at approximately 1:,d+[DATE]:27 PM after being told Resident #1 had passed away. Interview on [DATE] at 2:42 PM and on [DATE] at 5:04 PM with LPN #2, who made the appointment for procedure, revealed she was not aware she was required to call Resident #1's responsible party/Guardian related to medical consent for procedures, per the resident's plan of care. Interview on [DATE] with the Director of Nursing (DON) at 3:10 PM and Administrator at 3:40 PM, revealed they expected the staff to follow the care plans for residents. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides in the facility since [DATE]. 2. On [DATE], all current residents were assessed for change in condition by facility employed RN's and LPN's. No change in condition was identified for these residents. 3. On [DATE], all current residents currently on opioid medications were assessed for signs or symptoms of adverse effects, or medication error. No concerns were identified. No additional residents were identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. 4. On ,d+[DATE]-[DATE] all current residents who had appointments within the next thirty (30) days were reviewed by Unit Manager (UM). The Responsible party, including Power of Attorney or court appointed guardians, were notified and recorded in the clinical record by Unit Manager 5. On [DATE], care plans on all current residents receiving prescribed opioids were reviewed for addressing and implementation of resident preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or Staffing Development Coordinator (SDC). 6. On [DATE], all current residents who had an active order for opioids were evaluated for a need of PRN [MEDICATION(S)] by the Medical Director. Forty (40) residents received orders for opioid reversal agent. 7. Education was drafted by Administrator, who is also a RN, and she provided education to the DON, ADON, SDC, and UM on [DATE] and [DATE]. Education consisted of change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and Resident Assessment Instrument (RAI) manual requirements. Education was also provided on pain management including oral, intravenous (IV), and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. Additionally, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). 8. Beginning [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM on side effects of pain medication including pain pump monitoring and change in condition. This education also included the purpose of the [MEDICATION(S)] pump, the functionality of the pump, and the risks associated with opioid medications delivered intrathecally in conjunction with or without opioid management. The education also included the need for available antidote for residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], education to licensed staff was started by the ADON and/or SDC on notifying residents responsible party, power of attorney or court appointed guardian of upcoming appointments and documenting notification in resident's medical record. On [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM, on updating care plans and implementation of interventions to meet resident goals, medical, physical mental, psychosocial needs. No licensed staff will work after [DATE], before receiving the required education. Education was completed with all licensed staff by [DATE]. 9. New hires will be educated during orientation by the DON, ADON, SDC and/or UM. 10. An order identifying that Resident #1 had an implanted pain pump with [MEDICATION(S)] medication was present on the TAR. The facility utilizes CMA's to assist in the delivery of routine medications and therefore they utilize the MAR. while the licensed nursing staff utilize the TAR. It would be inappropriate for the order to be placed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Moreover, the EHR software employed by the facility is unable to list an order on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility employees did not administer the [MEDICATION(S)] that was used in the implanted pain pump. 11. On [DATE], the QA Committee (Medical Director, Administrator, DON, and ADON) met to discuss the event set forth in the notice of immediate jeopardy. 12. Beginning [DATE], five (5) random residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff will also ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs are in place and followed. The residents will also be reviewed for side effects of pain medication, changes in condition, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then three (3) times a week times two (2) months, then two (2) times a week x one (1) month, then a minimum of quarterly. This will be completed by DON, ADON, SDC, and UM. Beginning on [DATE] weekend monitoring to be completed by Weekend RN Supervisor, Administrator, MDS Coordinator, DON, ADON, SDC or UM. Monitoring to include the audits mentioned above. The results of this audit will be reported to QA by the DON and/or ADON. 13. QA meeting will be held weekly times eight (8) weeks then monthly times one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, Regional Reimbursement Director and or Chief Operating Officer) will attend the weekly QA meeting times eight (8) weeks. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Discharge/Transfer Summary dated [DATE] revealed Resident #1 passed away. Review of State Death Certificated signed by Physician #1 and dated [DATE] revealed expiration of the resident. 2. Review of change in condition audit dated [DATE] revealed the DON had completed audit of all residents for change in status. No concerns identified. Interview with the DON on [DATE] at 3:55 PM revealed she conducted the audit related to change in condition. No concerns were identified. 3. Review of a list of residents currently on opioid medications revealed the residents were assessed on [DATE], for signs or symptoms of adverse effects, or medication error. No concerns were identified and there were no additional residents identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. Interview with the DON, on [DATE] at 3:55 PM revealed she conducted the audit related to resident being assessed for signs/symptoms of adverse effects, or medication error. No concerns were identified. 4. Review of a list of residents with appointments on [DATE] through [DATE] revealed UM #3 ensured the residents' responsible party, guardian, or Power of Attorney was made aware of the appointments and documented in the medical record. Interview on [DATE] at 3:35 PM with UM #3 revealed she had completed audit related to resident appointments and ensure responsible party, guardian, or POA were made aware and documented the notification in the medical record. 5. Review of a Daily Census Form dated [DATE] revealed all residents receiving prescribed opioids care plans were reviewed to ensure the care plans addressed and were implemented related to preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or SDC. Interviews on [DATE] with ADON at 3:40 PM, DON at 3:55 PM, and Administrator at 4:29 PM revealed they completed the audit of all residents' care plans who were received opioid medication on [DATE]. No concerns were identified. 6. Review of a list of residents who were on opioid medication revealed all current residents on opioids were evaluated by the Medical Director with orders written for as needed [MEDICATION(S)] for forty (40) residents on [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she was involved in writing the [MEDICATION(S)] orders and availability. 7. Review of education provided by the Administrator to the DON, ADON, SDC and UM on [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the EDK. Review of signature pages dated [DATE] and [DATE] revealed the DON, ADON, SDC, and UM were provided the above education. Further review revealed Post Tests were conducted and the staff scored 100%. Interviews on [DATE] with UM #3 at 3:35 PM, and on [DATE], UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM and SDC at 4:20 PM revealed they had been educated on the above information. 8. Review of education provided to Licensed Staff by the DON, ADON, SDC and UM on [DATE], [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). Review of signature pages dated [DATE], [DATE], and [DATE] revealed all licensed staff was provided the above education. Further review revealed Post Tests were conducted and each staff scored 100%. Interviews on [DATE] with LPN #2 at 10:44 AM, LPN #5 at 11:07 AM, LPN #3 at 12:14 PM, LPN #1 at 12:31 PM, RN #1, at 1:41 PM, RN #2 at 3:30 PM, and the MDS Coordinator, at 4:20 PM, revealed they received the above education. 9. Review of a list of new hires revealed there were no licensed staff hired after [DATE]. 10. Interview on [DATE] at 4:29 PM with Administrator revealed there were no other residents with pain pumps 11. Review of QA Signature page revealed an Ad-Hoc Quality Assurance (QA) meeting was conducted on [DATE]. Interviews on [DATE] with the ADON at 3:40 PM, DON at 3:55 PM, Acting Medical Director at 4:00 PM, and MDS Coordinator at 4:10 PM revealed they were present for Ad-Hoc meeting and discussed how to address removal of Immediate Jeopardy. 12. Review of daily audits conducted seven (7) days a week five (5) random residents starting on [DATE], revealed the residents' records were reviewed to ensure notification of responsible party, power of attorney, or court appointed guardian of upcoming appointments; and, documentation in resident's medical record. Records were also reviewed to ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs in place and followed. In addition, residents were reviewed for side effects of pain medication, changes in condition, signs and symptoms of adverse effects, concurrent opioid therapies, and to ensure opioid antidote available; seven days a week. Interviews on [DATE] with UM #3, on [DATE] with UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM, MDS Coordinator at 4:10 PM, revealed they were reviewing five (5) random resident a day to ensure the above information was in place. Interview on [DATE] at 4:29 PM with Administrator revealed he would review the the daily audits to include weekend audits. 13. Review of [DATE] QA meeting minutes revealed the Regional Clinical Services, Administrator, DON, MDS Coordinator, and SDC attended and discussed F551 (Guardian, Notification / Communication), F656 (Comprehensive Care Plan Implementation), F658 (Standards of Practice), and F760 (Significant Medication Error). Interviewed with Regional Clinical Services on [DATE] at 2:00 PM revealed she was involved in the QA meeting dated [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she attended the QA meeting on [DATE]. Interview with the Administrator on [DATE] at 1:03 PM revealed QA meetings will be held weekly for eight (8) weeks to ensure AoC implemented.

Based on interview, record review, hospital record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents' Guardian was notified and informed the resident's [MEDICATION(S)] pain pump was activated (Resident #1). Resident #1 had court appointed guardians who were responsible for making medical procedure decisions for the resident. The resident had chronic lower back pain and had an implanted [MEDICATION(S)] pain pump that was turned off on [DATE] due to the resident possibly overdosing on [MEDICATION(S)]. On [DATE], the facility scheduled the resident an appointment on [DATE] to refill and turn on the resident's implanted pain pump without making the resident's guardians aware and obtaining consent, per facility policy. Resident #1's Guardians stated they would not have consented due to the resident's history. Resident #1 received [MEDICATION(S)] by pain pump for pain; and [MEDICATION(S)] (Hydrocodone-Acetaminophen), by mouth every five (5) hours for pain from [DATE] through [DATE]. The resident became lethargic and passed away on [DATE]. The facility's failure to notify the resident's representative of an appointment to restart his/her pain pump has caused or was likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC), was received on [DATE]. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on [DATE]. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility policy titled, Appointing a Resident Representative, dated [DATE] revealed the term resident representative was defined as the court-appointed guardian or conservator of a resident and has the right to exercise the resident's rights to the extent required by the court. The facility will treat the decisions of a resident representative as the decisions of the resident to the extent required by the court. The right of the resident will devolve to and will be exercised by the resident representative appointed to act on the resident's behalf. Closed record review revealed the facility admitted Resident #1 on [DATE] with diagnoses, which included Type II Diabetes Mellitus with Diabetic Chronic Kidney Disease Heart Failure, Low Back Pain, Other Chronic Pain, and Chronic Obstructive Pulmonary Disease. Further review revealed the resident expired on [DATE] at 1:20 PM. Review of a State Order of Appointment of Guardian, dated [DATE] revealed the court appointed Resident #1's friends co-guardians for the resident and appointed them duty and power to consent to medical procedures. Review of Patient Registration from Implanted Pain Pump Device revealed Resident #1 received implanted pain pump on [DATE]. Review of Resident #1's Comprehensive Care Plan dated [DATE], revealed he/she was a long term resident due to non-compliance with medication and serious safety issues; and was no longer able to manage personal affairs/finances or make medical decisions due to impaired cognitive function/impaired thought processes related to forgetfulness and impaired decision making ability. Communicate with resident, guardian and caregivers regarding capabilities and needs. Review of Hospital Records dated [DATE]-[DATE] revealed the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was admitted to the hospital due to lethargy suspected to be due to overdose. Resident #1's implanted pain pump was turned off and the resident was discharged back to the facility on [DATE]. Review of Resident #1's facility Progress Note, dated [DATE] revealed a decision was made to not have implanted pain pump turned back on and the resident was to receive oral opioids. Review of Clinical Sheets (information for nurse to know what needs to be done for a resident related to appointments), dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] revealed to call physician about consult to turn on [MEDICATION(S)] pain pump for Resident #1. Review of a Physician Order Entry dated [DATE] (by Physician #1) revealed Resident #1 was made an appointment for [DATE] at 1:00 PM with Physician #2 for [MEDICATION(S)] pump refill. Review of a Progress Note, dated [DATE] at 2:31 PM revealed Resident #1 was seen by Physician #2 with [MEDICATION(S)] pump filled and turned on, and review of the February 2020 Physician Orders revealed the resident continued to received [MEDICATION(S)] ,d+[DATE] milligrams by mouth every five (5) hours. However, review of the Progress Notes dated [DATE] through [DATE] revealed there was no documented evidence the facility obtained consent from the resident's guardians to refill and turn on the resident [MEDICATION(S)] pain pump; nor, made them aware the pain pump was turned on again. Review of a Nursing Progress Note dated [DATE] at 1:12 PM, revealed the nurse was summoned to room with Resident #1 not responding to stimuli and the Supervisor paged to room at 1:15 PM. The resident was not responding to verbal or tactile stimuli and sternal rub; and, the resident's lips and fingers were cyanotic, and there was no respirations or pulse noted. Resident expired. Interviews with Certified Nursing Assistant (CNA) #2 on [DATE] at 12:08 PM, and CNA #2 on [DATE] at 11:45 AM, and Licensed Practical Nurse (LPN) #1 on [DATE] at 2:24 PM, [DATE] at 4:51 PM and [DATE] at 10:17 AM, revealed Resident #1 was hard to wake up the morning of [DATE], required extensive assistance of both of them to transfer to/from shower chair, and was hard to wake for lunch tray and only ate a few bites. Interview with Resident #1's Guardians, on [DATE] at 1:24 PM and 2:04 PM revealed they were not made aware an appointment was made for [DATE] to have Resident #1's [MEDICATION(S)] pain pump refilled and turned on until [DATE] at approximately 1:,d+[DATE]:27 PM after being told Resident #1 had passed away. The Guardians stated they would not have agreed to the pain pump being turned on due to Resident #1's prior history of overdoses related to opioids and [MEDICATION(S)] pain pump used concurrently. The Guardians further revealed they had taken Resident #1 to the emergency room at least four (4) times to be given [MEDICATION(S)] (opioid reversal agent) in the past and they had discussed the resident's history of overdosing while on the pump and opioids together during Resident #1's admission ([DATE]). Interview with Licensed Practical Nurse (LPN) #2 (made appointment for procedure) on [DATE] at 2:42 PM and on [DATE] at 5:04 PM revealed she was not aware she was required to call Resident #1's responsible party/Guardian related to medical consent for procedures. LPN #2 stated she had not received any formal training related to guardianship and she was not aware Resident #1 had a guardian, but was aware that she could go to the resident's profile page on electronic chart and view the information. Interview with LPN #1 (nurse present when went to appointment) on [DATE] at 2:24 PM revealed the normal procedure for residents who have orders for appointments was for nursing to contact responsible party/power of attorney (POA) when appointment was made. Interview with the Staff Development Coordinator (SDC)/Unit Manager (UM) #1 of Resident#1's hall, on [DATE] at 2:41 PM revealed Resident #1 was not supposed to make medical decisions apparently per his/her care plan, and guardianship form. SDC/UM #1 stated guardianship should have been called regarding the appointment because Guardianship cannot make a decision if they do not know. SDC/UM #1 further revealed she had not provided any guardianship training but when nurses are hired in and trained they are oriented to call for medication changes. Interview with the Director of Nursing (DON) on [DATE] at 3:10 PM revealed a resident's Guardian(s)/Representative, and/or Power of Attorney is on the resident's profile page of the electronic chart. The DON stated staff review progress notes and physician orders at morning meeting to ensure guardians/representatives are notified of any changes. Interview with Administrator and Director of Nursing (DON) on [DATE] at 3:40 PM revealed the facility honors guardianship for residents. **The facility implemented the following corrective actions to remove the Immediate Jeopardy: 1. Resident #1 no longer resides in the facility since [DATE]. 2. On [DATE], all current residents were assessed for change in condition by facility employed RN's and LPN's. No change in condition was identified for these residents. 3. On [DATE], all current residents currently on opioid medications were assessed for signs or symptoms of adverse effects, or medication error. No concerns were identified. No additional residents were identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. 4. On ,d+[DATE]-[DATE] all current residents who had appointments within the next thirty (30) days were reviewed by Unit Manager (UM). The Responsible party, including Power of Attorney or court appointed guardians, were notified and recorded in the clinical record by Unit Manager 5. On [DATE], care plans on all current residents receiving prescribed opioids were reviewed for addressing and implementation of resident preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or Staffing Development Coordinator (SDC). 6. On [DATE], all current residents who had an active order for opioids were evaluated for a need of PRN [MEDICATION(S)] by the Medical Director. Forty (40) residents received orders for opioid reversal agent. 7. Education was drafted by Administrator, who is also a RN, and she provided education to the DON, ADON, SDC, and UM on [DATE] and [DATE]. Education consisted of change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and Resident Assessment Instrument (RAI) manual requirements. Education was also provided on pain management including oral, intravenous (IV), and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. Additionally, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). 8. Beginning [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM on side effects of pain medication including pain pump monitoring and change in condition. This education also included the purpose of the [MEDICATION(S)] pump, the functionality of the pump, and the risks associated with opioid medications delivered intrathecally in conjunction with or without opioid management. The education also included the need for available antidote for residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], education to licensed staff was started by the ADON and/or SDC on notifying residents responsible party, power of attorney or court appointed guardian of upcoming appointments and documenting notification in resident's medical record. On [DATE], education was provided to licensed nursing staff by Administrator, DON, ADON, SDC, and UM, on updating care plans and implementation of interventions to meet resident goals, medical, physical mental, psychosocial needs. No licensed staff will work after [DATE], before receiving the required education. Education was completed with all licensed staff by [DATE]. 9. New hires will be educated during orientation by the DON, ADON, SDC and/or UM. 10. An order identifying that Resident #1 had an implanted pain pump with [MEDICATION(S)] medication was present on the TAR. The facility utilizes CMA's to assist in the delivery of routine medications and therefore they utilize the MAR. while the licensed nursing staff utilize the TAR. It would be inappropriate for the order to be placed on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Moreover, the EHR software employed by the facility is unable to list an order on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility employees did not administer the [MEDICATION(S)] that was used in the implanted pain pump. 11. On [DATE], the QA Committee (Medical Director, Administrator, DON, and ADON) met to discuss the event set forth in the notice of immediate jeopardy. 12. Beginning [DATE], five (5) random residents with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff will also ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs are in place and followed. The residents will also be reviewed for side effects of pain medication, changes in condition, an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Then three (3) times a week times two (2) months, then two (2) times a week x one (1) month, then a minimum of quarterly. This will be completed by DON, ADON, SDC, and UM. Beginning on [DATE] weekend monitoring to be completed by Weekend RN Supervisor, Administrator, MDS Coordinator, DON, ADON, SDC or UM. Monitoring to include the audits mentioned above. The results of this audit will be reported to QA by the DON and/or ADON. 13. QA meeting will be held weekly times eight (8) weeks then monthly times one (1) month. A regional team member (consisting of Regional Director of Operations, Regional Director of Clinical Services, Regional Reimbursement Director and or Chief Operating Officer) will attend the weekly QA meeting times eight (8) weeks. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Discharge/Transfer Summary dated [DATE] revealed Resident #1 passed away. Review of State Death Certificated signed by Physician #1 and dated [DATE] revealed expiration of the resident. 2. Review of change in condition audit dated [DATE] revealed the DON had completed audit of all residents for change in status. No concerns identified. Interview with the DON on [DATE] at 3:55 PM revealed she conducted the audit related to change in condition. No concerns were identified. 3. Review of a list of residents currently on opioid medications revealed the residents were assessed on [DATE], for signs or symptoms of adverse effects, or medication error. No concerns were identified and there were no additional residents identified as using concurrent opioid therapies via oral and [MEDICATION(S)] pain pump. Interview with the DON, on [DATE] at 3:55 PM revealed she conducted the audit related to resident being assessed for signs/symptoms of adverse effects, or medication error. No concerns were identified. 4. Review of a list of residents with appointments on [DATE] through [DATE] revealed UM #3 ensured the residents' responsible party, guardian, or Power of Attorney was made aware of the appointments and documented in the medical record. Interview on [DATE] at 3:35 PM with UM #3 revealed she had completed audit related to resident appointments and ensure responsible party, guardian, or POA were made aware and documented the notification in the medical record. 5. Review of a Daily Census Form dated [DATE] revealed all residents receiving prescribed opioids care plans were reviewed to ensure the care plans addressed and were implemented related to preferences, goals, medical, physical, mental and psychosocial needs by Administrator, DON, ADON, and/or SDC. Interviews on [DATE] with ADON at 3:40 PM, DON at 3:55 PM, and Administrator at 4:29 PM revealed they completed the audit of all residents' care plans who were received opioid medication on [DATE]. No concerns were identified. 6. Review of a list of residents who were on opioid medication revealed all current residents on opioids were evaluated by the Medical Director with orders written for as needed [MEDICATION(S)] for forty (40) residents on [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she was involved in writing the [MEDICATION(S)] orders and availability. 7. Review of education provided by the Administrator to the DON, ADON, SDC and UM on [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the EDK. Review of signature pages dated [DATE] and [DATE] revealed the DON, ADON, SDC, and UM were provided the above education. Further review revealed Post Tests were conducted and the staff scored 100%. Interviews on [DATE] with UM #3 at 3:35 PM, and on [DATE], UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM and SDC at 4:20 PM revealed they had been educated on the above information. 8. Review of education provided to Licensed Staff by the DON, ADON, SDC and UM on [DATE], [DATE] and [DATE] revealed they were educated on change in status, notification of the physician and responsible party including but not limited to legally appointed guardian, and documentation in the clinical record; and, on comprehensive care plan implementation, revision, and RAI manual requirement. Further review revealed education was also provided on pain management including oral, IV, and [MEDICATION(S)] pain pump; risks associated with each pain management regimen, and when it may be appropriate for escalation of pain management. In addition, opioid reversal [MEDICATION(S)] was discussed including when it would be appropriate to administer and the location of the medication in the emergency drug kit (EDK). Review of signature pages dated [DATE], [DATE], and [DATE] revealed all licensed staff was provided the above education. Further review revealed Post Tests were conducted and each staff scored 100%. Interviews on [DATE] with LPN #2 at 10:44 AM, LPN #5 at 11:07 AM, LPN #3 at 12:14 PM, LPN #1 at 12:31 PM, RN #1, at 1:41 PM, RN #2 at 3:30 PM, and the MDS Coordinator, at 4:20 PM, revealed they received the above education. 9. Review of a list of new hires revealed there were no licensed staff hired after [DATE]. 10. Interview on [DATE] at 4:29 PM with Administrator revealed there were no other residents with pain pumps 11. Review of QA Signature page revealed an Ad-Hoc Quality Assurance (QA) meeting was conducted on [DATE]. Interviews on [DATE] with the ADON at 3:40 PM, DON at 3:55 PM, Acting Medical Director at 4:00 PM, and MDS Coordinator at 4:10 PM revealed they were present for Ad-Hoc meeting and discussed how to address removal of Immediate Jeopardy. 12. Review of daily audits conducted seven (7) days a week five (5) random residents starting on [DATE], revealed the residents' records were reviewed to ensure notification of responsible party, power of attorney, or court appointed guardian of upcoming appointments; and, documentation in resident's medical record. Records were also reviewed to ensure implementation of resident preferences, goals, medical, physical, mental, and psychosocial needs in place and followed. In addition, residents were reviewed for side effects of pain medication, changes in condition, signs and symptoms of adverse effects, concurrent opioid therapies, and to ensure opioid antidote available; seven days a week. Interviews on [DATE] with UM #3, on [DATE] with UM #2 at 10:50 AM, ADON at 3:40 PM, DON at 3:55 PM, MDS Coordinator at 4:10 PM, revealed they were reviewing five (5) random resident a day to ensure the above information was in place. Interview on [DATE] at 4:29 PM with Administrator revealed he would review the the daily audits to include weekend audits. 13. Review of [DATE] QA meeting minutes revealed the Regional Clinical Services, Administrator, DON, MDS Coordinator, and SDC attended and discussed F551 (Guardian, Notification / Communication), F656 (Comprehensive Care Plan Implementation), F658 (Standards of Practice), and F760 (Significant Medication Error). Interviewed with Regional Clinical Services on [DATE] at 2:00 PM revealed she was involved in the QA meeting dated [DATE]. Interview with the Medical Director on [DATE] at 4:00 PM revealed she attended the QA meeting on [DATE]. Interview with the Administrator on [DATE] at 1:03 PM revealed QA meetings will be held weekly for eight (8) weeks to ensure AoC implemented.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure infection control practices were maintained in the kitchen. On 01/14/2020, at 12:03 PM, during service of the lunch meal, observation revealed a contract repairman working on the dishwasher was not wearing a hair net. The findings include: Review of the facility policy, Personal Hygiene, undated, revealed the key to a safe and sanitary Dietary Department was healthy employees, properly trained in safe food handling, and the practice of good hygiene. The policy also revealed if hair was long and not covered properly by a cap, a hair net must be worn. Observation in the kitchen on 01/14/2020 at 12:03 PM, revealed an individual working on the dishwasher who was not wearing a hair net. Further observation revealed the kitchen staff were plating and serving the lunch meal for the residents. At 12:15 PM, observation revealed the repairman donned a hair net after he stated to the surveyor that he thought he needed a hair net. Interview with the Dietary Manager on 01/16/2020 at 9:31 AM, revealed measures to maintain infection control in the kitchen were to ensure personal hygiene, consistent hand hygiene, including the use of gloves, and the wearing of a hair net. She further stated anyone who entered the kitchen needed to don a hairnet. She also stated there was a repairman in the kitchen on 01/14/2020 during the time lunch was being served. The Dietary Manager stated that individual should have had a hair net on. Interview with the Director of Nursing (DON) on 01/16/2020 at 2:28 PM, revealed the Dietary Manager performed audits in the kitchen to ensure infection control practices were maintained. The DON stated the Dietary Manager provided her with the results of those audits and she was not aware of any issues regarding infection control. She then stated anyone who entered the kitchen would need to wear a hair net and wash their hands. The DON concluded by stating the repairman should have worn a hair net.

Based on observation, interview, and review of the facility maintenance policy it was determined the facility failed to provide a safe, comfortable, and homelike environment for residents. Observation on 01/14/2020 revealed two (2) of four (4) facility hallways (Round Station and C Hall) had baseboard heaters with missing and/or bent cover panels. In addition, one (1) of eight (8) rooms in the Round Station hallway (room [ROOM NUMBER]) had a broken heating and air-conditioning electrical outlet cover. The findings include: A review of the maintenance policy titled Work Orders and Maintenance Services, undated, revealed maintenance work orders shall be completed in order to establish a priority of maintenance services and the maintenance director was responsible for scheduling preventive maintenance services. Observations conducted on the Round Station hall on 01/14/2020 at 12:20 PM revealed four (4) of six (6) baseboard heaters with bent, loose, and/or missing cover panels. Observation on the C Wing hall on 01/14/2020 at 12:20 PM revealed three (3) of seven (7) heaters with bent, loose, and/or missing cover panels. Observation of room [ROOM NUMBER] on 01/14/2020 at 2:23 PM revealed an electrical outlet for the heating and air-conditioning unit was broken, exposing the outlet wiring. A review of the facility maintenance work orders and a critical/non-critical list of maintenance and remodel projects identified by the facility revealed no evidence the baseboard heaters had been scheduled for removal or remodeling. There was no evidence the electrical outlet plug had a work order submitted for repair/replacement. Interview with the Maintenance Director on 01/16/2020 at 2:05 PM revealed the Maintenance Director made rounds monthly to check for items in need of repair and had not noticed the broken outlet cover in room [ROOM NUMBER] or the baseboard heaters with the bent, loose, and/or missing cover panels. According to the Maintenance Director, the baseboard heaters were in an older section of the building and not connected to the current facility heating system and were no longer used.

Based on observation and interview, the facility failed to ensure controlled drugs were stored in a permanently affixed compartment as required in one (1) of two (2) refrigerators in the medication rooms. Observation of the B Hall medication room revealed the locked narcotic box in the refrigerator was not permanently affixed to the refrigerator. The findings include: Review of the facility policy titled Controlled Substances, with a revision date of December 2019 and a reviewed/revised date of 08/14/2019, revealed that controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The policy did not address that the locked box would be permanently affixed. Observation of the B Hall medication room on 01/16/2020 at 2:45 PM revealed a locked plastic container in the refrigerator that was being utilized for storage of narcotic medications; however, the container was not permanently affixed to the refrigerator and could be easily removed from the refrigerator. Observation of the contents of the narcotic box revealed six (6) [MEDICATION NAME] Patches, six (6) [MEDICATION NAME]/[MEDICATION NAME] 5/325 milligram tablets, six (6) [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 milligram tablets, six (6) [MEDICATION NAME] ER 10 milligram tablets, six (6) [MEDICATION NAME]/[MEDICATION NAME] 5/325 milligram tablets, and one (1) thirty (30) milliliter bottle of [MEDICATION NAME] Oral Concentrate 10 mg/0.5 milliliters. Interview with [ENTITY] #1 on 01/16/2020 at 3:59 PM revealed only one medication room refrigerator contained a locked container for narcotics and it was the refrigerator in the B Hall medication room. [ENTITY] #1 further revealed the locked container for narcotics had never been permanently affixed to the refrigerator. Interview with the Director of Nursing (DON) on 01/16/2020 at 3:34 PM revealed the narcotics are stored in a zip tie locked plastic box in the medication refrigerator on B Hall and the box is not permanently affixed to the refrigerator. The DON further revealed she was not aware the locked narcotic box should be permanently affixed to the refrigerator. The DON revealed she and the Administrator would immediately correct the incorrect storage of the locked narcotic box.

Based on interview, record review, review of bathing sheets, and facility policy review, it was determined the facility failed to provide bed baths/showers or toileting/incontinent care for four (4) of four (4) sampled residents (Residents #1, #2, #3, and #4), who were unable to bathe self or toilet self. The findings include: Review of the facility policies titled, Giving a Bed Bath and Shower/Tub Bath, both dated (MONTH) 2010, revealed the purpose of this procedure is to promote cleanliness, provide comfort to the resident and to observe the resident's skin. Review the resident's care plan for any special needs of the resident (type of bath/shower, amount of assistance needed, limitation in positioning or activity, and skin care products to use. further review revealed the following information should be recorded on the resident's ADL record and/or in the medical record 1. Date and time the procedure was performed. 2. Name and title of individual who performed the bed bath/shower or tub bath. 3. All assessment data obtained during the bed bath/shower or tub bath. 4. How the resident tolerated the bath or shower. 5. If the resident refused the bath or shower, reasons why and interventions taken. 6. Signature of person recording the data. Additionally, Under the Reporting section: Notify the Supervisor if the resident refuses the bed bath/shower/ tub bath. 1. Record review revealed the facility admitted Resident #1 on 07/27/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/10/19 revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of this MDS revealed the resident was totally dependent on one person for bathing. Review of Resident #1's Comprehensive Care Plan for Unable to perform Activities of Daily Living and resident requires staff assist with all ADL's, dated 04/30/18, revealed interventions to assist with bathing daily, and provide personal hygiene after all eliminations. Review of the (MONTH) and (MONTH) (YEAR) Certified Nurse Aide (CNA) shower/bath sheets for Resident #1 revealed Resident #1 was to be provided a bed bath every and have hair washed on Mondays. Further review revealed there was no initials indicating the resident received a bed bath/shower on 11/01/18, 11/02/18, 11/07/18 through 11/09/18, 11/12/18 through 11/18/18, 11/20/18, 11/25/18 through 11/29/18 (eighteen {18} of thirty {30} days in November); and on 12/01/18 through 12/06/18, 12/09/18-12/10/18, 12/13/18 through 12/16/18, 12/18/18 through 12/22/18, 12/24/18 through 12/25/18, and 12/27/18 through 12/30/18 (twenty-three {23}of thirty-one {31}days in December). There was no documented evidence indicating the reason there were no initials. Interview with Resident #1 on 01/15/19 at 10:34 AM revealed It sometimes takes one hour or longer for staff to answer his/her call light, and [MEDICAL CONDITION] skin from the urine being on my skin so long. 2. Record review revealed the facility admitted Resident #2 on 12/14/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated revealed the facility assessed Resident # 2's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Resident has an ADL self care performance deficit dated 01/03/19 revealed and intervention to provide extensive assistance of one staff for toileting. Interview with Resident #2 on 01/14/19 at 5:15 PM revealed on more than one occasion he/she has waited an hour for help to the bath room and he/she is not supposed to go without help as he/she recently had hip surgery. The resident stated once he/she had to sit on side of bed waiting for someone to come after putting on call light with stool running down his/her leg and stated It is very embarrassing and insulting to me when this happens. 3. Record review revealed the facility admitted Resident #3 on 04/18/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/22/18 revealed the facility assessed Resident #3's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of this same MDS revealed the resident required Review of Resident #3's Comprehensive Care Plan for Unable to perform Activities of Daily Living (ADL's) dated 09/21/18 revealed interventions for staff to bathe and groom daily and as needed. Review of (MONTH) and (MONTH) (YEAR) CNA shower/bath sheets for Resident #3 revealed the resident was to receive showers on Mondays, and Thursdays and bed baths all other days. Further review revealed there was no initials indicating the resident received a bed bath/shower on 11/11/18, 11/12/18, 11/14/18, 11/25/18, 11/27/18, and 11/30/18 (six {6} of thirty {30} days in November); and on 12/01/18, 12/02/18, 12/04/18, 12/05/19, 12/08/18, 12/09/18, 12/11/18, 12/14/18, 12/17/18, 12/18/18, 12/20/18 through 12/27/18, and 12/29/18 (nineteen {19} of thirty-one {31} days in December. 4. Record review revealed the facility admitted Resident #4 on 08/24/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 11/30/18 revealed the facility assessed Resident #4's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS revealed the resident required extensive assist of one (1) for bathing. Review of the Comprehensive Care Plan for At risk for decline in ADL function, dated 09/13/18, revealed interventions to assist with bathing daily as needed and provide personal hygiene care after all eliminations. Review of the (MONTH) and (MONTH) (YEAR) CNA shower/bath sheets for Resident #4 revealed the resident was to receive a shower on Tuesdays and Fridays with bed baths all other days. Further review revealed there was no initials the resident received a bed bath/shower on 11/11/18, 11/12/18, 11/15/18, 11/18/18, 11/19/18, 11/20/18, 11/24/18, 11/25/18, 11/29/18, and 11/30/18 (ten {10} of thirty {30} days in (MONTH) and on 12/01/18,12/02/18, 12/13/18, 12/14/18, 12/16/18, 12/17/18, 12/21/18, 12/22/18, 12/14/18, 12/25/18, 1216/18 and 12/29/18 (twelve (12) of thirty-one (31) days in December). Interview with Resident #4 on 01/15/19 at 10:22 AM revealed sometimes it takes forty-five (45) minutes to an hour for someone to answer call light and it is irritating when he/she wets self waiting for someone to come. The resident also stated I have sorta got over being embarrassed about it as it happens so often. The resident revealed he/she does not get bed bath every day. Interview with CNA #2 on 01/15/19 at 2:17 PM and 01/16/19 at 3:23 PM revealed she works C Hall (Rooms 109-126), 7:00 AM-3:00 PM shift, and is responsible for fourteen (14) residents with thirteen (13) of those residents dependent on staff. She stated baths/showers were not being done as there are not enough staff. Interview with CNA #4 on 01/16/19 at 2:45 PM revealed if the shower/bathing sheets were blank on some days, it was because here was not enough staff to do them. She stated the Administrator stated it was not in the budget for more staff. She stated some residents tell her call lights were not getting answered sometimes for an hour or longer; and they were not getting their baths/showers. Interview with CNA #5 on 01/15/19 at 4:15 PM revealed residents have told her they have waited for an hour to have call light answered. She stated it is a struggle to get all the baths/showers done with the staff we have. Interview with RN #2 on 01/15/19 at 5:08 PM revealed she has had some residents complain to her about call lights not being answered. Interview with Staffing Coordinator on 01/16/19 at 3:05 PM revealed there were discussions held in morning meeting with the Director of Nursing (DON), Administrator, and MDS about call lights not being answered timely and they have known since (MONTH) (YEAR). She stated, I know a lot do not get baths/showers as they should as I work on the floor all shifts as I am a CNA. Interview with the Director of Nursing (DON) on 01/16/19 at 8:50 AM revealed she received no complaints about call lights not being answered timely, or about not getting baths/showers. Interview with Administrator on 01/16/19 at 5:42 PM revealed she had no knowledge of call lights not being answered timely or baths/showers not being given. She stated she expected baths/showers to be given as scheduled and call lights to be answered within thirty (30) minutes. She revealed if showers/baths were not getting done, someone should tell her.

Based on observation, interview, record review and facility policy review it was determined the facility failed to ensure there was sufficient nursing staff to provide nursing services for four (4) of four (4) sampled residents (Residents # 1, # 2, # 3, and # 4). The facility failed to ensure adequate staffing to meet resident's needs related to bathing and answering the call light in a timely manner to ensure toileting/incontinent care was provided in a timely manner. The findings include: Review of the facility policy titled Staffing, last revised (MONTH) 2007, revealed the facility provides adequate staffing to meet needed care and services for our resident population. Interpretation and Implementation stated: 1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met; and, licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. 2. Certified Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plans. 3. Our facility furnishes information from payroll records setting forth the average numbers and types of personnel (in full time equivalents) on each shift during at least one week of each quarter to appropriate state agencies as required Review of the 11/01/18 through 11/30/18 staffing schedules revealed six (6) to nine (9) Certified Nurse Aides (CNA's) for day shift, five (5) to seven (7) CNA's for afternoon shift, and four to five (5) CNA's on night shift. Review of staffing schedule for 12/01/18 through 12/31/18 revealed eight (8) to nine (9) CNA's on day shift, five (5) to six (6) CNA's on afternoon shift, and, four (4) to five (5) CNA's on night shift. 1. Record review revealed the facility admitted Resident #1 on 07/27/10 with [DIAGNOSES REDACTED]. Review of Resident #1's (MONTH) and (MONTH) (YEAR) CNA shower/bath sheets revealed Resident #1 was to be provided a bed bath every day; however, further review revealed there was no initials indicating the resident received a bed bath/shower eighteen {18} of thirty {30} days in (MONTH) and twenty-three {23}of thirty-one {31}days in December. Interview with Resident #1 on 01/15/19 at 10:34 AM revealed It sometimes takes one hour or longer for staff to answer his/her call light, and [MEDICAL CONDITION] skin from the urine being on my skin so long. She stated, I am almost numb to it emotionally now. 2. Record review revealed the facility admitted Resident #2 on 12/14/18 with [DIAGNOSES REDACTED]. Interview with Resident #2 on 01/14/19 at 5:15 PM revealed staffing is bad. The resident stated more than once he/she has had to wait an hour for help to the bath room and is not supposed to go without help as has recently had hip surgery. He/she revealed more than once he/she had to sit on side of bed waiting for someone to come after putting on call light with stool running down his/her leg and stated It is very embarrassing and insulting to me when this happens. 3. Record review revealed the facility admitted Resident #3 on 04/18/13 with [DIAGNOSES REDACTED]. Review of Resident #3's (MONTH) and (MONTH) (YEAR) CNA shower/bath sheets revealed the resident was to receive showers on Mondays, and Thursdays and bed baths all other days. However, further review revealed there was no initials indicating the resident received a bed bath/shower on six {6} of thirty {30} days in (MONTH) and nineteen {19} of thirty-one {31} days in December. Interview with Resident #3's daughter on 01/16/19 at 11:06 AM revealed she comes every day except Thursday and there is not enough staff. She stated it takes an hour for call light to be answered and Resident #3 cannot toilet or bathe self. 4. Record review revealed the facility admitted Resident #4 on 08/24/18 with [DIAGNOSES REDACTED]. Review of Resident #4's (MONTH) (YEAR) and (MONTH) CNA shower/bath sheets revealed there was no initials the resident received a bed bath/shower for ten (10) of thirty (30) days in (MONTH) and twelve (12) of thirty-one (31) day in December. Interview with Resident #4 on 01/15/19 at 10:22 AM revealed they do not have enough staff as sometimes it takes forty-five (45) minutes to an hour for someone to answer call light and it is irritating when he/she wets self waiting for someone to come, Resident stated I have sorta got over being embarrassed about it as it happens so often. The resident revealed he/she does not get bed bath every day due to not enough staff. 5. Observation on 01/15/19 at 9:40 AM revealed there were no CNA's on Hall 200 as one aide was taking a resident to the beauty shop and there was no other aide on the floor. Further observation revealed there was one CNA on Hall 100. Interview with Unsampled Resident E on 01/16/19 at 11:34 AM revealed sometimes it takes an hour for them to answer call light and it is embarrassing when he/she wets on self because no one comes in time. Interview with Unsampled Resident G on 01/15/19 at 10:40 AM revealed they are under staffed and cannot get the work done. It takes one to two hours to answer my call light, and it is embarrassing when I wet on myself waiting so long, sometimes there are only four CNA's for the entire building. Interview with Unsampled Resident I's spouse on 01/15/19 at 11:35 AM revealed the facility is short staffed, and she usually has to go to the nursing station two (2) or three (3) times to get someone to help get the resident to bed as it takes two (2) people. Interview with Unsampled Resident K (roommate of Resident I) on 01/15/19 at 11:40 AM revealed they are short staffed, it takes an hour or longer to get help. The resident stated lots of times he/she puts call light on for roommate as roommate cannot and a lot of times he/she goes out to the nursing station to get help as no one coming. Interview with Unsampled Resident J on 01/15/19 at 9:09 AM and Unsampled Resident A revealed there is not enough staff for what what is not being done as Administration will not let any extra staff come in. Interview with Unsampled Resident L on 01/15/19 at 10:32 AM revealed he/she stated they are short staffed since new company took over, lot of turnover in CNA's. I can take myself to the bath room but my roommate (Resident #1) cannot and it sometimes takes an hour or longer for staff to come, that I just go and tell someone as I cannot stand it taking so long. Interview with CNA's #2 on 01/15/19 at 2:17 PM and on 01/16/19 at 3:23 PM revealed she works C Hall (Rooms 109-126), 7:00 AM-3:00 PM shift, and was responsible for fourteen (14) residents, thirteen (13) of those dependent. She stated there is seven (7) to eight (8) CNA's for the entire building with eight-five (85) residents at present. She revealed bed baths/showers were not being done as there was not enough staff. She stated the new company has cut back budget and are getting cheaper supplies like the depends, and body wash that does not clean the resident as well. She revealed both the DON and Administrator have been told about the short staffing. Interview with CNA's # 3 on 01/15/19 at 3:51 PM revealed she works 3:00 PM-11:00 PM shift, and they usually have five (5) CNA's for the entire building. She stated it was a lot better when there were six (6) CNA's because she can get all her work done. She revealed one extra CNA's makes a big difference. Interview with CNA's #4 on 01/15/19 at 4:00 PM and on 01/16/19 at 2:45 PM revealed she works C hall, rooms 109-124 A, and she had some residents tell her call lights were not getting answered sometimes for an hour or longer; and they were not getting their baths/showers. She stated if the shower/bath sheets were blank on some days, it was because there was not enough staff to do them. She revealed the Administrator says it is not in the budget for more staff. She stated several CNA's have quit as they did not want to work for the new company as they have cut our supplies and budget. Interview with CNA's #5 on 01/15/19 at 4:15 PM revealed residents have told her they have waited for an hour to have call light answered. She stated it is a struggle to get all the baths/showers done with the staff we have. Interview with RN #2 on 01/15/19 at 5:08 PM revealed she has had some residents complain to her about call lights not being answered. She stated the facility is short staffed when we have call-ins. Interview with Staffing Coordinator on 01/16/19 at 3:05 PM revealed there were discussions held in morning meeting with the Director of Nursing (DON), Administrator, and MDS about call lights not being answered timely and they have known since (MONTH) (YEAR). She stated, I know a lot do not get baths/showers as they should as I work on the floor all shifts as I am a CNA's and cannot get all the work done as not enough staff. She revealed a lot of CNA's have quit as they do not like the new company as new company has cut staff, is using cheaper supplies, staff lost sick days and any seniority they had, and insurance not good. She stated she suggested to get Agency staff but was told it was not in the budget, so mandatory over time, was put in place. She stated since last pay period she had worked one-hundred twenty-eight (128) hours in two weeks. She further stated since the new company took over, ten (10) CNA's have quit. She revealed the Administration does not go by the census when staffing. Interview with the DON on 01/16/19 at 8:50 AM revealed she received no complaints about call lights not being answered timely, or about not getting baths/showers. She stated she expected call lights to be answered timely, in less than thirty minutes. She also stated there should be six to seven (6-7) CNA's on second shift but sometimes there is five (5) due to call-ins. She revealed they have tried to hire more staff through word of mouth, and ads on the web. Interview with Administrator on 01/16/19 at 5:42 PM revealed she had no knowledge of call lights not being answered timely or baths/showers not being given, as no one had told her there was not enough staff to get baths/showers done. She stated she expected call lights would be answered in less than thirty minutes, and baths/showers to be given as scheduled. She revealed if showers/baths were not getting done or call lights not being answered timely due to low staff, then someone should tell her. She further stated, I did have one (1) resident (Resident #2) tell me the call light was not being answered and I took care of it and the resident never complained again, I do not know how long the resident had waited.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety. The facility failed to ensure food was served at appropriate temperatures before leaving the kitchen. Review of the facility Census and Condition, dated 01/15/19, revealed seventy-nine (79) of eight-five (85) resident received their food from the kitchen. The findings include: Review of facility policy titled, Resident Nutrition Services, last revised (MONTH) (YEAR), revealed to minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 degrees F to 135 degrees F) will be kept to a minimum. Foods that are left without a heat source (for hot foods) or refrigeration (for cold foods) longer than two (2) hours will be discarded. Observation of meal on 01/15/19 at 5:25 PM revealed menu of a roll, wax beans mixed with green beans and carrot, a round piece of meat, baked potato with butter, milk, and ice cream. A taste test of this meal revealed the vegetables did not taste good, no seasoning; roll was semi-hard, meat had no taste and surveyor could not discern what the meat was. Observation on 01/16/19 at 5:30 PM revealed food trays on a cart to be delivered to Hall 100 with approximately five (5) other trays. Temperatures were taken and the fried chicken was one hundred twenty five (125) degrees Fahrenheit (F) and the beets were one-hundred ten (110) degrees F. Interview with Resident #2 on 01/15/19 at 12:55 PM revealed the food is almost always cold. Interview with Unsampled Resident J on 01/15/19 at 9:09 AM revealed the food is cold a lot of the time. Interview with Unsampled Resident B on 01/15/19 at 9:25 AM revealed the food is horrible and cold. Interview with Unsampled Resident C on 01/15/19 at 9:32 AM revealed the food is cold and not good, but he/she eats it because he/she is hungry, and he/she does not want a sandwich, which is the alternative. Interview with Unsampled Resident D on 01/15/19 at 9:51 AM revealed the food is not good as it is cold when it arrives. Interview with Resident #1 on 01/15/19 at 10:34 AM revealed the food is awful, and cold sometimes. Interview with Unsampled Resident G on 01/15/19 at 10:40 AM revealed food is sometimes cold. The resident stated Interview with Unsampled Resident #1's spouse of Resident I on 01/15/19 at 11:35 AM revealed food is cold if I do not take it to the room before it gets to the room. The Spouse stated most times he/she just goes and gets the food from the CNA's for her spouse and roommate so it will still be warm. Interview with Unsampled Resident K (roommate of Resident I) on 01/15/19 at 11:40 AM revealed food is cold most of the time. The resident stated he/she has asked for two pieces of bacon but never gets it and never gets a full cup of coffee (cup of coffee observed to be 3/4 of the way full when first delivered). Interview with Unsampled Resident E on 01/16/19 at 11:30 AM revealed the food is not good. Interview with Certified Nurse Aide (CNA) #2 on 01/16/19 at 3:23 PM revealed I know the residents have told the Administrator multiple times the food is horrible. Interview with CNA #4 on 01/15/19 at 4:00 PM and on 01/16 19 at 2:45 PM revealed Just about every resident has complained to me about the food tasting awful, being cold and we get it to the residents as soon as we get it and it is still cold, no variety with the food. She stated I know the DON has been told about the food being cold and awful, I am not sure if the Administrator was told. Interview with CNA #6 on 01/15/19 at 4:40 PM revealed None of the residents like the food. Interview with Registered Nurse (RN) #2 on 01/15/19 at 5:12 PM revealed Residents do not like the food, since new company took over, they say it is cold. Interview with Dietary Manager on 01/16/19 at 8:33 AM revealed I know the food is not cold when it leaves the kitchen, we do temperatures at every meal. She stated we get the menus from the new company, and she has received some complaints in (MONTH) about the food not being good and no variety. She stated she addressed this and thought things were better. She revealed she had not received any complaints of from residents or staff about the food being cold or not good since November. Interview with the Staffing Coordinator on 01/16/19 at 3:05 PM revealed I have had residents complain to me about the food being not fit to eat and cold, I told the kitchen staff and we have discussed this in morning meetings with the DON, Administrator, MDS, and ADON present. Interview with Director of Nursing (DON), on 01/16/19 at 8:50 AM revealed she had not had any resident or staff member complain to her about the food not being good or being cold. She stated she expected the food to be warm and food that the residents enjoyed. Interview with the Administrator on 01/16/19 at 5:42 PM revealed I do not know why the food would have been at 125 degrees before it left the kitchen. She stated we do not have heated transport but we have insulated carts. She revealed sometimes a resident or two says they do not like this or that food and we offer an alternative. She stated she expected the residents to have food they liked and that the food be warm when it got to the residents.

Based on interview, record review, and review of facility policy review, it was determined the facility failed to ensure four (4) of four (4) sampled residents' Comprehensive Care Plans were implemented related to bathing and/or incontinent care/toileting. Resident #1, #2, #3, and #4 were care planned to received a shower/bed bath every day and/or to be toileted/or provided incontinent care; however, interviews residents and staff; and, review of Certified Nurse Aide (CNA) shower/bath sheets revealed showers/bed baths were not being completed daily as care planned and call lights were not answered timely to ensure incontinent care/toileting was provided timely. The findings include: Review of the facility policy titled, Using the Care Plan, not dated, revealed documentation must be consistent with the resident's care plan. The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. 1. Record review revealed the facility admitted Resident #1 on 07/27/10 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/10/19 revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of this MDS revealed the resident was totally dependent on one person for bathing. Review of Resident #1's Comprehensive Care Plan for Unable to perform Activities of Daily Living (ADL's) and resident requires staff assist with all ADL's dated 04/30/18, and (MONTH) and (MONTH) (YEAR) CNA shower/bath sheets revealed interventions to provide personal hygiene after all eliminations and to assist with bathing daily. However, further review of the (MONTH) and (MONTH) (YEAR) CNA shower/bath sheets revealed there was no initials indicating the resident received a bed bath/shower eighteen {18} of thirty {30} days in (MONTH) and twenty-three {23}of thirty-one {31}days in December). In addition, interview with Resident #1 on 01/15/19 at 10:34 AM revealed It sometimes takes one hour or longer for staff to answer his/her call light, and [MEDICAL CONDITION] skin from the urine being on my skin so long. The resident also stated he/she gets a bed bath on Monday Wednesday and Friday. 2. Record review revealed the facility admitted Resident #2 on 12/14/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated revealed the facility assessed Resident # 2's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Resident has an ADL self care performance deficit dated 01/03/19 revealed an intervention to provide extensive assistance of one staff for toileting; however, interview with Resident #2 on 01/14/19 at 5:15 PM revealed on more than one occasion he/she has waited an hour for help to the bath room. The resident stated once he/she had to sit on side of bed waiting for someone to come after putting on call light with stool running down his/her leg and stated It is very embarrassing and insulting to me when this happens. 3. Record review revealed the facility admitted Resident #3 on 04/18/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/22/18 revealed the facility assessed Resident #3's cognition as severely impaired with a BIMS score of three (3) which indicated the resident was not interviewable. Further review of the MDS revealed the resident was totally dependent on one (1) person for bathing Review of Resident #3's Comprehensive Care Plan for Unable to perform Activities of Daily Living (ADL's) dated 09/21/18 revealed interventions for staff to bathe and groom daily and as needed. Review of the (MONTH) and (MONTH) (YEAR) shower/bath sheets for Resident #3 revealed the resident was to receive showers on Mondays, and Thursdays and bed baths all other days. However, further review revealed there was no initials indicating the resident received a bed bath/shower six {6} of thirty {30} days in (MONTH) and nineteen {19} of thirty-one {31} days in December. 4. Record review revealed the facility admitted Resident #4 on 08/24/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 11/30/18 revealed the facility assessed Resident #4's cognition as intact with a BIMS score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS revealed the resident required extensive assist of one (1) for bathing. Review of the Comprehensive Care Plan for At risk for decline in ADL function, dated 09/13/18, revealed interventions to assist with bathing daily and as needed; and provide personal hygiene care after all eliminations. However, review of the (MONTH) and (MONTH) (YEAR) CNA shower/bath sheets for Resident #4 revealed there were no initials the resident received a bed bath/shower on ten{10} of thirty {30} days in (MONTH) and twelve (12) of thirty-one (31) days in December. In addition, interview with Resident #4 on 01/15/19 at 10:22 AM revealed it sometimes take forty-five (45) minutes to an hour for someone to answer call light and it is irritating when he/she wets self waiting for someone to come. The resident also stated he/she was over being embarrassed about it as it happens so often. The resident also revealed he/she does not get bed bath every day. Interview with CNA # 2 on 01/15/19 at 3:23 PM revealed baths/showers were not getting done per Care Plan and as scheduled. Interview with CNA #4 on 01/15/19 at 4:00 PM and on 01/16/19 at 2:45 PM revealed residents have told her they were not getting their baths/showers and call lights were not getting answered sometimes for an hour or longer. She stated if the shower/bath sheets were blank on some days, it was because they were not done. Interview with CNA #5 on 01/15/19 at 4:15 PM revealed it is a struggle to get all the baths/showers on their CNA sheet done and residents have told her they have waited for an hour to have call light answered. Interview with Director of Nursing (DON) on 01/16/19 at 8:50 AM revealed she expected staff to follow the Care Plan for resident care. .

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of twenty-two (22) sampled residents who has an indwelling urinary catheter is provided appropriate treatment and services in accordance with professional standards (Residents #81). Observations on 10/23/18, revealed Resident #81's urinary indwelling catheter was not secured below the level of the bladder. The findings include: Review of the facility policy, Catheter Care, Urinary, last revised (MONTH) 2014, revealed in order to maintain unobstructed urine flow the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Record review revealed the facility readmitted Resident #81 on 08/10/18 with [DIAGNOSES REDACTED]. Observation, on 10/23/18 at 1:47 PM and 2:41 PM, revealed Resident #81's urinary indwelling catheter was positioned near the head of the bed and not below the level of the bladder. Interview with Certified Nurse Aide (CNA) #1 on 10/23/18 at 2:42 PM, revealed the catheter should be secured lower on the bed frame and below the level of the bladder to keep the urine from backing up into the bladder. Interview with Registered Nurse (RN) #1 on 10/25/18 at 2:26 PM, revealed the aides should ensure the catheters are secured below the level of the bladder to allow the urine to drain and decrease the risk of infections. Interview with the Director of Nursing (DON) on 10/25/18 at 4:47 PM, revealed she expected the catheter to be placed below the level of the bladder to aid in urine flow and decrease the risk of infections.

Based on interview, record review, and facility policy review, it was determined the facility failed to notify the physician and family regarding an incident of elopement for one (1) of four (4) sampled residents (Resident #1). On 09/26/18 at approximately 6:32 PM, Resident #1 was taken to the nursing station, and at approximately 6:39 PM, he/she wandered with a wheelchair (w/c), and then ambulated from the w/c by himself/herself disappearing into the sunroom/activity room/entrance leading to the courtyard. He/she was discovered by staff at approximately 9:12 PM. The findings include: Review of the facility policy titled, Elopements, last revised (MONTH) 2007, revealed, if a resident missing from the facility is found, the attending physician and legal representative should be notified. Review of the facility policy titled, Wandering, Unsafe Resident, last revised (MONTH) 2014, revealed if a resident is missing and the premises have been searched, then notify the Administrator, Director of Nursing (DON), the resident's legal representative, and the attending physician. When the resident is returned to the facility, contact the attending physician, and the resident's legal representative. Review of the facility policy titled, Accident and Incidents-Investigating and Reporting, last revised (MONTH) (YEAR), revealed the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor shall promptly initiate and document an investigation of the accident or incident, and the following data, as applicable, shall be included on the Incident/Accident form: time of notification, response of physician, time of notification of family, and who notified family and physician. Record review revealed the facility admitted Resident #1 on 05/18/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #1 to require extensive assistance with activities of daily living (ADLs) and to have a Brief Interview for Mental Status (BIMS) score of nine (9), with no behaviors noted. Review of the Quarterly MDS, dated [DATE], revealed he/she required extensive assistance with ADLs, and to have a BIMS score of six (6), with physical, verbal, and other behaviors noted. Review of a video, dated 09/26/18 at approximately 6:32 PM, revealed Resident #1 was taken to the nursing station with no activity box provided to the resident, and he/she wandered with a wheelchair (w/c), then ambulated from the w/c by himself/herself, disappearing into the sunroom/activity room/entrance that led to the courtyard at approximately 6:39 PM. He/she was not seen again until his/her w/c was retrieved at approximately 9:12 PM, and he/she was brought from the sunroom/activity room entrance that led to the courtyard. Review of Nursing Progress Notes, dated 09/20/18-10/09/18, revealed there was no documented evidence the family or physician was notified when Resident #1 was found in the courtyard on 09/26/18. The resident was missing for approximately two (2) hours and thirty-three (33) minutes, from the 6:39 PM view on the camera, disappearing into the sunroom/activity room/entrance that led to the courtyard, until approximately 9:12 PM coming from the sunroom/activity room/entrance that led to the courtyard, being assisted by staff in his/her wheelchair. Interview with Registered Nurse (RN) #2, on 10/11/18 at 3:12 PM, revealed she called the physician and documented in the nursing notes; however, there was no evidence of documentation in the nursing notes about Resident #1 being found in the courtyard, nor family or physician informed. She revealed she did not notify family because there was nothing to report. Interview with Licensed Practical Nurse (LPN) #2, on 10/10/18 at 12:07 PM, revealed family and physician should be notified, and should be documented in the nursing notes. She stated if it was not documented, it was not done. Interview with RN #4, on 10/11/18 at 1:36 PM, revealed when an incident happened, notify the immediate supervisor, DON, family, and physician. Interview with Physician #2, on 10/15/18 at 4:30 PM, revealed she had not been informed about Resident #1. She stated she had been on vacation last week and was not aware of the incident. She stated typically an incident should be reported to the physician on-call; however, staff did not call unless the resident was injured, and would inform her whenever she went to the facility. Interview with the DON, on 10/11/18 at 4:15 PM, revealed when there was an accident/incident, staff should notify the DON, Administrator (if needed), family, and physician. However, the DON stated she did not consider the situation regarding Resident #1, who was discovered around 9:30 PM - 9:45 PM in the courtyard, as an incident or occurrence.

Based on interview, record review, and review of the Hospital emergency room Report and the facility's policy and procedures titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, it was determined the facility failed to protect one (1) of three (3) sampled residents (Resident #1) from sexual abuse (non-consensual sexual contact of any type) from an employee who is considered an agent of the facility. The facility failed to identify Resident #1 was vulnerable for abuse due to the resident's decreased cognition and immobility; and, failed to care plan and implement interventions to monitor for possible abuse. In addition, the facility failed to ensure staff were thoroughly screened prior to hire, in order to provide a safe environment for the residents, as they failed to follow their policy related to background checks on new hires. On 03/04/18, Certified Nurse Aide (CNA) #2 entered Resident #1's room and observed CNA #1 on Resident #1's bed, hunched over, between Resident #1's legs. When CNA #2 walked into the room, CNA #1 jumped off the bed with his genitals exposed and continued to masturbate. CNA #1 then ran out of the room and out of the facility. Resident #1 was observed to be naked with his/her legs bent and spread open with his/her hands behind his/her head. Resident #1 was sent to the hospital, on 03/04/18 at 3:14 AM, via ambulance and returned to the facility at 5:45 AM with no new orders. The resident was instructed to follow-up with his/her primary physician on the next visit day. Review of the emergency room (ER) Provider Notes revealed the resident had mild vaginal [DIAGNOSES REDACTED]. Follow-up assessment, on 03/05/18 at 10:20 AM, revealed the resident had a small bruise to the perineal area. CNA #1 was arrested later that day for first degree sexual assault. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/07/18 and determined to exist on 03/04/18. The facility was notified of the Immediate Jeopardy on 03/07/18. An acceptable Allegation of Compliance (AoC) was received on 03/09/18 alleging the removal of Immediate Jeopardy on 03/09/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 03/09/18, as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 08/01/01 and revised on 12/11/17, revealed abuse, neglect, misappropriation of resident property and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, residents, consultants, volunteers, family members or legal guardians, friends, visitors or any other individual in this Center. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Center's Administrator is responsible for assuring that resident safety, including freedom from risk of abuse or neglect, holds the highest priority. Residents with needs and behaviors that might lead to conflict with employees or other residents will be identified by the Care Planning Team, with interventions and follow through designed to minimize the risk of conflict. The definition of abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact or any type with a resident that includes but is not limited to, sexual harassment, sexual coercion, or sexual assault. Medical and emotional support will be made immediately available to any individual suffering either alleged abuse, neglect, or misappropriation of resident property. Review of the facility's policy, Employment References, dated 08/01/99 and last reviewed/revised 12/01/07, revealed the company views obtaining relevant work or professional reference information on applicants for employment as an important part of the selection process. The hiring manager is responsible for obtaining valid, relevant work reference information on applicants before employment decisions are made. The hiring manager is expected to contact no less than two (2) of the candidate's most recent work references. References should be obtained verbally, documented, and filed separately from the candidate's file. Record review revealed the facility admitted Resident #1 on 06/30/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) Assessment, dated 01/21/18, revealed the resident rarely/never understands and required extensive assist of two (2) staff for bed mobility, dressing, hygiene, and toilet use. In addition, the resident did not transfer. Review of the Comprehensive Care Plan, dated 11/07/17, revealed Resident #1 required two (2) assist with all Activities of Daily Living and had frequent nonsensical verbalizations. The resident would not usually respond to questions asked, due to chanting, and his/her decision making was severely impaired as the resident was unable to communicate needs. Further review of the Care Plan revealed the care plan did not address the resident's increased risk for abuse due to his/her's physical and cognitive vulnerabilities. Observation of Resident #1, on 03/06/18 at 1:43 PM, revealed the resident lying in bed holding a doll. The resident was unable to answer questions asked. Review of Nurse's Note, dated 03/04/18 at 2:45 AM, written by Registered Nurse (RN) #1 revealed RN #1 heard CNA #2 yell for help, and ran to Resident #1's room to find CNA #1 running from Resident #1's room. RN #1 documented CNA #2 stated she witnessed a sexual assault. RN #1 observed Resident #1 in the bed with his/her legs drawn up staring at the ceiling mumbling which was normal for the resident. A CNA called 911 while RN #1 was with the resident. CNA #2 and RN #1 stayed with the resident until the police arrived. Further review of the Nurse's Note revealed the Director of Nursing (DON), Assistant Director of Nursing (ADON), Administrator, and Physician were called. An order was received to send the resident to the emergency room (ER) for evaluation and treatment. Police arrived at 2:58 AM and Resident #1 was sent to the hospital at 3:14 AM via ambulance. A Nurse's Note by RN #1, on 03/04/18 at 5:45 AM, revealed the resident returned to the facility with no new orders and to follow-up with his/her primary physician on the next visit day. Review of a Nurse's Note, dated 03/05/18 at 10:20 AM, by Licensed Practical Nurse (LPN) #2 revealed the resident had a small bruise to the perineal area. Review of the ER Provider Notes, dated 03/04/18 at 5:12 AM, revealed the primary impression of sexual assault by bodily force by caregiver. The chief complaint reported sexual assault. Subjective Comments: Nursing Home nurse presents to the emergency department, states she entered the patient's room and saw a male CNA having intercourse with the patient. The Nursing Home Nurse shouted and the male CNA, who allegedly had his pants down to his knees, got off the patient and continued to masturbate, and then ran out of the nursing home on foot. The Police have been notified. Male CNA on the run. Patient is nonverbal, bedridden, with flexion contracture. The incident occurred one (1) to two (2) hours ago. The patient has no vaginal discharge and no vaginal bleeding, however; mild vaginal [DIAGNOSES REDACTED] found. Final Diagnoses, sexual assault by bodily force by caregiver. Sexual assault kit performed. Review of CNA #1's employee time card revealed the CNA clocked in, at 3:00 PM on 03/03/18, and the facility clocked him out when he fled the facility at 2:45 AM on 03/04/18. Furthermore, review of the assignment sheet revealed the CNA was assigned to care for Resident #1 on his shift. Interview with the Police Detective, on 03/07/18 at 1:35 PM, revealed CNA #1 was arrested on 03/04/18 and charged with sexual assault first degree based on witness testimony. He stated the cameras at the facility revealed the employee ran out of the building at 2:45 AM on 03/04/18. Interview with CNA #2, on 03/06/18 at 3:27 PM, with Adult Protective Services revealed she saw CNA #1 around 1:15 AM - 1:45 AM on 03/04/18. She stated she took dirty linen to the bathroom a little after 2:06 AM and noticed Resident #1's door was closed and a trash bag was sitting outside the door which indicated CNA #1 was in the resident's room providing care. She stated if care was not being provided the door was open to that room. CNA #2 stated she then went into the room next to Resident #1's room to place the resident's feet back on the bed and she asked RN #1 to help pull the resident back up in bed. She stated the resident's bed sheets were soiled and RN #1 asked her to get CNA #1 to give the resident a bath. CNA #1 stated the bag of trash was still outside Resident #1's door and the door remained closed so she walked on in and saw Resident #1's roommate was in the bed and Resident #1's curtain was halfway pulled. She stated she saw CNA #1 on Resident #1's bed in between the resident's legs hunched forward toward the resident with the back of his pants up. The resident's right leg was externally rotated out and the left leg was bent in the upward position. She stated CNA #1 jumped off the bed when he heard her; his pants were down in the front and he was masturbating as he continued to look at the resident. She stated CNA #1 never looked at her even though she was screaming stop. CNA #1 stated she backed up in the hallway where she could still see the resident and hollered for the nurse. She stated when she turned her head talking to the nurse, CNA #1 ran out of the room while RN #1 came out of the neighboring room and RN #1 starting running after CNA #1. Further interview revealed at that time she noticed there were no sheets on Resident #1's bed and the resident was completely naked. The resident was still in the bed with his/her legs spread, with his/her hands behind his/her head and the resident verbalized nothing. CNA #2 stated a pile of sheets were on the floor as well as the call light. She stated she did not witness any intercourse or CNA touching the resident's perineal area as the curtain was half way pulled. Further interview on 03/08/18 at 11:52 AM, revealed she went to the ER with the resident on 03/04/18 and there was redness to the perineal area at the ER. She stated the area looked really irritated from the vaginal area up through the labia area. Interview with RN #1, on 03/06/18 at 2:30 PM, with Adult Protective Services (APS) revealed CNA #2 asked for assistance in the room neighboring Resident #1. She stated she asked CNA #2 to find CNA #1 to give this resident a bath as she had not seen him in 20-30 minutes. She stated she heard CNA #2 screaming and when she came into the hallway, CNA #1 met her in the hallway and he was pulling up his pants running/hopping down the hall. She stated Resident #1's curtain was half way pulled and she observed Resident #1 lying naked with no brief or linens on him/her with his/her hands behind his/her head and legs in the birthing position with his/her knees bent and legs ups. She stated the resident did not lay with his/her hands behind his/her head or knees in that position as the resident could not place himself/herself in that position as he/she was total care. She stated linens were on the floor at the foot of the bed. RN #1 stated she chased CNA #1 down the hallway and hollered at a CNA to call 911. CNA #1 left the building. She then called the DON, ADON, Administrator, and Physician and received an order to send the resident to the hospital. RN #1 stated when she examined the resident she saw mild irritation at the vaginal area but no [MEDICAL CONDITION] or bleeding. Per interview, she had seen the resident a couple of hours before the event when she administered him/her medications via the gastrostomy ([DEVICE]) tube and the resident was lying on his/her right side and was wearing a gown and brief. Interview with CNA #11, on 03/07/18 at 11:36 AM, revealed she worked with CNA #1 for the first time on 03/03/18 and 03/04/18. She stated she saw the CNA on the computer behind the desk around midnight that night. CNA #11 stated she heard RN #1 holler, Stop him, and saw a flash of blue run out the door, at approximately 3:00 AM on 03/04/18. She stated she called the police. Interview with LPN #1, on 03/07/18 at 11:40 AM, revealed she had worked with CNA #1 for a few months and the employee was quiet and cooperative. She stated she was on the opposite hall working but CNA #1 came to her hall to place items in the dirty linen around 1:00 AM. She stated she heard CNA #2 and RN #1 yell. LPN #1 stated she got up from the desk and saw someone running but they were running so fast she could not even tell who it was. She stated she went to the door and saw CNA #1 going to the parking lot. LPN #1 stated she gathered the paperwork to send Resident #1 to the ER and watched the halls. Interview with LPN #2, on 03/07/18 at 1:30 PM, revealed she had noted a pinkish purple area to Resident #1's labia on 03/05/18 (after the incident) and the night nurse (LPN #3) had noted the shift prior. She stated she had not noticed that area to the labia before. Interview with the DON, on 03/07/18 at 10:10 AM and 11:55 AM, and on 03/08/18 at 4:33 PM, revealed she felt CNA #2 walked in at the right time as CNA #1 was grooming Resident #1 for more things. She stated this was evident by the washcloths on the floor indicating he was bathing the resident, grooming him/her for the act. She stated when the police arrived they removed all the linen for evidence. The DON stated video footage of the exits and nurses' station revealed CNA #1 was seen at the desk with a roll of trash bags in his hand headed toward the back part of the hall where Resident #1's room was at 2:03 AM. She stated she expected staff to be supervised and follow the policy and expected residents to be free from abuse. Review of CNA #1's Personnel Record revealed CNA #1 was hired on 10/27/17. Further review revealed there was no documented evidence two (2) reference checks were conducted prior to hire, as were required per the facility's policy. Interview with the DON, on 03/07/18 at 10:10 AM, validated there were no reference checks completed on CNA #1. Further review revealed abuse education was provided upon hire on 10/27/17; with no additional abuse education provided to CNA #1, according to the DON. Further interview (Post Survey) with the DON, on 04/10/18 at 9:04 AM revealed the facility's policies, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 12/11/17, and Employment References, dated 08/01/99 and last reviewed/revised 12/01/07, were the current policies. Even though the facility's Employment References policy stated, The hiring manager is expected to contact no less than two (2) of the candidate's most recent work references., the DON stated she was not aware reference checks were not being completed and staff were hired based on personal interviews. The DON stated the reference checks should have been obtained before the employee started working on the floor; however, review of the facility's Employment Reference policy revealed reference checks should be obtained before employment decisions were made. She stated she expected reference checks to be completed by the Staff Development Coordinator. In addition, she stated the facility had no system in place to identify residents who were vulnerable for abuse. Interview with the Administrator, on 03/15/18 at 3:00 PM, revealed the DON was the Abuse Coordinator. He stated it was the responsibility of the DON and the Administrator to protect the residents and ensure they received care. He further stated he expected reference checks to be completed prior to hire as part of the policy. Interview (Post Survey) on 04/10/18 at 9:04 AM revealed he was responsible to monitor the reference checks to ensure they were being done and was not aware the checks were not being done. He further stated he could have done a better job at monitoring. He stated according to the policy the department managers were to obtain two (2) reference checks and it was better if the reference checks were obtained prior to hire. He revealed he expected other department heads to obtain reference checks for their potential employees. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 03/04/18 Resident #1 was immediately assessed by Registered Nurse (RN) #1 after the sexual assault occurred and sent to the emergency room for evaluation. Upon return from the hospital the resident was reassessed by Team Leader #3. Hourly rounding was completed for twenty-four (24) hours and daily assessment by the Charge Nurse to assess for distress for five (5) days by the RN and LPN Charge Nurses. 2. The Licensed Social Worker (LSW) visited the resident on 03/05-03/07/18 with no changes identified. 3. On 03/07/18, the DON reviewed the two (2) incidents that were investigated from 10/27/18 through 03/04/18 in which she ruled out abuse and no connection between CNA #1 and Resident #1. 4. On 03/04/18, RN #1 assessed Resident #1's roommate and he/she was found to be sleeping soundly. 5. Skin assessments on every resident in the facility began on 03/04/18 by the Team Leaders and Charge Nurses. Cognitive residents were interviewed by the Team Leaders and Charge Nurses. Residents with a BIMS' score of 0-7 or moderately or severely impaired for cognitive skills of daily decision making were interviewed by the Team Leaders and Charge Nurses, when able and/or received every shift behavior monitoring, staff assessment for pain or charting that ruled out signs and symptoms of distress. The behavior monitoring and pain monitoring were in place prior to and after the incident. Behavior Monitoring for residents with psychoactive medications or with behaviors were on the MARs for residents with BIMS 0-7 prior to and after the incident. Residents with BIMS score of 0-7 as well as those moderately or severely impaired for cognitive skills of daily decision making had an additional observation task entered on the Medication Administration Record [REDACTED]. 6. On 03/04/18, 100% of staff on duty during the 11:00 PM-7:00 AM shift were interviewed regarding any knowledge of the event or suspected abuse prior to leaving their shift by the ADON regarding abuse protocols. On 03/04/18 or 03/05/18, 100% of staff were called and interviewed by the Administrator, DON, ADON, and Department Heads regarding preventing, recognizing and reporting abuse based on the event. 7. On 03/07/18, Urinary Tract Infection rates were reviewed by the ADON for the dates 11/01/17 through 02/28/18. On 03/07/18, residents' charts with increased depression and PHQ9 (mood indicator scoring) scores were reviewed by LPNs and RN Charge Nurses to identify any potential indicators. On 03/07/18, the DON reviewed investigation of bruises of unknown origins from 11/01/17 through 03/05/18. 8. On 03/05/18, the Administrator, DON, RN, and Team Leaders called the Responsible Parties for all residents to share that an incident had occurred at the center. All but five (5) responsible parties were reached on 03/05/18. 9. On 03/04/18-03/06/18, 100 % of staff were inserviced either by phone or in person by the Administrator, DON, ADON, and Department Heads regarding preventing, recognizing and reporting abuse based on this event. 10. On 03/07/18, the Center began a more thorough process of screening new hires and conducting reference checks overseen by the Administrator. This process was in-serviced by the Administrator on 03/07/18 to all the Department Heads. 11. On 03/07/18, overseen by the Administrator, 100% of personnel files of current staff were audited for presence of background check, abuse registry and reference checks. On 03/08/18, 100% of remaining files of current staff had completed evaluations or reference checks that were obtained on 03/08/18. An audit will be conducted every month for three (3) months and overseen by the Administrator. 12. On 03/08/18, a Licensed Social Worker from the area spoke to staff regarding recognizing and dealing with stress. 13. On 03/04/18, the DON and Corporate staff began an audit to monitor staff knowledge of abuse awareness and protocols for 100% of staff. This monitor of staff knowledge will continue for three (3) months and will be monitored by the DON and Administrator and brought to Quality Assurance meetings for three (3) months to be reviewed. This audit will determine effectiveness of abuse training and education. 14. On 03/04/18, a QA audit tool will continue to be used on thirty (30) residents with BIMS score of 8-15 every month for three (3) months to ask those residents of any concerns with staff. These audits will be brought to the QA meeting and the Administrator and DON will oversee the monitor. 15. After the initial skin assessment on all residents on the day of the event on 03/04/18, on 03/07/18 Charge Nurses will perform an additional skin assessment weekly on ten (10) residents for the residents with a BIMS score of 0-7, or with cognitive skills for daily decision making moderately or severely impaired. These checks will continue through 04/30/18. 16. On 03/07/18, an additional check to monitor for abuse signs and symptoms was added to the MAR indicated [REDACTED]. These checks will continue through 04/30/18. The Administrator and DON will oversee the QA monitor. 17. On 03/06/18, a Root Cause Analysis brainstorming formal meeting was held. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's Nurse's Notes dated 03/04/17 at 2:45 AM revealed the resident was assessed for presence for breath, vital signs, and demeanor. The doctor was notified and the resident sent to the emergency room . Review of Skin Assessment on 03/04/18 at 6:15 AM by Team Leader #3 revealed skin assessment was completed with no redness or bruising to thighs/buttocks/vaginal area. Unable to interview due to cognitive decline. Review of Nurse's Notes on 03/04/18 starting at 7:00 AM until 10:00 AM revealed hourly rounding. Review of (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with RN #1 on 03/06/18 at 2:55 PM revealed she assessed Resident #1 after the incident occurred. She stated the resident was talking nonsensical as normal for the resident. She stated the resident did not have a brief on and she did not see any bleeding. RN#1 revealed she also performed an assessment on the resident when he/she returned to the facility on [DATE] at 5:45 AM. Interview with Team Leader #3 on 03/07/18 at 2:36 PM revealed she performed skin assessment on Resident #1 and the resident had red areas to feet and ankles as the facility was already treating. She further stated she looked at the labia area and noted nothing out of the normal for the resident. Interview with RN #2 on 03/14/18 at 3:21 PM revealed the nurses monitor for physical and mental distress for residents that are not cognitively able to tell us if there is a problem. 2. Review of Social Service Notes dated 03/05/18, 03/06/17, and 03/07/18 revealed resident resting comfortably in bed with no change noted from usual demeanor. Interview with the Licensed Social Worker on 03/15/18 at 2:40 PM revealed she visited Resident #1 on 03/05/18, 03/06/18, and 03/07/18 and did not notice any changes in the resident's behavior. 3. Review of an Incident Detail Report dated 03/07/18 revealed two (2) incidents from 10/27/17-03/04/18. Resident #1 had two (2) incidents. One (1) incident, an injury of unknown source, was on 02/08/18. Another incident, a bruise, was on 02/17/18. In addition, there was a total of three (3) bruises of unknown origin from 11/01/17-03/05/18. Review of the root cause analysis performed on 03/07/18 of the incidents by the DON the causative actions/factors ruled out abuse. Interview with the DON on 03/08/18 at 3:00 PM revealed she reviewed incidents of Resident #1 and other residents with injury of unknown source since CNA #1 had been employed at the facility. CNA #1 was not working with the resident when the incident was determined to occurred on 02/02/17. It was determined when two (2) female staff were providing perineal care on 02/02/18 they were trying to separate his/her legs to clean the resident as his/her legs were contracted and the pulling caused a bruise to the right groin area. She stated the incident on 02/17/18 revealed the resident was noted to be biting his/her lip and staff found a small bruise on his/her lower lip on afternoon shift. She reviewed the staffing and found that CNA #1 did not work with Resident #1 on 02/16/18. 4. Review of Nurse's Notes dated 03/05/18 at 3:55 PM late entry for 03/04/18 approximately 1:45 AM revealed RN #1 documented Resident's #1's roommate was noted to sleeping quietly and did not wake up through the process of sending Resident #1 to the emergency room . Interview with RN #1 on 03/06/18 at 03/06/18 at 2:55 PM revealed when she came into the room after hearing CNA #1 screaming she saw Resident #1's roommate still asleep. 5. Review of Resident Census dated 03/04/18 and skin assessments dated 03/04/18 revealed all residents received a skin assessment after the incident. Review of the skin assessments revealed communicative residents were interviewed by the RN, Charge Nurses, and Team Leaders with directed questions of inappropriate touching by anyone at the facility, or afraid of any staff at the facility. This included questioning of residents with BIMS of 0-7 as well as those moderately or severely impaired for cognitive skills of daily decision making. Review of facility audit of resident's BIMS 0-7, moderately and severely impaired residents dated 03/07/18 revealed the facility reviewed a list of non-interviewable residents and determined there were forty-nine (49) residents that were either moderately impaired, severely impaired, BIMS 0-7, or residents the staff felt unable to or did not answer the abuse questions. Of those residents nineteen (19) residents were able to answer the directed questions regarding abuse; eighteen (18) of those residents had behavior monitoring in place previous to the incident due to [MEDICAL CONDITION] medications or previous behaviors; eight (8) of those residents had pain monitoring prior to and after the incident; one (1) of those residents had pain and behavior monitoring prior to and after the incident; and three (3) residents did not have monitoring. Review of those resident's (MONTH) (YEAR) MARs revealed the facility reviewed the resident's pain and behaviors from (MONTH) 1-7 on 03/07/18 and the facility added an additional observation task entered on the MAR for those residents on 03/07/18 to assess for symptoms of abuse. Interviews on 03/07/18 with LPN #2 at 1:30 PM, the Minimum Data Sets (MDS) Coordinator at 1:50 PM, Team Leader #1 at 2:24 PM, Team Leader #2 at 2:30 PM, and Team Leader #3 at 2:36 PM revealed they received phone calls around 3:00 AM-3:30 AM on 03/04/18 to come into the facility. When they arrived they began head to toe skin assessments on all residents in the building as well as asked the residents if they felt comfortable at the facility or if anyone had inappropriately touched them at the facility. Interview with the DON on 03/14/18 at 10:00 AM revealed on 03/07/18 the pain and behaviors on the MARs for residents BIMS 0-7 were reviewed to look for any changes in pain and behaviors prior to 03/04/18 and compared to present day (03/07/18) and none were found. Interview with Team Leader #1 on 03/15/18 at 2:06 PM revealed she assisted with adding the signs and symptoms of physical and mental distress to the MAR indicated [REDACTED]. 6. Review of written statements on 03/04/18 revealed 100% of staff on duty during the 11:00 PM to 7:00 AM shift were interviewed regarding any knowledge of event or suspected abuse prior to leaving their shift by the ADON. Review of Master Inservice Attendance Record dated 03/04/18-03/05/18 revealed 100% of staff were called and interviewed by the Administrator, DON, ADON, and Department Heads regarding preventing, recognizing and reporting abuse based on this event and found no further areas of concerns. Interviews on 03/14/18 with Licensed Practical Nurse (LPN) #4 at 2:46 PM, CNA #8 at 3:00 PM, and RN #2 at 3:21 PM revealed they were interviewed regarding CNA #1 as well as received abuse training for reporting and recognizing abuse. Interview with CNA #9 on 03/14/18 at 3:34 PM and CNA #10 at 3:42 PM revealed they were educated on abuse on 03/05/18 regarding abuse. Interview on 03/15/18 with MDS at 2:19 PM revealed she received inservice on 03/04/18 regarding abuse and how to recognize and report suspected abuse. Interview with the ADON on 03/07/18 at 2:11 PM revealed she gathered staff interviews on 03/04/18 as well as began education on abuse. Interview with the Administrator on 03/15/18 at 3:00 PM revealed he was part of the education to staff on abuse that took place on 03/05/18 and 03/04/18. 7. Review of facility's Urinary Tract Infections [MEDICAL CONDITION] audit dated 03/07/18 revealed UTIs were reviewed (MONTH) (YEAR)-February (YEAR) by the ADON with a decrease in UTIs noted. Review of the facility PHQ-9 Audit dated 03/07/18 revealed residents were reviewed for increased depression and those residents were reviewed by the Nurses on 03/07/18 to identify potential indicators. Review of the residents with an increase in PHQ-9 score revealed the Licensed Social Worker (LSW) met with the residents to assess. Interview with the ADON on 03/15/18 at 2:52 PM revealed she performed an audit on UTIs from (MONTH) (YEAR) to (MONTH) (YEAR) and there was a decrease in UTIs. Interview with MDS on 03/15/18 at 2:19 PM revealed she and the Coordinator gathered from the MDS the last PHQ-9 score prior to CNA #1 hire date and then the most recent and compared to determine if there was an increase in mood. She stated if there was an increase in mood we gave the list to the LSW after performing a root cause on each one. Interview with the LSW on 03/15/18 at 2:40 PM revealed MDS gave her a list of residents with an increase in PHQ-9 scores for residents with a BIMS 0-7. She stated she interviewed those residents on 03/07/18 and no concerns were noted. Those residents unable to verbalize, she noted no facial expressions of fear/anxiety. 8. Review of Resident Census Report dated 03/05/18 revealed each resident was listed with a staff member's name who called the family member or responsible party to report of the incident that had occurred on 03/04/18. Interview with the DON

Based on interview, record review, Personnel Record Review, facility investigation review, and review of the facility's policy and procedures titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, it was determined the facility failed to have an effective system to implement written policies and procedures which included prevention of abuse, identification, assessment, care planning and monitoring for one (1) of three sampled residents (Resident #1). The facility failed to have a system to assess and identify if non-interviewable residents required emotional and medical support from alleged abuse. In addition, the facility failed to check references and obtain information from previous employers and current employers for three (3) of three (3) sampled employees (who are agents of the facility) prior to hire (Certified Nurse Aide {CNA} #1, CNA #3, and Licensed Practical Nurse {LPN} #4). CNA #1 was hired on 10/27/17; however, the facility failed to implement their policy and obtain two (2) reference checks on CNA #1 prior to hire. On 03/14/18, the facility failed to protect Resident #1 from sexual abuse by CNA #1, who is considered an agent of the facility. CNA #2 entered Resident #1's room and found CNA #1 between Resident #1's legs in the resident's bed. CNA #1 jumped off the bed and continued to masturbate, then ran out of the room and out of the facility. After the allegation of sexual abuse of Resident #1 was made, the facility failed to identify vulnerable residents who may require emotional and medical support suffering from alleged abuse. The facility's failure to ensure the facility's Abuse and Employment Policies were implemented has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on 03/07/18 and determined to exist on 03/04/18. The facility was notified of the Immediate Jeopardy on 03/07/18. An acceptable Allegation of Compliance (AoC) was received on 03/09/18 alleging the Immediate Jeopardy was removed on 03/09/18. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 03/09/18 as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: 1. Review of the facility's policy, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 08/01/01 and revised on 12/11/17, revealed abuse, neglect, misappropriation of resident property and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, residents, consultants, volunteers, family members or legal guardians, friends, visitors or any other individual in this Center. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Center's Administrator is responsible for assuring that resident safety, including freedom from risk of abuse or neglect, holds the highest priority. Further review revealed medical and emotional support will be made immediately available to any individual suffering either alleged abuse, neglect, misappropriation of patient property or exploitation. In addition, it stated to check references for all applicants and obtain information from previous employers and current employers (with applicant permission). Review of the facility's policy, Employment References, dated 08/01/99 and reviewed/revised 12/01/07, revealed the company views obtaining relevant work or professional reference information on applicants for employment as an important part of the selection process. Furthermore, the hiring manager is responsible for obtaining valid, relevant work reference information on applicants before employment decisions are made. The hiring manager is expected to contact no less than two (2) of the candidate's most recent work references. References should be obtained verbally, documented on the company provided applicable form, Reference Checks and Verification of Credentials Reference Release Form and filed separately from the candidate's file. Interview (Post Survey) with the Director of Nursing (DON), on 04/10/18 at 9:04 AM revealed the facility's policies, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 12/11/17, and Employment References, dated 08/01/99 and last reviewed/revised 12/01/07, were the current policies. Review of Resident #1's Nurse's Notes dated 03/04/18 at 2:45 AM through 3:14 AM, and interviews on 03/06/18 with Registered Nurse (RN) #1 at 2:30 PM and CNA #2 at 3:27 PM revealed CNA #2 entered Resident #1's room and observed CNA #1 on Resident #1's bed in between Resident #1's legs hunched forward toward the resident, with the back of his pants up. The resident's right leg was externally rotated out and the left leg was bent in the upward position. CNA #1 jumped off the bed when he heard CNA #2. His (CNA #1) pants were down in the front and he was masturbating. CNA #2 screamed for him to stop and hollered for RN #1. RN #1 ran to the room and CNA #1 came running out of the room and down the hall and out of the facility. The Police, Administrator, and Assistant Director of Nursing were called and the resident was sent to the emergency room for evaluation. Interview with the Police Detective, on 03/07/18 at 1:35 PM, revealed CNA #1 was arrested on 03/04/18 and charged with sexual assault first degree based on witness testimony. Review of the facility's abuse policy revealed, Medical and emotional support will be made immediately available to any individual suffering alleged abuse . However, review of the facility's investigation, dated 03/04/18, revealed there was no documented evidence the facility had taken any action to identify if any non-interviewable residents were showing any behaviors/psychosocial changes that could be signs of abuse that may require medical and/or emotional support. Review of the facility census on 03/06/18 and the facility provided Brief Interview for Mental Status (BIMS) list dated 03/05/18 revealed thirty-one (31) of eighty-five (85) residents had a BIMS score of 0-7 indicating the residents' cognition was severely impaired and the residents were not interviewable. Interview with the Minimum Data Set (MDS) Coordinator on 03/07/18 at 1:50 PM revealed she came in at approximately 3:30 AM on 03/04/18 and began skin assessments on the residents and interviewed residents to identify if they had been abused. However, the residents unable to answer questions, only received a skin assessments. Interview with the MDS Licensed Practical Nurse (LPN) on 03/15/18 at 2:19 PM revealed the MDS staff pulled the PHQ-9 score (mood score) prior to 03/04/18 and a PHQ-9 score on 03/07/18 for the residents who were moderately and severely cognitively impaired and compared the scores. She stated if there was an increase in the score the Social Worker visited those residents. However, prior to 03/07/18 the facility had not reviewed changes in behaviors. Interview with the Licensed Social Worker on 03/15/18 at 2:40 PM revealed she visited Resident #1 the day after the event on 03/04/18. She stated she was given a list by the MDS staff of the residents with an increase in PHQ-9 scores for residents with BIMS less than eight (8) on 03/07/18. She stated the residents that were unable to verbalize yes or no were observed for facial expressions of fear or anxiety. Interview with the Director of Nursing (DON), on 03/07/18 at 10:10 AM, revealed the facility's Licensed Practical Nurses (LPN's) and Registered Nurses (RN's) had performed a skin assessment on every resident and asked interviewable residents if anyone harmed them or touched them inappropriately. Even though the facility's policy stated, medical and emotional support will be made immediately available to any individual suffering .alleged abuse . , The DON stated the facility had taken no action to address how they would determine if any non-interviewable residents were displaying any signs of behavior and/or psychosocial changes which could indicate abuse. Further interview, on 03/08/18 at 4:33 PM, revealed the plan after the incident should have included assessing non-interviewable residents for behavior/psychosocial changes that could indicate possible abuse. Interview (Post Survey) on 04/10/18 at 9:04 AM revealed a couple days after the event occurred the facility determined the non-interviewable residents by the resident's BIMS score and their ability to communicate. She stated there was nothing in place to monitor for abuse on a daily basis. The DON stated the initial approach was a skin assessment on all residents looking for obvious signs. Continued interview revealed all residents had a routine pain assessment every shift and if they were on a psychoactive medication, the behaviors were monitored on the Medication Administration Record [REDACTED]. The DON stated in her earlier interview on 03/07/18, the psychosocial changes that would be indicators of abuse would include being withdrawn, sucking on hands, increased behaviors, increased pain, decreased appetite, difficulty sleeping, and guarding. She stated the items that would indicate abuse and the psychosocial changes were the items added to the MAR indicated [REDACTED]. Interview with the Regional Nurse Consultant, on 03/07/18 at 5:50 PM, revealed the facility did not specifically monitor for behaviors/psychosocial changes for non-interviewable residents after the incident on 03/04/18. The facility presented a list dated 03/05/18, which revealed thirty-one (31) of eighty-five (85) residents had a BIMS score of 0-7 indicating the residents were not interviewable. 2. Review of personnel records revealed the facility failed to check references and obtain information from previous employers and current employers prior to hire for three (3) employees. However, review of the facility's policy and procedures revealed the facility would check references for all applicants and obtain information from previous employers and current employers. In addition, review of the facility's policy revealed, the hiring manager is responsible for obtaining valid, relevant work reference information on applicants before employment decisions are made. The hiring manager is expected to contact no less than two (2) of the candidate's most recent work references. References should be obtained verbally, documented on the company provided applicable form, Reference Checks and Verification of Credentials Reference Release Form and filed separately from the candidate's file. Review of CNA #1's Personnel Record revealed CNA #1 was hired on 10/27/17. Further review revealed there was no documented evidence reference checks were conducted prior to hire. Interview with the DON, on 03/07/18 at 10:10 AM, validated there were no reference checks completed on CNA #1 per facility policy Review of CNA #3's Personnel Record revealed she was hired on 10/27/17; however, further review revealed there was no documented evidence reference checks were conducted per facility policy. Review of LPN #4's Personnel Record revealed she was hired on 01/19/18; however, further review revealed there was no documented evidence reference checks were conducted per facility policy. Interview with the Business Office Manager (BOM), on 03/08/18 at 3:45 PM, revealed she entered the paperwork into the system and the DON conducted the interviews. She stated the Staff Development Coordinator (SDC) was responsible to perform reference checks on staff. She stated the Receptionist was the SDC a year ago and had a checklist to go by which included ensuring the reference checks were completed, but this was not being done. She further stated the roles changed within a year and that could have been the breakdown with the reference checks not being completed. She stated the breakdown of reference checks not being completed was revealed when the State Survey Agency came in to the building. Further interview revealed the facility has now audited all employees' personnel files and determined only six (6) of one-hundred and fourteen (114) employees had two (2) reference checks, as required by policy. She stated only one (1) reference check was performed on the remaining one-hundred and eight (108) employees who had not had any reference checks completed, even though the policy stated two (2) would be completed. The BOM stated the department heads should have been using the facility reference check form to validate references. Interview with the Receptionist, on 03/08/18 at 3:55 PM, revealed each department head was responsible for their own reference checks and the SDC was responsible for nursing. She stated when she left the SDC position she trained the new SDC on that role. She stated as the receptionist she did not look for a checklist or reference checks as she was not aware they went into the personnel file. Interview with the SDC, on 03/08/18 at 3:51 PM, revealed she was not aware who was responsible for performing reference checks on staff as she had only been in the SDC position for a couple of months. She stated she was told yesterday (03/07/18) that performing reference checks was part of her job and that the reference check form would be stapled to the application. Interview with the Assistant Director of Nursing (ADON) on 03/07/18 at 2:11 PM revealed she performed orientation with the SDC and the SDC was responsible for performing reference checks. Further interview with the DON, on 03/08/18 at 2:46 PM and 4:33 PM, revealed the Receptionist and SDC were responsible to perform reference checks on staff as she had made a new form for this process a couple months ago. She stated she expected reference checks to be done by the SDC. Interview (Post Survey) on 04/10/18 at 9:04 AM revealed she was not aware reference checks were not being completed and she hired staff based on a personal interview. She stated the Reference checks should be completed prior to the employee working the floor, however the Employment Reference policy stated, relevant work reference information on applicants are to be obtained before employment decisions are made. She stated she had inserviced the Receptionist, who was the SDC at the time, on the new Reference Verification Upon Employment Form and would have expected the form to be completed. Furthermore, she stated when the Receptionist trained the new SDC she would have expected her to train her on the Reference Form. Interview with the Administrator, on 03/15/18 at 3:00 PM, revealed he expected reference checks to be performed prior to hire as it is part of the facility's abuse policy. Interview (Post Survey) on 04/10/18 at 9:04 AM revealed he was responsible to monitor the reference checks and should have been doing a better job as he was not aware reference checks were not being done. The Administrator stated the department managers were to obtain two (2) reference checks per facility policy and it was better to obtain the reference checks before the employee was hired. He revealed all the department managers failed to perform reference checks as indicated on the facility audit. He stated there was not a consistent system in place to determine if reference checks were being completed. During further interview, he stated if a reference check was not completed until an employee started to work on the floor, and if a bad reference check was received, it would be grounds for termination and the staff would be terminated on the spot. However, since there was no system in place to monitor reference checks, staff who had bad reference checks would not be identified and stopped from providing resident care. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 03/04/18 Resident #1 was immediately assessed by Registered Nurse (RN) #1 after the sexual assault occurred and sent to the emergency room for evaluation. Upon return from the hospital the resident was reassessed by Team Leader #3. Hourly rounding was completed for twenty-four (24) hours and daily assessment by the Charge Nurse to assess for distress for five (5) days by the RN and LPN Charge Nurses. 2. The Licensed Social Worker (LSW) visited the resident on 03/05-03/07/18 with no changes identified. 3. On 03/07/18, the DON reviewed the two (2) incidents that were investigated from 10/27/18 through 03/04/18 in which she ruled out abuse and no connection between CNA #1 and Resident #1. 4. On 03/04/18, RN #1 assessed Resident #1's roommate and he/she was found to be sleeping soundly. 5. Skin assessments on every resident in the facility began on 03/04/18 by the Team Leaders and Charge Nurses. Cognitive residents were interviewed by the Team Leaders and Charge Nurses. Residents with a BIMS' score of 0-7 or moderately or severely impaired for cognitive skills of daily decision making were interviewed by the Team Leaders and Charge Nurses, when able and/or received every shift behavior monitoring, staff assessment for pain or charting that ruled out signs and symptoms of distress. The behavior monitoring and pain monitoring were in place prior to and after the incident. Behavior Monitoring for residents with psychoactive medications or with behaviors were on the MARs for residents with BIMS 0-7 prior to and after the incident. Residents with BIMS score of 0-7 as well as those moderately or severely impaired for cognitive skills of daily decision making had an additional observation task entered on the Medication Administration Record [REDACTED]. 6. On 03/04/18, 100% of staff on duty during the 11:00 PM-7:00 AM shift were interviewed regarding any knowledge of the event or suspected abuse prior to leaving their shift by the ADON regarding abuse protocols. On 03/04/18 or 03/05/18, 100% of staff were called and interviewed by the Administrator, DON, ADON, and Department Heads regarding preventing, recognizing and reporting abuse based on the event. 7. On 03/07/18, Urinary Tract Infection rates were reviewed by the ADON for the dates 11/01/17 through 02/28/18. On 03/07/18, residents' charts with increased depression and PHQ9 (mood indicator scoring) scores were reviewed by LPNs and RN Charge Nurses to identify any potential indicators. On 03/07/18, the DON reviewed investigation of bruises of unknown origins from 11/01/17 through 03/05/18. 8. On 03/05/18, the Administrator, DON, RN, and Team Leaders called the Responsible Parties for all residents to share that an incident had occurred at the center. All but five (5) responsible parties were reached on 03/05/18. 9. On 03/04/18-03/06/18, 100 % of staff were inserviced either by phone or in person by the Administrator, DON, ADON, and Department Heads regarding preventing, recognizing and reporting abuse based on this event. 10. On 03/07/18, the Center began a more thorough process of screening new hires and conducting reference checks overseen by the Administrator. This process was in-serviced by the Administrator on 03/07/18 to all the Department Heads. 11. On 03/07/18, overseen by the Administrator, 100% of personnel files of current staff were audited for presence of background check, abuse registry and reference checks. On 03/08/18, 100% of remaining files of current staff had completed evaluations or reference checks that were obtained on 03/08/18. An audit will be conducted every month for three (3) months and overseen by the Administrator. 12. On 03/08/18, a Licensed Social Worker from the area spoke to staff regarding recognizing and dealing with stress. 13. On 03/04/18, the DON and Corporate staff began an audit to monitor staff knowledge of abuse awareness and protocols for 100% of staff. This monitor of staff knowledge will continue for three (3) months and will be monitored by the DON and Administrator and brought to Quality Assurance meetings for three (3) months to be reviewed. This audit will determine effectiveness of abuse training and education. 14. On 03/04/18, a QA audit tool will continue to be used on thirty (30) residents with BIMS score of 8-15 every month for three (3) months to ask those residents of any concerns with staff. These audits will be brought to the QA meeting and the Administrator and DON will oversee the monitor. 15. After the initial skin assessment on all residents on the day of the event on 03/04/18, on 03/07/18 Charge Nurses will perform an additional skin assessment weekly on ten (10) residents for the residents with a BIMS score of 0-7, or with cognitive skills for daily decision making moderately or severely impaired. These checks will continue through 04/30/18. 16. On 03/07/18, an additional check to monitor for abuse signs and symptoms was added to the MAR indicated [REDACTED]. These checks will continue through 04/30/18. The Administrator and DON will oversee the QA monitor. 17. On 03/06/18, a Root Cause Analysis brainstorming formal meeting was held. **The State Survey Agency validated the corrective action taken by the facility as follows: 1. Review of Resident #1's Nurse's Notes dated 03/04/17 at 2:45 AM revealed the resident was assessed for presence for breath, vital signs, and demeanor. The doctor was notified and the resident sent to the emergency room . Review of Skin Assessment on 03/04/18 at 6:15 AM by Team Leader #3 revealed skin assessment was completed with no redness or bruising to thighs/buttocks/vaginal area. Unable to interview due to cognitive decline. Review of Nurse's Notes on 03/04/18 starting at 7:00 AM until 10:00 AM revealed hourly rounding. Review of (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with RN #1 on 03/06/18 at 2:55 PM revealed she assessed Resident #1 after the incident occurred. She stated the resident was talking nonsensical as normal for the resident. She stated the resident did not have a brief on and she did not see any bleeding. RN#1 revealed she also performed an assessment on the resident when he/she returned to the facility on [DATE] at 5:45 AM. Interview with Team Leader #3 on 03/07/18 at 2:36 PM revealed she performed skin assessment on Resident #1 and the resident had red areas to feet and ankles as the facility was already treating. She further stated she looked at the labia area and noted nothing out of the normal for the resident. Interview with RN #2 on 03/14/18 at 3:21 PM revealed the nurses monitor for physical and mental distress for residents that are not cognitively able to tell us if there is a problem. 2. Review of Social Service Notes dated 03/05/18, 03/06/17, and 03/07/18 revealed resident resting comfortably in bed with no change noted from usual demeanor. Interview with the Licensed Social Worker on 03/15/18 at 2:40 PM revealed she visited Resident #1 on 03/05/18, 03/06/18, and 03/07/18 and did not notice any changes in the resident's behavior. 3. Review of an Incident Detail Report dated 03/07/18 revealed two (2) incidents from 10/27/17-03/04/18. Resident #1 had two (2) incidents. One (1) incident, an injury of unknown source, was on 02/08/18. Another incident, a bruise, was on 02/17/18. In addition, there was a total of three (3) bruises of unknown origin from 11/01/17-03/05/18. Review of the root cause analysis performed on 03/07/18 of the incidents by the DON the causative actions/factors ruled out abuse. Interview with the DON on 03/08/18 at 3:00 PM revealed she reviewed incidents of Resident #1 and other residents with injury of unknown source since CNA #1 had been employed at the facility. CNA #1 was not working with the resident when the incident was determined to occurred on 02/02/17. It was determined when two (2) female staff were providing perineal care on 02/02/18 they were trying to separate his/her legs to clean the resident as his/her legs were contracted and the pulling caused a bruise to the right groin area. She stated the incident on 02/17/18 revealed the resident was noted to be biting his/her lip and staff found a small bruise on his/her lower lip on afternoon shift. She reviewed the staffing and found that CNA #1 did not work with Resident #1 on 02/16/18. 4. Review of Nurse's Notes dated 03/05/18 at 3:55 PM late entry for 03/04/18 approximately 1:45 AM revealed RN #1 documented Resident's #1's roommate was noted to sleeping quietly and did not wake up through the process of sending Resident #1 to the emergency room . Interview with RN #1 on 03/06/18 at 03/06/18 at 2:55 PM revealed when she came into the room after hearing CNA #1 screaming she saw Resident #1's roommate still asleep. 5. Review of Resident Census dated 03/04/18 and skin assessments dated 03/04/18 revealed all residents received a skin assessment after the incident. Review of the skin assessments revealed communicative residents were interviewed by the RN, Charge Nurses, and Team Leaders with directed questions of inappropriate touching by anyone at the facility, or afraid of any staff at the facility. This included questioning of residents with BIMS of 0-7 as well as those moderately or severely impaired for cognitive skills of daily decision making. Review of facility audit of resident's BIMS 0-7, moderately and severely impaired residents dated 03/07/18 revealed the facility reviewed a list of non-interviewable residents and determined there were forty-nine (49) residents that were either moderately impaired, severely impaired, BIMS 0-7, or residents the staff felt unable to or did not answer the abuse questions. Of those residents nineteen (19) residents were able to answer the directed questions regarding abuse; eighteen (18) of those residents had behavior monitoring in place previous to the incident due to [MEDICAL CONDITION] medications or previous behaviors; eight (8) of those residents had pain monitoring prior to and after the incident; one (1) of those residents had pain and behavior monitoring prior to and after the incident; and three (3) residents did not have monitoring. Review of those resident's (MONTH) (YEAR) MARs revealed the facility reviewed the resident's pain and behaviors from (MONTH) 1-7 on 03/07/18 and the facility added an additional observation task entered on the MAR for those residents on 03/07/18 to assess for symptoms of abuse. Interviews on 03/07/18 with LPN #2 at 1:30 PM, the Minimum Data Sets (MDS) Coordinator at 1:50 PM, Team Leader #1 at 2:24 PM, Team Leader #2 at 2:30 PM, and Team Leader #3 at 2:36 PM revealed they received phone calls around 3:00 AM-3:30 AM on 03/04/18 to come into the facility. When they arrived they began head to toe skin assessments on all residents in the building as well as asked the residents if they felt comfortable at the facility or if anyone had inappropriately touched them at the facility. Interview with the DON on 03/14/18 at 10:00 AM revealed on 03/07/18 the pain and behaviors on the MARs for residents BIMS 0-7 were reviewed to look for any changes in pain and behaviors prior to 03/04/18 and compared to present day (03/07/18) and none were found. Interview with Team Leader #1 on 03/15/18 at 2:06 PM revealed she assisted with adding the signs and symptoms of physical and mental distress to the MAR indicated [REDACTED]. 6. Review of written statements on 03/04/18 revealed 100% of staff on duty during the 11:00 PM to 7:00 AM shift were interviewed regarding any knowledge of event or suspected abuse prior to leaving their shift by the ADON. Review of Master Inservice Attendance Record dated 03/04/18-03/05/18 revealed 100% of staff were called and interviewed by the Administrator, DON, ADON, and Department Heads regarding preventing, recognizing and reporting abuse based on this event and found no further areas of concerns. Interviews on 03/14/18 with Licensed Practical Nurse (LPN) #4 at 2:46 PM, CNA #8 at 3:00 PM, and RN #2 at 3:21 PM revealed they were interviewed regarding CNA #1 as well as received abuse training for reporting and recognizing abuse. Interview with CNA #9 on 03/14/18 at 3:34 PM and CNA #10 at 3:42 PM revealed they were educated on abuse on 03/05/18 regarding abuse. Interview on 03/15/18 with MDS at 2:19 PM revealed she received inservice on 03/04/18 regarding abuse and how to recognize and report suspected abuse. Interview with the ADON on 03/07/18 at 2:11 PM revealed she gathered staff interviews on 03/04/18 as well as began education on abuse. Interview with the Administrator on 03/15/18 at 3:00 PM revealed he was part of the education to staff on abuse that took place on 03/05/18 and 03/04/18. 7. Review of facility's Urinary Tract Infections [MEDICAL CONDITION] audit dated 03/07/18 revealed UTIs were reviewed (MONTH) (YEAR)-February (YEAR) by the ADON with a decrease in UTIs noted. Review of the facility PHQ-9 Audit dated 03/07/18 revealed residents were reviewed for increased depression and those residents were reviewed by the Nurses on 03/07/18 to identify potential indicators. Review of the residents with an increase in PHQ-9 score revealed the Licensed Social Worker (LSW) met with the residents to assess. Interview with the ADON on 03/15/18 at 2:52 PM revealed she performed an audit on UTIs from (MONTH) (YEAR) to (MONTH) (YEAR) and there was a decrease in UTIs. Interview with MDS on 03/15/18 at 2:19 PM revealed she and the Coordinator gathered from the MDS the last PHQ-9 score prior to CNA #1 hire date and then the most recent and compared to determine if there was an increase in mood. She stated if there was an increase in mood we gave the list to the LSW after performing a root cause on each one. Interview with the LSW on 03/15/18 at 2:40 PM revealed MDS gave her a list of residents with an increase in PHQ-9 scores for residents with a BIMS 0-7. She stated she interviewed those residents on 03/07/18 and no concerns were noted. Those residents unable to verbalize, she noted no facial expressions of fear/anxiety. 8. Review of Resident Census Report dated 03/05/18 revealed each resident was listed with a staff member's name who called the family member or responsible party to report of the incident that had occurred on 03/04/18. Interview with the DON on 03/07/18 at 10:10 AM revealed she assisted with calling the families on 03/05/15 to report the incident and asked if they had any questions related to the incident. Interview with Team Leader #3 on 03/07/18 at 2:36 PM revealed she participated in calling the families on 03/05/18. Interview with Team Leader #1 on 03/15/18 at 2:06 PM revealed she assisted with calling families on 03/05/18. Interview with the Administrator on 03/15/18 at 3:00 PM revealed the resident's families were divided among the department heads on 03/05/18 and the families were called. He further stated five (5) family members that were unable to be reached voicemail's were left. 9. Review of the Master Inservice Attendance Record dated 03/04/18-03/06/18 for review of Abuse Policy inservice revealed all staff signatures were completed. This inservice included the policy for recognizing, preventing, and reporting abuse. Interviews on 03/14/18 with Licensed Practical Nurse ( (TRUNCATED)

Based on interview, record review, review of the facility's policy and procedure, and review of the Hospital History and Physical, Hospital emergency room Note it was determined the facility failed to provide adequate supervision to prevent accidents for two (2) of nine (9) sampled residents (Resident #1 and Resident #2). Resident #2 was re-admitted to the facility on [DATE] from a psychiatric hospitalization with new orders for an antipsychotic medication, Haldol five (5) milligrams (mg) twice a day. On [DATE], the Consultant Pharmacist, during the monthly medication regimen review recommended a trial dose reduction of Haldol from five (5) mg to two and one half (2.5 mg). On [DATE], Resident #2 had a fall with injury and was noted at the time of the fall, to have a shuffling gait, which was a side effect of the Haldol. Resident #2 was diagnosed with [REDACTED]. The physician was notified of the shuffling gait; however, was not notified of the Consultant Pharmacist's recommendation. The physician ordered Cogentin, a medication to help reduce the side effects of the antipsychotic medication, Haldol. Resident #2 had a second fall three (3) days later on [DATE] resulting in three (3) additional fractures (his/her humerus, radius, and ulna). The physician was not made aware of the recommendation until [DATE], after the resident had sustained two (2) falls with injury. On [DATE], the facility assessed Resident #1 as dependent on two (2) staff for transfers; however, review of the care plan revealed an intervention for one (1) to two (2) staff to transfer. On [DATE], Resident #1 was lowered to the floor during a transfer when he/she was being transferred by one (1) Certified Nursing Assistant (CNA). Resident #1 sustained a fracture of the right fibula (leg bone) after the fall. The resident was assessed as having a significant decline in ADLs and expired at the facility on [DATE]. The facility's failure to provide adequate supervision to prevent accidents has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. The findings include: Review of the facility's policy and procedures titled "Accidents and Incident Investigations" not dated, revealed that when an accident occurs, the staff are to identify the activity and cause of the fall, perform a review of the resident's medication, update the care plan and ensure all appropriate parties are notified. 1. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed the resident as requiring the extensive physical assistance of two (2) plus persons for transfers. In addition, review of an Admission Nursing Assessment conducted on [DATE], revealed Resident #1 was totally dependent on two (2) plus staff for transfers. However, review of the Comprehensive Care Plan, dated [DATE], revealed an intervention to provide the assistance of one (1) to two (2) staff with transfers. Review of a Post Falls Nursing Assessment, dated [DATE], revealed one CNA was transferring Resident #1 from the bed to the chair on [DATE] at 9:30 AM, when the resident had to be lowered to the floor. There were no injuries identified at the time. However, review of a Hospital History and Physical, dated [DATE], revealed Resident #1 complained of right ankle pain and shortness of breath when he/she arrived at the hospital. An x-ray was conducted which revealed a displaced spiral fracture of the distal fibula. Interview with CNA #2, on [DATE] at 1:16 PM, revealed she was the primary aide for Resident #1 most of the time. She stated the resident had gotten weaker since his/her most recent hospitalization . CNA #2 stated, "Now I am doing everything for the resident because he/she just can't do it." She revealed she was no longer able to get the resident up to use the bedside commode per the care plan. She stated, "I just put the resident on the bed pan." Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 1:11 PM, revealed she was the nurse on duty at the time of Resident #1's fall. She stated she was called to the room by a CNA to assist with getting the resident back in bed which required several people to get him/her back in bed. She stated she assessed the resident and did not identify any injuries and the resident had no complaints of pain. LPN #2 stated at approximately 8:45 PM, she went to administer Resident #1's medication and the resident was "kind of shaky" and had decreased alertness. She stated the resident's oxygen saturation was eighty-four percent (84%) and the resident had no complaints of pain. LPN #2 stated she phoned the physician and sent the resident to the emergency room (ER) via ambulance. Interview with Registered Nurse (RN) #2, on [DATE] at 3:38 PM, revealed she was the nurse who completed the re-admission assessment for Resident #1. She stated the resident required a lot of care due to the Congestive Heart Failure and Chronic Pulmonary Disease. RN #2 stated Resident #1 had chronic pain and fluid overload. RN #2 stated the resident had been able to transfer and ambulate with the assistance of one (1) staff member before his/her hospitalization and she thought the CNAs would get two (2) staff if it was needed, therefore she did not update the Comprehensive Care Plan to ensure adequate supervision was provided. Interview with RN #3, MDS Coordinator, on [DATE] at 9:43 AM, revealed when a resident was readmitted to the facility from the hospital, the nurse completing the re-admission assessment would update the care plan based on any necessary changes and if an MDS was done, it would be reviewed at that time. She stated the care plan should be based on the resident's current conditions and diagnoses 2. Record review revealed the facility readmitted Resident #2 on on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change MDS assessment, dated [DATE], revealed the facility assessed the resident to require supervision only with transfers and ambulation. Review of Resident #2's Comprehensive Care Plan, dated [DATE], revealed Resident #2 was at risk for falls related to impaired balance during transitions and walking, and the use of multiple psychoactive medications. Interventions included to observe for unsafe actions such as unassisted transfers and intervene as needed. Review of a Post Falls Nursing Assessment and Falls Investigation Summary, dated [DATE], revealed Resident #2 had a fall on [DATE], and at the time of the fall the resident was observed shuffling his/her feet which caused him/her to fall. The resident was assessed immediately after the fall and it was noted that the resident had complaints of pain, rating the pain as an eight (8) out of ten (10) on the pain rating scale. The resident also had a two (2) centimeter laceration above his/her left eyebrow area with bruising and swelling. The resident's left eye was cleaned with normal saline and the resident was given a cold pack to the left eyebrow area. Review of the Comprehensive Care Plan, updated [DATE], revealed a referral screen for therapy related to shuffling gait and Cogentin, as ordered. Review of a physician's orders [REDACTED]. Review of the Post Falls Investigation, dated [DATE], revealed a physician's orders [REDACTED]. Further review of a Physician's Note, dated [DATE], revealed the resident sustained [REDACTED]. Review of a Post Falls Investigation, dated [DATE], revealed the resident had an unwitnessed fall on [DATE] at approximately 3:45 AM, when he/she was ambulating in the hall unsupervised. Resident #2 was assessed immediately after the fall and noted the resident to have complaints of pain to his/her right arm, rating the pain as a ten (10) out of ten (10) on the pain scale. Review of a Nurse's Note, dated [DATE] at 4:00 AM, revealed Resident #2 continued to complain of pain in his/her arm and stated he/she was unable to move his/her arm. Further review revealed the physician was notified and Resident #2 was sent to the emergency room . Review of a Hospital emergency room Note, dated [DATE], revealed Resident #2 received x-rays of his/her arm and was diagnosed with [REDACTED]. Further review revealed the resident received a splint to his/her right wrist and a sling for his/her right arm and was discharged back to the facility on [DATE]. Review of a Significant Change MDS Assessment, dated [DATE], revealed the facility had assessed Resident #2 as having severe cognitive impairment, and was rarely or never understood and unable to complete the Mental Status Assessment. In addition, the facility had assessed Resident #2 to require extensive, two (2) plus persons physical assist with bed mobility, transfer and ambulation. Review of a Consultant Pharmacy Recommendation, dated [DATE], revealed a recommendation for the physician to consider a trial dose reduction of Haldol (an antipsychotic medication), as there was no documented evidence of the resident exhibiting behaviors for the use of the medication. The Haldol was to be decreased from five (5) to two and a half milligram (2.5 mg) twice a day. Review of a physician's orders [REDACTED]. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:22 PM, revealed she phoned the physician to inform him of the resident's fall and noted shuffling gait (side effect of Haldol). The ADON stated she was not sure if the physician was aware of the Pharmacy Consultant's recommendation when she phoned to report the fall related to the shuffling gait. She stated she reported the shuffling gait, and he ordered Cogentin for the side effects of Haldol. Interview with the Director of Nursing (DON), on [DATE] at 3:37 PM, revealed the ADON and the Team Leaders work with the pharmacy recommendations to ensure they were addressed by the physician. She stated ultimately it was the DON's responsibility to make sure the pharmacy recommendations were addressed. She stated she was not sure how this was overlooked. Further interview revealed the physician should have been made aware of the Consultant Pharmacist's recommendations ([DATE]) at the time of the first fall ([DATE]). Further interview revealed Resident #1 did not receive a therapy evaluation at that time and the order was put on hold related to the new [DIAGNOSES REDACTED]. Additionally, the DON stated, "The care plan was not updated related to the falls, and it should have been." Interview with the Administrator, on [DATE] at 4:14 PM, revealed the physician should have been made aware of the Pharmacist's recommendations at the time of the first fall. Interview with the Consultant Pharmacist, on [DATE] at 1:04 PM, revealed the side effects of the Haldol could include a shuffling gait, abnormal movements and gait disturbance. Further interview revealed the side effects of Haldol were generally abrupt in nature but could develop at any time. She stated Cogentin was used to control the side effects of the Haldol. Further interview revealed if side effects developed the appropriate thing to do was to ask for a reduction. She stated, "If the physician had agreed to the trial dose reduction at the time of recommendation, it is possible the fall could have been avoided." Interview with Resident #2's Physician, on [DATE] at 9:12 AM, revealed he did not know if he was aware Resident #2 had a shuffling gait at the time of his/her fall. Additionally, he stated that he did not recall being made aware of the Consultant Pharmacist's recommendations ([DATE]) at the time of Resident # 2's fall on [DATE]. Additionally, he stated he ordered the medication, Cogentin when he was made aware of the shuffling gait. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE] through [DATE] the DON and RN/LPN Team Leaders audited the investigations of 100% of eighteen (18) residents that fell from [DATE] through [DATE] to ensure that previous investigation of the falls were appropriate. 2. On [DATE] the DON, RN/LPN Team Leaders and RN MDS Coordinator reviewed 100% of the care plans to ensure current physician orders, treatments, code status, diet orders, fall interventions, nursing tasks, therapy orders, adaptive equipment, and labs were included on the care plan. 3. On [DATE], the DON revised the falls review process which included daily meetings Monday through Friday to review the nursing notes, medications, care plan, staff statements, and details regarding the falls of any resident who had a fall. In addition, the falls team cross checks the pharmacy recommendations within the proceeding thirty (30) days. Additionally, any falls that occur after hours or on the weekend the DON or ADON is notified prior to the end of the shift to ensure appropriate interventions and actions were taken. 4. Beginning on [DATE], the CNAs will be interviewed by the RN/LPN team leaders, twelve (12) per week for five (5) weeks to ensure there understanding of the care plans. 5. All QA monitors will be reported to the QA Committee and will continue as directed by the QA Committee and Regional Nurse. The State Survey Agency validated the Corrective Action taken by the facility as follows: 1. Interview with the DON on [DATE] at 1:06 PM revealed she along with the RN/LPN Team Leaders audited the investigations of 100% of eighteen (18) residents that fell from [DATE] through [DATE] to ensure that previous investigation of the falls were appropriate. Interview with Team Leader (RN #5) on [DATE] at 9:51 AM revealed she audited the investigations of 100% of eighteen (18) residents that fell from [DATE] through [DATE] to ensure that previous investigation of the falls were appropriate. Interview with the Team Leader (LPN #1) on [DATE] at 10:27 AM revealed she audited the investigations of 100% of eighteen (18) residents that fell from [DATE] through [DATE] to ensure that previous investigation of the falls were appropriate. 2. Interview with the DON on [DATE] at 1:06 PM revealed she reviewed 100% of the care plans to ensure current physician orders, treatments, code status, diet orders, fall interventions, nursing tasks, therapy orders, adaptive equipment, and labs were included on the care plan. Interview with Team Leader (RN # 5) on [DATE] at 9:51 AM revealed she audited 100% of the care plans to ensure current physician orders, treatments, code status, diet orders, fall interventions, nursing tasks, therapy orders, adaptive equipment, and labs were included on the care plan. Interview with Team Leader (LPN # 1) on [DATE] at 10:27 AM, revealed she audited 100% of the care plans to ensure current physician orders, treatments, code status, diet orders, fall interventions, nursing tasks, therapy orders, adaptive equipment, and labs were included on the care plan. 3. Interview with the DON on [DATE] at 1:06 PM revealed she revised the falls review process which included daily meetings Monday through Friday to review the nursing notes, medications, care plan, staff statements, and details regarding the falls of any resident who had a fall. In addition, she stated the falls team cross checks the pharmacy recommendations within the proceeding thirty (30) days. Additionally, any falls that occur after hours or on the weekend the DON or ADON is notified prior to the end of the shift to ensure appropriate interventions and actions taken. 4. Interview on [DATE] with CNA #6 at 4:18 PM, CNA #7 at 4:20 PM, CNA #8 at 4:22 PM and CNA #9 at 4:25 PM, revealed they were interviewed by the RN/LPN Team Leaders related to the location and interventions on the residents care plans. 5. Interview with the Activities Director on [DATE] at 12:37 PM revealed she is a member of the QA Committee and has been informed of the progress and results of the audit tool and monitors in place at the facility. Interview with the Licensed Social Worker (LSW) on [DATE] at 12:42 PM revealed she is a member of the QA Committee and has been informed of the progress and results of the audit tools and monitors in place at the facility.

Based on interview, record review, review of the facility's policies and procedures, and review of a Hospital emergency room (ER) Note, it was determined the facility failed to immediately consult with the physician for two (2) of nine (9) sampled residents (Resident #1 and Resident #2). On [DATE] at approximately 1:50 PM, Resident #1 was found to be unresponsive and cyanotic (low oxygen causing bluish discoloration of the skin and a late sign of low oxygen levels in the blood) by the Assistant Director of Nursing (ADON) and Floor Nurse. The resident's oxygen saturation was sixty-nine percent (69%, normal ,[DATE]), blood pressure was ,[DATE] mm/Hg (millimeters of mercury), (normal ,[DATE]) and heart rate was 136 beats per minute (bpm) (normal ,[DATE]). The facility failed to call the physician immediately per the facility's policy and procedure. At 2:25 PM, approximately thirty-five (35) minutes later, the facility sent the physician a text message. A physician's orders [REDACTED]. The resident was noted again, at 5:30 PM, to have oxygen saturations of seventy-four percent (74%), labored respirations, and his/her skin was cyanotic. The physician was phoned and a new order was received to send Resident #1 to the emergency room . Resident #1 was admitted to the Critical Care Unit with the [DIAGNOSES REDACTED]. Resident #2 was re-admitted to the facility on [DATE] from a psychiatric hospitalization with new orders for [MEDICATION NAME] (antipsychotic) five (5) milligrams (mg) twice a day. On [DATE], the Consultant Pharmacist performed the monthly medication regimen review and recommended a trial dose reduction of the antipsychotic medication, [MEDICATION NAME], from five (5) mg to two and one half (2.5 mg), two (2) times daily. However, the physician was not made aware of the Pharmacy's Consultant's recommendation. Resident #2 had a fall on [DATE] at approximately 4:00 PM, which resulted in a non-displaced fracture of his/her left clavicle (collarbone). Resident #2 was noted to have a shuffling gait at the time of this fall (a side effect of the [MEDICATION NAME]). The physician was notified of the shuffling gait, and he ordered [MEDICATION NAME] to help reduce the side effects of the [MEDICATION NAME]. However, the facility failed to make the physician aware of the Consultant's recommendation to do a drug reduction for the [MEDICATION NAME]. Resident #2 had a second fall three (3) days later on [DATE], resulting in three (3) additional fractures of his/her arm (humerus, radius, and ulna). The physician was still not made aware of the Consultant Pharmacy Recommendation to consider a trial dose reduction. There was no documented evidence the physician was made aware of the recommendation until [DATE], at that time, a physician's orders [REDACTED]. The facility's failure to notify and consult with the physician immediately when the resident had a significant change in condition has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. The findings include: 1. Review of the facility's policy and procedure titled, "Care of Critically Ill Patient/Significant Change in Medical Condition", not dated, revealed when a significant change in medical condition has occurred or the resident is assessed to be critically ill, the attending physician will be notified immediately. Review of the facility's policy and procedure titled, "When to Call the Physician Immediately", not dated, revealed that acute changes in vital signs included an increase or decrease in heart rate, respirations, blood pressure, labored breathing, a drop in oxygen saturations, or any other significant changes in the resident's status. Review of the facility's policy and procedure titled, "Change in Patient Status", last revised [DATE], revealed in an emergency situation the charge nurse will render appropriate care to the resident, notify the physician, and transfer the patient as appropriate. In addition, the policy stated in the event of an acute change in medical condition and the attending physician was unavailable the nursing partner would take steps necessary to assure appropriate medical intervention. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #1 as cognitively intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of a Nurse's Note, dated [DATE] at 1:00 PM, revealed Resident #1 was found to have removed his/her oxygen and further review revealed Resident #1 was educated to leave nasal canula in place. Review of a Nurse's Note, dated [DATE] at 4:00 AM, revealed the resident "keeps taking oxygen off". However there was no documented evidence this was addressed in Resident #1's care plan and no documented evidence the facility had made the physician aware. Interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 12:45 PM, revealed Resident #1 had behaviors of taking his/her oxygen off. CNA #1 stated Resident #1 would do this to go to the hospital. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 3:04 PM, revealed Resident #1 was non compliant with care at times. She further stated Resident #1 takes the oxygen off at times and we just remind him/her to put it back on. Interview with Registered Nurse (RN) #1, on [DATE] at 8:55 AM, revealed Resident #1 did have a history of taking oxygen off but did not know why he/she did this. Interview with the Resident #1's Physician, on [DATE] at 8:30 AM, revealed that he was not aware of Resident #1 constantly removing his/her oxygen. Review of a Nurse's Note, dated [DATE] at 1:50 PM, revealed Resident #1 was found in his/her bed to be cyanotic and unresponsive. The resident's oxygen saturation was noted to be sixty-nine percent (69%), (normal ,[DATE]), blood pressure was ,[DATE] mm/Hg, (normal ,[DATE]) and heart rate was 136 bpm (normal ,[DATE]). There was no documented evidence the physician was called immediately to notify her of the resident's significant change in condition related to the acute change in vital signs as indicated by an increase or decrease in heart rate, respirations, blood pressure, labored breathing, a drop in oxygen saturations, or any other significant changes in the patient's status as per the facility's policy and procedure. Review of a Nurse's Note, dated [DATE] at 1:55 PM, revealed the resident's oxygen saturation increased to eighty-five percent (85%) on oxygen at four (4) liters per minute and his/her blood pressure was noted to be ,[DATE] mm/Hg. Review of a Nurse's Note, dated [DATE] at 2:25 PM, revealed the oxygen saturation was noted to be eighty-eight (88%) and the physician was sent a text message; however, there was still no documented evidence the physician was called per the facility's policy and procedure due to the low blood pressure and oxygen saturation rate. Review of a Nurse's Note, dated [DATE] at 3:45 PM, revealed a new order was received approximately one-hour and thirty minutes after the text message to obtain labs and a chest x-ray. At 5:30 PM, approximately three (3) hours and thirty-five (35) minutes after the resident was first identified with the significant change in condition, Resident #1 was noted to be cyanotic, with labored respirations and an oxygen saturation of seventy-four percent (74%) on oxygen at four (4) liters per nasal cannula. The Physician was notified and Resident #1 was sent to the emergency room (ER). Review of a Hospital ER Note, dated [DATE], revealed Resident #1 was placed on a non-rebreather mask with fifteen (15) liters of oxygen when he/she arrived in the ER. Resident #1 was admitted to the Critical Care Unit with [DIAGNOSES REDACTED]. Review of a Provisional Report of Death revealed Resident #1 expired on [DATE] at the hospital. The Provisional Report of Death did not reveal the resident's [DIAGNOSES REDACTED]. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:48 PM, revealed she was making rounds on [DATE] at approximately 1:50 PM, and as she approached Resident #1's room she noted the resident had oxygen tubing "coiled up" around his/her hand. The ADON stated after she placed the oxygen back on Resident #1, he/she was able to state his/her name, the time, and place. The ADON revealed she administered an "as needed" (PRN) [MEDICATION NAME] nebulizer treatment between 1:50 PM and 1:55 PM; however, she failed to document this information in the Nurse's Notes or on the Medication Administration Record [REDACTED]. She stated, "I gave instructions for Registered Nurse (RN #1) to notify the physician; however, I was not aware RN #1 had sent a text message instead of calling the physician." Interview with Registered Nurse (RN) #1, on [DATE] at 8:33 AM; and, on [DATE] at 8:55 AM, revealed she worked on [DATE] during the day shift and was Resident #1's nurse. RN #1 stated the ADON called her to Resident #1's room and as she entered the room, the ADON was putting oxygen on Resident #1, who was cyanotic and unresponsive. She stated "we had to do a sternal rub, pat the resident and work with him/her a little to get him/her to respond." RN #1 stated she later sent the physician a text message to inform him of Resident #1's status. She stated according to her message history on her cell phone, the message was not sent to the physician until 3:15 PM rather than 2:25 PM, as the Nurse's Note had stated. RN #1 stated she did not send Resident #1 out to the hospital because the resident stated he/she did not want to go. She further stated Resident #1 was his/her own guardian. However, she was not sure the resident was capable of making that decision and she did not consider this at that time. In addition, she stated the physician had responded to the text message at 3:45 PM with new orders and when Resident #1's oxygen saturations "started coming up (oxygen saturation of 88%), I felt like we could manage (him/her) here." RN #1 stated, "When we identify a change in condition, we try to notify the physician as soon as possible, but we take care of the resident first." Interview with Licensed Practical Nurse (LPN) #1, Team Leader on Resident #1's unit, on [DATE] at 9:47 AM, revealed her expectation and the facility's policy was to call the physician when a resident had a change in condition. She further stated the resident comes first; in a crisis situation, "I would expect the nurse to send the resident out to the hospital and then notify the MD." Interview with the Director of Nursing (DON), on [DATE] at 3:25 PM, revealed her expectation was for the staff to phone the resident's physician immediately when a significant change had been identified. She stated the nurse should not have sent a text message in that situation. The DON stated she expected the nurse to have sent the resident out to the hospital when she assessed the resident to be cyanotic and unresponsive. The DON stated the facility did not have a policy that addressed what to do if a resident refused to be sent to the hospital. Interview with the Administrator, on [DATE] at 4:04 PM, revealed his expectation in a crisis situation was for the staff to phone the physician and do what they needed to do to rescue the resident, and the next thing would be to transfer the resident out to the hospital. Interview with Resident #1's Physician, on [DATE] at 8:30 AM, revealed the resident had an order for [REDACTED].#1 had a history of [REDACTED]. The Physician revealed when the nurse assessed the resident to be cyanotic, and unresponsive with unstable vital signs, the resident should have immediately been sent to the emergency room (ER) at that time. 2. Record review revealed the facility readmitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change MDS assessment, dated [DATE], revealed the facility assessed Resident #2's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of eight (8). Review of a physician's orders [REDACTED]. Review of a Consultant Pharmacy Recommendation, dated [DATE], revealed a recommendation for the physician to consider a trial dose reduction of [MEDICATION NAME] to assess the lowest effective dose, with a recommendation to decrease the dose from five (5) milligram (mg) to two and a half milligram (2.5 mg) twice a day. Further review revealed no documented evidence the facility notified the physician of the pharmacy's recommendation at that time. Review of a Falls Investigation Summary, dated [DATE], revealed Resident #2 had a fall on [DATE] and at the time of the fall the resident was observed shuffling his/her feet which caused him/her to fall. The physician was notified of the fall and the shuffling gait with orders to administer [MEDICATION NAME] to help reduce the side effect (shuffling gait) of [MEDICATION NAME]. However, there was no documented evidence the physician was made aware of the Consultant's Pharmacy Recommendation to decrease the dosage of [MEDICATION NAME]. Review of a Post Falls Investigation, dated [DATE], revealed the resident had an unwitnessed fall on [DATE] at approximately 3:45 AM, while ambulating in the hall unattended. Resident #2 was assessed immediately after the fall and was noted to have complaints of pain to his/her right arm, rating the pain as a ten (10) out of ten (10) on the pain scale. The resident was transferred to the emergency room . Review of a Hospital emergency room (ER) Note, dated [DATE], revealed [DIAGNOSES REDACTED]. Further review revealed an order was written for an arm sling and splint and to refer the resident to the Orthopedic Surgeon. Review of a Physician's Note, dated [DATE], revealed Resident #2's physician visited him/her at the facility and noted the resident had two (2) significant recent falls resulting in fractures. The physician assessed the resident to be markedly lethargic and confused and discontinued the [MEDICATION NAME] and the [MEDICATION NAME]. Interview with the Consultant Pharmacist, on [DATE] at 1:04 PM, revealed [MEDICATION NAME] was an antipsychotic medication and it was not the first choice of medications to use in older adults. She stated the side effects of the [MEDICATION NAME] could include Extrapyramidal Symptoms (EPS) such as shuffling gait, abnormal movements and gait disturbance. She revealed the side effects of [MEDICATION NAME] were generally abrupt in nature but may develop at any time. She stated [MEDICATION NAME] was used to control side effects of the [MEDICATION NAME] but if EPS side effects developed the appropriate thing to do was ask for a reduction. She stated, "If the physician had agreed to the trial dose reduction at the time of the recommendation (recommendation was [DATE] and first fall was [DATE]), it was possible the fall could have been avoided. Interview with Resident #2's Physician, on [DATE] at 9:12 AM, revealed he did not recall being made aware of the pharmacy's recommendation to decrease the [MEDICATION NAME] dosage at the time of Resident # 2's falls. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:22 PM, revealed she phoned the physician to inform him of the resident's fall and the shuffling gait; however, she did not make the physician aware of the pharmacy's recommendation. She stated, "I reported the shuffling gait, and he ordered [MEDICATION NAME] for the side effects of [MEDICATION NAME]." Interview with the Director of Nursing (DON), on [DATE] at 3:37 PM, revealed the ADON should have made the physician aware of the pharmacy's recommendations at the time of the first fall. Interview with the Administrator, on [DATE] at 4:14 PM, revealed the physician should have been made aware of the pharmacy recommendation at the time of the first fall. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the facility obtained the vital signs of one hundred percent (100%) of all the residents. This was done by the Registered Nurse (RN), Licensed Practical Nurse (LPN) and the Certified Nursing Assistant (CNA) staff. The vital signs included blood pressure (B/P), respiration rate, pulse, temperature, and oxygen saturations to determine if residents presented with vital signs outside established parameters. (B/P 20 points (mm/Hg) above or below ,[DATE], pulse below 60 or above 100, respirations above 20 breaths per minute or below 12 per minute, and a temperature above 99 degrees Fahrenheit.) 2. On [DATE], one hundred percent (100%) of all residents receiving oxygen, residents with a respiratory diagnosis, and residents with [MEDICAL CONDITION] received respiratory assessments by the DON, RN/LPN team leaders. The respiratory assessments included vital signs, oxygen saturations, lung sounds, and observations for any cough or additional complaints. 3. On [DATE]-[DATE], the Director of Nursing (DON) provided an in-service to one hundred percent (100%) of the facility's RNs, LPNs and CNAs regarding the results of the survey/review findings. The DON provided additional in-services to all licensed nurses on emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation, which was also completed on [DATE]. In addition, a Respiratory Therapist provided in-service to all licensed nurses regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse/ oxygen which was completed on [DATE]. 4. On [DATE], the Regional Nurse reviewed the twenty-four (24) hour reports to ensure the physician was notified of all residents with a change of condition from [DATE]-[DATE]. 5. Quality Assurance Monitors began the week of [DATE], which included audits of respiratory status/documentation for all residents with respiratory related [DIAGNOSES REDACTED]. In addition, on [DATE], the facility began mock "code" situations to evaluate the appropriateness of response and action by facility staff. Additionally, on [DATE]-[DATE], the facility verbally interviewed one hundred percent (100%) of all RN and LPN staff regarding when and how to notify the physician in the event of a medical crisis. An additional five (5) weeks of monitoring was added with five (5) interviews per week for five (5) additional weeks. Additional Quality Assurance Monitors included audits to observe the correct oxygen flow, oxygen signs, clean and dated tubing, oxygen tubing off the floor, oxygen saturation monitoring and care plan accuracy which began, on [DATE], for one hundred percent (100%) of all residents receiving oxygen therapy by the Regional Nurse. The State Survey Agency validated the Corrective Action taken by the facility as follows: 1. Interview with the Director of Nursing (DON), on [DATE] at 2:04 PM, revealed the facility obtained the vital signs of one hundred percent (100%) of all the residents on [DATE]. Review of the facility's Vital Sign Audit tool revealed one hundred percent of all the residents had his/her vital signs assessed on [DATE]. 2. Review of the facility's Respiratory Assessment Audit Tool revealed that each resident with a respiratory [DIAGNOSES REDACTED]. Interview with the RN Team Leader (RN #5), on [DATE] at 9:46 AM, the LPN Team Leader (LPN #10), on [DATE] at 10:04 AM, and the LPN Team Leader (LPN #1), on [DATE] at 10:22 AM, revealed respiratory assessments were completed on their halls daily. They stated the Nurse's Notes were reviewed for accuracy in documentation and the results of the respiratory assessment were also documented on the audit tool for Quality Assurance. 3. Review, on [DATE], of the inservice logs, dated [DATE], [DATE], [DATE], [DATE], and [DATE], revealed all staff was inserviced related to emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation. Further review, revealed they received an inservice provided by the Respiratory Therapist regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse/oxygen Interviews with CNA #3, CNA #4, and CNA #2, on [DATE] at 9:06 AM, 9:12 AM, and 9:16 AM, respectively, revealed they had received in-servicing regarding the survey results. Interviews, on [DATE], with LPN #3 at 3:57 PM, LPN #4 at 4:10 PM, LPN #5 at 4:23 PM; and, on [DATE] with LPN #6 at 8:12 AM, LPN #7 at 8:21 AM, LPN #8 at 8:31 AM, LPN #9 at 8:42 AM, and LPN #10 at 10:04 AM, revealed they had been in-serviced regarding the survey results. In addition, they stated they also received in-services on emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation. Further interview revealed they received an inservice provided by the Respiratory Therapist regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse/oxygen Interviews with RN #4 on [DATE] at 3:45 PM; and, on [DATE] with RN #5 at 9:46 AM, RN #3 at 10:56 AM, and RN #6 at 11:08 AM, revealed they had received inservicing regarding the survey results. In addition, they stated they also received in-services on emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation. Further interview revealed they received an inservice provided by the Respiratory Therapist regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse/oxygen. 4. Interview with the Regional Nurse Consultant, on [DATE] at 12:24 PM, revealed she reviewed the twenty-four hour (24) reports on [DATE] to ensure all residents who were on the 24 hour report, had the appropriate physician notification. Review of the audit reports for the physician notification revealed residents identified with a change of condition received appropriate physician notification. 5. Review of facility audits, dated [DATE], on all residents with a respiratory [DIAGNOSES REDACTED]. Review of the facility's audit reports, dated [DATE], revealed the facility conducted audits regarding residents who were receiving oxygen to observe for the correct oxygen flow, oxygen door signs, clean and dated tubing, oxygen tubing off the floor, oxygen saturation monitoring and care plan accuracy, beginning on [DATE], for one hundred percent (100%) of all residents receiving oxygen therapy by the Regional Nurse. Interview with the Regional Nurse Consultant, on [DATE] at 12:24 PM, revealed she performed an audit on all residents receiving oxygen to observe for the correct oxygen flow, appropriate placement of oxygen signs, clean and dated oxygen tubing, observed for oxygen tubing off the floor, oxygen saturation monitoring and the care plan was accurate and appropriate for all residents receiving oxygen. Interviews on [DATE], with LPN #3 at 3:57 PM, LPN #4 at 4:10 PM, LPN #5 at 4:23 PM, and interviews on [DATE] with LPN #6 at 8:12 AM, LPN #7 at 8:21 AM, LPN #8 at 8:31 AM , LPN #9 at 8:42 AM, and LPN #10 at 10:04 AM, revealed they had been verbally interviewed regarding when and how to notify the physician in the event of a medical crisis. In addition, interview with the LPNs revealed the Director of Nursing (DON) was conducting random mock "code" situations to monitor and evaluate the appropriateness of response and action by the facility's licensed staff. Interviews with RN #4 on [DATE] at 3:45 PM, and on [DATE] with RN #5 at 9:46 AM, RN #3 at 10:56 AM, and RN #6 at 11:08 AM, revealed they had been verbally interviewed regarding when and how to notify the physician in the event of a medical crisis. In addition, interview with the RN staff revealed the Director of Nursing (DON) was conducting random mock "code" situations to monitor and evaluate the appropriateness of response and action by the facility licensed staff.

Based on interview, record review, review of the facility's policy and procedures, and review of the Hospital's History and Physical, it was determined the facility failed to review and revise one (1) of nine (9) sampled residents' (Resident #1) care plan to reflect the resident's significant change in condition and the resident's non-compliance with wearing his/her oxygen. Resident #1 was re-admitted to the facility on [DATE]. The facility assessed Resident #1 as requiring two (2) staff for transfers; however, the facility failed to ensure the care plan reflected the assessment findings. On [DATE], Resident #1 was transferred from the bed to his/her recliner by one (1) staff and became too weak to stand and had to be lowered to the floor. The resident sustained [REDACTED]. In addition, Resident #1 had a physician's orders [REDACTED]. On [DATE] at approximately 1:50 PM, Resident #1 was found in his/her bed by the Assistant Director of Nursing (ADON) with the nasal cannula "coiled up" around his/her hand. The resident was cyanotic (low oxygen causing bluish discoloration of the skin). The resident's oxygen saturation was sixty-nine percent (69%) and his/her oxygen was not in place. Interviews with the direct care staff revealed the resident had a history of [REDACTED]. The facility's failure to review and revise the care plan has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE]. The findings include: Review of the facility's policy and procedure titled, "Documentation Guidelines/Care Plans", dated [DATE], revealed care plan approaches should be specific and individualized to assist the resident to achieve a goal. The approaches are the instructions for providing resident care and ensuring the continuity of care. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 as cognitively intact, with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Further review revealed the facility assessed Resident #1 to require the extensive assistance of two (2) plus persons physical assistance for bed mobility. Review of Resident #1's Comprehensive Care Plan, dated [DATE], revealed an intervention to transfer with the assistance of one (1) to two (2) staff instead of the assessed need of two (2) staff; and, the resident was at risk for signs and symptoms of cardiac/respiratory distress. Interventions included administer oxygen as ordered, check oxygen saturations as needed, observe for signs and symptoms of [MEDICAL CONDITION] and intervene as needed, and to observe for signs and symptoms of respiratory distress and report. Review of a Hospital Discharge Summary, dated [DATE], revealed Resident #1 was hospitalized from [DATE] through [DATE] related to the [DIAGNOSES REDACTED]. Review of a Re-Admission Nursing Assessment, dated [DATE], revealed the facility assessed Resident #1 as totally dependent on two (2) plus person, physical assistance for transfer. Additionally, Resident #1 was assessed to have severe [MEDICAL CONDITION] to all extremities, and the resident was unable to transfer from the bed to wheelchair to be weighed. However, further review of the Comprehensive Care Plan, dated [DATE], revealed the care plan still reflected the need for one (1) to two (2) staff for transfers. Review of a Post Falls Nursing Assessment, dated [DATE], revealed Resident #1 had to be lowered to the floor by a Certified Nursing Assistant (CNA) while transferring him/her from the bed to a chair on [DATE] at 9:30 AM with no injuries identified at the time. The CNA was transferring the resident without assistance. Review of a Nurse's Note, dated [DATE] at 8:55 PM, revealed the facility assessed the resident to have an oxygen saturation of eighty-four percent (84%) on four (4) liters of oxygen. The physician was notified and the resident was sent to the emergency room (ER) via ambulance. Review of a Hospital History and Physical, dated [DATE], revealed Resident #1 complained of right ankle pain and shortness of breath when he/she arrived at the hospital. An x-ray was conducted which revealed a displaced spiral [MEDICAL CONDITION] fibula. Interview with CNA #1, on [DATE] at 12:45 PM, revealed she had entered Resident #1's room to provide personal care. She stated Resident #1 was in his/her bed and had requested to stand up for a minute because he/she had not been out of bed since he/she had been back from the hospital. CNA #1 stated she assisted Resident #1 to stand at the bedside for approximately three (3) to four (4) minutes, then asked Resident #1 if he/she would like to sit in his/her recliner while she made the bed and the resident agreed. Further interview revealed when the resident went to pivot, his/her knee gave out and she (CNA #1) assisted the resident to the floor as much as she possibly could. She stated Resident #1 landed on his/her knees with his/her feet under him/her. CNA #1 stated she had to get the nurse and two (2) additional aides to assist her to get the resident back to bed. She stated the resident didn't complain of pain, but said she was "shaken up". CNA #1 stated, "Honestly, I didn't know the resident had been in the hospital and had a decline." She stated she was not normally assigned to Resident #1 and it had been a little while since she had worked with him/her. Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 1:11 PM, revealed she was the nurse on duty at the time of Resident #1's fall. She stated she was called to the room by one of the CNAs to assist with getting the resident back in bed. The LPN stated it took several people to get the resident back in bed. She stated once Resident #1 was back in bed, she immediately did a head to toe skin assessment including range of motion on all extremities, and a full pain assessment. She revealed the assessment was baseline for the resident with no complaints of pain to the lower extremities. LPN #2 stated she checked on the resident approximately thirty (30) minutes after the fall and then was in and out of the resident's room the rest of the day. She stated at approximately 8:45 PM, when she entered the resident's room for the medication pass, the resident was "kind of shaky" and had decreased alertness. She stated she obtained the resident's oxygen saturations and it was eighty-four percent (84%). She stated the resident did not complain of any pain. LPN #2 stated she phoned the physician and sent the resident to the emergency room (ER) via ambulance. Interview with Registered Nurse (RN) #2, on [DATE] at 3:38 PM, revealed she was the nurse who completed the re-admission assessment for Resident #1. She stated the resident required a lot of care due to the [MEDICAL CONDITIONS] and Chronic [MEDICAL CONDITION] Disease ([MEDICAL CONDITION]). RN #2 revealed Resident #1 had chronic pain and fluid overload. She stated the resident had been able to transfer and ambulate with the assistance of one (1) staff member before the hospitalization . RN #2 stated she thought the CNAs would get two (2) staff if it was needed; therefore, she did not update the Comprehensive Care Plan. Interview with CNA #2, on [DATE] at 1:16 PM, revealed she was the primary CNA for Resident #1 most of the time. She stated the resident had gotten weaker since the most recent hospitalization . She stated, "Now I am doing everything for the resident because (he/she) just can't do it." Further interview revealed she was no longer able to get the resident up to use the bedside commode per the care plan. CNA #2 stated, "I just put the resident on the bed pan." Additionally, CNA #2 stated the resident used to be able to transfer with the assistance of one (1), but he/she needed two (2) staff now. Further review of the Nurse's Notes revealed on [DATE] at 1:50 PM, Resident #1 was found in his/her bed to be cyanotic and he/she was not wearing his/her oxygen. The resident was assessed to have oxygen saturations of sixty-nine percent (69%). In addition, his/her blood pressure was ,[DATE] mm/Hg (millimeters of mercury) and the heart rate was 136 (normal range ,[DATE]). Oxygen was placed on the resident at that time at four (4) liters per nasal cannula. At 1:55 PM, Resident #1's oxygen saturations increased to eighty-five percent (85%) on four (4) liters per nasal cannula and at 2:25 PM, the resident's oxygen saturation was eighty-eight percent (88%). However, at 5:30 PM, the resident's oxygen saturations was seventy-four percent (74%) on four (4) liters of oxygen. The resident was sent to the emergency room (ER). Review of an ER Note, dated [DATE], revealed Resident #1 was admitted to the Critical Care Unit with [DIAGNOSES REDACTED].#1 expired on [DATE] at the hospital. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 2:48 PM revealed she was making rounds on [DATE] at approximately 1:50 PM, and as she approached Resident #1's room she noted the resident was holding the oxygen tubing "coiled up" around his/her hand. The ADON stated she called for the floor nurse who was also in the hall. The ADON stated after she placed the oxygen back on Resident #1, he/she was able to state his/her name, time, and place. Interview with Registered Nurse (RN) #1, on [DATE] at 8:33 AM; and, on [DATE] at 8:55 AM, revealed she worked on [DATE] during the day shift and was Resident #1's nurse. RN #1 stated Resident #1 did have behaviors of taking his/her oxygen off. She stated, "I don't know why (he/she) does that." Interview with Certified Nursing Assistant (CNA) #1, on [DATE] at 12:45 PM, revealed Resident #1 would hold his/her breath at times to make his/her oxygen saturation "go down" and would take his/her oxygen off at times. She stated the resident would do this, "to go back to the hospital." Interview with Licensed Practical Nurse (LPN) #2, on [DATE] at 3:04 PM, revealed Resident #1 was non-compliant with his/her care at times and would take his/her oxygen off at times. She stated, "I have sent (him/her) to the emergency room (ER) two (2) times for this since the first of July." Further review of the Comprehensive Care Plan, dated [DATE], revealed there were no interventions to address Resident #1's removing his/her oxygen and no interventions to address monitoring the resident to ensure the resident's oxygen was in place. Interview with RN #3, MDS Coordinator, on [DATE] at 9:43 AM, revealed when a resident was readmitted to the facility from the hospital, the nurse completing the re-admission assessment would update the care plan based on any necessary changes and if a MDS was done, it would be reviewed at that time. In addition, she stated the care plan was developed based on the resident's current conditions and diagnoses. She revealed the care plan would be updated by the nurse taking care of the resident. Interview with the Director of Nursing (DON), on [DATE] at 3:25 PM, revealed she expected care plans to be updated based on the resident's current assessed needs. In addition, she stated, "The expectation was, the care plan should be updated when there had been a change in condition or a status change." Interview with the Physician, on [DATE] at 8:30 AM, revealed Resident #1 was a very non-compliant resident and had multiple comorbid diagnoses. He stated staff had not made him aware the resident had behaviors of taking the oxygen off. He revealed that he attended care plan meetings and the nurses were very good at keeping him informed. He stated when the resident's oxygen saturations would drop we would send him/her out to the hospital. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], the RN MDS Coordinator completed a review of all residents at the facility with known [DIAGNOSES REDACTED]. The care plans were reviewed to ensure the care plans appropriately addressed the problems and interventions. Additionally, the RN MDS Coordinator completed an audit on 100% of all residents who had returned to the facility post hospitalization beginning [DATE] to ensure appropriate care needs were reflected in the care plan accurately. 2. On [DATE], the Director of Nursing, the RN MDS Coordinator, and the RN/LPN Team Leaders conducted a review of 100% of all care plans with 100% of all physicians orders, nursing interventions, fall interventions, treatment orders, code status, therapy orders, diet orders, adaptive equipment, and labs orders were accurate and appropriately addressed in the care plan. 3. The Director of Nursing conducted inservice training to all licensed staff regarding updating care plan problems based on resident condition changes, updating care plan interventions as new orders/changes occur, updating care plans upon return from the hospital and updating CNA care plans with any changes on the medical record care plan. All RNs and LPNs were inserviced which was completed on [DATE]. 4. 100% of all CNAs were inserviced by the DON and RN/LPN Team Leaders beginning on [DATE] related to care plan location and CNA responsibility to review information for updates on the care plan. The State Survey Agency validated the Corrective Action taken by the facility as follows: 1. Review of the facility's audit of all residents with known [DIAGNOSES REDACTED]. Additionally, review of the audit dated [DATE], revealed 100% of all residents who returned to the facility post hospitalization had care plans reviewed to ensure appropriate care plan needs were accurate. Interview with the RN MDS Coordinator, RN #3 on [DATE] at 10:56 AM, revealed she reviewed the care plans of all residents with the known [DIAGNOSES REDACTED]. In addition, she stated she reviewed all residents readmitted to the facility post hospitalized from [DATE] to [DATE] to ensure accurate and appropriate care plans. 2. Review of a facility's audit dated [DATE], revealed all care plans were reviewed and updated for 100% of all residents to include physician orders, nursing interventions, fall interventions, treatment orders, code status, therapy orders, diet orders, adaptive equipment and lab orders to ensure appropriateness and accuracy. Review of Resident #10's, Resident #11's, Resident #12's, and Resident #13's record revealed the care plans were updated with no concerns noted related to care plans. Interview with the RN Team Leader, RN #5, on [DATE] at 9:46 AM, revealed she completed the care plan audit on [DATE]. She stated all physician orders [REDACTED]. Interview with the LPN/ Team Leader, LPN #1, on [DATE] at 10:22 AM, and LPN #10 on [DATE] at 10:04 AM, revealed all physician orders [REDACTED]. Interview with the RN MDS Coordinator, RN #3, on [DATE] at 10:56 AM, revealed all physician orders [REDACTED]. Interview with the Director of Nursing, on [DATE] at 2:04 PM, revealed she along with the MDS Coordinator and the RN/LPN Team Leaders reviewed 100% of all care plans to ensure accuracy 3. Review of a facility inservice log, dated [DATE] and [DATE], revealed all staff was inserviced regarding updating care plan problems based on resident condition changes, updating care plan interventions as new orders/changes occur, updating care plans upon return from the hospital and updating CNA care plans with any changes on the medical record care plan. Interviews on [DATE], with LPN #3 at 3:57 PM, LPN #4 at 4:10 PM, LPN #5 at 4:23 PM, and interviews on [DATE] with LPN #6 at 8:12 AM, LPN #7 at 8:21 AM, LPN #8 at 8:31 AM, LPN #9 at 8:42 AM, and LPN #10 at 10:04 AM, revealed they had been inserviced regarding updating care plan problems based on resident condition changes, updating care plan interventions as new orders/changes occurred, updating care plans upon return from the hospital and updating CNA care plans with any changes on the medical record care plan. Interviews with RN #4 on [DATE] at 3:45 PM; and, on [DATE] with RN #5 at 9:46 AM, RN #3 at 10:56 AM, and RN #6 at 11:08 AM, revealed they had been verbally interviewed regarding when and how to notify the physician in the event of a medical crisis. In addition, interview with the RN staff revealed the Director of Nursing was conducting random mock "code" situations to monitor and evaluate the appropriateness of response and action by the facility licensed staff. 4. Review of a facility inservice log revealed 100% of all CNAs were inserviced by the DON and RN/LPN Team Leaders beginning on [DATE] through [DATE] related to care plan location and CNA responsibility to review information for updates on the care plan. Interviews with CNA #3, CNA #4, and CNA #2, on [DATE] at 9:06 AM, 9:12 AM, and 9:16 AM, respectively, revealed they had been inserviced related to care plan location and CNA responsibility to review information for updates on the care plan.

Based on interview, record review, review of the facility's policy and procedure, review of the Hospital emergency room Note, and review of a Provisional Report of Death, it was determined the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one (1) of nine (9) sampled residents (Resident #1). The facility failed to provide ongoing assessments and monitoring for Resident #1 when a significant change in condition was identified. On 07/25/14, at approximately 1:50 PM, Resident #1 was found in his/her room by facility staff unresponsive and cyanotic (low oxygen causing bluish discoloration of the skin). The resident's oxygen saturation was sixty-nine percent (69%) (normal 90-100) on room air, blood pressure was 79/45 (normal 118/68), and heart rate was 136 (normal 60-100) beats per minute (bpm). There was no documented evidence the physician was called to notify her of the resident's significant change in condition; however, at 2:25 PM, thirty-five (35) minutes later, a text message was sent to the physician. At 3:45 PM, a physician's orders [REDACTED]. At 5:30 PM, approximately three (3) hours and ten (10) minutes after the resident's significant change in condition, Resident #1 was noted to be cyanotic, with labored respiration and an oxygen saturation of seventy-four percent (74%). The Physician was notified and a new order was received to send Resident #1 to the emergency room (ER). The resident was transferred to the hospital where he/she was admitted to the Critical Care Unit with the [DIAGNOSES REDACTED]. (Refer to F-157) The facility's failure to ensure each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 08/07/14 and determined to exist on 07/25/14. The findings include: Review of the facility's policy and procedures titled, "Care of Critically Ill Patient/Significant Change in Medical Condition", not dated, revealed that when a significant change in medical condition has occurred or the resident is assessed to be critically ill, the attending physician will be notified immediately. Review of the policy titled, "When to Call the Physician Immediately", not dated, revealed acute changes in vital signs includes an increase or decrease in heart rate, respirations, blood pressure, labored breathing, a drop in oxygen saturations, or any other significant changes in the resident's status. Review of the facility's policy and procedure titled, "Change in Patient Status", revised 03/06/13, revealed in an emergency situation the charge nurse will render appropriate care to the resident, notify the physician, and transfer the patient as appropriate. In addition, the policy stated in the event of an acute change in medical condition and the attending physician was unavailable the nursing partner will take steps necessary to assure appropriate medical intervention. Record review revealed the facility admitted Resident #1 on 10/24/13 with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment, dated 05/08/14 revealed the facility had assessed Resident #1 as cognitively intact with a Brief Interview Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Review of the Comprehensive Care Plan, dated 05/20/14, revealed Resident #1 was at risk for signs and symptoms of cardiac/respiratory distress with interventions that included administer oxygen as ordered, check oxygen saturations as needed, observe for signs and symptoms of [MEDICAL CONDITION] and intervene as needed and observe for signs and symptoms of respiratory distress and report. Review of the physician's orders [REDACTED]. Review of a Hospital Discharge Summary, dated 07/19/14, revealed Resident #1 was hosptalized on [DATE] through 07/19/14 with Acute onset Chronic [MEDICAL CONDITION]. The facility readmitted Resident #1 on 07/19/14. Review of a Nurse's Note, dated 07/25/14 at 1:50 PM, revealed Resident #1 was found in his/her bed unresponsive and cyanotic with an oxygen saturation of sixty-nine percent (69%) on room air, blood pressure was 79/45 and heart rate was 136 bpm. Oxygen was placed on the resident at four (4) liters per nasal cannula. There was no documented evidence the physician was called and notified of the resident's significant change in condition per the facility's policy and procedures. Further review of the 07/25/14 Nurse's Notes revealed the resident's oxygen saturation was eighty-eight percent (88%) on four (4) liters of oxygen at 2:25 PM and a text message was sent to the physician. At 3:45 PM, new orders were received for labs and a chest x ray. Review of a Nurse's Note at 5:30 PM, revealed Resident #1 was noted to have an oxygen saturation of 74%, labored respirations, and the resident's skin was again noted to be cyanotic. The physician was notified at that time and an order was received to send Resident #1 to the emergency room (ER). However, there was no documented evidence the facility assessed the resident from 2:25 PM to 5:30 PM. Review of an emergency room (ER) Note, dated 07/25/14, revealed Resident #1 was noted to have an altered mental status and was in moderate distress. The resident was placed on a non-rebreather mask with fifteen (15) liters of oxygen. The resident was admitted to the Critical Care Unit with [DIAGNOSES REDACTED]. Interview with the Assistant Director of Nursing (ADON), on 08/06/14 at 2:48 PM, revealed she was making routine rounds and as she approached Resident #1's room she noted that the resident had the oxygen tubing "coiled up" around his/her hand. She stated she saw the resident's nurse, who was also in the hallway, and summoned her to Resident #1's room. Further interview with the ADON revealed after she placed the oxygen back on Resident #1, the resident was able to state his/her name, time, and place. The ADON revealed she administered an as needed (PRN) [MEDICATION NAME] nebulizer treatment between the time of 1:50 PM and 1:55 PM but did not document this in the Nurse's Notes or on the Medication Administration Record [REDACTED]. The ADON stated Resident #1 did not want to be sent out to the hospital. Further interview revealed the ADON stated the resident was monitored as she "checked on the resident throughout the day, and the Certified Nursing Assistants perform every two (2) hour checks, so someone was in and out of the room all the time". Interview with Registered Nurse (RN) #1, on 07/31/14 at 8:33 AM; and, on 08/06/14 at 8:55 AM revealed she had worked on 07/25/14 during the day shift and was the nurse for Resident #1. RN #1 stated she was summoned to Resident #1's room by the Assistant Director of Nursing (ADON) who was standing at the resident's doorway. RN #1 revealed she entered the room, and the ADON was putting oxygen on Resident #1. RN #1 stated Resident #1 was cyanotic and unresponsive and "we had to do a sternal rub, pat (him/her) and work with (him/her) a little to get (him/her) to respond. Just a few minutes after the ADON put the O2 on the resident, (his/her) O2 sats came up to 85%". Further interview with RN #1 revealed she did not send Resident #1 out to the hospital because the resident stated he/she did not want to go. She further stated Resident #1 was his/her own guardian; however, she was not sure the resident was capable of making that decision, but she did not consider that at the time. Further interview revealed, she continued to monitor Resident #1 throughout the day, she stated, "I was going back in (his/her) room every little bit to make sure that (his/her) oxygen was on because (he/she) would take it off." She further revealed, she continued to observe Resident #1's color, and obtained his/her oxygen saturation. She stated, "I was concerned about (his/her) oxygen saturations being a little low; however, I felt like Resident #1 was making an improvement." In addition, RN #1 revealed she did not document the assessments in the resident's medical record; however, no explanation was provided as to why this was not completed. Interview with Resident #1's Physician, on 08/01/14 at 8:30 AM, revealed the resident was legally competent; however, was very non-compliant and had multiple comorbid diagnoses. He stated the physician orders [REDACTED]. The Physician revealed Resident #1 had a history of [REDACTED]. The Physician stated when the nurse assessed the resident to be cyanotic, unresponsive with unstable vitals, the resident should have been sent out immediately to the ER at that time. Interview with the Director of Nursing, (DON) on 08/07/14 at 3:25 PM, revealed that based on the documentation the resident was not capable of determining if he/she was going to the hospital. Further interview revealed the DON stated, "I do expect the staff should have sent the resident out to the hospital, absolutely". She stated the facility did not have a policy to address what to do when a resident refused to be sent to the hospital. Additionally, she stated the nurse should have not sent a text message to the physician and should have phoned him immediately. Interview with the Administrator, on 08/07/14 at 4:04 PM, revealed he expected the staff to phone the physician in a crisis situation, rescue the resident, and transfer the resident out to the hospital. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 08/07/14, the facility obtained the vital signs of one hundred percent (100%) of all the residents. This was done by the Registered Nurse (RN), Licensed Practical Nurse (LPN) and the Certified Nursing Assistant (CNA) staff. The vital signs included blood pressure (B/P), respiration rate, pulse, temperature, and oxygen saturations to determine if residents presented with vital signs outside established parameters. (B/P 20 points (mm/Hg) above or below 120/80, pulse below 60 or above 100, respirations above 20 breaths per minute or below 12 per minute, and a temperature above 99 degrees Fahrenheit. 2. On 08/09/14, one hundred percent (100%) of all residents receiving oxygen, residents with a respiratory diagnosis, and residents with [MEDICAL CONDITION] received respiratory assessments by the DON, RN/LPN team leaders. The respiratory assessments included vital signs, oxygen saturations, lung sounds, and observations for any cough or additional complaints. 3. On 08/08/14-08/13/14, the Director of Nursing (DON) provided an in-service to one hundred percent (100%) of the facility's RNs, LPNs and CNAs regarding the results of the survey/review findings. The DON provided additional in-services to all licensed nurses on emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation, which was also completed on 08/13/14. In addition, a Respiratory Therapist provided in-service to all licensed nurses regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse oxygen which was completed on 08/13/14. 4. On 08/12/14, the Regional Nurse reviewed the twenty-four (24) hour reports to ensure the physician was notified of all residents with a change of condition from 08/01/14-08/12/14. 5. Quality Assurance Monitors began the week of 08/10/14, which included audits of respiratory status/documentation for all residents with respiratory related [DIAGNOSES REDACTED]. In addition, on 08/09/14, the facility began mock "code" situations to evaluate the appropriateness of response and action by facility staff. Additionally, on 08/12/14-08/13/14, the facility verbally interviewed one hundred percent (100%) of all RN and LPN staff regarding when and how to notify the physician in the event of a medical crisis. An additional five (5) weeks of monitoring was added with five (5) interviews per week for five (5) additional weeks. Additional Quality Assurance Monitors included audits to observe the correct oxygen flow, oxygen signs, clean and dated tubing, oxygen tubing off the floor, oxygen saturation monitoring and care plan accuracy which began, on 08/14/14, for one hundred percent (100%) of all residents receiving oxygen therapy by the Regional Nurse. The State Survey Agency validated the Corrective Action taken by the facility as follows: 1. Interview with the Director of Nursing (DON), on 08/20/14 at 2:04 PM, revealed the facility obtained the vital signs of one hundred percent (100%) of all the residents on 08/07/14. Review of the facility's Vital Sign Audit tool revealed one hundred percent of all the residents had his/her vital signs assessed on 08/07/14. 2. Review of the facility's Respiratory Assessment Audit Tool revealed that each resident with a respiratory [DIAGNOSES REDACTED]. Interview with the RN Team Leader (RN #5), on 08/20/14 at 9:46 AM, the LPN Team Leader (LPN #10), on 08/20/14 at 10:04 AM, and the LPN Team Leader (LPN #1), on 08/20/14 at 10:22 AM, revealed respiratory assessments were completed on their halls daily. They stated the Nurse's Notes were reviewed for accuracy in documentation and the results of the respiratory assessment were also documented on the audit tool for Quality Assurance. 3. Review, on 08/19/14, of the inservice logs, dated 08/08/14, 08/09/14, 08/10/14, 08/11/14, and 08/13/14, revealed all staff was inserviced related to emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation. Further review, revealed they received an inservice provided by the Respiratory Therapist regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse oxygen Interviews with CNA #3, CNA #4, and CNA #2, on 08/20/14 at 9:06 AM, 9:12 AM, and 9:16 AM, respectively, revealed they had received in-servicing regarding the survey results. Interviews, on 08/19/14, with LPN #3 at 3:57 PM, LPN #4 at 4:10 PM, LPN #5 at 4:23 PM, and on 08/20/14 with LPN #6 at 8:12 AM, LPN #7 at 8:21 AM, LPN #8 at 8:31 AM, LPN #9 at 8:42 AM, and LPN #10 at 10:04 AM, revealed they had been in-serviced regarding the survey results. In addition, they stated they also received in-services on emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation. Further interview revealed they received an inservice provided by the Respiratory Therapist regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse oxygen Interviews with RN #4 on 08/19/14 at 3:45 PM, and on 08/20/14 with RN #5 at 9:46 AM, RN #3 at 10:56 AM, and RN #6 at 11:08 AM, revealed they had received inservicing regarding the survey results. In addition, they stated they also received in-services on emergency care of the resident, when to send a resident to the hospital, and respiratory assessment and documentation. Further interview revealed they received an inservice provided by the Respiratory Therapist regarding signs of severe respiratory distress, signs of imminent respiratory distress, and vital sign assessment/pulse oxygen 4. Interview with the Regional Nurse Consultant, on 08/20/14 at 12:24 PM, revealed she reviewed the twenty-four hour (24) reports on 08/12/14 to ensure all residents who were on the 24 hour report, had the appropriate physician notification. Review of the audit reports for the physician notification revealed residents identified with a change of condition received appropriate physician notification. 5. Review of facility audits, dated 08/09/14, on all residents with a respiratory [DIAGNOSES REDACTED]. Review of the facility's audit reports, dated 08/14/14, revealed the facility conducted audits regarding residents who were receiving oxygen to observe for the correct oxygen flow, oxygen door signs, clean and dated tubing, oxygen tubing off the floor, oxygen saturation monitoring and care plan accuracy, beginning on 08/14/14, for one hundred percent (100%) of all residents receiving oxygen therapy by the Regional Nurse. Interview with the Regional Nurse Consultant, on 08/20/14 at 12:24 PM, revealed she performed an audit on all residents receiving oxygen to observe for the correct oxygen flow, appropriate placement of oxygen signs, clean and dated oxygen tubing, observed for oxygen tubing off the floor, oxygen saturation monitoring and the care plan was accurate and appropriate for all residents receiving oxygen. Interviews on 08/19/14, with LPN #3 at 3:57 PM, LPN #4 at 4:10 PM, LPN #5 at 4:23 PM, and interviews on 08/20/14 with LPN #6 at 8:12 AM, LPN #7 at 8:21 AM, LPN #8 at 8:31 AM , LPN #9 at 8:42 AM, and LPN #10 at 10:04 AM, revealed they had been verbally interviewed regarding when and how to notify the physician in the event of a medical crisis. In addition, interview with the LPNs revealed the Director of Nursing(DON) was conducting random mock "code" situations to monitor and evaluate the appropriateness of response and action by the facility's licensed staff. Interviews with RN #4 on 08/19/14 at 3:45 PM, and on 08/20/14 with RN #5 at 9:46 AM, RN #3 at 10:56 AM, and RN #6 at 11:08 AM, revealed they had been verbally interviewed regarding when and how to notify the physician in the event of a medical crisis. In addition, interview with the RN staff revealed the Director of Nursing (DON) was conducting random mock "code" situations to monitor and evaluate the appropriateness of response and action by the facility licensed staff.

Based on interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure the pharmacist's recommendation for a gradual dose reduction was reported to the attending physician in order for the reports to be acted upon for one (1) of nine (9) sampled residents (Resident #2). Resident #2 was re-admitted to the facility on [DATE] from a psychiatric hospitalization with a new order for Haldol (antipsychotic) five (5) milligrams (mg) twice a day. On 06/03/14, the Consultant Pharmacist performed the monthly medication regimen review and recommended a trial dose reduction of the Haldol from five (5) mg to two and one half (2.5 mg), two (2) times daily; however, the facility failed to ensure the physician was made aware of the report and that it was acted upon. On 06/12/14 at approximately 4:00 PM, approximately nine (9) days after the recommendation was made, Resident #2 had a fall which resulted in a fracture to his/her left clavicle (collarbone). Resident #2 was noted to have a shuffling gait which was a side effect of the antipsychotic medication. The physician was made aware of the shuffling gait but the facility failed to make the physician aware of the Consultant's recommendation. The physician ordered Cogentin to help reduce the side effects of the Haldol. Resident #2 had a second fall three (3) days later on 06/15/14, which resulted in fractures of the resident's humerus, radius, and ulna (arm); the physician was still not made aware of the Consultant's recommendation to consider a trial dose reduction. The physician was not notified of the pharmacy recommendations until 06/17/14, approximately fourteen (14) days after the recommendation. The physician reduced the Haldol dosage to two (2) milligrams (mg) twice a day. The physician visited the resident on 06/19/14 and discontinued the Haldol and Cogentin due to the resident having the two (2) significant falls and noting the resident was markedly lethargic. The facility's failure to notify the physician of the pharmacy recommendation for the gradual dose reduction of the antipsychotic medication has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/23/14 and was determined to exist on 06/15/14. The findings include: Review of the facility's policy and procedure titled, "Consultant Pharmacist Reports", dated 10/2011, revealed the consultant pharmacist works with the facility to establish a system whereby the consultant pharmacist's observations and recommendations regarding residents' medication therapy are communicated to those with authority and /or responsibility to implement the recommendations, and respond in an appropriate and timely fashion. Further review revealed the Consultant Pharmacist documents potential or actual medication-related problems, irregularities, and other medication regimen review findings appropriate for the prescriber and/or nursing review. Additionally, review of the policy revealed the comments and recommendations concerning medication therapy were to be communicated in a timely fashion. Review of the facility's policy and procedures titled, "Medication Monitoring and Management", dated 10/2011, revealed when a resident's clinical condition had improved or stabilized, the underlying causes of the original target symptoms had resolved, and/or non-pharmacological interventions, including behavioral interventions, had been effective in reducing the symptoms, the resident would be evaluated for the appropriateness of a taper or gradual dose reduction (GDR) of the medication. Record review revealed the facility admitted Resident #2 on 01/28/14; and readmitted him/her on 04/08/14 with [DIAGNOSES REDACTED]. Review of the readmission orders [REDACTED]. Review of Resident #2's Behavior Flow Record, dated 05/2014, revealed Resident #2 was monitored for throwing objects, hitting staff, and paranoid behavior. Staff was to evaluate the effectiveness of the antipsychotic medication Haldol. Further review revealed no behaviors were reported during that time. Review of a Pharmacy Recommendation, dated 06/03/14, revealed a recommendation for the physician to consider a trial dose reduction of Haldol. The Haldol was to be decreased from five (5) to two and a half milligram (2.5 mg) twice a day. Review of a physician's orders [REDACTED]. The Haldol was decreased to two (2) milligrams. Review of a Falls Investigation Summary, dated 06/13/14, revealed Resident #2 had a fall on 06/12/14 and at the time of the fall the resident was observed shuffling his/her feet which caused him/her to fall. The physician was made aware of the shuffling gait and ordered Cogentin to help reduce the side effects of the Haldol. Further review revealed, the resident was assessed immediately after the fall and noted to have complaints of pain, rating the pain as an eight (8) out of ten (10) on the pain rating scale. Further review of the Summary revealed the resident had a two (2) centimeter laceration above his/her left eyebrow area with bruising and swelling. The resident's left eye was cleansed with normal saline and the resident was given a cold pack to apply to his/her left eyebrow area. Review of a physician's orders [REDACTED]. Further Review of the POS [REDACTED]. Review of a Physician's Note, dated 06/19/14, revealed resident sustained [REDACTED]. Review of a Post Falls Investigation, dated 06/17/14, revealed the resident had an unwitnessed fall on 06/15/14 at approximately 3:45 AM, when he/she was ambulating in the hall unsupervised. Resident #2 was assessed immediately after the fall and had complaints of pain to his/her right arm, rating the pain as a ten (10) out of ten (10) on the pain scale. Review of a Nurse's Note, dated 06/15/14 at 4:00 AM, revealed Resident #2 continued to complain of pain in his/her arm and stated he/she was unable to move his/her arm. Further review revealed the physician was notified and Resident #2 was sent to the emergency room . Review of a Hospital emergency room Note, dated 06/15/14, revealed Resident #2 received x-rays of his/her arm and was diagnosed with [REDACTED]. Further review revealed the resident received a splint to his/her right wrist and a sling for his/her right arm and was discharged back to the facility on [DATE]. The physician ordered for the facility to follow up with an Orthopedic Surgeon in three (3) days. Interview with the Consultant Pharmacist, on 08/06/14 at 4:56 PM, revealed she performed medication regimen reviews at least monthly at the facility. She stated after she completed the pharmacy review, she would print the pharmacy recommendations and give them to the DON or the ADON. She stated they were hand delivered or placed in their mailboxes. She revealed she visits the facility monthly and each month she tracks the month before to ensure all recommendations were addressed and received a follow up. She stated if she finds a recommendation that has not been responded to she will reprint and alert the DON/ADON. Interview with the ADON, on 07/30/14 at 2:22 PM; and, on 08/05/14 at 9:00 AM, revealed the Consultant Pharmacist performs medication regimen reviews on each resident at least monthly. The ADON stated, "Once the reviews were completed, the Pharmacy Consultant would print the recommendations, and give them to us (DON/ADON) to follow up on." The ADON stated, "Once I receive the recommendations, I would phone the physician and make him aware of the recommendations received." The ADON revealed sometimes the physician would give an immediate verbal order and sometimes the physician would wait until he was at the facility to make rounds at least once a week. The ADON stated, "I do not know how the recommendation slipped through the cracks." Interview with the DON, on 08/07/14 at 3:37 PM, revealed the ADON and the Team Leaders work with the pharmacy's recommendations to ensure they were addressed by the physicians. She stated ultimately it was the her (DON's) responsibility to make sure the pharmacy recommendations were addressed. She stated she was not sure how this was overlooked. She stated when the Pharmacy Consultant completed the reviews, the Pharmacy Consultant printed the recommendations and gave them to the DON or the ADON for follow-up. Interview with Resident #2's Physician, on 08/01/14 at 9:12 AM, revealed he did not recall being made aware of the Pharmacy Consultant's Recommendation at the time of Resident #2's fall on 06/12/14. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 08/08/14 the Consultant Pharmacist reviewed the medical record of 100% of all patients on antipsychotic medications to assure diagnosis, dosages, duration, required lab work and gradual dose reduction were appropriate. 2. On 08/28/14 the DON and RN/LPN Team Leaders reviewed 100% of the pharmacy recommendations for 07/2014 to ensure they were acted upon within fourteen (14) days of writing, per the policy and procedure. 3. On 08/08/14 the DON met with the Consultant Pharmacist to review the correct practice of pharmacy recommendation review and the DON was trained by the Consultant Pharmacist on the revised practice and the DON trained the RN/LPN Team Leaders. 4. Review of the Consultant Pharmacist recommendations continue to be performed to assure compliance with-in a seven (7) day response guidelines, and the physician response to recommendations. In addition, the pharmacy recommendations will be monitored by the DON for completion weekly until 100 % compliance achieved and Quality Assurance (QA) Committee deems appropriate. 5. The Consultant Pharmacist will continue to conduct monthly medication reviews of all residents on antipsychotic medications and make recommendations as deemed necessary. These reviews will be evaluated for compliance with recommendations by the DON. The medication review will be continued monthly as required by regulation and the audit of compliance with recommendation will continue until the QA Committee deems compliance is achieved and maintained. 6. All QA monitors will be reported to the QA Committee and will continue as directed by the QA Committee and Regional Nurse. The State Survey Agency validated the Corrective Action taken by the facility as follows: 1. Interview with the Consultant Pharmacist on 09/25/14 at 10:07 AM, revealed she reviewed the medical record of 100% of all patients 08/08/14 who were on antipsychotic medications to assure diagnosis, dosages, duration, required lab work and gradual dose reduction were appropriate. Review of the facility's Pharmacy Anti-Psychotic Drug Audit dated 08/2014 and 09/2014 revealed 100% of all residents had a medication regimen review completed by the Consultant Pharmacy. 2. Interview with the DON on 09/25/14 at 1:01 PM revealed she reviewed 100% of the pharmacy recommendations for 07/2014 to ensure they were acted upon within fourteen (14) days of writing, per the policy and procedure. Interview with Team Leader (RN #5) on 09/25/14 at 9:55 AM, revealed she reviewed 100% of the pharmacy recommendations to ensure they were acted upon within fourteen (14) days of writing, per the policy and procedure. Interview with Team Leader (LPN #1) on 09/25/14 at 10:35 AM, revealed she reviewed 100% of the pharmacy recommendations to ensure they were acted upon within fourteen (14) days of writing, per the policy and procedure. Review of the facility's Pharmacy Recommendation Audit dated 07/2014, 08/2014, and 09/2014, revealed that 100% of all residents with pharmacy recommendations had the recommendations acted upon within fourteen (14) days. 3. Interview with the Consultant Pharmacist on 09/25/14 at 10:07 AM, revealed she met with the DON on 08/08/14 to review the correct practice of pharmacy recommendation and to train the DON on the newly revised practice. Interview with Team Leader (RN #5) on 09/25/14 at 9:55 AM, revealed she received training from the DON regarding the correct practice of pharmacy recommendations. Interview with Team Leader (LPN #1) on 09/25/14 at 10:35 AM, revealed she received training from the DON regarding the correct practice of pharmacy recommendations. Review of a facility inservice dated 08/08/14, revealed the RN/LPN Team Leaders were inserviced regarding the correct practice of pharmacy recommendations. 4. Interview with the DON on 09/25/14 at 1:01 PM revealed she monitors on a weekly basis for the timely response of the pharmacy recommendations by the physician to ensure they are addressed within fourteen (14) days. 5. Interview with the Consultant Pharmacist on 09/25/14 at 10:27 AM revealed she will continue to conduct monthly medication regimen reviews of all residents on antipsychotic medications and will make recommendations as deemed necessary. She further stated the DON has monitors in place to evaluate for compliance. 6. Interview with the Activities Director on 09/25/14 at 12:37 PM revealed she is a member of the QA Committee and has been informed of the progress and results of the audit tool and monitors in place at the facility. Interview with the Licensed Social Worker (LSW) on 09/25/14 at 12:42 PM revealed she is a member of the QA Committee and has been informed of the progress and results of the audit tools and monitors in place at the facility.